Every finding on record at Grace Manor Care Center

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of two units.Specifically, the facility failed to:-Ensure staff followed the correct dwell time when using disinfectant to clean resident rooms and was not sprayed near resident's personal hygiene items; -Ensure housekeeping staff performed hand hygiene appropriately when cleaning resident rooms; and,-Ensure staff changed gloves after moving from dirty to clean task during wound care. Findings include: I. Professional reference According to the Center for Disease Control (CDC) About Hand Hygiene for Patients Healthcare Settings, 2/27/24 and retrieved on 4/27/26, Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients. When should you clean your hands: Before preparing or eating food, before touching your eyes, nose, or mouth, before and after changing wound dressings or bandages, after using the restroom, after blowing your nose, coughing, or sneezing; and, after touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone. How should you clean your hands: with an alcohol-based hand sanitizer: Put the product on your hands and rub your hands together, cover all surfaces until hands feel dry. This should take around 20 seconds. With soap and water: Wet your hands with warm water. Use liquid soap if possible. Apply a nickel- or quarter-sized amount of soap to your hands. Rub your hands together until the soap forms a lather and then rub all over the top of your hands, in between your fingers and the area around and under the fingernails. Continue rubbing your hands for at least 15 seconds. Rinse your hands well under running water. Dry your hands using a paper towel. Then use a paper towel to turn off the faucet and to open the door if needed. II. Facility policy and procedure The Infection Control Guidelines for All Nursing Procedures policy, revised August 2012, was received from the NH) on 4/19/26. It documented in pertinent part, In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all of the following situations: Before and after direct contact with residents, before donning sterile gloves, before performing any non-surgical invasive procedures, before preparing or handling medications, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after handling used dressings or contaminated objects, after contact with objects in the immediate vicinity of the resident and after removing gloves. III. Housekeeping failures A. Facility disinfectant product specifications The Diversey Virex TB ready to use disinfectant cleaner product specification sheet, dated 2020, was provided by the nursing home administrator (NHA) on 4/20/26 at approximately 3:30 p.m. It read in pertinent part, The ready-to use disinfectant cleaner is a one-step cleaner and disinfectant for spray and wiping cleaning in health care and other facilities. It kills tuberculosis (TB) in five minutes, and all other bacteria in three minutes. It kills norovirus in 30 seconds. The product can be used in multiple areas, such as hospitals, health care facilities, medical offices, hotels, hotels, public restrooms, institutional facilities and schools. Use instructions: Spray area until it is covered with the solution. Allow the product to penetrate and remain wet: three minutes for all bacteria, five minutes for TB, one minute for HBV and HIV-1 and 30 seconds for norovirus. Air dry, wipe surfaces to dry and remove any resident or rinse with potable water as necessary. For heavily soiled areas, thoroughly clean the surface prior to disinfecting. B. Observations On 4/20/26 during a continuous observation from 9:58 a.m. to 10:17 a.m. the following was observed: At 10:07 a.m. housekeeper (HK) #3 placed her housekeeping supply cart outside room [ROOM NUMBER]. At 10:08 HK #3 donned (put on) a pair of single use gloves. HK #3 removed two towels from her housekeeping cart, then entered room [ROOM NUMBER]. She placed bottles of cleaner in the bathroom, and then removed the small trash bag from the trash can in the bathroom. HK #3 then emptied a small trash bag from a trash can by a bed in the room and placed them in a larger trash bag. At 10:12 a.m. there was a stack of clean white folded wash cloths on the sink and a yellow toothbrush on the sink and against the wall. HK #3 sprayed the cleaner on the sink and did not move the toothbrush or the hand towels. She immediately wiped the sink before letting the cleaner dwell on the surface. HK #3 sprayed the same chemical on the bedside tables in the room, then immediately wiped the tables and did not let the cleaner dwell on the surface. The cleaner was Diversy TB. C. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 4/21/26 at 12:21 p.m. CNA #4 said the washcloths were brought to the residents rooms after the shower aide was done in the afternoon, so the residents could have a washcloth for the night and the next morning. CNA #4 said toothbrushes were usually in a basin and were labeled. HK #2 was interviewed on 4/21/26 at 2:00 p.m. HK #2 said the chemical disinfectant was used to spray the bed, sink and toilet. She said after three minutes, the staff would go back and then wipe the areas. HK #2 said personal belongings should be put in a grey container. She said the container was picked up prior to spraying the disinfectant in the area, and the container set back down after spraying. The housekeeping supervisor was interviewed on 4/21/26 at 2:15 p.m. The housekeeping supervisor said the disinfectant had a three minute dwell time to ensure the bacteria and viruses were gone, and then wiped the disinfectant after three minutes. The housekeeping supervisor said beds, door knobs, side tables and any surface should be disinfected. She said all personal items should be removed prior to spraying chemicals and wiping it down because the chemical (residue) can get in the resident's mouth. The director of nursing (DON) was interviewed on 4/21/26 at 3:09 p.m. The DON said the chemicals dwell time was the time the cleaner was to set wet on the surface and then staff were supposed to wipe it off. The DON said resident belongings should be removed prior to spraying so the chemical did not get in the residents mouth or on their face. IV. Failure to use hand hygiene and glove use appropriately when cleaning resident rooms A. Observations During a continuous observation on 4/20/26, beginning at 9:30 a.m. and ending at 9:59 a.m., the following was observed: HK #1 was finishing cleaning resident room [ROOM NUMBER]. She said the room was already cleaned and she just needed to make the bed. She made the bed and then moved her cart to resident room [ROOM NUMBER]. Without performing hand hygiene, she donned (put on) clean gloves and cleaned the bathroom. She cleaned the high touch surfaces and the toilet. She got new rags and started to clean the bedroom. She moved around the personal items on the counter with a sink and wiped down the surfaces. She moved the items around again and wiped the mirror. She cleaned the high touch surfaces in the bedroom. She made the bed. She removed the soiled gloves and mopped the bedroom. -HK #1 did not use hand hygiene between resident rooms. -HK #1 did not use hand hygiene after removing soiled gloves. -HK #1 did not change gloves and use hand hygiene after touching a dirty (bathroom) area and before moving around and touching personal items and cleaning linen. B. Staff interviews The housekeeping supervisor was interviewed on 4/21/26 at 2:30 p.m. She said the housekeepers should be performing hand hygiene after each room before moving to another resident room. She said they should change gloves and wash hands between each area of cleaning the resident room, such as after cleaning the high touch surfaces, after cleaning the bathroom and after mopping. She said there could be cross contamination of germs if the housekeepers did not wash their hands. V. Failure to use hand hygiene and change gloves during wound care A. Observations During a continuous observation on 4/20/26, beginning at 2:24 p.m. and ending at 2:30 p.m., the following was observed: Licensed practical nurse (LPN) #1 was going to provide wound care for a resident. LPN #1 gathered supplies and went into the resident's room. There were two CNAs in the room providing perineal care to the resident. LPN #1 washed her hands and donned clean gloves. She wiped the area of the wound with a wet wipe to clean her bottom where the wound was. LPN #1 applied the betadine to the wound, applied calcium alginate (wound dressing) and covered it with a foam dressing. -LPN #1 did not change gloves and perform hand hygiene after cleaning the dirty wound before applying a clean dressing. B. Staff interviews The DON was interviewed on 4/21/26 at 3:09 p.m. The DON said she was the facility's full time infection preventionist. She said she provided education to all staff on hand washing monthly during the in service meetings. She said she made sure staff follow hand hygiene by having them demonstrate and had no concerns with staff following hand hygiene practices. She said during wound care, gloves should be changed and hand hygiene should be completed after removing the soiled dressing and after the wound is cleansed. She said the importance of this was so the germs did not cross contaminate to someone else. She said the importance of changing gloves appropriately while cleaning a resident room was to not cross contaminate germs.

Based on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#8) of three residents out of 25 sample residents. Specifically, the facility failed to ensure:-An assessment was conducted to determine whether the self-administration of medications was clinically appropriate; and,-There was a secured place to store Resident #8's medications. Findings include: I. Facility policy and procedure The Self-Administration of Medications policy, reviewed February 2021, was received from the director of nursing (DON) on 4/21/26 at 6:58 p.m. It documented in pertinent part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status. If the team determines that our resident cannot safely self-administer medications, the nursing staff administer the resident's medications. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.II. Resident #8A. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included type two diabetes, chronic heart failure and chronic kidney disease. The 3/30/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.B. Resident observation and interview Resident #8 was interviewed on 4/19/26 at 9:23 a.m. There was a cup on her bedside table that contained multiple. She said she wanted to go back to sleep. Resident #8 was interviewed again on 4/19/26 at 11:52 a.m. She was sitting up in a recliner chair. There was a bottle of eye drops, a bottle of dry mouth spray and a tube of triple antibiotic cream at her bedside table in front of her. She said she was approved by the doctor and nurses to be able to use the medications at her bedside because she had very dry eyes, nose and mouth. C. Record review A review of Resident #8's electronic medical record indicated no assessment completed for having medications at her bedside and being able to self-administer medication. The review also indicated no physician's order for self-administration of medication and nothing in the care plan for self-administering medication. D. Staff interviewLicensed practical nurse (LPN) #1 was interviewed on 4/20/26 at 1:45 p.m. She said the process they followed at the facility for when residents requested to self-administer medications included obtaining a physician's order, completing an assessment on the resident and getting a secured box for the medications to be stored in. LPN #1 was interviewed again on 4/21/26 at 10:30 a.m. She said a resident not properly assessed for self-administration of medication could be at a risk for taking over the recommended amount and potentially lead to harm for the resident. LPN #1 said another risk of residents having medications at their bedside is for wandering residents who have dementia. She said they could potentially get into the medication. The DON was interviewed on 4/20/26 at 4:20 p.m. She said when Resident #8 was admitted to the facility, she had over the counter medications in her room. The DON said the provider was notified and did not provide an order for the resident to self-administer medications. The DON said the medications were confiscated at that time. She said on 4/20/26, she was notified that Resident #8 had more over the counter medications on her bedside table. The DON said she found out that Resident #8's son brought them in for her and the DON confiscated the medications. The DON said she notified the provider and the resident's son to provide education not to bring them in. The DON said in order for a resident to be able to self-administer medications, they needed an order from the provider, an assessment completed to ensure the resident could use the medication appropriately and a secured box in the room to store the medication so other residents could not get to the medication.

Based on observations, record review and interviews, the facility failed to ensure one (#16) of five residents reviewed for accidents out of 25 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure person centered fall interventions were consistently implemented for Resident #16, who sustained multiple falls Findings include: I. Facility policy and procedure The Fall Guidelines- Assessing Falls and Their Causes policy,reviewed October 2010, was received from the director of nursing (DON) on 4/21/26 at 6:58 p.m. It documented in pertinent part, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.Nursing staff, in collaboration with the interdisciplinary team will begin to try to identify possible or likely causes of the incident. They will refer to resident specific evidence. Nursing staff and the interdisciplinary team will evaluate chains of events or circumstances preceding a recent fall. This could include time of day of the fall, what the resident was doing, whether the resident was standing, walking, reaching or transferring from one position to another, whether the resident was trying to get to the toilet or whether any environmental risk factors were involved. Post fall physical head to toe evaluation should be conducted by the licensed nurse. If an individual falls, an incident report must be completed in a risk management portion of the electronic medical record. Notify the following individuals when a resident falls: the resident's family, the attending physician, the director of nursing services and the nursing supervisor on duty.II. Resident #16A. Resident status Resident #16, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included Friedreich ataxia (neurodegenerative disease causing weakness), muscle weakness, unsteadiness on feet, dementia and macular degeneration (vision loss). The 3/17/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for a mental status score of seven out of 15. She required maximal assistance with toileting, dressing, bathing and transfers. B. Observations and interview During a continuous observation on 4/20/26, beginning at 8:57 a.m. and ending at 9:40 a.m., the following was observed: At 8:57 a.m. Resident #16 was sitting in her wheelchair in her room by the closet. There was one water cup on the opposite side of the room on the night stand. At 9:36 a.m. CNA #2 came in and asked Resident #16 if she would like to get into her recliner. Resident #16 said she wanted to go home. The unidentified staff member assisted Resident #16 into the recliner and handed her a call light. The bedside table was next to Resident #16 with no water cup in reach. There was a water cup still on the night stand across the room. During a continuous observation on 4/20/26, beginning at 2:30 p.m. and ending at 4:10 p.m., the following was observed: At 2:30 p.m. Resident #16 was sitting in her recliner. The bedside table was next to her with no water cup. The call light was within reach. Resident #16 said she did not know how to call for help. There was a water cup on the opposite side of the room on her night stand. At 3:38 p.m.CNA #2 was walking around room to room collecting water pitchers. At 3:46 p.m. CNA #3 walked into Resident #16's room and had a conversation with her. At 4:00 p.m. CNA #2 dropped off Resident #16's water pitcher to her bedside table next to her. There was no water pitcher on her night stand anymore. -Staff failed to offer to toilet Resident #16 around the 3:00 p.m. time. C. Record review 1. Care planResident #16's fall care plan, revised 4/2/26, documented the goal of the care plan was to minimize the risk of falls with interventions. Pertinent interventions included assisting Resident #16 to the bathroom at approximately 3:00 p.m. daily (initiated 11/2/23) and putting two water cups in the room, one on the bedside table and one on the night stand (initiated 4/1/26). 2. Fall on 1/11/26- unwitnessed The 1/11/26 nursing note documented at 6:00 a.m., documented that staff reported Resident #16 was on the floor during this morning's rounds. The resident described she had rolled out of bed, stating she was not trying to get up. No injuries were noted. A new intervention was implemented to place pillows on the bed to define the edges of the bed (which was later removed). 3. Fall on 1/15/26- unwitnessed The 1/15/26 nursing note documented at 11:43 a.m., documented that staff alerted the nurse that the resident was on the floor. Resident #16 did not know what she was doing and she needed the bathroom but that was not the reason she was getting up. No injuries noted. A new intervention was to remove Resident #16's wheelchair from within her reach to avoid the urge to self-transfer (which was later removed). 4. Fall on 3/16/26- unwitnessed The 3/16/26 nursing note documented at 4:30 a.m., documented that the aides found the resident laying on the floor along the side of her bed during rounds. Her head was facing the sink and feet were at the edge of the bed. She was laying on her left side with her arm tucked under her. She did not have footwear on. She was alert and at her normal baseline which was confused but she could answer questions. A 5 centimeter skin tear was noted on her left forearm and was cleaned and dressed. The resident stated she was just messing around. A new intervention was implemented to re-educate staff to keep the bed in the lowest position. 5. Fall on 3/26/26- unwitnessed The 3/26/26 nursing note documented at 6:30 p.m., documented that walking rounds were done at 6:00 p.m. At that time, Resident #16 was at her sink in her wheelchair washing her face. Another resident's caregiver had heard Resident #16 yelling for help and checked on her to find her laying on the floor. The caregiver alerted the staff. Resident #16 was unable to give a description of what happened. No injuries noted. A new intervention was implemented to offer assistance with evening cares. 6. Fall on 4/1/26- unwitnessed The 4/1/26 nursing note documented at 3:45 p.m., documented that the nurse was sitting at the south nurse's station when a resident was heard calling out for help. Upon the nurse's arrival to the resident's doorway, the resident was on the floor laying on her left side with feet pointed north and head south. The resident described to the nurse and two CNA's that she crawled out of her bedside chair, crawled around the bed on her stomach because she was so thirsty and she just had to get to her water. The water glass was noted to be on the night stand. There were no injuries noted. A new intervention was implemented to put one water cup by her chair on the bedside table and one on the night stand. -However, there was only one water cup implemented on the night stand (see observations above). D. Staff interviews CNA #3 was interviewed on 4/20/26 at 4:10 p.m. She said Resident #16 was a fall risk because she tried to get out of bed without assistance and she was confused. CNA #3 said for intervention to help prevent Resident #16 from falling, the staff check on her more frequently on days she is more confused, they use nonskid footwear, the call light within reach and keep the door open. Licensed practical nurse (LPN) #1 was interviewed on 4/20/26 at 10:30 a.m. She said Resident #16 was a fall risk and interventions they have in place included a fall mat at night, trying to keep her in activities during the day, transfer her to the recliner chair instead of leaving her in her wheelchair in her room and trying to not leave her alone. LPN #1 said Resident #16 liked to stay busy and always do something. LPN #1 said new interventions are sent out in a text message alert and also an alert on the computer. The DON and the regional clinical resource nurse were interviewed together on 4/21/26 at 11:45 a.m. The DON said Resident #16's cognition had declined quite a bit over the last couple months. She said she had macular degeneration, but still tried to be as independent as she could. The DON said Resident #16 is a fall risk due to her diagnosis of dementia, vision problems and her muscle weakness. The DON said her current fall interventions included placing water on both sides of the bed, making sure her stuff was within reach, nonskid strips on the floor, getting her dressed and ready for bed, offering the bathroom around 3:00 p.m. (because she fell once at that time going to the bathroom), family and the facility to help out with her holiday cards, a reacher, making sure the bedside table was locked, therapy to evaluate, pink tape on her call light, pink balls on her wheelchair brakes and a sign on her closet to call for help. The DON said all staff were responsible for ensuring interventions are in place.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in two of two medication carts and one of one medication rooms. Specifically the facility failed to: -Ensure medications were not loose in medication carts; and, -Ensure expired medications were not stored with current medications in the medication storage room. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised November 2020, was received from the director of nursing (DON) on 4/10/24 at 2:40 p.m. It documented in pertinent part, The facility stores all drugs and biologics in a safe, secure, and orderly manner. Drugs and biologicals are stored in packaging, containers or other dispensing systems in which they were received. Nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Discontinued, outdated, or deteriorated drugs and biologicals are returned to the dispensing pharmacy or destroyed. II. Observations and staff interviews On 4/10/24 at 1:57 p.m. medication cart #1 was reviewed with licensed practical nurse (LPN) #1. -The medication cart had 28 whole medication tablets and one half medication tablet loose in the medication drawers. On 4/10/24 at 2:09 p.m. medication cart #2 was reviewed with LPN #1. -The medication cart had 16 whole medication tablets loose in the medication drawers. LPN #1 was interviewed on 4/10/24 at 2:11 p.m. LPN #1 said there was no formal cleaning schedule but it was the nurses responsibility to keep medication carts clean. LPN #1 siad medication carts were to be kept clean to prevent contamination and aid in medication stocking. On 4/10/23 at 2:15 p.m. the medication room was observed with LPN #1. -The medication room contained two boxes of 50 Tylenol 650 milligram (mg) suppositories that expired in February 2024. LPN #1 was interviewed on 4/10/24 at 2:17 p.m. LPN #1 said the medications were expired and should have been removed from the medication room for destruction. LPN #1 said expired medications had the potential for the full dose of the medications not to be administered to a resident. III. Additional staff interview The DON was interviewed on 4/10/24 at 2:31 p.m. The DON said medication carts were to be cleaned daily by the charge nurse. The DON said the pharmacy consultant came into the facility monthly to perform inspections on medication carts. The DON said nurses working the floor were expected to check the cart every day for expired medications and cleanliness. The DON said the facility did not have a schedule that identified a certain day or shift the medication carts were to be cleaned. The DON said if a nurse dropped a medication tablet into the drawer they should go looking for it and destroy it. The DON said it was important for medications to be stored in their dispensing containers so they did not get mixed up, creating a potential for medication errors. The DON said her nurse manager was to check the medication room for expired medications every two weeks. The DON said if a medication was used past the expiration date it could alter the strength and effectiveness of the medications.

Based on observations, record review and interviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#19) of 12 residents out of 15 sample residents. Specifically, the facility failed to have a wound care order in place prior to treatment being provided for Resident #19. Findings include: I. Facility policy and procedure The Care of Skin Tears, Abrasions and Minor Breaks policy, revised September 2013, was provided by the director of nursing (DON) on 4/10/24 at 2:31 p.m. It read in pertinent part, The purpose of the procedure was to guide the prevention and treatment of abrasions, skin tears and minor breaks in the skin. An abrasion is an area of the skin that has been damaged by friction, scraping, rubbing or trauma. Preparation: -Obtain a physician's order as needed; -Check the treatment record; and, -Generate a non-pressure form and complete it. II. Resident #19 A. Resident status Resident #19, age above 65, was admitted on [DATE] and readmitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included a history of falling, neoplasm of uncertain behavior of skin (a skin growth that could not be predicted), chronic kidney disease, hypertension (high blood pressure) and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). The 1/29/24 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of nine out of 15. He required moderate assistance with toilet transfers, chair to bed transfers, sit to stand and lying to sitting. The resident was at risk of developing pressure injuries. B. Resident observations and interviews Resident #19 was observed on 4/9/24 at 11:37 a.m. with a soiled border foam dressing to his right elbow. The dressing had dried blood on it and no date to indicate when it was changed or nurse initials. Resident #19 was observed a second time on 4/10/24 sitting in his recliner. His right elbow was open to air and scabbed over. Resident #19 said he received the wound on his right elbow when he fell a couple of weeks ago. He said a staff member put the dressing on because it was bleeding but it had not been changed since the fall. He said he took it off that morning (4/10/24) himself. C. Record review -Review of the March 2024 and April 2024 CPO revealed no treatment orders for the right elbow wound. A progress note dated 3/31/24 documented the resident received the abrasion to his right elbow following an unwitnessed fall. -However, the progress note did not document a dressing had been ordered and applied to the resident's elbow. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/10/24 at 12:54 p.m. LPN #1 said Resident #19 had a skin tear to his right elbow from a previous fall. She said there was not a physician's order in place for the treatment of the wound. She said there should be a physician's order in place on what to treat the wound with and for monitoring for infection. The DON was interviewed on 4/10/24 at 1:30 p.m. The DON said Resident #19 had an abrasion to his right elbow from a previous fall. She said she overheard LPN #1 and the unit manager discussing there was no physician's order for a treatment and it was left open to the air. She said the nurse should have called the physician for an order to treat the abrasion and to monitor for infection.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents received adequate supervision to prevent an accident/hazard. Resident #1, who had a diagnosis of neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning and independent function), was admitted to the facility on [DATE]. The facility failed to follow standards of practice in providing incontinence care by not having all supplies ready and letting go of the resident after helping the resident into the sitting position on the edge of bed. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living (ADL) as documented in his quarterly 1/6/23 minimum data set (MDS) assessment. The facility failed to provide and implement two person bed mobility/toileting and dressing assistance and failed to consistently provide two person bed mobility/toileting and dressing assistance after the fall according to record review, interviews and in accordance with the post fall intervention and education provided by the director of nursing (DON). Due to the facility's failures, and the staff's failure to take proper and reasonable care when providing bed mobility/toileting and dressing assistance resulted in the resident falling from seated on the edge of bed to the floor landing on his head, neck, and shoulder. It resulted in the resident sustaining injuries of a head injury, scalp hematoma (bleeding on brain), facial bruising, cervical spine strain, and right shoulder contusion. His pain went from a baseline of 0 out of 10 (on a pain scale with 10 being the worst pain) to 8 out of 10 resulting in a decrease in functional ability and he required evaluation and treatment at the emergency department (ED). Findings include: I. Facility policy and procedure The Falls and Fall Risk, Managing policy and procedure, revised March 2018, was provided by the DON on 4/18/23 at 10:41 a.m. It read in pertinent part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls. II. Resident #1 A. Resident status Resident #1, age 86, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies, muscle weakness, unsteadiness on feet, and repeated falls. The 1/6/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required extensive assistance with two persons for transfers, bed mobility, toilet use, dressing, and locomotion on the unit. He required extensive assistance with one person for personal hygiene, and bathing. The resident did not require scheduled pain medication regimen and pain assessment revealed the resident had no pain (0/10) in the last five days. The 3/10/23 annual MDS assessment (after the fall on 2/27/23) revealed the resident required and received scheduled pain medication regimen, PRN (as needed) pain medications, and non-medication interventions for pain. The pain assessment revealed the resident had frequent pain in the last five days with a pain intensity of 7 out of 10. B. Resident interview Resident #1 was interviewed on 4/18/23 at 1:00 p.m. He said the fall on 2/27/23 occurred when the nurse aide (NA) left him on the edge of bed and she went to go pick something up and that was when he fell to the floor from the bed. Resident #1 said he did not have pain before the fall but the pain was quite a bit after. He said he really felt it in his neck, he had a black eye and a goose egg on the right side of his head. He said after they picked him up he noticed the right shoulder pain. He was sent to the ED. He said the Tylenol was not helping his pain the first weeks because he was very sore with a great amount of pain. He said the staff tried muscle relaxant medication but that did not seem to help. Resident #1 said he could not get out of bed unless he had help, usually one person but sometimes two. C. Record review Review of the ADL care plan revealed the resident required assistance with activities of daily living (ADLs) related to weakness with decreased mobility, history of fall falls prior to admission and during admission, unsteadiness, history of transient ischemic attacks (TIAs). Residents' ADL function was unpredictable from day to day, initiated 3/7/22, and revised 3/13/23. Interventions related to bed mobility, transfers and dressing included, bed mobility one to two person assist, initiated 10/24/22 and revised 3/15/23; dressing one to two person assist, initiated 3/7/22, and revised 3/15/23; resident was not to be left on edge of bed unattended, initiated 2/27/23; toileting two person assist, initiated 3/7/22, revised 10/24/22; and transfers two person assist, initiated 3/7/22, and revised 3/15/23. -Although the 1/6/23 MDS assessment had been coded as requiring extensive assistance with two persons for transfers, bed mobility, toilet use, and dressing during the seven day period. The ADL care plan revealed it had not been developed to include two persons physical assistance consistently. Review of the fall care plan revealed the resident was at risk for falls related to multiple falls prior to admission with fractured ribs, weakness, decreased mobility, unsteady balance, unsteady gait, diagnosis of history of idiopathic normal pressure hydrocephalus (fluid on the brain), history of TIA/cerebrovascular accident (stroke). Decreased safety awareness and confusion at times, initiated 3/7/22 and revised 10/31/22. New interventions introduced following fall on 2/27/23 was, resident is not to be left on edge of bed unattended. initiated 2/27/23. Review of Resident #1's medical record (EMR) revealed the following progress notes documented in pertinent part: 2/27/23 at 9:26 a.m., Full Description of Fall: staff alerted this nurse that resident had fallen onto floor. Nurse walked into room and saw resident laying on his right side on the floor. No shoes on, staff was present and in the bathroom when he fell . Resident's Description of Fall: states to have fallen off the bed while sitting on the edge and was not able to keep himself up. States to have hit head, no other complaints during assessment. Description of Environment Where Fall Occurred: Resident Assessment: Full assessment completed, resident sustained a goose egg on top of right forehead, extremities equally strong and baseline ROM (range of motion) intact, no pain complaints other than a headache during assessment. Alert and oriented per baseline. Vitals and neuros started per protocol. Provider, DON and daughter notified. Resident assisted off the floor two person assist and sat into wheelchair to finish getting dressed, resident taken to breakfast by choice. While eating he complained about having right arm pain and nausea. Daughter in to visit and requests that resident be seen in ED. Vital Signs / Neurological Checks: 160/91, 76, 18, 98.3, 95% , alert and oriented x3 (to person, place and time) per baseline. Injuries: first aid provided, 'goose egg' top of right forehead. Pain: Level (1-10), Pain: 4 from headache. No other complaints while doing assessment. Later while eating breakfast complains of right arm pain and nausea. Fall intervention(s): immediate & suggested long term: no more sitting on edge of bed per usual. Physician notification: messaged provider to personal phone. Responsible party notification and response: daughter and first contact. The 2/27/23 at 8:27 a.m. emergency department physician note revealed in pertinent part, Chief complaint: Fall at 7:15 a.m. History of present illness: Wheelchair bound two-person assist at baseline presenting in the emergency department for evaluation after a fall. Patient resides at a nursing facility, they put him on the side of the bed and left the room. Patient fell off the bed and landed on his right side. Patient complaining of head, neck and right shoulder pain. He also complains of nausea when sitting up. A complete 10-point review of systems was performed and was negative. Head: right frontal hematoma with associated tenderness to palpation. Neck: Mild right paraspinal tenderness to palpation. Musculoskeletal: right shoulder-positive mild posterior lateral tenderness to palpation. Imaging CT (computerized tomography) head -Right front scalp swelling with intact calvarium. CT cervical spine: No acute traumatic injury to the cervical spine. Right shoulder x-ray: No acute fracture. Assessment: Scalp hematoma, head injury, cervical spine strain as well as right shoulder contusion, also persistent UTI (urinary tract infection). Family will discuss two-person assistance issues with the nursing facility. 2/27/23 at 11:33 a.m. Nursing note: resident back from ED, comes back with orders for Keflex 500 mg (milligrams) PO (by mouth) TID (three times per day) for ten days, first dose given at the hospital for UTI (urinary tract infection), Occupational Therapy (OT), additional instructions include ice to head 20 minutes on 60 off, Acetaminophen prn, gentle range of motion and stretching, and check in two days for a recheck. Resident to return as needed. 2/28/23 at 10:00 a.m. Nursing note: post fall monitoring continued, resident 'sore' feeling neck and right shoulder pain, prn ibuprofen administered resident laid down to rest. Chiropractor coming into the facility to see resident later this afternoon. Neuros (neurological) and vitals WNL (within normal limits). 3/1/23 at 7:17 a.m. Orders-Administration note: Resident states neck pain from recent fall. Requests PRN med (medication). 3/1/23 at 8:51 a.m. Orders-Administration note: PRN administration was ineffective. Follow-up Pain Scale was: 5. 3/1/23 at 10:03 a.m. Orders-administration note: Resident reports pain at neck and right arm and requests PRN med. Daughter states that tylenol has not been helping the discomfort, but that ibuprofen has been helping. Resident has a follow up doctor appointment today at 10:30 a.m. The 3/1/23 physician progress note, in pertinent part, for follow up from the ER (emergency room ), History of present illness: resident presents for follow up status post rolling out of his bed accidently. Apparently the CNA that was taking care of the patient was unaware that she had to watch and he fell out of bed. Patient was placed into bed and then left unattended; he ultimately rolled out landing on his right side. Patient has multiple bruises on the face, neck, and shoulder. Patient was evaluated in the ER with multiple studies including CT scans with negative fractures. Patient voices agreement that he would like to get his ibuprofen scheduled. Physical examination: Pleasant elderly male, wheelchair dependent with facial bruising consistent with his history of fall from bed. Facial bruising of the head, face right side. Spasticity of the strap neck muscles right greater than left no cervical spine tenderness. Assessment: Multiple contusions and dysuria (painful or difficult urination). 3/2/23 at 9:46 p.m. Nursing note: seems out of sorts, was telling the aides that he needed to lay down and he already was and then he asked to take him out of the car when he was lying in bed. 3/9/23 at 8:08 a.m. Nursing note: provider phoned and gave order for biofreeze to be applied to neck and shoulders TID for residents discomfort. 3/10/23 at 8:43 p.m. Nursing note: This resident is S/P (status post) unwitnessed fall in his room on 3/5/2023. His vital signs remain stable and his neurological examination remains benign, at his baseline. Will continue to monitor. -Another fall on 3/5/23, seven days after fall with injury on 2/27/23. There was no charting in the progress notes of the 3/5/23 fall until 3/10/23, five days later. 3/14/23 at 10:09 a.m. Fall note description of fall, in pertinent part, resident was found on floor between his wheelchair and recliner in room, laying on his right side. Call light was next to the wheelchair but was not able to reach while on the floor. When asked how long he had been there, he states it was just a few minutes. Residents' wheelchair wheels were unlocked at the time due to the resident self propelling himself. Resident's description of fall: resident states that he could not remember what he was reaching for but was reaching for something and slid out of his wheelchair, and due to wheels being unlocked, wheelchair rolled away. Description of environment where fall occurred: Resident was transferring himself to his recliner from his wheelchair. Wheelchair brakes were unlocked at the time of all. His call light was beside his chair and he wasn't able to use it after the fall. He did not use it before the fall either. Resident assessment: full assessment complete and VS (vital signs) taken. Neuro's are all intact. Denies pain at this time. Vital signs / neurological checks: VS and neuro's were intact with no problems noted. No injuries and no pain at this time. Fall Intervention: Immediate and suggested long term: Reacher device implemented. Physician notification and response: No orders noted from doctor. Responsible party notification and response: Daughter notified. Administration and Director of Nursing Notification: Both were notified of the fall. 3/15/23 at 7:19 a.m. Orders-administration note: Resident states that neck pain 'was getting a lot better' , but reports pain at right upper arm from previous fall. 3/16/23 at 5:14 p.m. Nursing note: Resident had complaints of pain in his right arm below his shoulder spoke with PCP (primary care physician) and order to have X-rays taken tomorrow was given and to extend his scheduled IBU (ibuprofen) for another 10 days. Daughter notified of new orders and will be present during x-rays. 3/23/23 at 9:58 a.m. Annual care conference in pertinent part, Care conference summary, late entry: Care plan reviewed at length and appropriate questions asked and answered. Daughter voiced a concern regarding one night shift CNA (certified nurse aide) continues to transfer resident alone, without a second person. DON will follow up on this. Review of the bed mobility task support provided for the past 30 days documentation revealed the following: 3/19/23 at 9:04 a.m. two person physical assistance was provided. 3/20/23 at 2:28 a.m., 12:33 p.m., 8:38 p.m. one person physical assistance was provided. 3/21/23 at 10:19 a.m., 7:22 p.m. one person physical assistance was provided. 3/21/23 at 10:38 a.m. two person physical assistance was provided. 3/22/23 at 1:57 p.m., 7:15 p.m. one person physical assistance was provided. 3/23/23 at 1:30 p.m. one person physical assistance was provided. 3/24/23 at 2:58 a.m., 10:19 a.m. two person physical assistance was provided. 3/25/23 at 1:17 a.m., 7:41 p.m. one person physical assistance was provided. 3/25/23 at 10:10 a.m. two person physical assistance was provided. 3/26/23 at 9:55 a.m. one person physical assistance was provided. 3/26/23 at 9:55 a.m., 11:34 p.m. two person assistance was provided. 3/27/23 at 12:56 p.m. one person physical assistance was provided. 3/27/23 at 9:58 p.m. two person physical assistance was provided. 3/28/23 at 2:32 p.m. one person physical assistance was provided. 3/29/23 at 2:29 a.m., 10:18 a.m. one person physical assistance was provided. 3/30/23 at 4:19 a.m., 2:29 a.m. one person physical assistance was provided. 3/30/23 at 9:38 p.m. two person physical assistance was provided. 3/31/23 at 9:49 a.m. two person physical assistance was provided. 3/31/23 at 8:08 p.m. one person physical assistance was provided. 4/1/23 at 9:31 a.m. two person physical assistance was provided. 4/2/23 at 12:24 a.m. one person physical assistance was provided. 4/2/23 at 9:26 a.m. two person physical assistance was provided. 4/3/23 at 2:55 a.m., 10:11 a.m. one person physical assistance was provided. 4/4/23 at 12:23 a.m. one person physical assistance was provided. 4/4/23 at 2:57 p.m. two person physical assistance was provided. 4/5/23 at 1:48 a.m., 10:05 a.m. one person physical assistance was provided. 4/6/23 at 5:23 a.m., 1:19 p.m. one person physical assistance was provided. 4/7/23 at 2:01 a.m., 12:55 p.m. one person physical assistance was provided. 4/8/23 at 5:59 a.m., 1:11 p.m. two person physical assistance was provided. 4/8/23 at 10:46 p.m. one person physical assistance was provided. 4/9/23 at 11:50 a.m. two persons physical assistance was provided. 4/10/23 at 2:05 a.m., 10:17 a.m., 7:27 p.m. one person physical assistance was provided. 4/10/23 at 10:17 a.m. two person physical assistance was provided. 4/11/23 at 5:59 p.m. one person physical assistance was provided. 4/12/23 at 12:30 a.m., 1:47 p.m. one person physical assistance was provided. 4/12/23 at 8:19 p.m. two person physical assistance was provided. 4/13/23 at 5:58 p.m. two person physical assistance was provided. 4/14//23 at 1:47 a.m., 7:56 p.m. two person physical assistance was provided. 4/14/23 at 2:09 p.m. no setup or physical help from staff. 4/15/23 at 1:24 p.m. one person physical assistance was provided. 4/16/23 at 5:41 a.m. two person physical assistance was provided. 4/16/23 at 3:30 p.m. one person physical assistance was provided. 4/17/23 at 12:01 a.m. two person physical assistance was provided. -Although, the DON educated the staff to provide two person assistance (see below) after Resident #1's fall and the daughter requested it during the recent care conference, the staff continued to provide one person assistance, placing Resident #1 at a continued risk of another fall. Fall risk tool assessment conducted 2/8/23 and 2/27/23 revealed high risk of fall. The February 2023 MAR (medication administration record) pain level was documented as 0 out of 10 on 2/26/23; and 7 out of 10 on 2/27/23 (after fall). Occupational therapy (OT) evaluation, dated 3/2/23, revealed right shoulder pain with movement, prior pain with movement 0 out of 10, current baseline (3/2/23) pain with movement 8 out of 10 resulting in increasing difficulty with transfers, completing ADLs and low activity tolerance. III. Facility's investigation of Resident #1's fall The post fall investigation noted in pertinent part, Fall investigation: Fall 2/27/23-Staff alerted the nurse that the resident had fallen forward onto the floor. Nurse walked into room and saw resident laying on his right side, bed was half way up off the floor, call button was within reach, room well lit. Root cause analysis: Poor core strength to body, resident was weak at this time. IDT (interdisciplinary team) recommendations: Do not leave resident on the side of the bed unattended. Was abuse & neglect ruled out?-No abuse. Further investigation for this fall: Completed neuros starting 2/27/23. Nurse aide (NA) #1 had left Resident #1 unattended. NA#1 statement: I sat the patient up on the side of the bed while getting ready and dressed before getting assistance to transfer per usual, I stepped into the restroom to get him depend, and as I walked out I heard a thump and found him on the floor, and went to alert the nurse right away. Resident did return from the hospital by facility van. He has a diagnosis of a concussion. No brain bleed, or broken bones. On the spot re-education, date 2/27/23, conducted by DON: For Resident #1, Resident needs two person assistance for all dressing and transfer cares. Never leave him unattended sitting on the edge of bed. His core strength is unpredictable. Inservice training class, 3/9/23, conducted by clinical administrators. Subjects covered: abuse, neglect, donning and doffing of PPE (personal protective equipment), relias training policy, above and beyond program, Protocol on where and how to find care plans and the importance of them, Resident care including education on a Resident #1. The ADL Assistance Spot Checks paperwork was blank and had not been conducted after the fall. IV. Staff interviews NA #1 was interviewed via telephone on 4/18/23 at 12:37 p.m. She said she obtained her certificate for NA on 12/15/22 and she was currently working toward completing her certified nurse aide (CNA) certificate. She said that Resident #1 required two person assistance for transfers, and for dressing it was usually one person assist. She said for toileting he required two person assistance and for bed mobility one person assistance for rolling and transfer from lying down to the sitting position. NA #1 said at the time of the fall on 2/27/23 she needed to let go of the resident who was seated on the edge of bed and go into the bathroom to get a brief. NA #1 said the staff usually changed him in bed but she noticed there was no brief and normally two people would help. NA #1 said the other staff member was busy with another resident. NA #1 said with Resident #1's incontinence care we would stand him and pull up pants and complete tasks that way. NA #1 said typically she would have gathered her supplies first. She said when she realized she did not have all of her supplies with her she should not have left Resident #1 seated on the edge of the bed unattended but she did and he fell . She said after he fell she checked the resident and told him she would go get the nurse. NA #1 said the DON talked to her about everything after and told her not to transfer the resident by herself and if she needed to get anything to lie the resident down and not to leave the resident unattended in an unsafe position. NA#1 said bed mobility for Resident #1 was now two person assistance for safety. Registered nurse (RN) #1 and DON were interviewed on 4/18/23 at 2:08 p.m. They said the information for the care plan was gathered in the first week after admission and went off of what the CNAs were charting of actual functioning needs. They said they made a decision on the care levels needed but they did not always care plan for extensive assistance for two people even though that was on the MDS assessment. They said the care plan may not match the MDS assessment in the functional level because the person varies. They said if the MDS assessment documented the resident needed two person assistance they may have needed it once in seven days. RN #1 said Resident #1 had his fall during bed mobility but she did not make any changes to his bed mobility care plan because he was fluctuating between needing one to two person assistance. The DON said prior to the fall bed mobility was typically one person assistance, our intervention after that time was to not be left on the edge of bed without hands on support and to transfer off the bed with two person assistance. After the fall we determined he needed one person support on the edge of bed, he had been a two person assistance for transfers, and toileting for a long time. The DON said the care plan had not been updated yet to match the training she provided to the staff which was to provide two person assistance for all dressing and all transfer cares for best safety. The DON said she meant to put two person assistance with all transfer cares (including bed mobility, transfers, toileting, and dressing) on the resident's care plan. The DON said she would update the care plan to two person assistance because that was what she said in the training she provided to the staff and to the family in the care conference. The DON, RN #1, social services coordinator (SS) acknowledged the record review of the last 30 day (after the fall) task CNA documentation for transferring and toileting revealed one person assistance was provided frequently, although the care plan stated to provide two person assistance. The DON, RN #1, and SS acknowledged the last 30 day (after the fall) task CNA documentation for bed mobility and dressing revealed one person assistance was frequently provided although the DON had educated the staff on 2/27/23 to provide two person assistance. The DON said she would re-educate the staff on ADL charting and the care levels that Resident #1 needed. The DON said she wanted Resident #1 to have two person assistance for all cares for his safety. CNA #1 was interviewed on 4/18/23 at 4:09 p.m. She said the incontinence care procedure was first to sanitize your hands and put on gloves and explain to the resident the procedure. CNA #1 said she would get supplies first when she walked into a room such as spray, wipes, and a brief. CNA #1 said then she got the resident positioned safely to change them. CNA #1 said if she needed to leave the resident, she lowered the bed and if there was a resident that she could not take her hands off, then she would use the call light for another staff member to come and help. CNA #2 was interviewed on 4/18/23 at 4:16 p.m. She said the incontinence care procedure was to knock on the door, sanitize hands, put on gloves, and tell the resident why she was there. CNA #2 said she would gather supplies first such as peri wash, wipes, briefs, and dry clothes. CNA #2 said then she would transfer the resident to the toilet or the bed depending on the resident. CNA #2 said if she forgot something, she would lay the resident down, cover them up, lower the bed then go get what she needed. CNA #2 said there were some residents that she knew not to let go of while changing them and she would have two people assist for safety. The NHA was interviewed on 4/18/23 at 4:52 p.m. The NHA acknowledged that if the NA had not taken her hand off the resident and walked away the resident would not have fallen. The NHA said it was an accident.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure hand hygiene was performed during medication administration. Findings include: I. Professional reference Centers for Disease Control and Prevention (CDC). Hand Hygiene in Healthcare Settings: Hand Hygiene Guidance. Reviewed January 30, 2020. https://www.cdc.gov/handhygiene/providers/guideline.html retrieved on 1/24/23. Healthcare personnel should use an alcohol based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, before performing an aseptic task (placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal. II. Facility policy The Medication Administration and Management policy, revised June 2019, was provided by the director of nurses (DON) on 1/10/23 at 1:50 p.m. The policy read in pertinent part: Administration of medication: -sanitize hands; -administer the medication as outlined; and, -wash hands with soap and water or antiseptic gel and follow the same guidelines for administering medication to the next resident. Steps for administration of eye medications: -wash hands and don gloves that are provided; -administer the eye drops as directed; -dispose gloves; and, -wash hands with soap and water or antiseptic gel and follow the same guidelines for administering medication to the next resident. III. Observations On 1/10/23 at 8:40 a.m. licensed practical nurse (LPN) #1 was observed as medications were administered. LPN #1 prepared medications for Resident #17 and entered the dining room. As the LPN approached the resident, the LPN touched the resident's face, mouth, and scratched her head. The medications were administered, and the LPN returned to the medication cart. There was no hand hygiene performed after the medication administration. The LPN prepared Resident #1's medications and entered the resident's room. The LPN assisted the resident with items on her meal tray, then administered the medications. The LPN returned to the medication cart. The LPN failed to perform hand hygiene. The LPN prepared medications for Resident #16 and entered the resident's room. The LPN was searching for tissues, the LPN was observed scratching her head and touching and moving her hair/ponytail from one side of her head to the other. The LPN provided the resident with tissue and administered eye drops. She then administered oral medications, and then administered the final eye drops. The LPN completed the medication pass without performing hand hygiene administrations and did not don gloves for administration of eye medication. She performed hand hygiene after exiting the room. On 1/10/23 at 12:10 p.m. LPN #1 was observed as medications were administered. The LPN prepared medications for Resident #11 and approached the resident in the dining room. The LPN rubbed her nose, touched her mouth, face, eyeglasses, hair, and scratched her head. After administration, while walking to the medication cart, the LPN touched her nose, cheeks, eyeglasses, pill cups and other items on the medication cart. The LPN failed to perform hand hygiene. IV. Interviews LPN #1 was interviewed on 1/10/23 at 1:30 p.m. She stated she had previously received education regarding hand hygiene and was surprised she did not perform hand hygiene in the above observations. The LPN stated hand hygiene should be performed before and after administering medications. She acknowledged that in addition to hand hygiene, gloves should be worn while administering eye medications. The director of nursing (DON) was interviewed on 1/10/23 at 3:25 p.m. The DON stated when the nurse was administering medication hand hygiene was to be performed before and after administering medications to a resident. She stated if eye drops were administered, the nurse should complete hand hygiene and don gloves prior to administering the eye medication. V. Facility follow-up On 1/11/23 at 3:05 p.m. the DON provided a signature page for on the spot re-education which was signed by all staff nurses. The education was in regards to completing hand hygiene with medication administration, which began on 1/10/23 and was completed on 1/11/23.

Based on observation, record review and interviews, the facility failed to ensure two (#20 and #13) of five residents were free from unnecessary psychotropic medications out of 18 sample residents. Specifically, the facility failed to monitor targeted behaviors for psychotropic medications for Resident #20 and #13. Findings include: I. Facility policy and procedure The Behavior Evaluation, Intervention and Monitoring policy and procedure, revised December 2016, was provided by the nursing home administrator (NHA) on 1/11/23 at 9:25 a.m. It revealed in pertinent part, The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strive to understand, prevent or relieve the resident's distress or loss of abilities. Interventions and approaches will be based on a detailed evaluation of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. Behavior symptoms will be incorporated into the care plan. Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. II. Resident #20 A. Professional reference Mosby's 2023 Nursing Drug Reference, Thirty-Sixth Edition, a current drug reference, summarized drug information: Lorazepam/Ativan is a benzodiazepine medication that is used to treat anxiety disorders, insomnia, and agitation. Side effects include dizziness, drowsiness, confusion, fatigue, depression, insomnia, weakness, vomiting, and anorexia. Sertraline/Zoloft is an antidepressant medication that is used to treat major depression. It is effective to treat panic disorders, social anxiety disorder, and generalized anxiety order. Side effects include agitation, dizziness, fatigue, confusion, and anxiety Memantine/Namenda is an anti-Alzheimer's medication that is used to treat moderate to severe dementia in Alzheimer's disease. Side effects include dizziness, confusion, and fatigue. Olanzapine/Zyprexa is an antipsychotic medication used to treat acute agitation, bipolar disorders, or schizophrenia. Side effects include agitation, hostility, dizziness, confusion, drowsiness, nausea, anorexia, tardive dyskinesia, and seizures. Residents that receive psychotropic medications must be monitored to include side effects, responses to as needed doses, mental status, orientation, sleep pattern disturbances, suicidal thoughts, and renal function over prolonged therapy. B. Resident status Resident #20, over the age [AGE] years, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO) diagnoses included dementia with agitation, unspecified anxiety disorders, restlessness, agitations, and other specified depressive episodes. The 10/11/22 minimum data set (MDS) assessment revealed the resident's brief interview for mental status (BIMS) with a score of one out of 15, which indicated the resident had severe cognitive impairment. The resident required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The resident required limited assistance for eating. C. Observations On 1/9/22 at 9:00 a.m. Resident #20 was observed sitting in her wheelchair near the nurse's station. She appeared lethargic, confused, and did not interact with staff. On the morning of 1/9/23 the resident was administered Namenda 5 milligrams, Zoloft 50 milligrams, and Lorazepam 1 milligram. -At 11:36 a.m. the resident was assisted into the dining room by certified nurse assistant (CNA) #1 -At 11:38 a.m., the resident was served her noon meal. Dietary aide (DA) #1 assisted with the resident's eating because the resident could not keep her eyes open and when the resident tried to pick up her silverware she dropped the silverware and food into her lap and was unable to use her sippy cup without DA #1 holding it to her mouth. The resident did not open her eyes for most of the meal but she allowed staff to assist her with eating. During the meal, the resident yelled out one time and she was easily redirected by staff. -At 4:15 p.m. the resident was assisted by staff into the dining room in her wheelchair. Her eyes were open. -At 4:17 p.m. she was asleep after being assisted to the dining room table. -At 4:30 p.m. she continued to sleep while at the table. CNA #1 sat next to the resident and tried to wake her up to eat. The resident did not respond to the CNA's questions given her choices of crackers in her soup. -At 4:32 p.m. the CNA tried again to wake the resident to eat her grilled cheese sandwich, but the resident remained unresponsive to staff. -At 4:35 p.m. the CNA approached the resident to wake her for her meal and she remained unresponsive. The resident oriented for approximately one minute and -At 4:36 p.m. she went back to sleep with food in her mouth. The CNA and an additional staff member called her loudly by name six times before she responded and opened her eyes. The resident then began to chew and swallow the food in her mouth. -At 4:39 p.m. registered nurse (RN) #1 told the CNA the resident had been up since early that morning at which time the CNA informed the RN the resident had taken a nap in her bed that afternoon. The RN said the resident should return to her room for a nap and finish her evening meal at a later time. On 1/10/23 at 10:15 a.m. the resident was alert and yelling out for her son. Review of the resident's medication record revealed the nurse held the lorazepam 1 mg dose. C. Record review The resident's CPO included: Lorazepam for anxiety 0.25 milligrams daily. The order was active 10/11/22-10/13/22. On 10/18/22-11/2/22 the Lorazepam 0.25 milligram order was update/changed to be administered every 12 hours as needed when the resident experiences anxiety/depression. On 11/1/22-11/12/22 the Lorazepam 0.5 milligrams order was updated/changed to be administered every six hours as needed when the resident experienced restlessness or agitation. On 1/4/23 the Lorazepam order was increased to 1.0 milligrams, was ordered and scheduled twice a day for anxiety. On 10/12/22 Zoloft 50 milligram was ordered and scheduled for every morning 1 tab every morning depression. On 10/11/22 Namenda 5 milligrams was ordered and scheduled for every morning for dementia. On 10/13/22 Zyprexa was ordered and scheduled for every evening for anxiety and depression. Behavior tracking was ordered to be assessed every shift. In October 2022, the resident had no behaviors. In November 2022, the resident had restlessness documented on 11/11/22 and 11/12/22. On 11/11/22 she responded effectively to interventions of redirection, staff listened emphatically, and staff validated her feelings. On 11/13/22 the resident had agitation and interventions of redirection, staff listened emphatically, and staff validated her feelings were ineffective. In December 2022, the resident had agitation episodes on 12/2/22, 12/12/22 and 12/13/22 and it was documented she responded to interventions of redirection, validating her feelings, and empathetic listening. In January 2023, the resident was agitated on 1/1/23. The record review indicated the resident responded effectively to interventions of redirection, staff listened emphatically, and staff validated her feelings, and activity. On 1/3/23 the resident had an episode of agitation, notes regarding what interventions were not located in the resident's medical record. The medication administration record revealed: In November 2022 the resident was administered as needed doses of lorazepam three times, with two (11/16/22 and 11/14/22) of the three times, behavioral details were not documented. In December 2022 the resident was administered three as needed doses of lorazepam, 12/22/22, 12/29/22, and 12/30/22 and the record revealed no documented behaviors for those doses. -There were no documented non-pharmacological interventions prior to the administration of the as needed lorazepam. The progress notes revealed: On 1/3/23 a progress note discussed increasing the lorazepam dose with the resident's son to which he gave consent. After that consent was obtained from the son, the physician was contacted to obtain the new medication orders/dosing changes. On 1/4/23 there was a telemedicine visit with a physician. There was no documentation in the medical record the physician reviewed the behavior changes and need for increased dosing of lorazepam. The resident's care plan included a focus for antidepressant, antipsychotic, anti-anxiety, and ACE (anti-hypertensive medication) inhibitor. The care plan focus was initiated on 10/11/22 and revised 12/15/22. Interventions indicated the staff were to monitor for side effects for anti-anxiety medication, anti-psychotropic medication, and antidepressant medication. The care plan to monitor the resident's mood and behavior that began when the resident began yelling out, having aggression, and refusing assistance from staff. This care focus was initiated on 10/14/22 and revised on 11/4/22. The interventions listed included: allow resident time to calm down and reapproach at a later time, evaluate the need and refer to psychological counseling as recommended by physician, monitor and document each behavior event. D. Interviews The social services designee (SSD) was interviewed on 1/10/23 at 9:41 a.m. regarding the review and scheduling of residents with the facility psychotropic review committee. The SSD residents that received psychotropic medications were reviewed by the psychotropic review committee every quarter. The SSD elaborated if a resident was not scheduled for review but was taking psychotropic medications and exhibited behaviors such as restlessness or sleep disturbances the psychotropic review committee could review the resident on an as needed basis. Resident #20 was admitted in October 2022 and was scheduled for her quarterly committee review during 1/23/23. The SSD stated Resident #20 had not been reviewed by the committee on an as needed basis although she exhibited agitation in November and December 2022 which required three changes to the lorazepam antianxiety medication. CNA #2 was interviewed on 1/10/23 at 1:00 p.m. The CNA said she was familiar and worked frequently with Resident #20. She stated after the resident was admitted she had behaviors of yelling. She stated staff learned when the resident yelled she was perhaps feeling cold. The staff were able to anticipate the needs of the resident and kept her warm with a lap blanket dressing with warmer clothes. The CNA stated the resident responded to reassurance from staff, such as holding her hand and talking about her son. The CNA stated she was aware the resident had an episode in the dining room on 1/9/22 when the staff had difficulty arousing the resident. The CNA stated the resident has had similar responses before and the staff treat the episodes as extreme fatigue and assist the resident to her bed for rest. The CNA stated she notified the nurse when she helped the resident to bed because of the extreme fatigue. Licensed practical nurse (LPN) #1 was interviewed 1/10/23 at 1:30 p.m. regarding the medications she administered the resident on 1/9/23. The LPN stated she administered Namenda 5 milligrams, Zoloft 50 mg, and lorazepam 1 milligram. The LPN stated the lorazepam was a scheduled medication and it was administered regardless of behaviors present in the resident. The LPN stated when she administered the lorazepam the resident was sitting in her wheelchair and able to swallow the tablet without difficulty. The LPN stated she was aware the resident had previous episodes of extreme fatigue on previous days and when that happened the resident was assisted to her bed. The director of nursing (DON) was interviewed on 1/10/23 at 2:55 p.m. She stated nurses should assess and document resident behaviors and side effects related to antidepressants, antianxiety, and antipsychotic medications. She verified the behavior tracking order was inclusive of all medication groups and side effects which prevented the identification and tracking of specific behaviors and how medication use was effective or not. The DON stated she was aware of the episode on 1/9/23 in which the resident was difficult to arouse in the dining room. The episode was not documented in the medical record (see observation), the DON stated the nurse should document the patient assessment, the nurse's response, physician notification, and continue to monitor the resident's status. -The nurse did not contact the physician regarding the resident on 1/9/23. E. Facility follow-up On 1/11/23 at 3:05 p.m. the DON provided a signature page for on the spot re-education which was signed by all staff nurses. The education regarding behavior management of residents began on 1/10/23 and was completed on 1/11/23. III. Resident #13 A. Resident status Resident #13, age 67, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included other specified depressive episodes and unspecified mood affective disorder. The 10/4/22 minimum data set (MDS) assessment revealed that the resident had mild cognitive impairment with a brief interview of mental status (BIMS) score of twelve out of 15. No behaviors were identified in the MDS assessment for the resident. B. Record review The mood and behavior care plan, initiated on 7/8/22, revealed the resident had a history of altered mood related to unspecified mood affective disorder and other specified anxiety disorders. Interventions indicated to monitor and document each behavioral event. The January 2023 CPO revealed the following physician orders for psychotropic medications: -Cymbalta 30 MG (milligrams)- give one tablet by mouth for unspecified depressive episodes- ordered 9/26/22 and discontinued 12/28/22. -Venlafaxine 75 MG (milligrams)-give one tablet via G-tube (gastrostomy tube, a tube in the stomach) for unspecified depressive episodes-ordered 12/28/22. A review of the physician progress notes revealed in pertinent part: The 7/22/22 progress note stated the resident had an underlying mood disorder but with no mention of behaviors or treatment plan. The 8/17/22 progress note was without any mention of a psychological condition. The 10/26/22 progress note stated that the resident had requested an increase in her Cymbalta for depression, which was later discontinued in favor of Venlafaxine for depression. There was no mention of the resident explaining why she wanted the increase. The patient health questionnaire-9 (PHQ-9) for depression dated 7/10/22 revealed the resident admitted with a score of nine out of twenty seven indicating mild depression. The PHQ-9 conducted again on 10/3/22 revealed a score of twelve out of twenty seven indicating moderate depression. The medication administration records (MAR) dated July 2022 through January 2023 showed active behavior tracking for lack of motivation, lack of appetite, or sadness and irritability. -There were no behaviors marked for this time period. C. Staff interviews The SSD was interviewed on 1/10/23 at 9:41 a.m. The SSD said Resident #13 had not been reviewed in the psychotropic meeting. The SSD had recently submitted a level 2 PASRR for an evaluation due to increased behaviors of manipulation towards staff. Resident #13 would behave contradictory towards staff, presenting more independence in her activities of daily living (ADL) for some staff and then would present as more debilitated for other staff members. -However, the resident had no behavior tracking documented despite having changes in medications, increased symptoms, and having been at the facility for over five months. RN #1 was interviewed on 1/10/23 at 1:28 p.m. She stated that Resident #13 could be difficult to provide care for. The resident micro managed the care the staff provided and would participate in care with some staff and with other staff would demand more assistance. RN #1 said she believed it was due to whether the resident trusted staff or not. CNA #1 was interviewed 1/10/23 at 1:35p.m. CNA #1 said that Resident #13 could do things like walking or standing but decided she did not want to, saying she was tired. Sometimes she would refuse to use the toilet and would rather use the brief. She stated that the resident did not want to participate in care as much as she was capable of. The SSD and DON were interviewed on 1/10/22 at 2:46 p.m. The SSD stated that Resident #13's antidepressant medication Cymbalta was changed due to the medication getting stuck in her G-tube during administration as well as her increase in behaviors of manipulating staff. A PASRR level 2 was submitted due to the medication change and increased behaviors. The SSD could not explain why the resident did not have behaviors marked in her behavior tracker for the entire period of time she had been at the facility. The SSD stated that there was not a process to train the nurses on what individual behaviors were for each resident. The SSD confirmed that since she did not conduct interviews or observations for the psychotropic drug meeting and only did a record review, a resident who had not displayed behaviors on their behavior tracker for the same period of time as Resident #13, would be recommended for a discontinuation or dose reduction of their medications. The SSD said the behavior tracker was that established target behaviors would be included and the nurses would document the behaviors that the resident displayed. The tracker would then be reviewed every quarter. The SSD acknowledged that the behaviors indicated on the trackers were generic signs/symptoms/and interventions and the same on every resident's tracker. They did not customize the tracker to reflect the individualized behaviors or interventions of each resident. The regional nurse consultant (RNC) was interviewed on 1/10/23 at 4:16 p.m. The current process for the behavior tracking was that one tracker was established for each resident. The tracker would include all the psychotropic medications the resident was taking regardless of drug class. The nursing home administrator (NHA) was interviewed on 1/11/23 at 1:23 p.m. She said that the facility would immediately begin working on going through each resident with behavior tracking and creating trackers for each medication as well as individualizing each tracker. 46849

Based on interviews and record review, the facility failed to ensure four residents (#5, #18, #28 and #129) of 10 residents had the right to a dignified existence out of 16 sample residents. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely for Resident #5, #18, #28 and #129. The feelings of dehumanization and being treated in an undignified manner were evidenced by the residents' interviews. Resident #5, who was totally dependent on two staff with transfers and toilet use, said, I wet myself frequently. It usually happens in the morning when it is very hard to get some help. I felt very uncomfortable and embarrassed. Resident #18, who required two staff extensive assistance with transfers and toilet use, said waiting too long for assistance, 30 minutes to an hour, made him feel he was not important. He said, I'm just a number here and eventually someone will get to me and help me. Resident #28 required assistance with transfers and toilet use, was at risk for falls and took diuretics (medication, often called water pills). She said she had to wait 30 minutes or more for call light response, and had incontinence accidents as a result. She said it made her feel angry, ashamed and embarrassed. Resident #129, who was dependent with transfers and toilet use, said she waited 30-45 minutes for call light response, and had incontinence accidents as a result. She said it felt awful, humiliating, and she was now anxious that staff would not respond timely and she did not want to have another accident. Cross reference F725, insufficient nursing staff. Findings include: I. Facility policy and procedure The Dignity policy, revised February 2021, provided by the director of nursing (DON) on 9/15/21 at 2:00 p.m., documented in part: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. II. Resident #5 A. Resident status Resident #5, age 76, was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/21 minimum data set (MDS) assessment revealed intact cognition with a brief interview for mental status (BIMS) score 13 out of 15. No hallucinations, delusions or rejection of care behavior were documented. He required one person extensive assistance with bed mobility, dressing and personal hygiene. He was totally dependent on two staff with transfers and toilet use, and required set up and supervision with eating. His bilateral lower extremities range of motion (ROM) was impaired. He was frequently incontinent of urine. He was not on a toileting program. He received daily antidepressant, anticoagulant and diuretic medications. B. Resident interview Resident #5 was interviewed on 9/13/21 at 2:30 p.m. He said there had been many times when he had to wait 45 minutes to as long as over an hour for a CNA (certified nurse aide) after he turned his call light on. He said it made him feel frustrated and depressed that he was going downhill and not able to care for himself. He said, I wet myself frequently. It usually happens in the morning when it is very hard to get some help. I felt very uncomfortable and embarrassed. C. Record review Review of the call light logs from 7/1/21-9/13/21 for Residents #5 revealed 35 instances of the call light not being answered for longer than 20 minutes including two times that were greater than 55 minutes. III. Resident #18 A. Resident status Resident #18, age 76, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/6/21 MDS assessment revealed intact cognition with BIMS score 13 out of 15 with no hallucinations, delusions or rejection of care behavior present. Resident #18 required limited assistance of one person with bed mobility, two staff extensive assistance with transfers and toilet use, one person extensive assistance with dressing and personal hygiene, and setup supervision with eating. B. Resident interview Resident #18 was interviewed on 9/13/21 at 10:27 a.m. He said, There were times I had to wait for 45 minutes for a CNA to come after I turned my call light on. Thirty minutes waiting is pretty normal here. I use the urinal when I need to pee and have it close by, however when I need to go to the bathroom I can't wait that long. They are always in a hurry and don't want to take time to listen when I was hurting when they transferred me to the wheelchair. He added that waiting too long for assistance made him feel he was not important. He said, I'm just a number here and eventually someone will get to me and help me. C. Record review Review of the call light logs from 7/30/21-9/13/21 for Resident #18 revealed 27 instances of the call light not being answered for longer than 20 minutes, including two times that were greater than an hour. IV. Resident #28 A. Resident status Resident #28, age 93, was admitted [DATE]. According to the September 2021 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/27/21 MDS assessment indicated Resident #28 was cognitively intact with a BIMS score of 14 out of 15. She required limited assistance of one staff member for transfers and toilet use. She used a walker for mobility. She was occasionally incontinent of bladder and frequently incontinent of bowel. She was not on a toileting program and received a diuretic (causing increased passing of urine) seven out of seven days. B. Resident interview Resident #28 was interviewed on 9/13/21 at 9:30 a.m. She said during the day she has had to wait a long time to have her call light answered. She said she had waited up to 30 minutes or more. She said when she had to wait a long time she would have accidents and it made her feel bad. She said I'm not a child, I'm [AGE] years old and this should not be happening. She said if she could get to the restroom by herself she would do it but I have issues with being dizzy and unsteady so I need help getting there and it makes me angry to have to wait so long. Resident #28 was again interviewed on 9/15/21 at 2:30 p.m. She said when she turned her call light on for help getting to the restroom and she had to wait extended periods of time she would end up having accidents because she was on a diuretic and it made her feel ashamed and embarrassed. She said she did not want urine on her skin or clothing and it was discouraging to call for help knowing they would not come for quite a while. C. Record review The September 2021 CPO revealed an order dated 5/30/21 for [MEDICATION(S)] (diuretic) 40 milligram (mg) by mouth for [CONDITION(S)] (swelling). The 8/29/21 care plan indicated Resident #28 required assistance with ADLs related to decreased mobility as evidenced by dizziness and unsteadiness. She required the assistance of one staff member and used a wheelchair for mobility. -She was at risk for fluid volume deficit related to the use of a daily diuretic for [CONDITION(S)]. -She was at risk for falls related to decreased mobility, unsteady gait, weakness, dizziness. Interventions included: Educate Resident #28 to sit for a moment to allow dizziness to pass and raise up slowly, to ensure she is not dizzy upon standing to avoid falls. -She was at risk for bowel and bladder incontinence due to decreased mobility and history of incontinence prior to admission. -She had impaired neurological status related to [CONDITION(S)]. Interventions included: to monitor/document/report to physician as needed for neurological deficits: level of consciousness, visual function changes, dizziness, weakness. Review of the call light response times for Resident #28 from 7/1/21-9/13/21 revealed the following wait times: -There were 81 instances the resident waited over 20 minutes. -She waited 36 times over 30 minutes. -She waited 12 times over 45 minutes. -Twice she waited over an hour and once she waited over two hours. V. Resident #129 A. Resident #129 status Resident #129, age 78, was admitted on [DATE]. According to the September 2021 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/3/21 MDS assessment indicated Resident #129 was cognitively intact with a BIMS score of 15 out of 15. She was dependent on two staff members for transfers and toilet use. She was not steady and was only able to stabilize with staff assistance when moving on and off the toilet. She used a wheelchair for mobility and was occasionally incontinent of bladder and always continent of bowel. B. Resident interview Resident #129 was interviewed on 9/13/21 at 10:21 a.m. She said she was new to the facility and early this morning she had turned her call light on because she needed to go to the restroom and she could not get there by herself. She said it took them more than 30 minutes to get to her and by that time she had had two accidents and it made her feel awful. She said now she anticipated having to wait an extended period of time when she needed help. Resident #129 was interviewed again on 9/14/21 at 2:10 p.m. She said when she needed to go to the restroom but had to wait for 30 or 45 minutes for her call light to be answered and she had accidents, she felt awful and it was humiliating. She said because they had taken so long to get to her she was now afraid they were not going to show up for a long time and it caused her to feel anxious because she did not want to have an accident. C. Record review The 8/28/21 care plan indicated Resident #129 required assistance with ADLs related to decreased mobility, stiffness/pain of joints, ataxia, weakness and a history of falls. -She required the assistance of two staff members with transfers and toileting. -She was at risk for incontinence related to decreased mobility and [CONDITION(S)] (involving the nerves) bladder and preferred a bedside commode at night. She was able to use the toilet or commode only with staff assistance throughout the day. Review of the call light response times for Resident #129 from 8/28/21-9/13/21 revealed the following wait times: -There were 27 instances when Resident #129 waited over 20 minutes. -She waited 16 times over 30 minutes and five times her call light was not answered for over 45 minutes. VI. Resident council group interview The Resident Council group interview was conducted on 9/15/21 at 2:00 p.m. During the meeting several residents expressed their dissatisfaction with delayed call light response related to low staffing in the facility (cross-reference F725). VII. Frequent visitor interview A frequent visitor in the facility was interviewed on 9/14/21 at 12:30 p.m. She said she heard from many residents that call light response was significantly delayed related to low staffing in the facility. (Cross-reference F725) VIII. Staff interviews CNA #1 was interviewed on 9/14/21 at 3:00 p.m. She said the facility experienced a nursing staff shortage for quite some time. She said she was assigned an administrative office position, however she was frequently asked to work day shifts as a CNA. The DON was interviewed on 9/15/21 at 4:00 p.m. She said it was unacceptable for the residents to feel that they were not treated with dignity and respect. She said staff were to provide care to the residents in a respectful and dignified manner. She acknowledged residents should not have to wait longer than 15-20 minutes maximum for their call light to be answered.

Based on interviews and record review, the facility failed to provide services by sufficient numbers of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans on three of three halls reviewed for sufficient nursing staff. Specifically, the facility failed to provide sufficient certified nurse aide (CNA) staff to ensure Resident #5 on B hall, Resident #18 on A hall, and Residents #28 and #129, on C hall, had their call lights answered timely to prevent accidents and to prevent frequent falls for Resident #11. Cross reference F689 for accidents related to frequent falls for Resident #11. Cross reference F550 for dignity/respect related to Residents #5, #18, #129 and #11. Findings include: The facility assessment tool dated 3/20/21 provided by the administrator in training (AIT) on 9/15/21 at 8:07 a.m. indicated an average daily census of 25 residents. The staffing plan for certified nurse aides (CNAs) was three daily plus a shower aide and two nightly depending on census and acuity. I. Facility policy The Staffing policy, dated 2001, revised April 2007, provided by the quality assurance consultant (QAC) on 9/14/21 at 5:18 p.m., documented in pertinent part: -Our facility provides adequate staffing to meet needed care and services for our resident population. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. -Our facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. -Certified nursing assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. -Staffing levels are assessed on a continuing basis. Adjustments to staffing levels are based on the average census of the facility as well as the individual needs of the residents, as identified in the care plans. -Staff are assigned to units based on resident need and secondarily by staff preference. II. Record review Review of the resident census and conditions, dated 9/13/21, revealed the following: -For bathing: 20 residents needed assistance of one to two staff members and nine residents were dependent; -For dressing: 24 residents needed assistance of one to two staff and one resident was dependent; -For transfers: 21 residents needed assistance of one to two staff and four residents were dependent; -For toilet use: 22 residents needed assistance of one to two staff and five residents were dependent; -For eating: 12 residents needed assistance of one to two staff and zero residents were dependent. -The current facility census was 29. Review of the September 2021 certified nurse aide (CNA) schedule revealed there was no shower aide scheduled on any of the day shifts. Five of the night shifts were missing the CNA scheduled for the 6:00 p.m. to 12:00 a.m. shift. After midnight there was only one CNA scheduled. Review of the call light logs from 7/1/21-9/13/21 for Resident #28 and 8/28/21-9/13/21 for Resident #129 revealed the following: The call light logs for Resident #28 revealed 81 instances of the call light not being answered for longer than 20 minutes; 36 instances of greater than 30 minutes; 12 instances of greater than 45 minutes; two were greater than an hour, and one was greater than two hours. The call light logs for Resident #129 revealed wait times of greater than 20 minutes on 27 occasions; 16 instances were greater than 30 minutes, and five instances of greater than 45 minutes. Cross-reference F550 for dignity related to long call light wait times for Residents #5, #18, #28 and #129. Residents #28 and #129 reported they felt awful, ashamed, humiliated and embarrassed when they were required to wait for long periods of time to go to the restroom. They felt there was not enough staff available to help them to the restroom in a timely manner to avoid incontinence accidents. III. Resident interviews Residents, who per facility assessment were cognitively intact and interviewable, made the following comments regarding insufficient staffing. Resident #28 was interviewed on 9/13/21 at 9:30 a.m. She said during the day she had to wait to have her call light answered. She said she had waited up to 30 minutes and that was too long when you take a diuretic and have to get to the restroom quickly. She said she had had accidents and that would not happen if they had enough CNAs to help us. She said she required assistance to and from the restroom because of dizziness and unsteadiness. Resident #129 was interviewed on 9/13/21 at 10:21 a.m. She said she was new to the facility and felt that they did not have enough CNAs to help the residents, especially when they needed to get to the restroom. She said early that morning (9/13/21) she had turned her call light on to go to the restroom and it took them more than 30 minutes to get to her, and when they did not show up for so long she had a couple of accidents. She said she was dependent on the staff to help her with toileting. Resident #5 was interviewed on 9/13/21 at 2:30 p.m. He said there had been many times when he had to wait 45 minutes to as long as over an hour for a CNA (certified nurse aide) after he turned his call light on. He said it made him feel frustrated and depressed that he was going downhill and not able to care for himself. He said the facility did not have sufficient staff to assist residents with timely call light response. Resident #18 was interviewed on 9/13/21 at 10:27 a.m. He said there were times he had to wait for 45 minutes for a CNA to come after he turned on his call light, and a 30-minute wait was pretty normal here. He said, When I need to go to the bathroom I can't wait that long. They are always in a hurry and don't want to take time to listen when I was hurting when they transferred me to the wheelchair. He said the facility did not have sufficient staffing to ensure timely call light response. IV. Resident Council group interview The Resident Council group interview was conducted on 9/15/21 at 2:00 p.m. During the meeting several residents expressed their dissatisfaction with delayed call light response related to low staffing in the facility. Five female residents said they were not getting their showers in the morning for the past several weeks as they used to. V. Resident Council meeting minutes Review of the 3/17/21 Resident Council meeting minutes revealed, (Staff name) inquired to all residents present about if their call lights were being answered timely, which some residents voiced that it really varies but there are times when it is better than others when it's worst. -No further details were documented, and no evidence of facility follow-up was documented. The 5/19/21 Resident Council meeting minutes revealed, (Staff name) discussed a frequent concern of staff, specifically CNA's telling residents that the facility is short staffed, which is false. (Staff name) discussed the staffing and the recent changes that the new Director of Nursing completed with having 3 (three) CNA's working a 12 (hours) shift for the day shift. -No further details were documented, and no evidence of facility follow-up was documented. The 5/19/21 Resident Council meeting minutes review revealed, (Resident) reports that her bed is still not being made until almost the time when she is going back to bed. -No further details were documented, and no evidence of facility follow-up was documented. VI. Frequent visitor interview A frequent visitor in the facility was interviewed on 9/14/21 at 12:30 p.m. She said she heard from many residents that delayed call light response was related to low staffing in the facility. VIII. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/12/21 at 5:00 p.m. She said the facility did not use agency staff. She said this evening there were two CNAs: one of them was to leave at 5:00 p.m., one was to come in at 6:00 p.m., and one was there until 9:00 p.m. She said there would be one CNA and one nurse after midnight and they did not have a registered nurse (RN) on duty but the facility had an RN on call if needed. She said the facility had a high turnover rate with their CNA staff but the nursing staff was consistent with little turnover. RN #2 was interviewed on 9/14/21 at 8:30 a.m. She said she worked yesterday, 9/13/21, from 6:00 a.m. to 6:00 p.m. and had to come back in last night at midnight because a nurse called off their shift. She said there was a nurse that was supposed to come in at noon today, if she shows up. CNAs #2 and #3 were interviewed on 9/14/21 at 3:06 p.m. They said on this day there were three CNAs in the facility for the 12 hour day shift. CNA #2 said she was supposed to be an as needed (PRN) employee and lately she had been working at least three days a week because they are short staffed. CNA #3 said she worked full time three days a week. The CNAs said they used to have a shower aide during the day but the director of nursing (DON) took that person away and they were told it was because of the facility's budget. They said they had been at the facility since 6:00 a.m. this morning and so far they had not completed the 11-12 scheduled showers, the ice water had not been passed, and they had not completed any of their required computer documentation and it's three o'clock in the afternoon. CNA #2 said she was only able to take 10 minutes of her lunch break because they called her back to help in the dining room for the lunch meal because there were not enough people to help pass the meals and assist the residents that required help eating. They said when they were short on staff it usually depended on the day of the week, who called off their shift, or who was sick. They said after midnight there was only one CNA and one nurse. They said they each had worked the night shift when they were the only CNA on duty and it was nearly impossible to get everything done. They felt there needed to be two CNAs at night to complete all tasks because often when they came in for the day shift many residents were soiled and you can tell it had been a while since they had been checked or changed, we would have to totally strip several beds. They said there were 10 or more residents that required the assistance of two people and they required more time. They said when they had worked the overnight shift and were the only CNA after midnight, ice water did not get passed, and wheelchairs did not get washed. The nurse overnight may or may not help the CNA. They said during the day no other staff helped the CNAs answer call lights with the exception of one nurse. They said there used to be a light above the resident room that would light up when they activated their call light but those were no longer there. The call light system now had phones that the CNAs were to carry to alert them to a call light that had been activated but if the phone was in our pocket when we are giving a shower we would not be unable to check it to see who needed help. They said the call light response time goal was three to five minutes but that is not possible with the staff we are given. CNA #1 was interviewed on 9/14/21 at 3:00 p.m. She said the facility had experienced a nursing staff shortage for quite some time. She said she was assigned an administrative office position, however she was frequently asked to work day shifts as a CNA. IX. DON interview The DON was interviewed on 9/15/21 at 4:00 p.m. She acknowledged it was unacceptable for the residents to wait over 20 minutes to have their call lights answered because having to wait on staff for help could result in the resident trying to get up on their own and potentially resulting in a fall. She was unaware of the excessive call light wait times since 7/1/21 for Residents #5, #18, #28 and #129. She said the goal was for the call lights to be answered within 10 minutes. By the end of the survey she had not provided documentation or a plan to provide sufficient staffing or education to staff regarding call light wait times.

Based on observations, record review and interviews the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption of food and beverages stored in personal resident refrigerators. Specifically, the facility failed to keep daily temperature logs and remove expired food and beverages from three of five personal resident refrigerators. Findings include: I. Facility policies and procedures The Refrigerators in Resident Rooms policy and procedure, dated 2011, provided by the quality assurance consultant (QAC) on [DATE] at 4:57 p.m., read in pertinent part: -The facility encourages a home-like environment for residents. Some residents will request to have a refrigerator in the room. Resident and/or responsible party will agree to allow periodic safety checks by staff and allow staff to discard outdated food per safety guidelines. -Each refrigerator will have a temperature log with daily entry. -The housekeeper will enter the temperature once daily. -All food in the refrigerator will be labeled with the common name and use by date. -All food will be monitored when daily temperature check is performed. Any food item past its use by date will be discarded by staff or resident. -The housekeeping department will clean and sanitize the refrigerators at least once a month or as required. -Housekeeping supervisor will conduct at least monthly quality assurance audit of refrigerators to monitor adherence to procedure. The Foods Brought by Family/Visitors policy and procedure, revised [DATE], provided by the QAC on [DATE] at 4:57 p.m., read in pertinent part: -Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a home-like environment with the nutritional and safety needs of residents. -The nursing staff will discard perishable foods on or before the use by date. -The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, past due package expiration dates). II. Observations On [DATE] at 2:00 p.m. three of five personal resident refrigerators revealed the following: The personal refrigerator in room 6 had no temperature log and contained the following expired foods: -Three eight ounce bottles of nutritional drinks that expired [DATE]. -One eight ounce bottle of a nutritional drink that expired [DATE]. -One four ounce container of diced pears that expired [DATE]. -One 11 ounce bottle of a protein drink that expired [DATE]. -One 14 ounce bottle of a protein milkshake that expired [DATE]. -At 2:10 p.m. the personal refrigerator in room 17 had no temperature log and contained the following expired foods: -Two 11.5 ounce bottles of orange juice that expired [DATE] and [DATE]. -One 11.5 ounce bottle of apple juice that expired [DATE]. -One 15.2 ounce bottle of a strawberry smoothie that expired [DATE]. -Four 3.25 ounce containers of chocolate pudding that expired [DATE]. -Two 3.25 ounce containers of strawberry orange gelatin that expired [DATE]. -One opened 32 ounce bottle of a sports drink that was two thirds full and expired [DATE]. -At 2:20 p.m. the personal refrigerator in room 23 had no temperature log and contained the following expired foods: -Two six ounce containers of yogurt that expired [DATE]. -Seven 3.25 ounce containers of strawberry gelatin that expired [DATE]. -Four 3.25 ounce containers of chocolate pudding that expired [DATE]. -Four 4.3 ounce containers of peaches in gelatin that expired [DATE]. -Three 16 ounce bottles of lemon lime soda that expired [DATE]. III. Director of nursing (DON) interview The DON was interviewed on [DATE] at 2:27 p.m. She acknowledged the above foods and beverages were far past their expiration dates and should have discarded long ago. She said expired food and drinks were not to be kept past their expiration dates because of the potential for contaminated foodborne illness. She said the housekeeping department was responsible for keeping track of and removing any expired foods from the personal resident refrigerators and the maintenance department was responsible for completing the temperature logs for the refrigerators on a daily basis. She said a new maintenance staff member just started in the position today and had no clue about the temperature logs for the refrigerators. She said she would find a copy of the temperature log to place on each of the refrigerators and she would ensure they were completed from here forward. IV. Facility follow-up On [DATE] at 8:26 a.m. and on [DATE] at 9:15 a.m. the refrigerators in rooms 6, 17, and 23 did not have temperature logs. Upon exit of the facility on [DATE] the temperature logs had not been placed on the refrigerators.

Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and likelihood of transmission of communicable diseases and infections, including coronavirus disease (COVID-19) in one of one dining room and two of three halls observed for infection control practices. Specifically, the facility failed to: -Ensure residents were offered hand hygiene prior to eating meals in the dining room; -Ensure staff wore N95 (filtering facepiece respirator) masks correctly and encouraged residents to wear a mask when out of their rooms; and, -Ensure condiments were not shared among residents. Findings include: I. Hand hygiene and mask use A. The CDC (2020) Hand Hygiene, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate [CONDITION(S)]-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% [MEDICATION(S)] or 70% [MEDICATION(S)] in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. Accessed on 9/22/21. The CDC (2020) Coronavirus Infection Control Recommendations, retrieved from :https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed in part, Healthcare professionals (HCP) should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. Universal use of a facemask for source control is recommended for HCP. According to the CDC website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes last updated 3/29/21, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others enter their room. -Face masks should be extended under the chin. -Both your mouth and nose should be protected. Accessed on 9/22/21. B. Facility policies The Handwashing/Hand Hygiene policy, dated 2001, revised August 2019, provided by the quality assurance consultant (QAC) on 9/15/21 at 11:08 a.m. read in pertinent part: -This facility considers hand hygiene the primary means to prevent the spread of infection. -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Residents will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials posted throughout the facility. -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water before and after eating. -Apply generous amount of product to palm of hand and rub hands together. -Cover all surfaces of hands and fingers until hands are dry. The COVID-19 Infection Control Policy, revised 8/5/21, provided by the director of nursing (DON) on 9/15/21 at 1:27 p.m. read in pertinent part: -Keep residents and employees informed on what they can do to protect themselves and their fell ow residents. -Have them wear a facemask if they must leave their room. -Educate staff on proper use of personal protective equipment and application. -All staff must wear facemasks while in the facility. -The infection preventionist will educate staff on proper use of personal protective equipment. -To don an N95 mask, secure the elastic band at the middle of head and neck, seal mask to face ensuring straps are not crossed and are properly located at crown of head and at base of neck, fit snug to face and below chin. C. Staff education On 9/15/21 at 1:00 p.m. the DON and the QAC provided documentation of all staff in-service education on infection control procedures that occured monthly in June, July, and August 2021. The education covered hand hygiene, appropriate personal protective equipment, isolation techniques, and COVID-19 updates. All staff were also required to complete yearly online computer based infection control training. II. Observations On 9/12/21 at 5:00 p.m. the main dining room revealed six tables with bottles of honey, hot sauce, steak sauce, mustard, ketchup, packets of sugar and glass containers of salt and pepper shakers that were positioned in the center of each table. On 9/13/21 observation of the lunch meal in the main dining room from 11:00-11:45 a.m. revealed the following breaks in infection control: There were 27 residents seated for the meal. As the meals were prepared to be delivered to the residents, an unknown dietary staff member, the DON and certified nurse aide (CNA) #1 were seen with both elastic straps of their N95 masks around their necks. Although masks were hanging on a hook just inside each resident's room with a sign reminding the resident to apply a mask when leaving their rooms, three of five unvaccinated residents were observed exiting their rooms not wearing masks and staff did not encourage them to apply one. As the residents were escorted by staff into the dining room and were seated at a table, no hand hygiene was offered to them prior to eating their meal. -At 11:05 a.m. an unknown male resident propelled himself into the dining room with his hands on both wheels of his wheelchair and he was not offered hand hygiene prior to eating. -At 11:09 a.m. another unknown male resident entered the dining room by himself, touching the wheels of his wheelchair, and he was not offered hand hygiene prior to eating. -At 11:13 a.m. an unknown female resident propelled herself into the dining room with one hand touching the wheel of her wheelchair and she was not offered hand hygiene prior to eating. -At 11:20 a.m. an unknown male resident seated at a table with five other male residents was seen passing salt and pepper shakers to one of the residents touching/covering the top of each container with the palm of his hand as he picked them up. He had not been offered hand hygiene when he seated himself at the table. On 9/15/21 at 9:20 a.m. an unknown resident was seen in the hallway, not wearing a mask, seated in a wheelchair next to registered nurse (RN) #1 who was standing next to the medication cart. The RN did not encourage the resident to wear a mask. -At 9:30 a.m. an unknown female resident was seen exiting the dining room not wearing a mask. An unidentified CNA escorted her to her room and did not encourage her to apply a mask. -At 12:45 p.m. an unknown female resident was seen walking in the hallway not wearing a mask. She spoke to the DON and another unknown staff member and they did not encourage her to apply a mask. -At 3:24 p.m. an unknown female resident was seen exiting the dining room from a group activity not wearing a mask. She walked down the hallway to the nurses station at the front of the building. The DON, the QAC and RN #1 stood around the desk. The resident stopped at the desk and spoke to the three staff members and they did not encourage her to apply a mask. At this time, there was also an unknown female resident seated in a wheelchair at the desk with her mask below her chin, the staff did not encourage her to raise the mask above her nose. On 9/16/21 at 9:00 a.m. an unidentified CNA was seen standing at the food service counter in the dining room with her N95 mask below her chin. She was eating an unknown item as she talked with the kitchen staff. When she realized she was being observed she raised the mask above her nose. -At 9:12 a.m. the DON entered the conference room with both of the elastic straps of her N95 mask around her neck. III. Facility follow-up/DON interview On 9/13/21 at 2:20 p.m., after the DON was made aware of the above breaks in infection control the she provided documentation that read: Beginning today we will begin implementing the following infection control procedures: -Staff will be educated to offer hand hygiene to residents before they leave their room for meals. -Staff will also be stationed at the dining room doors to offer alcohol based hand rub (ABHR) to all residents as they enter the dining room. -Staff will have hand sanitizer readily available to access when feeding residents. -All condiments will be removed from the dining room tables and individual condiments will be offred to each resident at the time of their meal. -Residents will be encouraged to wear their masks each time they leave their room. Staff will provide education regarding the risk of infection if not wearing their mask. -Added daily task to point of care (POC) for staff to document if resident wears their mask. The DON was interviewed on 9/15/21 at 1:00 p.m. She said she had only been employed at the facility for five months or so. She acknowledged the elastic straps of the N95 masks were to be positioned with one strap around the top of the head and the other around the neck. She said some residents had been refusing to wear their masks but there was no documentation that documented the refusals or that the residents were being encouraged to wear the masks. She said staff were to provide hand hygiene to the residents prior to and after meals. She said all the condiments had been removed from the dining room tables and residents would be offered individual condiments upon request. She said education had been provided on a monthly basis on infection control practices so staff should be aware of the correct procedures. She did not provide any documentation of education provided to staff after she was made aware of the breaks in infection control during the survey. IV. COVID-19 status The QAC and the infection preventionist (DON) were interviewed on 9/15/21 at 1:00 p.m. They said the facility had zero COVID-19 positive residents and two COVID-19 positive staff who were out. They said a housekeeper had tested positive on a rapid test. She was asymptomatic and had been off since 9/6/21. They said the nursing home administrators (NHA) husband had tested positive so she was out in quarantine and had tested positive as well. They said they were testing twice weekly and there were no presumptive COVID-19 positive residents or staff at this time.

Based on record review and interviews, the facility failed to ensure a safe environment and adequate supervision to prevent accidents for one (#11) of three out of 16 sample residents. Specifically, the facility failed to implement effective and appropriate interventions after each of six falls sustained within a seven week period to prevent recurrent falls for Resident #11. All of Resident #11's falls were unwitnessed, and staff were notified by Resident #11 calling for help or another resident calling for assistance for her after each of her falls. Although the resident was not cognitively capable of using the call light, and several of her falls involved needing to use the bathroom, the facility failed to develop interventions to effectively anticipate and meet the resident's needs and keep her safe. Findings include: I. Resident status Resident #11, age 90, was admitted on [DATE] with diagnoses of [CONDITION(S)], personal history of [CONDITION(S)] (TIA), cerebral infarction without residual deficits, [CONDITION(S)] and [CONDITION(S)]. The minimum data set (MDS) assessment, dated 7/21/21, revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score four out of 15. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Functional limitation in range of motion (ROM) included upper extremity impairment on both sides. The resident was frequently incontinent of urine and bowel. II. Record review A. Care plans The resident's care plan for activities of daily living (ADLs) documented: (Resident's name) requires assistance with ADL's r/t (related to) decreased mobility AEB (as evidenced by): weakness, confusion, RA ([CONDITION(S)]) in all major joints. (Resident's name) also does some of ADL's without assistance at times (dated 2/8/21). The care plan for falls documented: (Resident's name) is at risk for falls related to: cognitive deficit, history of falls, unsteady balance/gait, weakness, RA, tremors, [CONDITION(S)], resistive to cares, and transfers/ambulation without staff assistance and without walker at times (dated 5/14/21). Interventions included: Assist (Resident) to restroom to void upon awakening, before and after each meal and at bed time. Bright colored tape on call light to remind (Resident) to utilize prior to transfers (dated 6/17/21). Bright colored tape on wheelchair brakes to remind (Resident) to set brakes to help prevent falls (dated 7/30/21). -Although the resident had severe cognitive impairment (see MDS) and vision problems (see vision care plan below), the facility only documented visual reminders instead of anticipating the resident's needs and providing enhanced monitoring and supervision to prevent falls. The vision care plan documented: (Resident's name) admits with visual impairment/poor vision r/t: [CONDITION(S)] and utilizes eyeglasses for improvement (10/30/20). The incontinence care plan documented: (Resident's name) is at risk for bowel and bladder incontinence r/t: impaired cognition, impaired mobility. Her daughter reports that she at first dealt with stress incontinence, until about June 2020 when she became more prone to both bowel & bladder incontinence (dated 11/4/20). Interventions included: Encourage fluids during the day to promote prompted voiding responses (dated 11/2/20). Staff will assist (Resident) to the restroom frequently throughout the day and night. Staff will provide proper peri care with each incontinent episode (dated 11/4/20). -The facility failed to assess the resident's voiding schedule to identify how frequently she needed to be assisted to the toilet to maintain continence and prevent accidents and discomfort. Nursing notes revealed the resident suffered six falls within seven weeks, as follows: 1. Fall #1 - 7/28/21 at 6:16 p.m. 7/28/21 (6:16 p.m.) full description of fall: This nurse was called to resident's room by CNA (certified nurse aide) who heard resident yelling from her room. Upon entering resident's room resident was sitting on the floor in front of her wheelchair. Brakes on wheel chair were not locked. Resident was wearing gripper socks. Resident stated she was scooting herself in her wheelchair and was sitting really close to the edge of the chair when she scooted herself out of her chair and onto the floor. When asked what happened, the resident said, I fell out of my chair, can ' t you tell. The resident was assessed with no injuries or pain. The resident was gotten back up in her chair and taken to her room. The recommendations included: find a chair that is lower so it is easier for her to reach the ground with her feet to self-propel. The family was notified and requested to ensure the resident was wearing her glasses. The interdisciplinary team (IDT) did not review until 8/10/21 (see below), after the resident suffered two more falls. 2. Fall 2 - 8/5/21 at 5:09 p.m. 8/5/21 (5:09 p.m.) Full description of fall: this nurse was called to resident room. Upon entering resident's room this resident was sitting on the floor leaning against resident recliner. This resident's wheelchair was facing the opposite direction as her and the brakes were not locked. Resident had been sitting in a recliner when she tried to transfer back to her wheelchair, when she fell . When asked what happened the resident just stated she fell out of the chair. Assessment revealed no injuries or pain. The resident was sat in her wheelchair and taken out of other resident's room. The 8/5/21 RN (registered nurse) assessment note revealed staff had been notified by another resident that Resident #11 was in his room on the floor. Resident #11 was found on the floor leaning against the other resident's bedside chair. Resident reports that (Resident #11) had been sitting in his bedside chair when she tried to transfer back to her wheelchair, and she fell . Both residents reported Resident #11 did not hit her head. Resident #11 was wearing gripper socks and was incontinent of urine. No injuries or pain were assessed or reported. The resident was assisted to the restroom by staff. 3. Fall #3 - 8/8/21 at 6:25 p.m. 8/8/21 (6:25 p.m.) Full description of fall: resident's roommate alerted this nurse that resident was laying on the floor, resident found lying next to her bed laying quietly on her back. Resident's description of fall: states that she fell out of bed. The RN assessment revealed the resident was wearing non-skid socks. There were no injuries. The resident reported pain at two out of 10, but the location of her pain was not documented. The Interdisciplinary Team (IDT) Review, dated 8/10/21 revealed: Root Cause Analysis: Resident was transferring by herself from chair to wheelchair. IDT Recommendations: Sign by resident's room that has her name on it. -The IDT review was not conducted until Resident #11 had experienced three falls, and not until two days after her third fall. 4. Fall #4 - 9/5/21 at 1:00 a.m. 9/5/21 (1:00 a.m.) Resident screamed out ' help ' . Upon entering room, staff observed resident sitting on the floor with feet out a few steps from the restroom. Resident stated she was going back to bed from the restroom. Resident had on nonskid socks walking without walker. Resident did not use call light for assistance. Staff assisted resident up and back to bed. The RN assessment revealed the resident had unrated pain to her right arm and back, and Tylenol was given. No injuries were documented. IDT review on 9/9/21, four days after the fall, identified the root cause as: Walking to bathroom without her walker. Recommendations were: Staff has been educated for increased bed checks throughout the night to offer the bathroom. 5. Fall #5 - 9/13/21 at 3:00 a.m. 9/13/21 (3:00 a.m.) Resident yelled out ' help ' from room, upon staff entering room, resident was observed sitting in the floor with back against recliner beside bed. Resident stated ' I was going to the bathroom ' . Non-slip socks on resident with call light in reach. Resident did not call for assistance. Resident c/o (complained) back pain, refused PRN (as needed) pain medication at this time. Resident assisted up off the floor and walked with staff to the restroom. Resident then walked back to bed with staff assist x 1 (of one person). ROM (range of motion) to all extremities WNL. Neuros and vitals are WNL. Resident denies hitting head. Staff in to check on resident frequently throughout the shift and toilet resident PRN. Resident was up to the restroom at approximately 0130 (1:30 a.m.). Provider notified via fax. (Family name) notified. Reinforced importance of using call light for assistance, call light within reach. -The resident, who was found after her fall, was not cognitively capable of following up on staff reminders to call for assistance. No further interventions or IDT review were documented. 6. 9/13/21 fall at 5:00 a.m. 9/13/21 (5:00 a.m.) Resident yelled out ' help ' from room. Upon staff entering room resident was observed lying flat on back beside bed side table. Resident assessed for injury, (staff name) RN, called for RN assessment, resident was assisted up from the floor and walked to the restroom and back to bed with staff assist x 1. Abrasion noted to middle of right side of back. C/o pain to back. Resident continues to refuse pain medication. Writer in for neuro check at 0445 (4:45 a.m.) and resident was noted to be snoring at this time. Neuro checks re-started and WNL. ROM = WNL. Non-skid socks on and call light within reach. Resident again did not call for assistance. Resident did have a large BM (bowel movement) when assisted to restroom and was incontinent of bladder. Urine noted to have foul odor. (Family name) notified. Day nurse to notify provider via phone today. The Interdisciplinary Team (IDT) Review, dated 9/14/21, revealed: -Root Cause Analysis: Resident got up unassisted and did not use the call light. She is unaware of safety needs. Possible [CONDITION(S)] (urinary tract infection) as urine is concentrated with a foul odor. Resident did need to have a BM. -IDT Recommendations: Upon environmental check of room, the pathway to the bathroom is dimmed lighted. A night lite was implemented. III. Staff Interviews Certified nurse aides (CNAs) #3 and #4 were interviewed on 9/15/21 at 3:48 p.m. They said they were not aware of Resident #11's frequent falls. CNA#3 said she was not informed about 15 minute checks on Resident#11. She said, We are so short of staff that we physically cannot check on a resident that often. (Cross-reference F725 insufficient nursing staff.) The director of rehabilitation (DOR) was interviewed on 9/15/21 at 11:30 a.m. She said she was a part of the falls committee. She said the resident received skilled occupational therapy treatment in the past month. She said Resident #11's cognition was impaired and she could not remember safety precautions with transfers. She said the resident was able to walk short distances with a walker and staff physical assistance with cueing. The director of nursing (DON) was interviewed on 9/15/21 at 4:17 p.m. She said the facility staff (CNAs) were supposed to check on the resident frequently and ask if she needed to go to the bathroom. She said the staff were supposed to remind the resident to use the call light if she wanted to get up from bed. She said the resident had bright colored tape on her wheelchair brakes to remind her to use it before she stood up.

Based on observation, record review and interview, the facility failed to ensure one (#5) of three residents reviewed for oxygen therapy out of 20 sample residents was provided respiratory care consistent with professional standards of practice, which included the safe administration of supplemental oxygen to the resident. Specifically, the facility failed to ensure a physician's orders [REDACTED].#5 during a period of [MEDICAL CONDITION] and afterwards. Findings include: I. Facility policy and procedure The Oxygen Administration and Storage policy and procedure, revised (MONTH) 2010, provided by the director of nurses (DON) 7/3/19 at 11:25 a.m., documented staff were to verify if a physician's orders [REDACTED]. It also said a review of the resident's care plan to access for any special needs should be done. II. Resident #5 status Resident #5, age 83, was initially admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 4/9/19 minimum data set (MDS) assessment revealed the resident impaired cognition with a brief interview for mental status (BIMS) score of 5 out of 15. No mood or behavioral symptoms were noted and he had no rejection of care. He required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. III. Observation On 7/1/19 at 9:45 a.m., resident #5 was lying in bed in his room and his nasal cannula was in his nose. The nasal cannula was in his nostrils with the other end of the oxygen tubing connected to the concentrator at 3 liters/min. IV. Record review The DON submitted a copy of the resident's care plan on 7/3/19 at 11:25 a.m. The care plan reviewed on 4/22/19 did not identify the resident as being on supplemental oxygen. There was a new addition to the resident's care plan on 7/1/19 by the charge nurse that stated, O2 per nasal cannula PRN, refer to current notes. The DON submitted a copy of the resident's medication review report on 7/3/19 at 11:25 a.m. The Medication review report printed on 7/3/19 at 3:54 p.m. showed a new oxygen order that was dated 7/1/19 with a start date of 7/1/19. It said oxygen via nasal cannula at 2 liters/min, as needed for oxygen saturation 88% or below, every day and night shift for [MEDICAL CONDITION]. The DON submitted a copy of the resident's treatment administration record (TAR) on 7/3/19 at 11:25 a.m. It said oxygen via nasal cannula at 2 liters/min, as needed for oxygen saturation 88% or below, every day and night shift for [MEDICAL CONDITION]. The order was written on 7/1/19 at 5:03 p.m. V. Resident's family interviews The resident's son was interviewed on 7/1/19 at 9:50 a.m. He said his father was hospitalized for [REDACTED]. He said his father was not on oxygen but the facility started oxygen on him during the night and as needed. He said sometimes his father's supplemental oxygen could go up to 6 liters/min, administered by the nurses in the facility but he did not know how much his dad was administered. The son said he did not know who initiated the supplemental oxygen therapy because it was not discussed with him nor any of the family members. VI. Staff interviews Certified nurse aide (CNA) #1 was interviewed 07/01/19 3:08 p.m. She said the resident was on 6 liters/min when he first readmitted back from the hospital but the nurses were gradually weaning him off and he was now on as needed until they got orders from the physician. She said she saw the resident on 3 liters/min the previous day and he was doing well with the supplementation. The DON was interviewed on 7/2/19 4:56 p.m. She said by nursing judgment, the facility had to supplement the resident's oxygenation whenever he was de-saturating. However, the facility did not call the physician to obtain orders for oxygen after the critical moment passed but continued to put resident under supplemental oxygen with varying concentrations between 2 to 6 liters/min. she said they should have called the physician but someone probably forgot. She said she called the physician to get orders for oxygen use after the surveyor noted there was no orders in place for oxygen administration. She said she would conduct an in-service education for all nursing staff on the issue.

Based on observations, record review, and interviews, the facility failed to provide medically related social service to maintain the highest practicable physical, the mental and psychosocial well-being of one (#2) of two residents reviewed for social services of 17 sample residents. Specifically, the facility failed to provide assistance in arranging for fitted hearing aids for Resident #2 as medically prescribed by the audiologist to promote quality of life. Findings include: I. Resident status Resident #2, age 71, was admitted [DATE]. According to the 5/18 computerized physician orders [REDACTED].(The [DIAGNOSES REDACTED]. According to the 2/16/18 minimum data set (MDS) assessment, The residents cognition was intact with a brief interview for mental status (BIMS) score of 13 out of 15. No mood or behavior symptoms were noted. She was independent of the activity of daily livings (ADLs). She had minimal difficulty hearing. II. Resident interview Resident #2 was interviewed on 5/29/18 at 12:54 p.m. She said her she was hard of hearing and received a hearing aid that was donated to her after the audiologist recommended the hearing aid. She said her hearing aids were not properly fitted properly and they kept falling off from her ears. She said she informed the social services and the nurses that the hearing aids were falling off her hears and she could not keep them in place. She said the social services staff did nothing about the issue. She said she kept the hearing aids in her draw so she would not lose them. She said she could not hear properly without her hearing aids and would like to have them fitted so she could wear them. III. Facility failures The facility failed to follow up with the recommendations of the audiologist for bilateral hearing aids and the ENT consultation to ensure the resident was properly fitted for hearing aids(including the donated hearing aids), and to promote quality of life. IV. Record review The care plan, initiated 8/24/17 and revised 11/14/17, identified impaired hearing loss. Interventions included the staff to be conscious of Resident #2 ' s position when in the group activities and the dining room to promote proper communication with others. Staff to wait 30 seconds before providing the resident with word. The resident could be seen possibly reading lips at times if the environment is too noisy, the staff to speak clearly, slower than normal and validate the resident's message by repeating aloud. Resident #2 to be referred to audiology for hearing consult as ordered. The care plan was not updated to include bilateral hearing aids. The (MONTH) (YEAR) physician orders [REDACTED]. Review of the social service notes revealed the following information: On 10/20/17 the social services director (SSD) received return fax from an audiology regarding estimated cost of the hearing services. The estimated cost was faxed to an organization for funding and approval. The approval was received; an appointment was scheduled for 10/30/17 at 1:00 p.m., for hearing aid fittings and the resident notified. The 11/15/17 social services note revealed the audiologist saw Resident #2 for hearing aids fit. The resident primary care provider (PCP) also scheduled another appointment for ENT (Ear, nose, and throat) specialist on 11/20/17 at 11:00 a.m. The 11/20/17 ENT consultation note revealed the resident had hearing loss bilateral. The physical examination of the external and internal inspection of the ears was without scars, lesion or masses. There was no infection of the ear canal and the tympanic membrane. According to the audiologist, I do not see any problems and think she can go ahead with hearing aids. The staff were not monitoring the residents bilateral hearing aid placement as evidence by not providing supportive documentation from the time she acquired donated hearing aids in (MONTH) (YEAR). No monitoring was found on the Medication Administration Record [REDACTED]. No further documentation was provided for follow up for the fitting of the residents bilateral hearing aids. V. Observations On 5/29/18 at 12:44 p.m., the resident was in the room turning the television (TV) to the highest volume. The TV volume could be heard two feet away from the outside of the resident's room in the hallway. -At 3:57 p.m., the resident was observed in the activity room playing cards without hearing aids in place. She asks the activity director repeatedly on several occasions, to repeat what card need to be played. On 5/30/18 at 11:59 a.m., the resident was in the dining room and did not have any hearing aids in place. One of the kitchen staff observed standing very close and faced the resident in order to have a discussion with the resident. The staff was also speaking very loudly to the resident in the presence of three other residents at the table. VI. Additional Resident interview and staff interviews The resident was interviewed again on 5/31/18 at 11:03 a.m. She said she would like to have her hearing in place all the time so she could hear well. She said the social worker had talked to her this morning and promised to schedule an audiology appointment for hearing aid fitting. The SSD was interviewed on 5/30/18 at 2:37 p.m. She said the resident was hard of hearing on admission. She said on 11/15/17, the resident was seen for medical management. She said the resident had hearing loss and the audiologist prescribed a hearing aid for the resident to wear all the time. She said on the 11/27/17, she was able to secure a set of hearing aids that were donated. She said she was aware the resident was not wearing the hearing aids because the oxygen tubing was in the way and making it impossible for the hearing aids to stay in place. She said there should be a way to make sure the resident had the hearing aids in place. She said she was supposed to schedule an ancillary/audiology appointment quarterly and as needed, she said the appointment to follow up was not scheduled for hearing aid fitting. She said there was no evidence the resident was wearing the hearing aids. She said the nurse supposed to keep the hearing aids in the medication cart so they could monitor the resident was wearing the hearing aids. She said no one was monitoring the resident hearing aids. She said the facility was not doing a good service for the resident ' s hearing problem. She said the resident could potentially continue to have a further hearing loss if the issue is not considered immediately. Activity coordinator (AC) was interviewed on 5/31/18 at 7:57 a.m. She said the resident was hard of hearing and was not very active in the activities in the last few months. She said the resident would select which activity to attend. She said the resident likes to play Bingo and Cards. She said the resident was wearing her hearing aids initially and was able to hear well with her hearing aids, but stopped wearing them suddenly. She said the resident had complained to her that the hearing aids were not fitted properly. She said she had mentioned the issue to the SSD toward the end of (YEAR). She said, she would have to speak very loud and face the resident when communicating with her during activities. She said the resident was missing the activities due to the inability to hear well without hearing aids. She said she did not follow up to find out if the SSD was getting the resident new hearing aids. She said she noticed the resident stayed in her room most of the time. She said she was sorry, for not following up with the SSD and not speaking up for the resident. Registered nurse (RN) #1 was interviewed on 5/31/18 at 8:05 a.m. She said the resident was hard of hearing and had hearing aids that she kept in her room. She said the resident was independent and she was allowed to keep her hearing aids. She said she was aware the resident does not wear them. She said she had to speak load and faced the resident when communicating with her. She said would expect the resident to communicate if there was a problem with her hearing aids to the certified nurse aide (CNA) or the nurse. She said resident always communicate her issues with the SSD. She said she was not paying attention to the resident's hearing issue. She said the resident needs the hearing aids because they were prescribed for the resident to manage her medically related hearing loss. Director of Nursing (DON) was interviewed on 5/31/18 at 1:29 p.m. She said the hearing loss was a medically related concern that must be followed by the SSD. She said she was not aware Resident #2 was not wearing her hearing aids. She said the nursing staff supposed to be checking for a proper functioning of the hearing aids, making sure the resident wears them and keep the hearing in the medication cart for safekeeping. She said if the resident decides to keep in the room, she said the resident could do so but the nurse was responsible to check it daily for proper functioning. She said, even if the resident refused to wear the hearing aids, she said that was okay. She said in this case, there was no evidence the resident was not refusing. She said would follow up immediately. She said the rationale for the hearing aids was the resident could function in the group, hear better and improve quality of life.

Based on observations, record review, and interviews, the facility failed to provide assistance with routine dental care for one (#3) of two residents reviewed for dental care out of 17 sample residents. Specifically, the facility failed to assist Resident #3 in obtaining routine dental cleanings and care. Findings include: I. Facility policy and procedure The Dental services policy, last revised on 12/13, was provided by the director of nursing (DON) on 5/30/18 at 2:58 p.m. It documented in part; Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment. Procedures included: All dental services provided are recorded in the resident's medical record. Nursing services are responsible for notifying Social services of a resident's need for dental services and Social services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary. II. Resident status Resident #3, age 84, admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. According to (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 2/23/18 minimum data set (MDS) assessment, the resident's was cognitively intact with a brief interview for mental status (BIMS) score was 15 out of 15. No mood and behavior symptoms were noted. She was independent and required set up for personal hygiene and had obvious or likely cavity or broken natural teeth. III. Resident observation and interview Resident #3 was interviewed on 5/29/18 at 1:22 p.m. She said she had a problem with chewing meat. She said all her back teeth were gone due to poor dentition. She said, I do not want denture because I do not have money to pay for it. I had to pay for my glasses by myself. She said she would like to try partial denture if the dentist would accept her Medicaid. On 5/30/18 at 12:05 p. m., the resident was observed in the dining room. She had no back teeth to chew the roast beef. Her roast beef was not cut up into smaller pieces. On 5/31/18 at 8:10 a.m., the resident was observed in her room. Her electric toothbrush prescribed to be used daily observed on top of the bathroom cabinet. The electric toothbrush was dirty and covered with dried toothpaste. The electric toothbrush was out of reach of the resident. The resident was interviewed regarding her dentition on 5/31/18 at 12:06 p.m. She denies pain from her mouth at this time. She said she had lost several teeth since admission and was having difficulty chewing her meat. She said she did not want to have the remaining natural teeth removed. She said it was inconvenient to travel a long distance to see a dentist and the facility was not helping with the situation. She said she had adapted to the situation because she could not afford partial denture. She said she could not remember the last time she had seen a dentist. She said she had oral surgery a long time ago. She said she would like to keep the remaining natural teeth and she could manage to chew with the partial denture. She said she used to have her teeth cleaned twice a year about four to five years ago. She said no one had offered her dental cleaning to get her teeth clean. She said no one had mentioned partial or full denture to her. She said she would like to have one if the facility would help her with obtaining one so she could chew better. She said, You have to ask before you get anything done here. She said she ran out of money and that was the reason she was not requesting for dental appointment by herself. She said she would like to have her teeth cleaned to make sure the remaining teeth was not going bad. IV. Record review The care plan, initiated 3/16/16 and revised 4/18/17, identified some broken/missing teeth. Interventions included the CNA to check the resident's mouth during daily cares and report any sign or symptoms of infection. Encourage and remind the resident to rinse mouth well after each use of nebulizer treatment. The Social worker (SW) to schedule an appointment for dental care and coordinate transportation to the appointments as needed and as requested by the resident. Review of the (MONTH) (YEAR) physician order [REDACTED]. Review of 12/1/17 social service note revealed the resident c/o (complained/of) L (left) lower mouth pain and requested a dental appointment ASAP (as soon as possible). SSD (social service director) phoned the dental office to schedule an appointment for 12/4/17 at 3:00 p.m. The daughter and the resident notified. On 12/4/17, the scheduled appointment was canceled due to high wind weather. There was no documentation found in the clinical record or provided by the facility that dental cleaning services were offered again to the resident. V. Staff interviews Social worker (SW) was interviewed on 5/30/18 at 3:14 p.m. She said the resident and her daughter refused to see a dentist for extractions in (YEAR) and again during the care conference on 12/11/17. She said she had not scheduled the resident for dental routine, nor offered for the partial. Registered nurse (RN) #1 was interviewed on 5/31/18 at 12:26 p.m. She said she was aware Resident #3 had multiple missing teeth. She said had not thought about the missing teeth and the resident had not complained of tooth pain. She said the resident received medication for breathing treatment via nebulizer that could be contributing to mouth or tooth decay and requiring constant oral care. She said the important for constant oral care included good health overall and with resident receiving breathing treatment; the staff should make sure the resident had regular and or routine dental care. She said the side effect associated with lack of routine dental care included mouth infection, heart problem, and mouth odor. SW was interviewed again on 5/31/18 at 12:49 p.m., regarding dental service payment. She said the nearby dental office takes only the private pay resident. She said the only dental office that would provide the dental service to Medicare and Medicaid resident was 45 miles away. She said she informed the resident and family that they had to travel 45 miles to get dental care for service for cleaning, teeth examination, denture fittings and partial fitting and repairs. She said she had not offered denture option or oral cleaning in the last three years to Resident #3. Director of Nursing (DON) was interviewed on 5/31/18 at 1:10 p.m. She said all residents were supposed to have ancillary services offer upon admission. She said if any resident required dental services, the facility had a way of providing the services to the resident. She said there should be no excuse for any resident not to have routine dental services. She said she was not aware Resident #3 had no dental services provided to her in the last two years. She said she would be auditing all resident for ancillary services immediately.

Based on observations, resident interview and staff interviews the facility failed to honor choices during meal times, in the dining room for eight (#1, #2, #4, #5, #6, #7, #8, #9) out of nine sample residents. Specifically, the facility failed to ensure: -Residents #1, #2, #4, #5, #6, #7, #8, #9 were asked if they would like to have what was on the menu for the main course or if they would like to order something else; and -Resident #1 was offered substitutes when he refused to eat, to encourage food intake. Findings included Policy and procedure The facility provided the Mealtime observation for food acceptance policy on 6/13/17 at 11:39 a.m. The following was documented, Staff members observing meals in the dining room will offer appropriate meal substitutions to residents, when needed, for noted poor intake of a food item or an expressed dislike of an item served. Residents that are on special programs to improve mealtime intake or on consistency altered diets will be carefully monitored by all staff in the dining room and will be offered interventions as necessary to promote mealtime intake. Observations of meals Lunch service on 6/12/17 At 12:00 p.m., resident #1 was brought into the dining room with one staff assistance. The certified nurse aide (CNA) #4 placed him at his table and the cook (CK) #1 brought a glass of water and a cup with supplement shake in it. -The staff did not ask the resident if he wanted to have the main course that was on the menu for lunch (BBQ pork, soft vegetables, macaroni, cheese, and cake) or something else. Dinner service on 6/12/17 During the dinner observation, the following residents, #1, #2, #4, #7, and #8 were not asked if they would like the main meal off the menu or other always available food. Breakfast service on 6/13/17 At 7:08 a.m. resident #7 meal came to the table. He had scrambled eggs and toast. No sausage was on his plate. At 7:25 a.m., resident #1 was observed at his table. The CNA #3 went to get this resident cereal for breakfast without asking him if he wanted to eat what was on the main menu. At 8:00 a.m., resident #4 received her meal without the CK #1 asking her what she wanted to eat when she came into the dining room. This resident was brought a toast and hot cereal in a sippy cup for breakfast. At 8:09 a.m., resident #6 received her meal without the CK #1 asking her what she wanted to eat when she came into the dining room. Resident interview On 6/13/17 at 8:18 a.m., resident #7 was interviewed. He said he did not know sausage/ham was offered today for breakfast. He said he was not asked what he would like to eat and the staff just bring him a meal. He said he would have eaten the sausage/ham had it been offered to him. Staff interviews The CNA #2 was interviewed on 6/12/17 at 12:18 p.m. She said resident #1 was only brought the cake from the main meal because he like sweets. She acknowledged the resident was not asked if he wanted the main meal for lunch. The dietary aide #2 (DA) was interviewed on 6/13/17 at 7:19 a.m. regarding resident #7. She said he was only given the scrambled eggs and toast for breakfast. She said he was not offered sausage/ham because he was a picky eater and the staff know what he wants to eat. DA #2 was interviewed on 6/13/17 at 8:15 a.m. regarding resident #4. She said the resident was not given eggs or ham for breakfast because she usually likes just toast and hot cereal. At this time, she acknowledged the resident was not asked what she wanted to eat but rather the staff brought her what they thought she wanted to eat. At 8:30 a.m., DA #2 was interviewed regarding choices. She said the staff normally asked the same three residents who eat in the dining room because they like to eat different things. She said everyone else eats the same food and gets what is on the menu because the staff know the residents well. The minimum data set coordinator (MDSC) was interviewed on 6/13/17 at 10:30 a.m. she said the staff do know what the residents like to eat for the most part. She said for example, one resident likes to eat chips all the time but the staff should still ask her if she would like something off the main menu for each meal. The staff should not just bring her chips without asking her. The director of nursing (DON) was interviewed on 6/13/17 at 11:15 a.m. she said the dining room service is a liberalized ad-lib dining. She said it is a la carte style and everyone in the dining room should be asked what they wanted to eat for each meal. The dietary manager (DM) was interviewed on 6/13/17 at 11:50 a.m. she said everyone should be asked in the dining room what resident's would like to eat from the main menu. She said if they wanted an alternative meal, they could ask for it or it would be offered to them. She said at the current time she did not have the alternative menu posted for the residents to be able to make a discussion based on if they wanted the main meal or the alternative meal. She said it was her goal to have it printed on the daily wall menu. She said the dietary staff only asking a few residents what they wanted to eat was not appropriate, as all residents should have a choice of what food/meal they would like to eat at each meal service.

Based observations, record review, and staff interviews the facility failed to follow physician orders [REDACTED].#2, #3, #8, #9, #6) out of nine sampled residents reviewed for physician orders. Specifically, the facility failed to ensure physician orders [REDACTED]. -Diet textures for resident's #2, #8, #9 and #6; and -Portion size for resident #3. The findings included: 1. Resident #6 status Resident #6, age 81, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 5/11/17 minimum data set (MDS) assessment, the resident's brief interview (BIMS) score was 11 out of 15 which indicated moderate cognitive impairment. She required extensive assistance with most activities of daily living (ADL) and one-person assistance for eating. The MDS documented the resident had a swallowing disorder and required a mechanical altered diet. Record review According to the June 2017, order summary the resident's current diet was not listed. According to the dental care plan initiated 12/21/16 and updated most recently on 1/27/17 the resident had her own natural teeth but was missing some in the back. An intervention included that the resident required mechanical soft diet; this was the only mention of the mechanical soft diet in the resident's care plan. There was not a nutrition care plan. According to the information on the CNAs Kardex-point of care (POC) electronic system revealed the residents diet was not listed under the Eating/Nutrition section. The resident's dietary profile, dated 12/23/16, documented the resident's current texture of food was mechanical soft. The resident's diet card documented the resident's diet was regular-mech(anical) soft. The 12/23/16 registered dietician assessment documented the resident's diet orders was regular, mechanical soft texture. Findings included Policy and procedure On 6/13/17 at 11:39 a.m. the dietary manager (DM) provided a copy of the Adaptive Devices policy, which revealed the following information in pertinent part, A physician's orders [REDACTED]. A physician's orders [REDACTED]. 2. Resident #2 status Resident #2, age 77, was admitted on [DATE] and readmitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 5/26/17 MDS assessment, his BIMS score was one out of 15. He had swallowing difficulties, pocked food in his mouth, coughing and chocking during meals. He required extensive assistance with eating/meals. Resident observations The resident was observed on 6/13/17 during breakfast meal. He was assisted by the certified occupational therapist assistant (COTA) with eating his meal. The COTA was observed putting two scoops of thickener for resident's liquids initially and then added one additional spoon of thickener. The liquid appeared thick pudding consistency and the resident was unable to drink it. Record review According to the June 2017, CPOs revealed the resident's current diet was pureed texture, honey consistency liquids. According to the revised 05/2017 care plan, this resident had actual weight loss and had potential for further weight loss related to history of weight loss and decline due to [MEDICAL CONDITION]. Interventions included, Encourage resident to eat meals in the dining room and this resident is having difficulty swallowing due to [MEDICAL CONDITION] brain stimulator battery losing power. We will provide him with foods that he can tolerate. 3. Resident #3 status Resident #3, age 72, was admitted on [DATE]. According to the June 2017 computerized physician orders [REDACTED]. According to the 5/25/17 minimum data set (MDS) assessment, she had a brief interview for mental status (BIMS)score 15 out of 15 indicating intact cognition. She was on a therapeutic diet and independent with eating after setup by staff. Resident observations On 6/12/17 the resident was observed during lunch service, in the dining room. Her meal was the same portion as other residents in the dining room who had the barbeque pork, macaroni and cheese, salad and cake. She was not asked if she wanted smaller portions for lunch. On 6/12/17 during dinner service, this resident's meal was the same portion as everyone else in the dining room who had the salmon patty, creamed potatoes and peas, and fresh fruit. She was not asked if she wanted smaller portions for dinner. On 6/13/17 during breakfast service, this resident's meal was the same portion as everyone else in the dining room who had the eggs, toast, ham/sausage and hot cereal. She was not asked if she wanted smaller portions for breakfast. Resident interview The resident was interviewed on 6/12/17 at 12:45 p.m. She said she had celiac diseaseand she could not eat any gluten. She said the staff have been better about her diet. She said she was trying to lose weight and it seems like food was wasted because she has asked for small portions and the staff only remembered sometimes. She said she has told them a number of times and has spoken with the dietary staff and her physician. She said her physician was okay with small portions during meal service. Record review According to the June 2017 CPO's the resident had orders for the following: No added salt, regular texture, gluten free, smaller portions are acceptable per physician and maybe served smaller portions at mealtime. (This order was written on 8/25/16). According to the revised 3/2/16 care plan, this resident is at risk for weight gain due to decreased mobility and muscle weakness. The intervention was to support her gluten free diet. Resident's care plan did not address smaller meal portions. 4. Resident #8 status Resident #8, age 81, was admitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 4/24/17 MDS assessment, his BIMS score was 11 out of 15. He was on a therapeutic diet and was independent with eating. Record review According to the June 2017, CPOs revealed the resident's current diet was mechanical soft texture and thin consistency liquids. According to the last revised 10/20/16 care plan, this resident has potential for weight loss related to no teeth. Interventions were to offer support for this resident with his mechanical soft diet and grind his meats when he request it. According to the 4/24/17 care conference review, revealed the following information, Only grind meats when resident requests it. Lunch service on 6/12/17 this resident was served the main menu items (BBQ shredded pork with macaroni and cheese, side mix salad and lime cake). Resident observation The resident was observed on 6/12/17 in the dining room during dinner. The resident was served the main menu items (fried salmon patty, creamed potatoes and peas with fresh fruit). The resident was observed on 6/13/17 in the ding room during breakfast. The resident was served the main menu items (eggs, toast, and ham). The ham was served as a whole slice. 5. Resident #9 status Resident #9, age 94, was admitted on [DATE] and readmitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 6/2/17 MDS assessment, her BIMS score was 13 out of 15 and indicated intact cognition. She has a mechanically altered diet and required setup assistance with eating. Record review According to the June 2017, CPOs revealed the resident's current diet was no concentrated sweet diets (NCS), mechanical soft texture and thin liquid consistency. According to the last revised 1/5/17 care plan, the resident has the potential for weight loss due to small appetite and diabetes mellitus. Her interventions did not include the resident's current diet: NCS, mechanical soft texture and thin liquid consistency. Resident observations The resident was observed eating lunch on 6/12/17. She was served the main menu items (BBQ shredded pork with macaroni and cheese, side mix salad and lime cake). The resident was observed eating dinner on 6/12/17. She was served the main menu items (fried salmon patty, creamed potatoes and peas with fresh fruit). Staff interviews The dietary manager (DM) was interviewed on 6/12/17 at 3:15 p.m. she said the kitchen staff should follow the physicians orders. She said the staff could always downgrade a food texture but never upgrade because the potential for harming the resident would be present. She said the speech therapist can give those recommendations to the physician. She said if the resident was on a specific texture of food that they did not like she said it would need to be discussed with the resident, speech therapist, physician and staff so everyone knew what was going on. She said all of this information would be documented in the residents medical chart. The registered dietician (RD) was interviewed on 6/12/17 at 7:35 p.m. She said the residents who were currently on a therapeutic diets were; Residents #1, #2, #4, #6, #7, #8, and #9. She said all of these residents should be receiving diets in the dining room that match their physician orders. She said the kitchen staff should not make the judgement call to give a resident a different texture of food. She said the dietary manager and the nursing staff would base this need for change off a pattern of observations and notify her and the physician if the change is necessary. The director of nursing (DON) was interviewed on 6/13/17 at 11:18 a.m. She said the physician orders [REDACTED]. She said the staff could not change the resident's diet or meal consistency without getting approval from the physician and going through the proper steps to make sure it was safe to do.

Based on observations, record review, and staff interviews the facility failed to provide therapeutic diets for six (#1, #2, #4, #6, #8, and #9) out of nine sampled residents that were reviewed for therapeutic diets. Specifically the facility failed to ensure: -The proper mechanical soft textured diet was provided for residents #8, #9, #6 and #4; and -The proper pureed textured diet was provided for residents #2 and #1. The findings included: Resident #1 Status Resident #1, age 88, originally admitted to the facility on [DATE] and readmitted on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. The resident had recently been set to a behavioral health facility to assist the resident with behaviors and medications adjustment, the resident was discharged on [DATE] and returned to the facility on [DATE]. See behavioral health facility dietitian note below. According to the 4/28/17, minimum data set (MDS) assessment, the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident required extensive assistance with all activities of daily living (ADLs) to include eating. The nutrition section of the MDS indicated the resident had a mechanically altered diet and did not have a swallowing disorder. Record Review Nursing Facility The 4/5/17 registered dietician assessment documented the resident's nutrition risk factors included altered diet texture. The nutritional summary documented To clarify texture tolerated is pureed and cannot tolerate M/S (mechanical soft). The weight-loss care plan, initiated 4/18/14 did not include interventions that included mechanical soft or puree texture The June 2017 order summary report documented the resident was ordered a regular diet, mechanical soft texture, thin consistency, and may puree foods as needed, with a start date of 5/12/17. The 4/5/17 nursing progress note documented, in pertinent part, Resident is working with ST (speech therapy) and is on puree diet at this time, no new recommendations except to clarify diet texture order (puree). The most recent care conference review, dated 6/2/17, revealed limited documentation related to the resident's diet and/or texture. The review documented the resident had a regular diet, had a slight weight loss due to his lack of appetite and swallowing difficulties. The 6/4/17 dietary profile, created by the dietary manager, documented the resident's current texture was mechanical soft and the resident doesn't enjoy pureed foods unless it is sweets or desserts, other foods he doesn't like pureed. The Kardex (certified nurse aide (CNA) communication) printed 6/13/17 did not reveal the resident's diet texture. The dietary card documented the resident's diet was regular-mechanical soft with puree circled. The 3/8/17 speech language pathologist (SLP) evaluation and plan of treatment documented the resident exhibited difficulty eating solid foods which caused decreased oral intake and oral function. The resident had increased signs and symptoms of dysphagia; at risk for weight loss and risk for aspiration The recommendations included mechanical soft textures, soft/ground textures, puree consistencies, and moist Puree Behavioral Health Facility The 5/21/17 dietician nutritional assessment, from the behavioral health facility, documented the resident's diet order was a pureed diet. The interventions included, in pertinent part: pureed texture and collaboration of care with speech therapist. This order was not carried over upon readmission to the facility. Staff Interview The registered dietician (RD) was interviewed on 6/12/17 at 6:43 p.m. She said the last time she had assessed resident #1 she was aware his weight was fluctuating. She said she was aware from the DM notifying her that the resident had been declining in the last couple of months. She said resident #1 required mechanical soft consistency but may puree if needed. Resident #6 status Resident #6, age 81, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 5/11/17 MDS assessment, the resident's BIMS score was 11 out of 15 which indicated moderate cognitive impairment. She required extensive assistance with most activities of daily living (ADL) and one-person assistance for eating. The MDS documented the resident had a swallowing disorder and required a mechanical altered diet. Record review According to the June 2017, order summary the resident's current diet was not listed. According to the dental care plan initiated 12/21/16 and updated most recently on 1/27/17 the resident had her own natural teeth but was missing some in the back. An intervention included that the resident required mechanical soft diet; this was the only mention of the mechanical soft diet in the resident's care plan. There was not a nutrition care plan. According to the information on the CNAs Kardex-point of care (POC) electronic system revealed the residents diet was not listed under the Eating/Nutrition section. The resident's dietary profile, dated 12/23/16, documented the resident's current texture of food was mechanical soft. The resident's diet card documented the resident's diet was regular-mech(anical) soft. The 12/23/16 registered dietician assessment documented the resident's diet orders was regular, mechanical soft texture. Resident #4 Status Resident #4, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 5/11/17 MDS assessment, the resident's BIMS score was 11 out of 15 which indicated moderate cognitive impairment. She required extensive assistance with most ADLs and one-person assistance for eating. The MDS documented the resident had a swallowing disorder which would cause coughing and choking during meals. The resident required a mechanically altered diet. Record Review According to the June 2017, medication review report the resident's current diet was mechanical soft texture with a start date of 9/27/16. According to the weight-loss care plan initiated 2/20/17 interventions included staff will offer resident support with mechanical soft diet. There was no care plan to address the resident's [DIAGNOSES REDACTED]. According to the information on the CNAs Kardex-point of care (POC) electronic system revealed the residents diet was not listed under the Eating/Nutrition section. The resident's most recent dietary profile, dated 3/13/17, documented the resident's current texture of food was mechanical soft. The resident's diet card documented the resident's diet was mechanical soft. The 4/5/16 registered dietician assessment documented the resident's diet order was mechanical soft texture. Staff Interviews/Observations The former speech language pathologist (SLP) was interviewed on 6/13/17 at 4:13 p.m. She said the dietary manager (DM) was not following the dietary orders. She said she had concerns while working in the facility because the DM did not know how to properly make homogenous textures. She said frequently resident #1 would spit out his food because it had lumps in it. She said the facility was not following the national dysphagia diet. On 6/12/17 at 12:00 p.m., the lunch service was observed. In the kitchen there was cook (CK) #1 while CK #2 was serving food. The dietary manager (DM) entered the kitchen at 12:09 p.m. The menu included barbeque pork, side salad, macaroni and cheese, jello cake with whipped topping, bread with margarine and a beverage. There were signs on the cabinet as the kitchen was entered. The signs revealed: - Resident #4 documented mechanical soft, thin liquids; - Resident #2 documented puree, honey think liquids; and - Resident #1 documented puree, think liquids, provide cup with straw. At 12:09 p.m. the DM said the kitchen could provide many choices and CK #2 said we would provide the resident anything they would like. At 12:17 p.m., CK #1 put pureed Jello cake on the tray. CK #2 served the cake to resident #1. At 12:25 p.m., the DM was interviewed. She said resident #2 and resident #1 should have pureed food. She said the kitchen does not serve any pureed food to either resident #1 or resident #2 because they will not eat it so they do not automatically get it. She said both of the resident prefer sweets, which was why the kitchen staff typically gave both resident deserts and sweets. She said the bread was not offered to the residents because they will not generally eat the bread and it would go to waste. She said even though on the menu was barbeque pork they did not have buns to offer the residents. She said in regard to making puree foods they do not have a commercial food processor, just a small home use food processor. She said they do not use their food processor very often. She said resident #4 did not like mechanical soft textured food so usually she would only get that based on her request; she said ultimately the texture was her choice. At 12:55 p.m. CK #1 placed barbeque pork in the small food processor. She pureed the pork then washed the food processor. She did the same for the macaroni and cheese and then another desert with cake and cream for resident #2. CK #1 did not puree bread. CK #1 said the old cook had showed her on one occasion about making puree food; otherwise she had not had any training. Upon tasting the pureed barbeque pork, it was identified that the puree required chewing and the pureed macaroni and cheese were grainy. On 6/12/17 at 5:16 p.m., CK #2 was interviewed. She said resident #2 has difficulty swallowing. She said because of that we give him puree or he runs the risk of choking. This was contradictory to the observations during the lunch meal. On 6/12/17 at 5:57 p.m., the DM was interviewed and said they will use dietary cards which are then placed in sheet protectors then placed into a three ring binder. She said at the end of March they moved into the new kitchen. She said the book was not moved into the new kitchen, therefor the diet orders were not in the kitchen. She said if a resident had an order for [REDACTED]. She said I would never harm a resident but I try to go by what they want and not the doctor's orders. The registered dietician (RD) was interviewed on 6/12/17 at 6:43 p.m. She said the kitchen would offer bread but the bread would not be put on the plate. She agreed it must be offered. She said mechanical soft texture should be food that was small enough to require minimal chewing. She said it should be fork tender and in some cases it would be ground. She said if the food can me mashed with a fork it would be mechanical soft. She said any whole muscle meat would be ground. She said the kitchen should definitely grind pork. She said if a resident asked for something in regular form then staff would assess the risk. She said the cook would not decide but someone with more experience. She said it might be the dietary manager and the director of nursing. She said if there were a pattern then the RD would be called. She said she was uncertain why the kitchen did not have a book with diet orders. She said it could be printed immediately and it is a very simple way for the cook to know. She said the DM oversees all meals and needs to determine the best way to ensure the diet list is accessible to all cooks. If the DM was not available, the morning cook (CK #1) was responsible. Professional Reference According to the Nutrition Care Manual with the Academy of Nutrition and Dietetics 2014, accessed on 6/19/17, for pureed foods, This diet consists of foods that are easy to swallow because they are blended, whipped, or mashed until they are a pudding-like texture . All foods on this diet should be smooth and free of lumps. Policy and procedure The dietary manager (DM) provided a copy of the mealtime observation for food acceptance policy on 6/13/17. It revealed the following information in pertinent part, The dining room will be monitored by the Dining Services Manager or designee at all mealtimes, including breakfast, lunch and dinner meals. Residents that are on special programs to improve mealtime intake or on consistency altered diets will be carefully monitored by all staff in the dining room and will be offered interventions as necessary to promote mealtime intake. The DM also provided a copy of the summary of diets the facility utilized as their guidelines. This revealed the following information, in pertinent part, Mechanical soft, this consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. This diet follows the regular diet planned and provided food that can be more successfully and easily chewed. The diet consists of food of nearly regular textures but eliminates very, hard, sticky, crunchy or hard to chew foods. Food should be moist and fork tender. Meat is ground or chopped into bite-size pieces (half inch or smaller) and should be mixed with gravy, broth, or another type of moistening agent. Pureed diet is designed for individuals who have difficulty swallowing or who cannot chew foods of the mechanical soft consistency. This consistency follows the regular diet planned with foods pureed or soaked as needed. The pureed diet is suggested when an individual has noted chewing or swallowing difficulties and no other consistency can be tolerated. Thickened liquids may be difficult to swallow and may require thickening. Liquids are divided into thin liquids or thickened liquids which are specified as Nectar-like, Honey-like, or Spoon-thick (pudding-like). Thick or thickened liquids may be purchased already mixed or made by adding commercial thickeners. On 6/13/17, the staff development coordinator (SDC) provided an in-service training documentation, conducted on 5/23/17, on Nutrition in elderly and maintaining nutrition, which revealed the following information in pertinent part, A few simple changes can have positive effects during meals like offering adequate amounts of foods with the appropriated consistency. Resident #2 status Resident #2, age 77, was admitted on [DATE] and readmitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 5/26/17 MDS assessment, his BIMS score was one out of 15 and indicated severely impaired cognition. He had swallowing difficulties, pocked food in his mouth, coughing and chocking during meals. He required extensive assistance with eating/meals. Resident observations The resident was observed on 6/13/17 during breakfast meal. He was assisted by the certified occupational therapist assistant (COTA) with eating his meal. The COTA was observed putting two scoops of thickener for resident's liquids initially and then added one additional spoon of thickener. The liquid appeared thick pudding consistency and the resident was unable to drink it. Record review According to the June 2017, CPOs revealed the resident's current diet was pureed texture, honey consistency liquids. According to the revised 5/17 care plan, this resident had actual weight loss and had potential for further weight loss related to history of weight loss and decline due to [MEDICAL CONDITION]. Interventions included, Encourage resident to eat meals in the dining room and this resident is having difficulty swallowing due to [MEDICAL CONDITION] brain stimulator battery losing power. We will provide him with foods that he can tolerate. According to the May and June 2017 meal percentage form documented, this resident was on a regular mechanical soft diet. (This residents order changed to pureed diet on 5/25/17). Resident #8 status Resident #8, age 81, was admitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 4/24/17 MDS assessment, his BIMS score was 11 out of 15. He was on a therapeutic diet and was independent with eating. Record review According to the June 2017, CPOs revealed the resident's current diet was mechanical soft texture and thin consistency liquids. According to the last revised 10/20/16 care plan, this resident has potential for weight loss related to no teeth. Interventions were to offer support for this resident with his mechanical soft diet and grind his meats when he request it. According to the 4/24/17 care conference review, revealed the following information, Only grind meats when resident requests it. Lunch service on 6/12/17 this resident was served the main menu items (BBQ shredded pork with macaroni and cheese, side mix salad and lime cake). Resident observation The resident was observed on 6/12/17 in the dining room during dinner. The resident was served the main menu items (fried salmon patty, creamed potatoes and peas with fresh fruit). The resident was observed on 6/13/17 in the ding room during breakfast. The resident was served the main menu items (eggs, toast, and ham). The ham was served as a whole slice. According to the June 2017 meal percentage form documented, this resident was on a regular mechanical soft diet. Resident #9 status Resident #9, age 94, was admitted on [DATE] and readmitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 6/2/17 MDS assessment, her BIMS score was 13 out of 15 and indicated intact cognition. She was on mechnically altered diet and required setup assistance with eating. Record review According to the June 2017, CPOs revealed the resident's current diet was no concentrated sweet diets (NCS), mechanical soft texture and thin liquid consistency. According to the last revised 1/5/17 care plan, the resident has the potential for weight loss due to small appetite and diabetes mellitus. Her interventions did not include the resident's current diet: NCS, mechanical soft texture and thin liquid consistency. Resident observations The resident was observed eating lunch on 6/12/17. She was served the main menu items (BBQ shredded pork with macaroni and cheese, side mix salad and lime cake). The resident was observed eating dinner on 6/12/17. She was served the main menu items (fried salmon patty, creamed potatoes and peas with fresh fruit). According to the June 2017 meal percentage form documented, this resident was on a regular mechanical soft diet. Staff interviews The certified nurse aide (CNA) #2 was interviewed on 6/12/17 at 12:30 p.m. She said she had not been trained how to thicken liquids. She said she had seen other CNAs do it and the dietary staff. She said the facility was small and they communicated by mouth what diets the residents were on. She said the facility used to use meal cards but then they stopped using them and she did not know why. The licensed practical nurse (LPN) #2 was interviewed on 6/12/17 at 12:41 p.m. She said the nurses and the CNAS can thicken the liquids for the residents. She said she was unaware of any onsite training that had been done on food textures or liquids. The DM was interviewed on 6/12/17 at 3:43 p.m. She said she was in charge of overseeing all meals that come out of the kitchen were the right meal ordered and the right texture ordered by the resident's physician. She said the meal percentage logs are used by the certified nurse aide to document the residents meal percentage consumed each meal. She said she was the one in charge of changing the diet information on the top of the form. She said the kitchen staff knew what type of diet each resident was on because they all work in a small building. She said some of the kitchen staff had been with the facility for more than ten years. She said the facility did utilize meal cards but they were currently still in the garage since they moved into their new kitchen. The move took place months ago. She acknowledged the residents who were on mechanical soft diets for 6/12/17 lunch service should have been served soft vegetables and not the salad. She said the cook did not make any vegetables to be served during the lunch service. The dietary aide (DA) #1 was interviewed on 6/12/17 at 5:52 p.m. He said he helps everyone with drinks in the dining room and serving the meal from the kitchen. He said everyone is on regular liquids in the dining room. He said he has not had any training on thickening fluids or meal textures. He said he serves what food the kitchen gives him and is not sure what each resident should be getting to eat, as he did not have a way to check. The registered dietitian (RD) was interviewed on 6/12/17 at 6:43 p.m. She said the resident had the right to receive food in a different texture. This would need to go through their risk management system first and the cooks should not make that judgement call. She said the kitchen staff could always down grade a residents diet but never upgrade if they were not previously on the upgraded diet. She said if a resident did not like the texture of their food and wanted to upgrade the food consistency they would need to go through the speech therapist first and then she would make the recommendations to the physician. She said the kitchen staff and the DM could start this process by making a referral in the residents chart. She said her kitchen staff would use the tool that was in the kitchen to help them determine the texture of the food for the residents. She said this tool would guide them on the right texture for the food- mechanical soft or pureed. The DM acknowledged the tool was not in the kitchen for the kitchen staff to use as a guide. The RD said the nursing staff and kitchen staff would know what diet the resident was currently on by the meal cards that should be present for every meal. She said the DM would update those. The RD said the kitchen staff, and the nursing staff would know what liquid texture the resident would be on by looking at the meal cards as well. She said the kitchen or the nursing staff could both thicken the liquid for residents. She acknowledged at this time no official training had been provided to the staff regarding thickened liquids besides following the instructions on the back of the container. She was aware the staff would not know what type of liquids the resident would be on (nectar, honey or pudding) if they did not have the meal cards and the meal percentage log was not updated nor was it used for this purpose. The RD said the DM is ultimately responsible for the oversight of the food coming out of the kitchen. She said she was unaware the meal cards were not in the kitchen for meal service and the facility needed to come up with a way to have a diet list available to the cook. She said when the DM was not present the lead cook was responsible for the oversight of the food. She said cook #2 was the lead cook. The lead cook, CK #2 was interviewed on 6/13/17 at 8:33 a.m. She said as of 6/12/17 the education that had been provided to her by the DM was that she need to taste the pureed foods before sending it out from the kitchen. She said, currently residents in the building who were on a mechanically altered diet were residents #1, #2, #4 and #7. She did not mention residents #6, #8, and #9.

Based on staff interviews and record review the facility failed to ensure the residents' care plans were revised to reflect recent changes. Specifically, the facility failed to ensure that six residents (#1, #2, #4, #5, #6, and #9) of nine sampled residents' nutrition care plans were updated to reflect recent changes related to diet textures. The findings included: 1.Resident #1 Resident #1, age 88, originally admitted to the facility on [DATE] and readmitted on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. The resident had recently been sent to a behavioral health facility to assist the resident with behaviors and medication adjustment. The resident was discharged on [DATE] and returned to facility on 6/1/17. See behavioral health facility dietitian note below. According to the 4/28/17, minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident required extensive assistance with all activities of daily living (ADL) to include eating. The nutrition section of the MDS indicated the resident had a mechanically altered diet and did not have a swallowing disorder. Record Review Nursing Facility The 4/5/17 registered dietician assessment documented the resident's nutrition risk factors included altered diet texture. The nutritional summary documented To clarify texture tolerated is pureed and cannot tolerate M/S (mechanical soft). The weight-loss care plan, initiated 4/18/14 did not include interventions that included mechanical soft or puree texture The June 2017 order summary report documented the resident was ordered a regular diet, mechanical soft texture, thin consistency, and may puree foods as needed, with a start date of 5/12/17. The 4/5/17 nursing progress note documented, in pertinent part, Resident is working with ST (speech therapy) and is on puree diet at this time, no new recommendations except to clarify diet texture order (puree). The most recent care conference review, dated 6/2/17, revealed limited documentation related to the resident's diet and/or texture. The review documented the resident had a regular diet, had a slight weight loss due to his lack of appetite and swallowing difficulties. The 6/4/17 dietary profile, created by the dietary manager, documented the resident's current texture was mechanical soft and the resident doesn't enjoy pureed foods unless it is sweets or desserts, other foods he doesn't like pureed. The Kardex (certified nurse aide (CNA) communication) printed 6/13/17 did not reveal the resident's diet texture. The dietary card documented the resident's diet was regular-mechanical soft with puree circled. The 3/8/17 speech language pathologist (SLP) evaluation and plan of treatment documented the resident exhibited difficulty eating solid foods which caused decreased oral intake and oral function. The resident had increased signs and symptoms of dysphagia; at risk for weight loss and risk for aspiration The recommendations included mechanical soft textures, soft/ground textures, puree consistencies, and moist Puree Behavioral Health Facility The 5/21/17 dietician nutritional assessment, from the behavioral health facility, documented the resident's diet order was a pureed diet. The interventions included, in pertinent part: pureed texture and collaboration of care with speech therapist. This order was not carried over upon readmission to the facility. 2.Resident #6 Resident #6, age 81, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 5/11/17 MDS assessment, the resident's BIMS score was 11 out of 15 which indicated moderate cognitive impairment. She required extensive assistance with most activities of daily living (ADL) and one-person assistance for eating. The MDS documented the resident had a swallowing disorder and required a mechanical altered diet. Record review According to the June 2017, order summary the resident's current diet was not listed. According to the dental care plan initiated 12/21/16 and updated most recently on 1/27/17 the resident had her own natural teeth but was missing some in the back. An intervention included that the resident required mechanical soft diet; this was the only mention of the mechanical soft diet in the resident's care plan. There was not a nutrition care plan. According to the information on the CNAs Kardex-point of care (POC) electronic system revealed the residents diet was not listed under the Eating/Nutrition section. The resident's dietary profile, dated 12/23/16, documented the resident's current texture of food was mechanical soft. The resident's diet card documented the resident's diet was regular-mech(anical) soft. The 12/23/16 registered dietician assessment documented the resident's diet orders was regular, mechanical soft texture. 3. Resident #4 Resident #4, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 5/11/17 MDS assessment, the resident's BIMS score was 11 out of 15 which indicated moderate cognitive impairment. She required extensive assistance with most ADLs and one-person assistance for eating. The MDS documented the resident had a swallowing disorder which would cause coughing and choking during meals. The resident required a mechanically altered diet. Record Review According to the June 2017, medication review report the resident's current diet was mechanical soft texture with a start date of 9/27/16. According to the weight-loss care plan initiated 2/20/17 interventions included staff will offer resident support with mechanical soft diet. There was no care plan to address the resident's [DIAGNOSES REDACTED]. According to the information on the CNAs Kardex-point of care (POC) electronic system revealed the residents diet was not listed under the Eating/Nutrition section. The resident's most recent dietary profile, dated 3/13/17, documented the resident's current texture of food was mechanical soft. The resident's diet card documented the resident's diet was mechanical soft. The 4/5/16 registered dietician assessment documented the resident's diet orders was mechanical soft texture. Staff Interviews On 6/12/17 at 6:04 p.m., the MDS Coordinator was interviewed. She said each department was responsible for completing their sections in the MDS and developing the care plan. However, she said ultimately the MDS and the care plans were her responsibility. Findings included Policy and procedure On 6/13/17, the dietary manager (DM) provided a copy of the Care Planning policy, which revealed the following information in pertinent part, Approaches/Interventions: action taken by the staff to assist residents in meeting their goals. Make approaches consistent with standards of care. Approaches must be consistent with standards of care as established by facility guidelines and procedures, the diet manual and department records, and notations in the medical records. Facility Staff In-service On 6/13/17, the staff development coordinator (SDC) provided documentation of an in-service training conducted on 5/23/17, on Nutrition in elderly and maintaining nutrition, which revealed the following information in pertinent part, After the care plan is initiated, it is reviewed and updated as needed. The plan could be updated for several reasons, including the following; if conditions change, if goals are met, if interventions ae determined to be ineffective, if specific, treatable causes of nutrition-related problems are identified later. 4. Resident #2 Resident #2, age 77, was admitted on [DATE] and readmitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 5/26/17 MDS assessment, his BIMS score was one out of 15 and indicated severely impaired cognition. His mood score was 15 out of 30 for staff interviews. He had swallowing difficulties, pocked food in his mouth, coughing and chocking during meals. He required extensive assistance with eating/meals. Record review According to the June 2017, CPOs revealed the resident's current diet was pureed texture, honey consistency liquids. According to the revised 05/2017 care plan revealed the resident has actual weight loss and has potential for further weight loss related to history of weight loss and decline due to [MEDICAL CONDITION]. Interventions included, Encourage resident to eat meals in the dining room and this resident is having difficulty swallowing due to [MEDICAL CONDITION] brain stimulator battery losing power. We will provide him with foods that he can tolerate. The care plan did not specify what consistency the physician has ordered for his diet or his liquids. According to the information on the CNAs Kardex-point of care (POC) electronic system revealed the residents diet was not listed under the Eating/Nutrition section. 5. Resident #5 status Resident #5, age 83, was admitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 4/7/17 MDS assessment, her BIMS score was ten out of 15 and indicated moderately impaired cognition. The resident was independent with eating. Record review According to the June 2017, CPOs revealed the resident's current diet was regular texture, thin consistency liquid, may have consistency as tolerated. Staff may provide mechanical soft foods per resident choice. According to the revised 01/2017, care plan the resident has potential for weight loss related to small appetite and history of weight loss. The interventions did not include the resident's current diet: regular texture, thin consistency liquid, may have consistency as tolerated. Staff may provide mechanical soft foods per resident choice. According to the information on the CNAs Kardex-point of care (POC) electronic system revealed the residents diet was not listed under the Eating/Nutrition section. 6. Resident #9 status Resident #9, age 94, was admitted on [DATE] and readmitted on [DATE]. According to the June 2017 CPOs, [DIAGNOSES REDACTED]. According to the 6/2/17 MDS assessment, her BIMS score was 13 out of 15 and indicated intact cognition. She was receiving mechanically altered diet and required setup assistance with eating. Record review According to the June 2017, CPOs revealed the resident's current diet was no concentrated sweet diets (NCS), mechanical soft texture and thin liquid consistency. According to the last revised 1/5/17 care plan, the resident had the potential for weight loss due to small appetite and diabetes mellitus. The interventions did not include the resident's current diet: NCS, mechanical soft texture and thin liquid consistency. According to the 06/2017, care conference review it did not list the resident was on a mechanical soft diet. The only information that was documented for her diet was NCS. According to the information on the CNAs Kardex-point of care (POC) electronic system revealed the residents diet was not listed under the Eating/Nutrition section. Staff interviews The dietary manager (DM) was interviewed on 6/12/17 at 8:06 p.m. she said, managers would update the residents care plan pertaining to their discipline. She said if she had a change in dietary she would put in the new information to the care plan right away. The director of nursing (DON) was interviewed on 6/13/17 at 11:15 a.m. She said each department was responsible for putting in care plans that pertained to their department. She said the care plans should match the physician orders.

Based on record review, observation and interview, the facility failed to ensure two (#32, #29) of 16 sample residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically: --Resident #32's pain was not addressed during a pressure ulcer treatment contributing to pain during such treatments. --Resident #29's pain was not adequately assessed after she sustained a skin tear and developed [MEDICAL CONDITION]; the resident reported she had pain. The findings include: A. Facility Policy The facility's pain policy directed, in pertinent part: "The physician and staff will identify individuals who have pain or who are at risk for having pain ...Such assessments should occur on admission to the facility, at each quarterly review, whenever there is a significant change in condition, and at any time pain is suspected. The staff and physician will identify the nature and severity of pain including characteristics (locations, intensity, frequency, duration, etc). Staff should use a standardized pain assessment instrument appropriate to the resident's cognitive level. The staff and physician will evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being repositioned or having a wound dressing changed." B. Resident Failures 1. Resident #32, according to the face sheet, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. a. Resident Status The 10/15/13 admission Minimum Data Set (MDS), dated [DATE], showed the resident's long- and short-term memory was impaired. Her cognitive skills for daily decision-making were severely impaired and she never or rarely was able to make decisions. The resident required total assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The resident did not display indicators of pain or possible pain in the last 5 days such as non-verbal sounds, vocal complaints of pain, facial expressions, or protective body movements. According to the communication care plan, dated 10/18/13, the resident was rarely verbal and had a difficult time communicating with people. Approaches included: --Anticipate needs such as toileting and hunger. --Ask (resident) simple questions. --Staff will observe (resident's) facial expressions and body language. A 10/23/13 physician progress notes [REDACTED]. "Patient unable to complain or deny of any problems ..." b. Pressure Areas The resident's nursing progress notes were reviewed back to her admitted and revealed, in pertinent part, the presence of pressure areas. Specifically: --10/2/13: "...Stage II breakdown noted at coccyx 1 cm x .5 cm. Stage II ulcer noted at rt lateral small toe, 1.8 x 1.5 cm. Stage II ulcer noted at rt (right) lateral ankle. All wounds cleaned, hydrogel applied with foam and [MEDICATION NAME] tape." --10/18/13: "While changing dressing at rt (right) foot, nurse notes that rt heel has a 4 x 3 cm fluid filled blister. Sure prep applied x 3 applications and heel protectors applied. Daughter in facility and notified by nurse. Will monitor every day until healed. (Physician) notified via fax." --10/21/13: "...Drsg (dressing) done on her rt foot. She does respond to pain during the drsg change." A 10/18/13 telephone order directed, "Monitor fluid filled blister at rt heel qd (every day) until healed, apply sure prep qd, and heel protectors." A 10/23/13 physician progress notes [REDACTED]." And a 10/23/13 telephone order directed, "Please pad back of heels." The 10/31/13 pressure ulcer report showed the resident had a stage I pressure ulcer to the right heel measuring 1 x 1 cm, a stage II pressure ulcer to the right lateral foot measuring .5 x .8 cm, and a stage II pressure ulcer to the right lateral ankle measuring 1 x .5 cm. The pressure ulcer report showed the wounds should be cleansed, have hydrogel applied with a foam dressing, and be covered with [MEDICATION NAME] tape. c. Failure to Address Resident's Pain during Dressing Change Observations: On 11/6/13 at 1:20 p.m., the registered nurse (RN) assigned to work with the resident was observed completing the treatment to the resident's right foot. She washed her hands and donned gloves. The resident was lying in bed and faced the wall. The resident's right foot was observed. Her feet were not in heel protectors as ordered and were resting directly on the mattress (cross reference F314). The RN stated the resident had a black area on her heel. She picked up the resident's foot so that her heel could be visualized. An approximate four centimeter area on the resident's right inner heel was black in color. A shallow, crater-like wound was observed in the middle of this area. A crevice was observed in the middle of the crater, but it was otherwise intact. The RN proceeded to clean and dress the areas on the resident's right outer foot. She then treated the blackened area on the resident's heel. The resident jolted her leg up toward her body and stuck her hands up in the air as soon as the sure prep wipe touched her skin. She then began furrowing her brow and said, "Oh God!" The resident then said, "Don't, don't, don't don't!" and began scratching at the wall. The RN replied, "I know, I know (resident #32)." The RN did not further assess the resident's pain or offer the resident pain relief. Record Review: Care plan review revealed there was no pain care plan developed for the resident who was non-verbal. The resident's pressure ulcer care plan, dated 10/18/13, did not address pain associated with treatment. The resident's November 2013 computerized physician orders [REDACTED].? tablet of [MEDICATION NAME] every six hours as needed for pain as of 10/9/13. The October 2013 and November 2013 medication administration records (MARs) were reviewed on 11/6/13 and no doses of the [MEDICATION NAME] had been administered. d. Staff Interview --On 11/6/13 at 2:30 p.m., the RN who completed the resident's treatment was interviewed. She said she had noticed the resident was in pain but only when she had her wound treatment. She said she knew the resident was ordered [MEDICATION NAME] ([MEDICATION NAME]), however she said she was hesitant to administer this because she did not want to sedate the resident adding, "I've thought do I give her the [MEDICATION NAME] and snow her out?" --On 11/6/13 at 3:02 p.m., the assistant director of nursing (ADON) reviewed the resident's care plan and stated a pain care plan was not implemented for the resident. She stated she was not aware the resident was experiencing pain with her wound treatments, but stated the pain should be assessed by asking and observing. --On 11/6/13 at 3:42 p.m., the director of nursing (DON) stated if a resident was experiencing pain, it should be treated. 2. The facility failed to adequately assess pain for resident #29 after she sustained a skin tear and developed [MEDICAL CONDITION]: Sample resident #29, an [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/5/13 Annual MDS noted the resident was cognitively intact. The resident was on a scheduled pain regimen. The 10/9/13 care plan for pain noted the resident was at risk for pain due to [MEDICAL CONDITION], carpal tunnel and arthritis. The approaches included to ask the resident what her pain level was when she asks for pain medication and to look for non-verbal signs of pain such as grimacing, guarding and rubbing an area. a. Resident Interview about Pain: On 11/5/13 at 4:40 p.m., the resident stated she had a skin tear on her ankle that was infected and ached continually. She stated the nurses would give her pain medications if she asked for them. She stated she hoped the antibiotic worked because she was tired of hurting. On 11/6/13 at 10:40 a.m., the resident stated her ankle hurt and it was a constant pain of at least 4 on a zero to ten scale. Record Review: Resident #29 sustained a skin tear on her right lower leg on 10/26/13 that was "V" shaped and measured 4.5 centimeters (cm) by 4.5 cm. The nurse approximated the skin tear and placed steri-strips followed by a 4 inch by four inch gauze pad. The 10/26/13 physician order [REDACTED]. There was no treatment ordered. Review of the medical record revealed the resident continued to have an open area on her right lower leg and developed a [MEDICAL CONDITION] requiring antibiotic treatment. Review of the resident's medication regime included [MEDICATION NAME] 100 mg (milligrams) twice a day for pain and prn (as needed) Tylenol 650 mg by mouth every four hours for mild pain. Review of the October and November Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of nurse's notes from 10/26/13 to 11/6/13 revealed no pain assessments. -Review of the prn medication administration records revealed nursing staff administered three doses of prn Tylenol 650 mg: On 11/1/13 at 6:40 p.m., for knee pain with no assessment of the resident's pain level or results documented to ensure pain relief was achieved. On 11/4/13 at 6:00 p.m. and 11/5/13 at 7:00 p.m., there was no assessment of the resident's pain level prior to administration and staff documented the resident's pain response as "better." Interviews: On 11/6/13 at 11:00 a.m., the facility nurse stated pain assessments were done when a resident was administered pain medications. She stated there was no place that a pain level was documented on each shift or if a non-pharmacological intervention was administered. On 11/6/13 at approximately 4:00 p.m., the DON stated there was no place on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated her understanding was that pain scales were documented only when a medication was administered.