Every finding on record at Gracepointe Crossing Gables

Based on observation, interview and document review the facility failed to ensure residents were given an opportunity to wash their hands prior to eating. This had the potential to affect any resident who chose to eat in the main dining room. In addition, the facility failed to follow enhanced barrier precautions (EBP) during transfer and care of 2 of 2 residents (R52, R9). This deficient practice had the potential to impact all residents who resided at the facility. Findings include: EBP: R52's Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact with diagnoses of multiple sclerosis, left hand contracture, and ataxia. R52's MDS section GG indicated R52 had limited one-sided upper extremity range of motion, and was staff dependent for eating, toilet hygiene, dressing, and transfers. R52's care plan dated 8/13/26, identified R52 was on EBP for an indwelling catheter. During an observation on 8/10/26 at 6:09 p.m., R52 was seated in their wheelchair in their room. R52's indwelling catheter drainage bag was in a dignity bag attached to the right side of their wheelchair. A soft touch call light was located on the bed a few inches below R52's bed pillow. R52's door had a sign that read Enhanced Barrier Precautions (EBP). A PPE cart with EBP signage was located at the entrance of R52's room. During an observation on 8/10/26 at 6:16 p.m., nursing assistant (NA-C ) entered R52 's room with a total body lift, exited, and then returned with NA-D. NA-C and NA-D did not apply gloves or a gown before they entered R52's room. -At 6:35 p.m., NA-D exited R52's room (no PPE) and then re-entered R52's room without applying PPE. -At 6:40 p.m., NA-D exited R52's room with a bag and the lift. -At 6:45 p.m., NA-C exited R52's room. During an interview on 8/10/26 at 6:46 p.m., NA-C stated they had just gotten R52 changed and moved into bed per R52's request. NA-C explained when a resident was on EBP they always put on a gown and gloves and sometimes eye protection if needed. NA-C stated they had not realized R52 was on EBP. NA-C reviewed the sign on R52's door and said they should have put PPE on before they provided care to R52. During an interview on 8/10/26 at 6:53 p.m., NA-D confirmed neither they nor NA-C had put on PPE when they provided care and transferred R-52. Normally with R52 being on EBP, they put on a mask and gloves. NA-D stated no gown was needed when a resident was on EBP, just gloves and masks were used for infection prevention. During an observation on 8/11/26 at 3:32 p.m., an NA-C responded to R52's call light, did not apply PPE, and proceeded to reposition R52's legs and upper body until R52 stated they were comfortable. During an interview on 8/12/26 at 12:39 p.m., registered nurse (RN-C) stated all staff should be utilizing appropriate PPE with any and all direct care provided to a resident who was on EBP. Gloves and gown should be worn for repositioning residents in their chair, moving residents from one location to another and for cares etc. The utilization of PPE helps prevent possible infection transmission to residents and it protects the staff. During an interview on 8/13/26 at 9:35 a.m., the director of nursing (DON) stated signage and carts were placed outside of resident rooms anytime a resident was placed on precautions that required PPE. The signs identified the type of precautions, actions, and the type of PPE required. The DON expected staff to follow the instructions on the signs and wear appropriate PPE as directed for all resident cares and interactions. R9's significant change Minimum Data Set (MDS) dated [DATE], identified he had diagnoses which included chronic heart failure (a condition where the heart muscle cannot pump blood efficiently enough to meet the body's need for oxygen and nutrients), palliative care, atrial fibrillation (an irregular and often very rapid heart rhythm), diabetes mellitus, depressive disorder, and pain. In addition, R9's MDS identified he was severely cognitively impaired, required substantial to maximum assistance with activities of daily living (ADL) and was always incontinent of bladder and frequently incontinent of bowel. R9's care plan dated 8/10/26, identified R9 had a pressure injury to his coccyx and was at risk for further impaired skin integrity. Interventions included to reposition and toilet every three hours. R9's care plan dated 8/11/26, identified he required enhanced barrier precautions due to a wound. Interventions included to follow enhanced barrier precautions in addition to standard precautions: wear gown and gloves during high-contact resident care activities. Notify and educate the resident or resident representative, IDT (interdisciplinary team) and direct care staff. Update physician/nurse practitioner as needed. R9's Order Summary Report identified the following order: Dressing change location: coccyx dressing change biweekly and as needed cleanse with normal saline, Tegaderm foam every day shift every Tuesday, Friday, and as needed for pressure ulcer dated 8/11/26. During an observation on 8/11/26 at 2:37 p.m., nursing assistant (NA)-F entered R9's room with a vital sign machine, they did not perform hand hygiene, put on an isolation gown, or gloves. NA-F closed the door after entering the room. During an interview on 8/11/26 at 2:47 p.m., NA-F verified they did not gown or glove when they entered R9's room with a vital sign machine and to see if R9 needed to be changed. NA-F verified there was a sign on R9's door identifying he was on EBP and verified there was a bin with personal protective equipment (PPE) outside of his room. During an interview on 8/12/26 at 11:45 a.m., registered nurse (RN)-E stated they would expect staff to follow the procedures for EBP whenever staff were providing direct care for the resident. During an interview on 8/12/26 at 1:33 p.m., the director of nursing (DON) verified staff should follow the directions posted on the door when they were going to provide direct care for a resident. The DON stated it was important to follow EBP because R9 was at risk for infection because of their wound. Enhanced Barrier Precautions Policy and Procedure dated 4/2025, identified the purpose of enhanced barrier precautions was to reduce the opportunities of multidrug-resistant organisms (MDROs) transmission during high-contact resident care. The procedure included having staff wear gowns and gloves in addition to standard precautions when caring for residents with wounds or indwelling medical devices even if the resident was not known to be colonized or infected with an MDRO. Dining: During an observation on 8/10/26 at 5:03 p.m., dining was in progress in the main dining room. Tables had hand wipes on the tables. Staff were not observed to offer residents an opportunity to clean their hands as they were brought in and seated at the tables. During an observation on 8/11/26 at 12:27 p.m., in the main dining room staff were bringing residents into the dining room, staff were not observed offering hand wipes to residents as they brought them in. During an observation on 8/12/26 at 8:21 a.m., residents were brought into the main dining room and placed at tables, they were not offered a hand wipe to clean their hands. During an interview on 8/11/26 at 1:09 p.m., nursing assistant (NA)-A stated it was the nursing assistants' job to make sure residents received assistance to wash their hands prior to eating. It was offered before the residents left their room, or if they were independent staff would do a verbal reminder as they went room to room to remind of the meal. During an interview on 8/12/26 at 8:09 a.m., registered nurse (RN)-A stated all staff should be helping residents with hand washing before meals. Staff should offer wipes to all the residents once they arrive at the resident's assigned spot in the dining hall, and prior to eating the meal. During an interview on 8/12/26 at 9:30 a.m., the infection preventionist (IP) stated there were sani-wipes on all the tables in the dining rooms. The staff should offer to open and assist the residents with the sani-wipes after the residents arrive in the dining hall and prior to serving the meal. During an interview on 8/12/26 at 2:03 p.m., the director of nursing (DON) stated staff should be offering hand hygiene according to the facility policy. Facility policy Dining Room Protocol Policy last reviewed 2/16, indicated staff would offer hand wipes or wash the resident hands and assist as indicated wipes would be available before and after the meal.

Based on interview and document review, the facility failed to follow provider orders and notify a provider with a greater than 2-pound (lb) weight gain in 24 hours (hr). The facility also failed to walk a resident twice a day per orders. This affected 1 of 1 resident (R8) reviewed for quality of care.Findings include:R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 was cognitively intact. Diagnoses included arthritis, diabetes, heart failure, and cirrhosis of the liver. The MDS indicated R8 needed supervision or touch assistance with ambulation. R8's care plan revised 7/6/26, indicated R8 should ambulate with one assist and walker 100 plus feet with a wheelchair to follow daily. The care plan lacked information that R8 needed to ambulate twice a day. The care plan dated 5/17/25, indicated R8 had a diagnosis of heart failure and to weigh per provider orders.R8's orders dated 4/22/26, indicated R8 should be weighed daily and notify the provider if there was a 2 lb. or more weight gain in 24 hr. or 5 lb. weight gain in a week. The orders lacked an order to ambulate twice a day.R8's orthopedic written orders dated 7/29/26, indicated R8 should be walked with walker and assistance twice a day.R8's walking program documentation from 7/29/26 to 8/11/26, was reviewed and indicated R8 was walked one time or less on 7/30/26, 7/31/26, 8/3/26 to 8/5/26, 8/8/26 to 8/10/26.Those dates did not indicate why the second walk or both walks were not completed.R8's daily weights from 6/1/26 to 8/11/26 were reviewed and indicated the following:From 6/7/26 to 6/8/26, the weight went from 191.2 to 193.2, a 2lb. gain in 24 hr.From 6/20/26 to 6/21/26, the weight went from 191.4 to 193.6, a 2.2 lb. gain in 24 hr.From 6/26/26 to 6/27/26, the weight went from 192.8 to 196.0, a 3.2 lb. gain in 24 hr.From 6/26/26 to 6/29/26, the weight went from 192.8 to 200.6, a 7.8 lb gain in 4 days.From 8/5/26 to 8/6/26, the weight went from 191.6 to 193.8, a 2.2 lb gain in 24 hr.R8's progress notes from 6/7/26 to 8/6/26, were reviewed and lacked documentation the provider was notified of any of the 24 hr. weight gains of 2 lbs. or more. R8's progress note dated 6/28/26 at 10:15 a.m., indicated R8's wight was up and had edema to the lower extremities. R8 had a cough that got worse when weight was up. Husband was concerned there was too much fluid and too R8 to urgent care. The note does not indicate if provider was notified.During an interview on 8/12/26 at 9:59 a.m., nursing assistant (NA)-B stated either nurses or NA's could perform the walking program and obtain weights. A lot of times the nurses got the weights of the residents on daily weights. If the NA did, the weight would be given to the nurse after obtained. R8 was on a daily weight and also on a walking program but was only supposed to be walked once a day.During an interview on 8/12/26 at 10:19 a.m., licensed practical nurse (LPN)-A stated if the order was for the provider to be notified based on the weight, then we should notify them. When the provider was notified, the nurse would make a notation in the resident's progress notes. LPN-A acknowledge she worked several shifts from 6/26/26 to 6/29/26. LPN-A reviewed R8's progress notes and weights from 6/26/26 to 6/29/26 and confirmed there was a gain of 3.2 lbs. in 24hr and also a gain of 7.8 lbs. in 4 days. Based on the progress notes there was no indication the provider was notified of the weight gains as ordered.During an interview on 8/12/26 at11:14 a.m., registered nurse (RN)-B reviewed R8's provider's written order and walking program documentation and acknowledged there had been an order on 7/29/26 to increase the walking program to twice a day. Several days after that indicated R8 was walked only one time or none. RN-B stated she was aware of the order but forgot to change in the walking program documentation. Regarding weights the providers did give the nurses some leeway not to call when the weight is just 2 lbs. but if more than that the nurse needed to notify the provider and document the call was made.During an interview on 8/12/26 at 2:03 p.m., the director of nursing (DON) stated Staff should be following the provider orders about notifying the provider of weight gains and walking programs.Facility policy Weight Policy dated 7/26 indicated weights would be on admission, weekly and monthly. Weights could be ordered more frequently per the provider. The policy did not discuss what should be done if a provider requested notification of weight change.A restorative therapy policy was requested but not received.

Based on observation, interview and document review the facility failed to ensure 1 of 1 resident (R9) was repositioned timely to prevent further skin concerns and to promote healing. Findings include:R9's significant change Minimum Data Set (MDS) dated [DATE], identified he had diagnoses which included chronic heart failure (a condition where the heart muscle cannot pump blood efficiently enough to meet the body's need for oxygen and nutrients), palliative care, atrial fibrillation (an irregular and often very rapid heart rhythm), diabetes mellitus, depressive disorder, and pain. In addition, R9's MDS identified he was severely cognitively impaired, required substantial to maximum assistance with activities of daily living (ADL) and was always incontinent of bladder and frequently incontinent of bowel.R9's care plan dated 3/27/26, identified R9 had an ADL self-care deficit. Interventions an assist of one for hygiene and assist of one for repositioning. In addition, R9's care plan identified he had a pressure injury to his coccyx and was at risk for further impaired skin integrity. Interventions included to reposition and toilet every three hours dated 8/10/26.Progress note dated 8/8/26 at 5:21 a.m., identified R9 had a new wound. It is unknown how long the wound has been present. The pressure ulcer was identified as a stage three. The note further identified he would be placed on a turning/repositioning program, incontinence management, and a moisture barrier.Progress note dated 8/8/26 at 12:18 p.m., identified he was calling out softly in the morning, Does state His bottom hurts.During a continuous observation on 8/12/26 from 7:20 a.m. to 11:01 a.m., the following was observed:-7:20 a.m., R9 was seated in his wheelchair, dressed for the day, blue heel boots on both feet, chair reclined, lights off, television was on, R9's eyes were closed. -7:31 a.m., staff entered R9's room carrying a water cup and a pill cup, after entering the room they closed the door.-7:34 a.m., staff exited the room, R9 remained in his wheelchair, remained semi-reclined.-8:25 a.m., staff went into his room and asked if he wanted breakfast.-8:27 a.m., staff was observed cleaning R9's hands with wipes and then they wheeled him to the dining room.-8:31 a.m., R9 remained seated in his wheelchair, eyes were closed.-8:43 a.m., dietary staff approached R9, asked him if he was name, he did not answer.-9:11 a.m., staff brought R9 his breakfast, raised his chair to 90 degrees.-9:13 a.m., staff cut up R9's food and placed silverware in the bowl and on the plate.-9:30 a.m., R9 took a bite of his food.-9:32 a.m., R9 took a drink of his orange juice.-9:48 a.m., staff took R9 out of the dining room.-9:56 a.m., R9 was placed in front of the television area near his room.-10:14 a.m., R9's visitor approached him and offered him coffee.-10:15 a.m., a staff member approached R9 and his visitor and stated they needed to add some thickener to his coffee.-10:18 a.m., a staff member brought the coffee back and raised R9's chair to 90 degrees.-10:24 a.m., a staff member approached R9 and brought him into his room, they took him off of the portable oxygen and placed him on the oxygen concentrator, R9 remained seated in his wheelchair.-10:32 a.m., registered nurse (RN)-F verified R9 had a current pressure ulcer, and she was not sure when he had last been checked and changed. RN-F stated it would be important for R9 to be repositioned and checked and changed timely to promote wound healing.-10:47 a.m., RN-F and nursing assistant (NA)-F put on gowns and gloves and told R9 what they were going to do, a sling was placed and R9 was lifted up, his brief was removed (RN-F) verified it was wet and that his buttocks were red about two inches from buttocks crease. RN-F stated his skin was blanchable. A new brief was placed after peri-care and R9 was moved from the toilet to his bed.-10:57 a.m., R9 was back in bed, blue boots were placed back on covers on, garbage removed from the room, and personal protective equipment was removed. Hand hygiene was performed upon exit from the room by both staff.During an interview on 8/12/26 at 11:01 a.m., RN-F stated R9's buttocks were very red but blanchable. She thought he had been in his chair since 7:00 a.m., and thought he was care planned to be repositioned every three hours but stated maybe that was too long and planned to talk to her clinical manager.During an interview on 8/12/26 at 11:45 a.m., RN-E verified R9 was on an every three hour reposition and check and change because of a new pressure ulcer. RN-E stated the facility based the intervals for repositioning and checking and changing based on incontinence and skin integrity issues. RN-E verified four hours was too long for R9 to be in his chair and to go without checking and changing him.During an interview on 8/12/26 at 1:33 p.m., the director of nursing (DON) stated she would expect staff to follow the care plan in regard to repositioning and checking and changing. The DON stated if a resident developed a new pressure ulcer, she would expect staff to complete an assessment and update the care plan. The DON verified four hours was too long for R9 to go without a position change or a check and change.Positioning the Resident dated 6/2021, identified the purpose of repositioning was to relieve pressure and prevent skin breakdown.

Based on observation, interview and document review the facility failed to ensure 1 of 1 resident (R9) was assisted/encouraged to eat during the meal service.Findings include:R9's significant change Minimum Data Set (MDS) dated [DATE], identified he had diagnoses which included chronic heart failure (a condition where the heart muscle cannot pump blood efficiently enough to meet the body's need for oxygen and nutrients), palliative care, atrial fibrillation (an irregular and often very rapid heart rhythm), diabetes mellitus, depressive disorder, and pain. In addition, R9's MDS identified he was severely cognitively impaired, required set up for eating and required substantial to maximum assistance with activities of daily living (ADL).R9's Order Summary Report dated 8/12/26, identified R9 had orders for a regular diet with regular texture, mildly thick consistency, lipped plate and dycem (a specialized, high-friction polymer material designed to grip and stabilize objects or prevent slipping).R9's care plan dated 3/27/26, identified R9 had an ADL self-care performance deficit. R9's care plan identified he was independent with eating but required staff to encourage him to participate in cares as able. In addition, R9 had a potential risk for nutritional problems dated 8/10/26. Interventions included to monitor intake per facility policy, to assist with tray set up at meals, provide with a lipped plate and dycem.During a continuous observation on 8/12/26 from 8:25 a.m. to 9:49 a.m., the following was observed;-8:25 a.m., staff greeted R9 and asked if he wanted breakfast-8:27 a.m., staff member brought R9 to the dining room-8:31 a.m., R9 was seated in his wheelchair, his wheelchair was reclined, R9's eyes were closed-8:39 a.m., R9's eyes remained closed, he had beverages in front of him but he was not drinking-8:43 a.m., dietary staff approached R9, asked him if he was name, he did not respond staff moved on-9:11 a.m., staff member brought R9 breakfast, they raised his chair to 90 degrees-9:13 a.m., staff member cut up food and placed R9's silverware in the bowl and on his plate, he did not start eating-9:15 a.m., a staff member pulled up a chair and assisted a different resident with eating, greeted a second resident at the table but did not say anything to R9 who remained at the table with eyes closed not eating-9:18 a.m., six staff remained in the dining room, a staff member was seated at the table assisting a different resident with eating but did not give R9 any verbal encouragement to eat-9:25 a.m., R9 remained at the table, a staff member remained at the table as well, no encouragement was given to R9 to eat. Another staff member approached the table and greeted all three residents at the table but did not encourage R9 to eat-9:30 a.m., R9 took one bite of food on his own-9:32 a.m., R9 picked up his orange juice and took a drink-9:48 a.m., R9 did not eat or drink anything more, staff took him out of the dining room, he was brought to the television area near his roomDuring an interview on 8/12/26 at 11:45 a.m., registered nurse (RN)-E stated the lipped plate and the dycem mat were meant to help give R9 independence with eating. RN-E did say they would expect staff to encourage him to eat while they were sitting at the table assisting another resident.During an interview on 8/12/26 at 1:33 p.m., the director of nursing (DON) stated she would expect any staff to encourage a resident to eat during the meal, especially if they were seated at the table assisting someone else. The DON stated she would expect a staff member to ask a resident who was not eating if they wanted something else to eat.Dining Room Protocol Policy dated 2/2016, identified the purpose of the protocol was to provide a dignified, prompt meal service. Procedures included that after all residents were served, staff would proceed to assigned tables and provide eating assistance as indicated or as appropriate and to initiate friendly conversation with residents at the table. In addition, staff were to rotate to tables and offer encouragement and or assistance where indicated.

Based on observation, interview, and record review the facility failed to ensure resident (R52) had access to their call light to call for assistance when needed. Findings include: R52's Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact with diagnoses of multiple sclerosis, left hand contracture, and ataxia. R52's MDS section GG indicated R52 had limited one-sided upper extremity range of motion, and was staff dependent for eating, toilet hygiene, dressing, and transfers.R52's care plan dated 8/13/26, identified R52 hand a left-hand contracture that was to be splinted during the day. Care interventions instructed staff to make sure R52's call light was within reach.An electronic medical record (EMR) note entered 6/21/26, documented R52 had said their call light was not where they could reach it on their bed. R52 had tried to position power chair closer to the bed to reach it and while attempting to get close to bed, R52 sustained a scratch measuring about 0.5 x 0.1cm with scant amount of blood surfaced.During an observation on 8/10/26 at 6:09 p.m., R52 was seated in their wheelchair in their room facing their TV. A soft touch call light was located on the bed a few inches below R52's bed pillow. A chair and garbage can were located on the right side of R52's bed. The left side of the bed was along the wall. R52 stated they needed to be changed and transferred to bed and asked writer to put their call light on. They could not do it themselves because they couldn't maneuver their chair to reach it.On 8/11/26 at 3:32 p.m., R52's call light was clipped to their bed just below their pillow. A garbage can and chair were positioned on the right side of the head of the bed. R52 stated they were uncomfortable in their chair and needed to be repositioned. R52 asked writer to put their call light on because they couldn't reach it. R52 explained they could not use their right hand, and their wheelchair could not be maneuvered so they could reach their call light with their left hand. Nursing assistant (NA-C) responded to the call light and repositioned R52 in their chair before leaving the room.During an observation on 8/12/26 at 12:06 p.m., R52 was in the dining room. R52's bed was stripped and the call light was located on the center of the mattress at the head of the bed. During an observation on 8/13/26 at 9:09 a.m., R52 was not in their room. The head of the bed was slightly raised, and the call light was on the right corner of the mattress. The chair and garbage can were at the head of the bed on the right side.During an interview on 8/13/26 at 9:16 a.m., R52 stated they were able to move about the building independently, but when in their room, they could not maneuver their chair to reach their call light when it was on the bed. They had never been offered a pendant call light.During an interview on 8/13/26 at 9:18 a.m., RN-B stated call lights should be placed so they are within reach of the resident.During an interview on 8/13/26 at 9:21 a.m., RN-D stated R52 should be able to reach their call light anytime they are in their room. Staff need to be aware of where the call light is placed so R52 can reach it when they are in their room. RN-D stated they did have pendant call lights at the facility, but they had not identified R52 for use of a pendant call light.During an interview on 8/13/26 at 9:33 a.m., the director of nursing (DON) stated call lights need to be placed in a location that residents are able to reach. The call light should be placed in a location that a resident can reach when returning to their room or when moving about in their room.The facility Call Light Policy dated November 2022, directed resident call lights should be placed within reach of residents, so they are able to call for staff assistance.

Based on observation and interview, the facility failed to provide a palatable diet by serving cold food at a temperature over 40 degrees. This had the potential to affect 17 residents who resided in the memory care unit. Findings include:During observation on 9/3/25 at 12:10 p.m., the dietary aid (DA)-A on the first floor kitchenet had started to serve the assisted living facility (ALF). The nursing home residents were scheduled to be served starting at 12:30 p.m. The ALF and nursing home (NH) hot food was in the steam table, and the dessert for the ALF and NH was a fruit salad served in individual bowls on trays on top of the counter. Facility's temperature log indicated the fruit salad's temperature was 38 degrees at 11:50 am. During observation on 9/3/25 at 12:47 p.m., DA-A started to serve lunch to the nursing home residents on the 1st floor. The dessert served in bowls were on top of the counter.During observation and interview on 9/3/25 at 1:21 p.m., after all the residents were served a food tray which included the fruit salad, testing was conducted on one tray with the culinary director assistant (CAD). The CAD used a facility's food thermometer to check the temperature of the foods. The fruit salad's temperature was 62 degrees Fahrenheit. The CAD stated the fruit salad was plated at 11:45 a.m., and they were not put in the refrigerator. CAD stated, I would like cold foods to be served at 38 to 40 degrees, 60 degrees is too high for the fruit salad. During interview on 9/4/25 at 7:35 a.m., the CAD stated the fruit salad was prepared at the facility. The recipe included the following ingredients, canned fruit cocktail, marshmallow, whipped topping, maraschino cherries, and vanilla pudding. During interview on 9/4/25 at 9:03 a.m., DA-A stated yesterday, she placed the individual bowls of fruit salad on the counter. DA-A stated the fruit salad was a cool item and it was not refrigerated.During interview on 9/4/25 at 9:08 a.m., the culinary director (CD) stated the fruit salad was a cold item. CD stated the fruit salad at 60 degrees could cause foodborne illnesses.During interview on 9/4/25 at 12:51 p.m., the director of nursing (DON) stated her expectation for cold food was not to sit on the counter for an extended period because the food will warm up. DON stated the concern about serving the cold food at a temperature over 40 or 41 degrees had the potential to cause foodborne illnesses.The Nutrition and Culinary Services Department, Menu item: Fruit Salad recipe indicated should be stored in the refrigerator at 41 degrees or lower. The Time/Temperature Control for Safety Food dated 2/15/23 indicated, the temperature danger zone was 41 and 135 degrees. This document also indicated maintaining cold food at 41 degrees or below.

Based on observation, interview and document review, the facility failed to ensure glucometers (a device used to monitor blood sugar levels) were appropriately disinfected between uses, for 1 of 4 residents (R85) in the sample who had a blood sugar check by a unit glucose meter. This had the potential to affect all four residents on 2nd Floor North unit who received scheduled blood sugar checks. In addition, the facility failed ensure personal protective equipment (PPE) was worn by staff while assisting 1 of 1 resident (R79) on contact precautions. Findings include: R85 R85's PointClickCare (PCC) (electronic medical record) diagnosis page documented resident had the following diagnoses: type 2 diabetes mellitus with unspecified complications, mild non-proliferative diabetic retinopathy without macular edema and morbid obesity due to excess calories. R85's Comprehensive Minimum Data Set (MDS), dated [DATE], indicated resident was moderately cognitively impaired and required partial to maximal assistance from staff to complete her activities of daily living (ADLS). In review of R85's PCC order summary report, resident had the following physician orders: 1. Insulin Glargine Subcutaneous Solution 100 UNIT/ML(milliliter) (Insulin Glargine) Inject 20 units subcutaneously in the morning 2. NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject 8 units subcutaneously one time a day for Hold insulin for BG < (less than) 120 or if not eating 3. Accu check before meals. Call if BS (blood sugar) less than 70 or greater than 450 three times a day for Diabetic Monitoring AM Is fasting check During observation on 9/3/25 at 1:01 p.m., licensed practical nurse (LPN)-A prepared to check R85's blood sugar before she received her noon meal in her room. LPN-A gathered the required supplies of the Accu-Check meter, a test strip, an prepackaged alcohol pad and needle lancet. LPN-A performed hand hygiene using alcohol hand gel and donned disposable gloves. Upon entering R85's room, LPN-A informed resident she was here to check her blood sugar level, prior to the noon meal and insulin injection. R85 indicated which finger she wished to be used and LPN-A prepped the finger, cleansing it with the alcohol pad. Once air dried, LPN-A used the lancet (device used to puncture the skin), obtained a droplet of blood and captured it on the Accu-Check test strip. A tissue was provided to R85 for her finger while the test calculated. R85's blood sugar level was 267. R85 stated she had just had some candy and it will go down shortly. Seeing the meal tray being delivered, LPN-A gave R85 her insulin. LPN-A Then left R85's room, returning to the medication cart and placed the glucometer on the medication cart, doffed her gloves and applied alcohol gel to her hands. LPN-A then open the medication cart, removed two more alcohol pads and wiped down the glucometer, placing it back into the medication cart. During interview on 9/3/25 at 1:24 p.m., LPN-A stated this unit only has one glucometer and is shared among all the diabetics on the unit. LPN-A stated they clean the device by wiping it down with alcohol pads and allow it to air dry between resident uses. During an interview on 09/3/25 at 1:33 p.m., LPN-B stated that each unit has bleach wipes which glucose meters are to be cleaned with before using with another resident. During an interview on 9/3/25 at 1:36 p.m., registered nurse (RN)-A, stated we use the alcohol wipes were used to clean the glucometer between residents. During an interview on 9/3/25 at 1:38 p.m., LPN-C stated each diabetic resident on this unit has their own glucometer, we clean them when soiled. Each room had a container of bleach wipes. During an interview on 9/3/25 1:44 PM, LPN-D stated the unit only has one glucometer and they used bleach wipes on the devices between residents. The facility used the Assure Platinum brand of glucose meter, which has the following cleaning / disinfection instructions from the manufacturer: To disinfect an Assure Platinum meter, you must first clean it with soap and water or 70-80% isopropyl alcohol, then disinfect using a lint-free cloth dampened with either a commercially available EPA-registered disinfectant wipe or a 1:10 bleach solution (1 part household bleach to 9 parts water). Always follow the manufacturer's instructions, use proper PPE, and be careful not to get liquid in the test strip or battery ports. Follow These Steps: 1. Prepare for a new patient: • Wash your hands thoroughly with soap and water. • Put on a new pair of clean gloves. • Use an auto-disabling, single-use lancing device for each patient. 2. Clean the meter: • Use a lint-free cloth dampened with a soap and water solution or a 70-80% isopropyl alcohol solution. • Clean the exterior of the meter, wiping off any dirt, blood, or other bodily fluids. 3. Disinfect the meter: • Use a different lint-free cloth dampened with either: • An EPA-registered disinfectant detergent or germicide. • A solution of 1 part household bleach (5-6% sodium hypochlorite) to 9 parts water (a 1:10 dilution). • Wipe down the meter thoroughly with the disinfectant solution. In review of the facility policy, entitled: Blood Glucose Monitor Disinfection (modified November 2022) documented the following for disinfecting glucometers between residents: Policy for Glucometer Use Between Multiple Residents: After the completion of blood glucose testing discard the test strip per policy. Wash hands or use waterless hand sanitizer. Apply a clean pain of gloves. If any visible soiling of the glucometer, first clean the glucometer with an alcohol wipe. Disinfect the glucometer using a bleach based disinfectant wipe. This product will be effective for devices that have come in contact with C-Diff and/or Norovirus. a. Disinfectant Sani-Cloth Bleach Wipe (Item # P54072) meets this requirement. Do not clean inside the battery compartment, code chip port or test strip port. The glucose monitor must be disinfected for 4 minutes using wipes and then throughly dried prior to use between clients. Remove gloves. Wash hands or use waterless hand sanitizer. R79 R79's quarterly Minimum Data Set (MDS) dated [DATE], indicated diagnosis of Alzheimer's, diabetes, non-traumatic brain dysfunction, and coronary artery disease (CAD). R79 had impaired cognition. R79 had a diagnosed of shingles. An observation on 9/3/25 at 1:20 p.m., nursing assistant (NA)-A was observed bringing a lunch tray to R79's room. R79's room had a sign posted outside the door indicating to staff contact precautions (gown and gloves worn for all interactions with patient [resident] and their environment to prevent pathogen transmission). NA-A place the lunch tray on the bin outside the room that had PPE in. The bin had no clean gowns. NA-A went into R79's room and took a soiled gown out of the white laundry basket in R79's room and put it on and put on clean gloves. NA-A brought the lunch tray to R79 and assisted R79 with the meal. NA-A stayed in the room while R79 ate. At 1:32 p.m., NA-A brought the tray to the counter in R79's room and took off the gloves and gown, placed the gown in the white laundry basket in R79's room. NA-A washed her hands with soap and water and brought the meal tray out of the room towards the dining area. An observation on 9/3/25 at 1:33 p.m., NA-A went into R79's room to get previous meal trays from the counter and did not put on PPE when she entered. NA-A organized both trays to one and left room with the meals trays and went towards the dining area. NA-A did not put PPE on, hand sanitize or wash her hands when entering or exiting R79's room. On 9/3/25 at 1:34 p.m., NA-B stated R79's was diagnosed with Shingles and was on contact precautions. NA-B stated staff needed to wear gowns and gloves when going into R79's room to do cares. NA-B staff were not to take gowns out of the white laundry basked in the room to wear as they were soiled. NA-B stated staff did not need to wear gown or gloves when just going into pick up trays from previous meals. On 9/3/25 at 1:37 p.m., NA-A stated she took the gown out of the white laundry basket from R79's room and did not know if they were clean or not and then put the gown on to go into R79's room. NA-A stated she should have asked someone if the gowns in the white laundry basket were clean or not. NA-A stated she did not know where to get clean gowns from. NA-A asked another staff to get more clean gowns for R79's bin outside the room. On 9/3/25 at 1:53 p.m., registered nurse (RN)-A stated staff are to wear gowns and gloves when going into a resident's room with contact precautions. RN-A stated staff were to wash their hands or use hand sanitizer before and after going into a resident's room with contact precautions. RN-A stated clean gowns are kept in the bin drawer outside the resident's room, if there were no clean gowns in the bin then staff had to get them from the clean storage room. RN-A stated the white laundry basket in the room was for soiled gowns and staff should not take a gown out of there and wear when entering the residents room. RN-A stated staff should wear a gown and gloves to enter R79's room even when getting meal trays from the counter in the room. On 9/4/25 at 10:17a.m., RN-B stated R79 had shingles and needed contact precautions for staff and visitors. RN-B stated staff were to wash hands before entering or use hand sanitizer, wear gown and gloves when entering R79's room, take off gloves and gown when leaving room and wash hands or use hand sanitizer. RN-B stated staff are to place the soiled gown in the white laundry basket inside the resident room. RN-B stated staff are to get clean gowns from the bin outside of R79's room and not to take the gown from the white laundry basket and wear again as it was soiled. RN-B expected staff to wear gown and gloves whenever they entered R79's room. On 9/4/25 at 1:25 p.m., infection preventionist (IP) stated all staff had been trained on all precautions. IP stated the gowns in the white laundry basket were soiled and staff were not to re-wear them. IP stated the clean gowns were kept in the bin outside the resident's room. IP stated taking a gown from the white laundry basket was not the process of the facility. The facility policy Infection Prevention and Control Manual Transmission-Based Precautions undated, indicated contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, spread by direct or indirect contact with the resident or the resident's environment. In addition to standard precautions, contact precautions will be used to prevent the healthcare acquired spread of organisms that can be transmitted by direct resident contact (hand or skin to skin contact that occurs when performing resident cares) or by indirect contact (touching) with environmental surfaces or contaminated resident care equipment.

Based on document review and interview, the facility failed to ensure the minimum data set (MDS) assessment was correctly coded for 1 of 5 residents (R4) in the sample reviewed for unnecessary medications.Findings Include: R4's PointClickCare (PCC) (electronic medical record) diagnosis listing documented resident had the diagnoses of type 2 diabetes, morbid obesity due to excess calories and intestinal bypass. R4's last comprehensive minimum data set (MDS) assessment dated [DATE], indicated resident moderately cognitively impaired and was independent with activities of daily living (ADLS). A review of R4's PCC Physician Orders, last updated 9/4/25, R4 was prescribed the following medication: Trulicity Subcutaneous Solution Auto-injector 1.5MG/0.5ML (Dulaglutide) Inject 1.5 mg subcutaneouslyin the evening every Tue related to TYPE 2DIABETES MELLITUS WITH DIABETIC CHRONICKIDNEY DISEASE (E11.22)Prescription date of 6/24/25 This medication is a GLP-1 (glucagon-like peptide-1), a hormone naturally produced in the intestines that plays a crucial role in regulating blood sugar levels. A review of the last two MDS assessments, both coded as Comprehensive MDS assessment, dated 7/15/25 and 9/3/25 were noted to have incorrect coding in Section N (Medications). It was noted in Section N of both assessments, R4 was marked as have received 1 injection of insulin. However, in review of the [NAME] Lilly and Company medication instruction sheet (last revised 9/2018 and found online at www.trulicity.com), informed the consumers Trulicity was not an insulin (used by diabetics to control blood sugar levels), but rather a medication used as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. In review of the medication reference guide, entitled Drugs.com, indicated the following:No, Trulicity is not a form of insulin.Trulicity mimics the effects of GLP-1 a naturally occurring hormone that stimulates insulin secretion.Trulicity is only suitable for people with type 2 diabetes who still have functioning insulin-producing cells in their pancreas.Trulicity is given by subcutaneous injection, once a week.In review of another medication reference guide, PDR (Physician's Drug Reference). which can be found at pdr.net, indicated the following:GLP-1 is an important, gut-derived, glucose homeostasis regulator that is released after the oral ingestion of carbohydrates or fats. In patients with type 2 diabetes, GLP-1 concentrations are decreased in response to an oral glucose load. GLP-1 enhances insulin secretion; it increases glucose-dependent insulin synthesis and in [NAME] secretion of insulin from pancreatic beta cells in the presence of elevated glucose. During interview on 9/4/25 at 10:15 a.m., the director of nursing (DON) and a Corporate registered nurse ((RN)-Corp stated that the corporation data inputs and completed all resident MDS assessments offsite. The unit managers for each unit completed individual resident nursing assessment which aided the offsite nurses to complete the MDS assessment. If the offsite nurses have a question the facility is emailed for clarification. The onsite MDS coordinator main role was to monitor MDS scheduling for all the units and to ensure the assessments are completed in required time frames. DON further stated the interdisciplinary team also gets together and reviews each resident prior to the completion and submission of the current MDS being assessed for. Both staff members indicated training may be at hand when it came to GLP-1 medication. In review of a facility policy, entitled: Resident Assessment Instrument (RAI) Process: MDS 3.0, Care Area Assessments, Care Planning and Submission (last modified March 2025) indicated the following:3. c. An accurate assessment requires collecting data and information from multiple sources. These sources must include the resident, and direct care staff on all shifts, and should also include the resident's clinical record, physician, and family, guardian or significant other as appropriate or acceptable. Documentation in clinical record must support the items coded on the MDS.

Based on observation, interview, and document review, the facility failed to ensure care-planned interventions for safety with hot beverages were consistently implemented to reduce the risk of accident and injury for 1 of 1 residents (R1) reviewed who required lids on their hot beverages. This resulted in actual harm for R1 who was served a cup of hot tea without a lid and spilled it onto herself causing multiple second-degree burns. However, the facility had taken multiple corrective action(s) prior to the onsite survey so these findings are issued at past non-compliance. Findings include: A United States (US) National Library of Medicine Burn Classification article, dated 9/2023, identified burns happen with the skin is exposed to heat sources such as flames or hot objects. The article listed definitions and/or types of burns which included a first-degree burn as, . involves the epidermis only. These burns can be pink-to-red, without blistering, are dry and can be moderately painful. The article then listed a section labeled, Partial-Thickness Burns, and recorded them as, A second-degree burn . affects the superficial layer of the dermis. Blisters are common and may still be intact when first evaluated . These burns are painful. Healing typically occurs within 2 to 3 weeks with minimal scarring. A submitted facility-reported incident (FRI), dated 7/22/25, identified an allegation of potential neglect was submitted for R1 by the care center staff. The report outlined R1 was brought into the dining room and was served hot tea in a mug without a lid despite R1 being care-planned to use mugs with a lid for hot beverages. R1 spilled the tea onto herself. R1 was immediately assessed and the provider contacted for treatment orders. The report outlined, The water in the carafe [pitcher] was obtained from the coffee machine which is set at a temp of 170 [F] . Hot beverage policy was followed at the time of the incident. R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment and had no other skin impairments (i.e., burns) present at the time of the review. On 8/8/25 at 9:05 a.m., R1 was observed seated in a high-back wheelchair while in the dining room. R1 was seated at a table with other residents and had a regular plate in front of her on the table which had stacked debris present (i.e., napkins, utensils). R1 had a visible dark-colored, hard plastic coffee cup next to her plate which was turned upside down and underneath of the cup was a white-colored lid. R1 was not served any hot beverages at that time. A white-colored menu slip was placed on the table next to R1's items which outlined R1's name, the date (8/8), and that R1 consumed a regular diet with thin liquids. The slip included a section labeled, Spec [special] Direct [directions], which outlined, HOT BEVERAGES IN MUGS WITH LIDS, ADD ICE TO HOT BEVERAGES IT [sic] REFUSING LIDS, NO STRAWS. Dietary aide (DA)-A was present in the dining room and picked up R1's used cutlery and menu slip from the table. R1 was interviewed and expressed she thought she had eaten pancakes for the breakfast meal but then added aloud, My memory's not that good. R1 stated she didn't have any coffee or tea then added, I got burnt a week ago. R1 recalled the incident and explained a woman was sitting across the table from her whom had spilled her cup which then poured onto her clothes causing a burn. R1 stated, It burnt so bad right into the skin! R1 stated it was painful adding, Oh God yes. R1 was unsure if the person who spilled it was a staff member or another resident responding with, Just a lady in a hurry I guess with her cup. Following this, at 9:12 a.m., DA-A was interviewed and explained the DA staff members are typically the people to make and serve the beverages within the dining room. DA-A stated R1 needed a lid on her coffee cups for hot beverages which was placed at the table for any staff to see and use. DA-A stated R1 had been required to use the lids for a while but was unsure exactly how long adding, Honestly, I don't know. DA-A stated any staff who serve R1 food or beverages should be reading the white-colored menu slip prior to setting the items on the table for her. R1's nutritional care plan, revised 7/28/25, identified R1 had a potential risk for nutritional problems due to requiring additional fluid/nutrition supplement. The care plan outlined R1 was able to eat independently at meals with tray set up and added, . hot beverages in mugs with lids or add ice in hot beverages if she refuses to have a lid. The care plan listed an intervention reading, Assist me with tray set up at meals and provide me with hot beverages in mugs with lids, which had a last revision date listed, 04/09/2025. The care plan listed another intervention which read, Add ice to hot beverages if refusing lids, with a date initiated, 07/28/25.On 8/8/25 at 9:43 a.m., R1's family member (FM)-A was interviewed and verified they were R1's emergency contact. FM-A explained they were aware of R1 having sustained a burn and expressed it had been explained to them that someone got bumped in the dining room which is what caused the hot beverage to spill onto R1. FM-A reiterated they were told the tea was going to someone else and had mistakenly got spilled onto R1. FM-A stated R1 did report having pain from the burns at the time, however, it had been improving more recently. FM-A stated they recalled hearing R1 say, They burned me. R1's progress note, dated 7/22/25, identified R1 had spilled hot tea on her lap. The note outlined, Cool wash clothes [sic] were applied right away to her right upper thigh, right lower abd [abdomen] and towards the back that were red and warm to the touch. The note outlined R1 repeatedly tried to remove the cloths. R1 was recorded as complaining of it hurting and the areas were hot. A subsequent note, dated 7/22/25, identified the medical provider ordered skin prep daily for five days with dictation, . was updated regarding the blisters forming on those areas. R1's corresponding Resident Occurrence Report, dated 7/22/25, identified two (2) burns were obtained including on her right upper thigh, and right lower abdomen towards her back. The report listed an analysis of the occurrence as R1 spilling hot tea on herself and directed to continue using lids with hot beverages along with immediately medical treatment orders. R1's Prescriber Order, dated 7/23/25, identified a telephone order from the medical provider was obtained. The order directed, Apply ABD pads [dressing] to right upper thigh and RLQ [right lower quadrant] blister areas one time a day . do not put tape on burn areas. Burns. R1's progress note, dated 7/24/25, identified a plan of care note which outlined, . wounds are blisters that are not weeping and light pink edging around that area . includes upper right thigh, RLQ [right lower quadrant], and abdomen area towards back area.R1's progress note, dated 7/26/25, identified an eMAR note which outlined, . blister on right thigh continues to be fluid filled with yellow colored fluid. Blister on RLQ is red in color and no fluid is noted in blister. A subsequent note, dated 7/29/25, identified all blisters had reabsorbed but R1's skin remained discolored in the affected areas adding, Still continues to have some areas that are slightly red.R1's progress note, dated 8/1/25, identified another plan of care note entry which outlined, Resident has 4 areas that vary in size, but all are under 5cm [centimeters] long that continue to be red. The areas that are red are the areas that had the blisters that have been reabsorbed. On 8/8/25 at 9:55 a.m., DA-A was interviewed, and explained they were aware of R1 getting burned. DA-A stated what they had heard about it was there was a relatively young DA working in R1's unit that day who had served her (R1) a hot beverage without a lid on it. R1 then spilled it onto herself and obtained the burns adding, I heard the burn was pretty bad. DA-A stated the DA who had served R1 must not have read the ticket which directed to use a lid. DA-A stated staff are trained and told to read those tickets or their I-pad (which had instructions on it) before serving meal or beverage items to the residents and reiterated aloud, You have to look at the ticket. DA-A explained that since the incident happened, they had been given repeated instructions to review the ticket with meal pass and that the kitchen was now sending up a highlighted form which had people who used adaptive equipment on it for another source of reference. Further, DA-A stated the staff involved with the incident directly was DA-B. Following, on 8/8/25 at 10:01 a.m., R1 was seated in her wheelchair in her room. R1 was asked about her burns and if there was still pain when R1 responded, You wanna see them? R1 then pulled down her waistband exposing two separate burn sites on her abdomen and upper leg, respectively. The areas were each dark pink in color around the perimeter getting more red in color towards the center of the wound; and each was approximately 8 to 10 centimeters (cm) in total length with a visible, white-colored center of the wound bed. R1 reiterated the burns were very painful when they happened but were improving now adding, It's getting better I think. When interviewed on 8/8/25 at 10:13 a.m., nursing assistant (NA)-A stated they had worked with R1 prior and described her as needing help with most cares. NA-A stated they were working on the day R1 spilled the tea onto herself, however, did not witness it personally. NA-A stated the burns took like a half a day to turn into what it turned into with blisters and skin damage. NA-A stated they say R1's skin shortly after the incident and the areas looked really hot and R1 kept saying aloud, It's hot, it's hot. NA-A verified R1 was supposed to have covered cups with all hot beverages which had been an intervention for sure six months. Further, NA-A stated since the incident happened, they had been told again to make sure lids were used for hot beverages and to check a resident' meal ticket when serving them. On 8/8/25 at 10:48 a.m., DA-B was interviewed, and verified they were the DA involved with the incident on 7/22/25. DA-B explained the DA staff were typically the people who served the beverages and meals to residents within the dining room adding they work all over kinda on multiple units. DA-B recalled the incident on 7/22/25, and explained they were in the dining room and R1 was seated in her wheelchair at the table. R1 had complained about not feeling well and DA-B offered to get her some tea. DA-B stated she prepared and served R1 hot tea without looking at the I-pad. DA-B stated then about a minute later she heard R1 scream and discovered she had spilled it onto herself. DA-B verified they had been trained to review the I-pad or menu ticket prior to serving, however, expressed they didn't that day as they were working on doing other orders when they offered R1 the hot tea. DA-B stated they figured they'd give the tea to R1 right quick and go back to the other orders. DA-B verified they physically poured and served R1 the hot tea directly with no other residents or staff members being involved. DA-B stated since the incident happened, the assistant culinary director (ACD) had spoken to them and verbally re-educated them on meal service procedures including to review the meal ticket or I-pad with service along with ongoing reminders to other staff. DA-B stated a new listing had been sent up just recently, too, for staff to have available and be able to reference any special equipment needed for residents. DA-B added, I feel horrible [about this].On 8/8/25 at 11:18 a.m., the ACD and director of nursing (DON) were interviewed, and the DON verified the intervention to use a lid with hot beverages was on the care plan and expected to be done on 7/22/25. ACD recalled the incident on 7/22/25, and explained they were in the kitchen working when they were notified someone had a burn and needed to be reviewed. ACD went to R1's unit and spoke with DA-B about it who reported they didn't put a cover on the mug when serving her hot tea. ACD stated they immediately re-educated DA-B on using the e-menu [I-pad] and did a demonstration for them. ACD verified staff should be reviewing the e-menu before serving beverages to a resident adding aloud, Correct. DON stated DA-B was then sent home for the rest of the day while the facility investigated the situation adding DA-B had completed a formal education on meal service before they had been allowed to return to work. DON explained the initial burns presented as red areas which then turned into a blister, and verified they were unaware of anything else which could have burned R1 that day. DON stated the nurses immediately assessed the area and obtained treatment orders from the medical provider for the two burns. DON stated they were unsure if having a lid on the mug that day would have prevented the burns adding, I can't answer that. However, DON acknowledged a lid being attached to the mug would have, at minimum, slowed or reduced the amount of fluid pouring out of the mug onto R1's clothes or skin. DON verified R1 was physically able to manipulate utensils and coffee cups on her own. DON stated they checked the temperature of the water inside the coffee carafe shortly after the incident and it was at 170 [F] then which was allowable per the manufacturer's guidelines.DON then explained that since the incident, several steps had been taken to correct the issue including immediate re-education to DA-B and the other culinary staff members, reviewing other residents for adaptive equipment use, having dietary now pre-setting the table with items needed, and continuing to do quality assurance audits of the dining service. DON stated they felt the care center had adequate systems in place to prevent accidents like what happened, however, with R1's incident it had been one staff member that for some reason that day chose to not do as she had been taught. DON reiterated the facility had a system for serving hot beverages safely adding, There's no way we could have foreseen [DA-B] would do that. A provided Hot Beverage Policy, dated 4/2021, identified the purpose of ensuring hot beverages were provided that were palatable but safe temperature. The policy outlined a procedure which directed to have all beverage machines set according to manufacturer recommended temperature settings, serving the machines as directed by the guidelines, and reporting concerns with resident safety to the interdisciplinary team (IDT) for review or care plan revisions. The past non-compliance harm-level findings were corrected prior to the onsite survey. The steps taken and re-education articulated by the DON were all verified as being implemented during the onsite investigation through observation, interviews with staff members, and review of the corresponding documentation. In addition, no further burns from hot beverages had happened since 7/22/25.

Based on interview and document review, the facility failed to provide safe transfers for 1 of 3 residents (R1) who required gait belts (transfer belt) for transfer and ambulation assistance. This resulted in actual harm when R1 was being ambulated without a gaitbelt, fell, and sustained a fracture of the shoulder. The facility implemented corrective action prior to the investigation, so the deficiency was issued at Past Noncompliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of heart failure, acute respiratory failure, and muscle weakness. The MDS indicated she required partial to moderate assistance with transfers and ambulation, and she had a history of falls in the prior 2-6 months to her admission. R1's care plan dated 4/15/25, directed assist of one staff and walker for transfers. R1's care sheet (nursing assistant care guide) directed use of a hemi walker (walker designed for individuals who require support with one arm) in/out of recliner and assist of 1 from wheelchair for toilet transfers. On 6/5/25 at 9:45 p.m., a progress note indicated R1 had a fall while ambulating to the bathroom with her walker and staff assistance. R1 had increased pain in her left arm/shoulder area at the time of the fall. On 6/7/25 an x-ray report indicated R1 had a nondisplaced fracture of the neck of the acromion (shoulder). On 6/24/25, at 11:08 a.m., nursing assistant (NA)-A stated she always used a gait belt to transfer R1. On 6/24/25, at 11:11 a.m., NA-B stated she always used a gait belt to transfer R1. Further, she stated she consistently observed other staff using a gait belt for R1's transfers. On 6/24/25 at 11:35 a.m., R1 stated she did not have a gait belt on when she fell on 6/5/25. The staff use the gait belt about 90% of the time when they assisted her with transfers. During an observation on 6/24/25, at 11:55 a.m., R2 was observed receiving ambulate assistance by a nurse aide with a gait belt. On 6/24/25, at 12:05 p.m., NA-C stated a gait belt was always indicated for all assistance of one staff (A1) transfers. During an observation, on 6/24/25, at 12:35 p.m., R3 was observed receiving assistance of A1 ambulating with his four-wheeled walker and a gait belt. On 6/24/25 at 1:30 p.m., NA-D stated she was assisting R1 to the bathroom on 6/5/25 when R1 fell. R1 had her walker, but did not have a gait belt on at the time of the fall. She had not been instructed to use a gait belt for transfers that required one assist. Following R1's fall on 6/5/25 she had been reeducated on the facility ambulation and transfers policy. On 6/24/25 at 1:55 p.m., registered nurse (RN)-A stated the care sheets were populated by the care plans. The care plans did not include direction to use a gait belt for transfers and ambulation, gait belts were expected to be utilized at all times for residents who required assist of 1 for transfers and ambulation. It was the facility's policy to use a gait belt for all transfers that required one assist. On 6/24/25 at 2:33 p.m., the administrator stated using gait belts for resident transfers and ambulation was not included in residents' care plans as it was the facility policy and a standard of care. NA-D was hired 4/18/25. Document review of NA-D's Skills Competency, signed by NA-D on 4/29/25, indicated she demonstrated competency assisting a resident to transfer and ambulate. NA-D's Role Orientation Checklist, dated 5/2/25, indicated she had received education on the use of a gait belt. The facility policy Gait Belts for Transfers and Ambulation dated 12/14, directed gait belts are not used as a restraint, and will be used for all transfers of weight bearing residents who require assistance with transfers and/or ambulation. The Past Noncompliance began on 6/5/25. The deficient practice was corrected by 6/6/25, after the facility implemented a systemic plan that included the following actions: immediate education on facility policy for all NA's and nurses requiring the use of a gait belt for all transfers and ambulation that required assist of one. Interviews with staff, on 6/24/25, confirmed understanding of facility policy requiring the use of gait belts with all assisted transfers. Observation of transfers, on 6/24/25, demonstrated compliance with use utilize gait belts for residents' transfers and ambulation.

Based on observation, interview and document review, the facility failed to assess and determine safety for 1 of 1 residents (R205) reviewed for self-administration of medications (SAM). Findings include: R205's hospital discharge orders printed 6/7/24, included an allergy of onions with a reaction of anaphylaxis (a serious life-threatening reaction usually occurring within a few seconds to minutes when coming in contact to an allergen). R205's order summary report dated 6/11/24, included an allergy to onions. Order summary report failed to include an order for an EpiPen or epinephrine (a medication given to treat anaphylaxis). R205's facility assessment titled Nursing Minnimum Data Set (MDS) dated [DATE], included a section addressing self-administration of medication. Response in that section indicated resident did not wish to self-administer medications. On 6/11/24 at 8:16 a.m., an EpiPen was on R205's movable bedside table. The EpiPen was approximately 6 inches in length, label was bright yellow and white with black lettering. The EpiPen was in a clear plastic container with a yellow top. Other objects on the beside table included a black television remote, a tissue box and a few pieces of paper. The EpiPen did not have a pharmacy label or patient identification. On 6/11/24 at 3:00 p.m., R205 was in his room sitting in his wheelchair with his movable beside table directly in front of him. A staff member brought a mug into R205's room and placed in on the bedside table. R205's EpiPen was visible on the bedside table. On 6/12/24 at 7:30 a.m., R205 was in his room with therapy. Other staff was observed exiting his room. Bedside table was against the wall opposite the door, next to the recliner chair. The EpiPen was visible on the bedside table. During interview on 6/12/24 at 7:15 a.m., trained medical assistant (TMA)-A stated if she found a medication in a resident's room that was not on the medication list or was not supposed to be left in the room, she would report it to the nurse or her supervisor. During interview on 6/12/24 at 5:52 p.m., licensed practical nurse (LPN)-A stated resident's who were able to self-administer medication are assessed by a registered nurse (RN). It was entered into each specific medication order and listed on the resident's care plan. During interview on 6/13/24 at 10:04 a.m., TMA-B stated if she noticed a medication in a resident's room, she would try to remove it to bring to a nurse. If the resident refused, she would have notified the nurse because sometimes resident's have medication in their rooms that they are not supposed to have. During interview on 6/12/24 at 12:22 p.m., RN-A stated the facility assessment titled Nursing Minnimum Data Set (MDS) was typically completed in the resident's room. RN-A confirmed R205's MDS indicated the resident did not want to self-administer medications. RN-A confirmed R205 did not have an order for an Epi-Pen nor an self-administration of medications. RN-A proceeded to the R205's room to ask about the EpiPen. R205 had one EpiPen in his T-Shirt pocket with the top visible and one EpiPen in an unlocked drawer of his bedside dresser. R205 gave both medications to RN-A. RN-A confirmed the medication was not properly labeled and had a past expiration date of October 2021. During interview on 6/12/24 at 12:34 p.m., director of nursing (DON) stated an assessment to evaluate cognitive and physical ability would have been completed if a resident wanted to self-administer medications. The resident would have been provided a lock box to store the medication safety. DON confirmed the resident did not have an active order for an EpiPen. She expected the staff to notify nursing if they noticed a medication in a resident's room. DON stated this would be important so the facility knows what the resident was taking and to ensure other residents did not have access to the medication. During an interview on 6/13/24 at 10:17 a.m., R205 stated staff were aware he had an EpiPen in his room. He said it was always sitting on his table within arm's reach and in the open. He stated he also took it with him to every meal and placed it on the table next to his meal. He stated staff have commented on the EpiPen while in his room. Facility document titled Self Administration of Medication Policy dated November 2016 included the facility would conduct a self-administration assessment upon admission, quarterly and with any significant change to determine if a resident was safe to self-administer medications. Any medications left in a resident's room would be secured. The resident's care plan would indicate if the resident was able to self-administer medications. All medications had to be kept in the original container and be properly labeled.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R89, R44, R37, R103) were offered or provided the pneumococcal vaccine (PCV20) in accordance with the Center for Disease (CDC) recommendations. Findings include: The CDC's PneumoRecs VaxAdvisor identified: -based on shared clinical decision-making, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. The CDC's Pneumococcal vaccine timing for adults identified: -together, with the patient, vaccine providers may choose to administer the PCV20 to adults [AGE] years and older who have already received the PCV13 (but not the PCV15 or the PCV20) at any age and PPSV23 at or after the age of [AGE] years old. R89's clinical census sheet, identified she was [AGE] years old and admitted on [DATE]. R89 had no allergies or contraindications to vaccines listed. R89's immunization report, identified she had previously received the pneumococcal vaccines (PCV13) on 11/30/15 and the (PPSV23) on 11/6/06. R89's medical record lacked evidence she was offered or provided the PCV20. R44's clinical census sheet, identified he was [AGE] years old and admitted on [DATE]. R44 had no allergies or contraindications to vaccines listed. R44's immunization report, identified he had previously received the PCV13 on 11/19/15 and the PPSV23 on 11/21/06 and 12/12/16. R44's medical record lacked evidence he was offered or provided the PCV20. R37's clinical census sheet, identified she was [AGE] years old and admitted on [DATE]. R37 had no allergies or contraindications to vaccines listed. R37's immunization report, identified she had previously received the PCV13 on 11/23/16 and the PPSV23 on 8/28/08. R37's medical record lacked evidence she was offered or provided the PCV20. R103's clinical census, sheet indicated he was [AGE] years old and admitted on [DATE]. R103 had no allergies or contraindications to vaccines listed. R103's immunization report, identified he had previously received the PCV13 on 4/6/16 and the PPSV23 on 12/8/04 and 11/13/17. R103's medical record lacked evidence he was offered or provided the PCV20. When interviewed on 7/19/23 at 9:59 a.m., the Infection Preventist (RN)-A stated the facilities normal process to determine a resident's eligibility for vaccination was to review their immunization history upon admit. The facility would then educate, offer, obtain consent and provider order and administer vaccinations per CDC guidelines and facility policy. The facility policy Pneumococcal Vaccination dated April 2022, identified each resident is offered the pneumococcal immunizations unless the immunizations are medically contraindicated, the resident declines, or the resident has already been immunized. The facility policy also outlined procedural guidelines for determining resident eligibility for pneumococcal vaccines. RN-A stated she had reached out to a facility representative and was informed the facility policy procedural guidelines were outdated and not in accordance with CDC guidelines.

Based on observation, interview and document review, the facility failed to provide routine facial hair removal for 5 of 9 residents (R7, R85, R30, R83, R21 ) and failed to provide nail care for 1 of 9 residents (R85) who were dependent on staff for assistance with grooming and personal hygiene. Findings included: R7's quarterly Minimum Data Set (MDS) completed 12/22/20, indicated R7 required physical assistance from staff with personal hygiene. R7 had severe cognitive impairment but was able to make herself understood and understood others. R7's care plan dated 11/12/17, indicated R7 required assistance from one staff for grooming and personal hygiene. On 3/29/21, at 3:22 p.m. R7 was in her room and was noted to have several long, coarse, white hairs on her chin. On 3/29/21, at 5:35 p.m. R7 in the dining room with two other residents. R7 had several long, white, coarse hairs on her chin. On 3/30/21, at 3:20 p.m. R7 was in her room, noted to have several long, white, coarse hairs on her chin. During interview on 3/31/21, at 12:13 p.m. nursing assistant (NA)-B stated R7 required assistance with grooming but stated R7 can use her electric razor independently after set-up in the bathroom. NA-B stated R7 has her own shaver located in her bathroom. On 3/31/21, at 12:55 p.m. clinical coordinator, licensed practical nurse (LPN)-A stated R7's care plan was up to date and R7 required physical assistance from staff for grooming which included shaving, that R7 is not able to shave herself after set up by staff. LPN-A stated the expectation was that female residents who required assistance with shaving facial hair would receive this assistance when facial hair is visible. LPN-A stated there were several white, long, coarse hairs on R7's chin. R85's annual MDS dated [DATE], indicated R85 had severe cognitive impairment and required physical assistance from two staff for personal hygiene. R85's care plan revised 6/4/20, indicated R85 required two staff assisted with grooming. On 3/29/21, at 3:14 p.m. noted to have several long, white, coarse hairs on R85's chin, upper and lower lips. The nails on R85's left hand were long, jagged and had brown substance under three of the nails. On 3/30/21, at 10:31 a.m. R85 was noted to have several long, white, coarse hairs on her chin, upper and lower lips. The nails on R85's left hand were long, jagged and had brown substance under the same three nails. On 3/31/21, at 7:37 a.m. during observation of cares two staff, NA-B and registered nurse (RN)-B assisted R85 with morning cares. Neither NA-B or RN-B attempted to assist R85 with shaving lip and chin hairs or with nail care. After completion of cares, noted R85 still had several long, white, coarse hairs on her chin, upper and lower lips. R85's nails on her left hand remained long and jagged. Brown substance still noted under 3 of the fingernails on her left hand. On 3/31/21, at 12:09 p.m., NA-B stated R85 can resist cares, but does not usually resist grooming which included nail care and shaving. NA-B confirmed R85 has her own electric razor in her room. NA-B stated she had completed shaving with R85 on 3/26/21. Nail care was typically completed on bath days. NA-B confirmed nursing assistants are able to provide nail care to R85 and it was noted on R85's care sheet. On 3/31/21, at 12:58 p.m. LPN-A confirmed R85's care plan was up to date and R85 required physical assistance from two staff for grooming which included shaving and nail care. LPN-A expected female residents who required assistance with shaving facial hair would receive this assistance when facial hair is visible. Nail care is expected to be completed weekly on bath day and as needed. LPN-A stated the presence of several white, long, coarse hairs on R85's chin, upper and lower lip. LPN-A also stated the nails on R85's left hand were long, jagged and had brown substance under three of the nails. On 4/1/21, at 1:11 p.m. clinical administrator (CA) stated she expected grooming, including shaving for female residents, to be completed as needed, upon rising. It is acceptable that grooming is complete after breakfast if that is the resident's preference. CA indicated it was not acceptable that female residents were noted to have long facial hair on their chin and lips or that residents, male or female, would have long, jagged nails with brown substance under the nails. R30's significant change MDS dated [DATE], indicated R30 had severe cognitive impairment, no behaviors or rejection of care, and required extensive assistance of two staff for activities of daily living (ADLs) which included transfers, dressing, toileting and personal hygiene. R30's care plan printed 4/1/21, indicated an ADL self-care performance deficit related to cognitive impairment with a goal to be clean and well-dressed daily. Further, care plan indicated R30 required physical assistance of one staff for personal hygiene and oral care. However, on 3/31/21, shaving preference and refusal was added to R30's care plan. During observation and interview on 3/29/21, at 6:02 p.m. R30 had several ¼ to ½ gray colored facial hairs across her upper lip, each side of her mouth, and on her chin. When asked about the facial hairs, R30 states I would like the whiskers off, they [whiskers] bother me but I don't want to bother the staff to get them [whiskers] off. On 3/30/21, at 3:34 p.m. R30's facial hair continued to be visible. During an observation on 3/31/21, at 7:10 a.m. nursing assistant (NA)-C and NA-D assisted R30 to get ready for the day. NA-C washed R30's face with a warm, wet, wash cloth and stated I am going to get your mouth, ok? NA-C and NA-D finished with getting R30 ready for the day and placed R30 in the wheelchair in front of her television. NA-C and NA-D grabbed the garbage and dirty linens and exit R30's room. R30's facial hair continued to be visible and R30 was not offered by NA-C or NA-D to remove the facial hair. During interview on 3/31/21, at 2:17 p.m. NA-E stated the care sheets tell you everything like if they [resident] eat independently or if they [resident] need help with personal hygiene. When asked what NA-E defined as personal hygiene, NA-E stated oral care, brushing hair, peri care. Further, NA-E indicated if a resident needs assistance shaving it would be under the miscellaneous box on the care sheets. In addition, NA-E stated if I notice some [facial hair] on a female resident, and if they have an electric razor, then I would offer. Most people [residents] would prefer that you [staff] do it. On 3/31/21, at 2:17 p.m. registered nurse (RN)-C indicated R30 required total assistance from staff for ADLs such as transfers and hygiene. Further, on 3/31/21, at 3:00 p.m. RN-C stated R30 had visible facial hair on her chin and mouth and indicated R30 prefers to have them plucked rather than shaved. In addition, RN-C stated we don't have a specific spot to chart if they [residents] like to be shaved and should be offered on bath days especially but there is no place to put that stuff [shaving preference]. On 3/31/21, at 3:07 p.m. RN-D stated R30 needs help with progressively everything and indicated R30 is dependent on staff assistance with personal hygiene. Further, RN-D stated R30 prefers to have facial hairs plucked however, R30 does refuse at times. Review of facility document titled CV2, which is referred to as a care sheet per staff, not dated, lacked evidence of shaving preference for R30. R83's quarterly MDS dated [DATE], indicated R83 had severe cognitive impairment, had physical and verbal behaviors however no rejection of care, and required extensive assistance of two staff for ADLs such as dressing, toileting and personal hygiene. R83's care plan indicated an ADL self-care performance deficit related to [CONDITION(S)], [CONDITION(S)]/[CONDITION(S)] and R83's goal was to be clean and well dressed daily. However, care plan lacked evidence of personal hygiene assistance and shaving preference. During an observation on 3/29/21, at 2:27 p.m. R83 was noted to have a white colored facial hair about ½ to 1.0 long on her chin. When asked about the facial hair, R83 stated I didn't even know I had whiskers oh my gosh. I would like them gone. The nurses here have never offered it [to shave] but the beautician I used to go to would. I don't like them and I need them gone. On 3/30/21, at 3:32 p.m. R83's facial hair continued to be visible. During an observation on 3/31/21, at 8:36 a.m. NA-C and NA-D assisted R83 to get ready for the day. R83 washed her face independently with a wet washcloth and dried with a towel. NA-C and NA-D assisted with R83's clothes. Further, R83 was transferred to the wheelchair after cares were completed. NA-C and NA-D exited R83's room and did not offer to shave R83 and facial hair continued to be visible. On 3/31/21, at 3:00 p.m. RN-C confirmed R83 had visible facial hair on her chin. In addition, RN-C stated I have noticed it [facial hair] before but not able to get rid of it [facial hair] because she doesn't have a shaver. However, RN-C did not report R83 did not have a shaver to any other staff. On 4/1/21, at 9:35 a.m. licensed practical nurse (LPN)-A indicated R83 displayed many behaviors and only likes certain staff to assist with ADLs. LPN-A indicated R83 required assistance of one staff for personal hygiene which would include applying a brief, oral care, washing under arm pits and perineal area. In addition, LPN-A indicated shaving and nail care would also be considered personal hygiene and should be offered every day during cares, bath days, and per request. LPN-A indicated shaving preference is not kept on the care sheets for the staff to reference and stated It [shaving] has always been recognized as part of daily cares. Review of facility document titled CV2, which is referred to as a care sheet per staff, not dated, lacked evidence of shaving preference for R83. Review of facility document titled Resident Care Policy modified 9/10, indicated every resident to have morning and bed time cares done daily. Further, the facility policy directs staff to review nursing assistant assignment sheet for required assistance and to shave residents in am and apply makeup to female residents as requested. R21's quarterly MDS dated [DATE], indicated R21 was an extensive assist from staff for personal hygiene. R21's had severe cognitive impairment. R21's care plan dated 7/1/20, indicated she required the assistance of one staff with personal hygiene. On 3/29/21, at 6:46 p.m. R21 was in her room and noted to have multiple long, white hairs on her chin from a half inch to three quarters of an inch in length. R21 stated no one had offered to help her with trimming them. R21 stated it bothers me. On 3/30/21, at 10:41 a.m. R21's chin hairs remained. On 3/31/21, at 8:44 a.m. R21 continued to have chin hairs. On 4/1/21, at 9:15 a.m. NA-G stated I did not shave R21 today. NA-G stated R21 did not have a razor and staff were not allowed to use a straight razor on residents. NA-G stated R21's chin hairs were a good length and there were quite a few there. NA-G stated typically the family bring in a razor for the resident to use. On 4/1/21, at 9:43 a.m. LPN-B stated shaving residents was a part of the cares staff provided to the residents. LPN-B stated staff should be shaving residents on their bath day and as needed. LPN-B stated I told staff to shave the residents with chin hairs last night. Facility document, Resident Care Policy, modified 9/2010, indicated to shave residents in the morning. Facility document, Nail Care, dated 12/2014, indicated the purpose of nail care was to provide cleanliness, prevent spread of infection, for comfort and to prevent skin problems. This document did not indicate the frequency this task needed to be completed.

Based on observation, interview and document review, the facility failed to ensure proper personal protective equipment (PPE) practices were maintained when a frontline staff failed to utilize eye protection when providing direct care to residents. This had the potential to affect all 20 residents who resided on the unit, North View II. In addition, the facility failed to ensure proper hand hygiene was performed following providing assistance with incontinent care for 1 of 1 residents (R30) who resided on the unit. Findings included: During observation on 3/29/21, at 5:35 p.m. nursing assistant (NA)-A was assisting in the dining room. NA-A was not wearing eye protection. NA-A was seen entering and exiting multiple resident rooms while not wearing eye protection. On 3/29/21, at 7:09 p.m. NA-A confirmed he had been trained on infection control and use of PPE upon hire which was approximately six months ago. NA-A stated he was aware he was supposed to get clean eye protection at the staff screening station, and the eye protection was supposed to be worn for infection control. He stated he forgot to grab clean eye protection at the start of his shift today, 4:00 p.m. and he had not been questioned about his lack of eye protection until he was interviewed by this surveyor. NA-A indicated he worked with several residents during this day shift. He provided personal cares including grooming, toileting assistance, incontinence care, positioning, and assistance with eating. On 3/31/21, at 11:00 a.m. clinical administrator (CA) and the facility infection preventionist (IP) stated eye protection should be worn by health care workers when they worked in the clinical area. The CA stated the expectation was that all staff monitor each other to ensure proper PPE was worn. Facility document, Mask Use and Eye Protection, updated 8/20/20, indicated eye protection is required for staff that have face to face contact (within 6 feet) of residents, other staff, or visitors. R30's significant change MDS dated [DATE], indicated R30 had severe cognitive impairment, no behaviors or rejection of care, and required extensive assistance of two staff for activities of daily living (ADLs) which included transfers, dressing, toileting and personal hygiene. R30's care plan indicated R30 was incontinent of bowel and bladder and required assistance of one staff with toileting. During an observation on 3/31/21, at 2:28 p.m. nursing assistant (NA)-E and NA-F assisted R30 with incontinent care following a bowel movement. NA-E and NA-F were wearing a face mask, eye protection and gloves during cares. NA-F assisted R30 with perineal care using a wet wipe, and NA-F then removed her gloves. NA-F then grabbed another wet wipe and proceeded to clean bowel off R30 with-out applying gloves. Further, NA-F then disposed of the wet wipe in the garbage and did not perform hand hygiene before NA-F assisted with dressing. NA-F then assisted NA-E with transferring R30 into the wheelchair using a hoyer lift and NA-F pushed R30 in the wheelchair to be placed in front of her television. NA-F did not perform hand hygiene until exiting R30's room where NA-F used the alcohol based hand rub (ABHR). On 3/31/21, at 2:40 p.m. NA-F confirmed NA-F removed gloves, wiped bowel off of R30's hip, and did not apply a new pair of gloves or perform hand hygiene until exiting R30's room. Further, NA-F indicated I panicked because I didn't know where the gloves were. NA-F indicated NA-F should have performed hand hygiene then donned a new pair a gloves before proceeding. In addition, NA-F indicated NA-F came in contact with R30, her clothes, the hoyer lift, and R30's wheelchair before hand hygiene was performed. NA-F stated hand hygiene is important to prevent spreading infections. On 4/1/21, at 11:57 a.m. registered nurse (RN)-D indicated staff were expected to perform hand hygiene, apply gloves, perform incontinent care, remove gloves and perform hand hygiene. RN-D indicated staff should be wearing gloves during incontinent care. Further, RN-D indicated ideally staff should remove gloves and perform hand hygiene when going from dirty to clean On 4/1/21, at 12:20 p.m. director of nursing (DON) indicated staff are expected to perform hand hygiene, apply gloves, and perform incontinent care. Further, DON indicated if you [staff] are soiled in between you would stop and hygiene before new gloves and then when you [staff] are done with the task you perform hygiene. Review of facility policy titled Incontinence Care dated 12/14, indicated the purpose is to prevent infection. However, policy lacked evidence of when staff are directed to perform hand hygiene. Review of facility policy titled Infection Control Stand Precautions dated year 2020, defined hand hygiene as a general term that applies to either hand washing, antiseptic handwash, antiseptic hand rub or surgical hand antisepsis. Further, policy indicated the purpose was to prevent the spread of potentially deadly infections, provide a clean and healthy environment, and reduce the risk to the healthcare provider or colonization or infections acquired from a resident. In addition, the policy indicated hand hygiene continues to be the primary means of preventing the transmission of infection. The policy indicated hand hygiene should be performed before and after contact with a resident, after contact with blood or body fluids, before donning personal protective equipment and after removing personal protective equipment.

Based on interview and document review, the facility failed to ensure the required nurse staffing information was posted daily. This had the potential to affect all 108 residents residing in the facility and visitors. Findings include: When reviewing the facility's daily nursing hour postings for 3/29/21, the posted hours were dated 1/14/21. The nursing hours were not posted for 3/29/21. On 4/1/21, at 9:47 a.m. staffing coordinator (SC) stated the staffing coordinators are responsible for ensuring the daily nursing hours are posted each morning and are updated as changes are needed. SC indicated the daily nursing hours were not posted 1/15/21-3/29/21. However, the daily nursing hours were tracked and maintained on the staffing computer and were updated in the computer as needed when changes to the schedule occurred. On 4/1/21, at 1:10 p.m. the clinical administrator (CA) confirmed the daily nursing hours had not been posted 1/15/21-3/29/21 due to the door they were posted at was no longer the main entrance to the facility. CA stated there was no other location these were being posted during that time. Facility document, Nursing Hours Posting Policy, modified date 7/2010, indicated nursing staff data will be posted in a designated public area by the staffing personnel.

Based on observation, interview and document review, the facility failed to implement a system for periodic reconciliation of controlled substance medications in 1 of 1 emergency kit (E-Kit) to prevent potential loss or diversion. This had the potential to affect any of the 131 residents residing in the facility who may require controlled medications from the E-Kit. Findings include: A tour of the Northview 1 medication storage room was conducted with licensed practical nurse (LPN)-A on 9/11/19 at 10:41 a.m At the time of the tour a refrigerator was observed in the medication room which contained a small tackle box identified by RN-A as part of the facility's E-Kit. When the list of contents of the E-Kit were reviewed, it was determined the E-kit contained 2 vials of injectable [MEDICATION NAME] (an anti-anxiety medication/controlled substance). The E-kit was secured with a numbered red plastic pull tag attached to the clasp of the box. In addition, in a cupboard was a tackle box which was identified by LPN-A as part of the E-Kit. The tackle box from the cupboard contained 6 [MEDICATION NAME] tablets, 4 syringes of injectable [MEDICATION NAME] sulfate, 4 suppositories of [MEDICATION NAME] sulfate, 6 tablets [MEDICATION NAME], (all controlled substances used for pain) and 6 oral tablets of [MEDICATION NAME], and an injectable [MEDICATION NAME] (both controlled substances use for anxiety). The tackle box was secured with a numbered red plastic pull tag attached to the clasp of the box. LPN-A stated facility staff did not routinely monitor patency of the pull tag, but would write the pull tag number down when removing an item from the E-Kit and replace it with a yellow pull tag. LPN-A further stated she thought the pharmacist monitored the pull tags but was not sure how often that occurred. During interview on 9/11/19, at 1:11 p.m. registered nurse (RN)-B stated the pharmacy switches the E-Kits every Sunday and Thursday. RN-B stated if there is a red pull tag on the E-Kits you can assume it's good adding there is a camera in the medication room. RN-B verified the pull tag numbers were not verified on the E-Kit during the end of shift narcotic count, or ever. During interview with the director of nursing (DON) on 9/12/19, at 9:29 a.m., the DON confirmed the E-Kit stored in the medication storage room contained controlled substances that were not routinely reconciled/monitored. The DON stated the night shift nurse should check for the presence of the E-kit but could not produce verification of this process, and confirmed the facility did not have a system in place to routinely monitor the contents or patency of their E-Kit controlled substances. The DON further included a camera was in the medication room. The facility's policy titled Narcotic and Controlled Substance Count revised 8/16, included: Emergency kits containing narcotics and controlled supplies will be checked daily. When the seal has been broken the narcotic and controlled substance count needs to be reconciled daily until the replacement kit arrives.

Based on interview and document review, the facility failed to ensure a written notice of transfer was provided to the resident and/or the resident representative for 1 of 1 residents (R90) reviewed for hospitalization . This had the potential to effect any resident transferred for a higher level of care. Findings include: R90's quarterly Minimum Data Set ((MDS) dated [DATE] identified R90 has impaired cognition. R90's progress notes dated 8/18/19, 5/16/19, and 2/1/19, identified R90 was transferred to the hospital via ambulance for fever. Documentation included resident and responsible party were informed through phone and copy of bed hold was sent with the resident. The medical record lacked documentation of a transfer notice given to the resident or resident representative. During interview on 9/12/19, at 11:31 a.m., corporate consultant (CC)-A stated they are not giving a notice of transfer/discharge at the time of transfer to the hospital. CC-A further indicated they do notify the ombudsman of all hospitalization s at the end of the month on a list per the ombudsman request.

Based on observation, interview and document review, the facility failed to ensure a safe and comfortable environment for 1 of 1 residents (R12) observed with a heavily soiled wheelchair. Findings include: R12's current physician orders, dated 9/12/19, included [DIAGNOSES REDACTED]. R12's quarterly Minimum Data Set, dated dated [DATE], revealed R12 had severe cognitive impairment, and required extensive assistance from staff for repositioning, hygiene, and transferring from one surface to another. During observation of the evening meal on 9/9/19, at 6:02 p.m., R12 was feeding herself a grilled cheese sandwich. R12's wheelchair was heavily soiled with food debris on the left wheel, spokes, frame, and front left side of cushion. During interview on 9/9/19, at 6:38 p.m. family member (FM)-A indicated the wheelchair is frequently soiled and notices the same food debris week to week during visits. FM-A further indicated it bothered her and she has asked for it to be cleaned. During observation on 9/10/19, at 8:32 a.m. and 9/11/19, at 11:23 a.m. R12's wheelchair cushion, left wheel, spokes, and frame continued to have a splattered dirty appearance with chunks of food debris present. During observation and interview on 9/12/19, at 7:14 a.m. nursing assistant (NA)-A confirmed R12's wheelchair was soiled with food debris and stated I agree that is really gross. NA-A further stated R12's wheelchair needed to be cleaned. During observation and interview on 9/12/19, at 7:23 a.m. registered nurse (RN)-A confirmed R12's cushion, left wheel, spokes, and frame were visibly soiled with dried food debris, and needed to be cleaned. RN-A further indicated the expectation is for staff to wipe down and clean a wheelchair when visibly soiled. During interview on 9/12/19, at 9:08 a.m. director of nursing (DON) confirmed her expectation is for wheelchairs to be clean. DON further indicated there was a monthly wheelchair cleaning room list for night staff to follow, but verified no documentation existed that R12's wheelchair cleanings had been completed. A facility policy titled Wheelchair Cleaning revised 10/15 included: wheelchairs will be maintained in a clean, hygienic condition.

Based on observation, interview and document review, the facility failed to provide care in a manner to promote self determination and dignity for 1 of 1 resident (R22) reviewed for dignity. Findings include: On 8/13/18, at 2:40 p.m. R22 was observed laying on his bed with the door open. R22 was wearing an incontinence product, but no clothing covering his brief such as pants, shorts or pajama bottoms. There was no sheet or blanket covering R22. At 5:55 p.m., R22 was again observed with the door open, wearing an incontinence brief but no other clothing covering his brief. R22 had no blanket or sheet covering him. On 8/14/18, at 8:43 a.m. R22 was observed in his room eating breakfast. R22's door was open. R22 was wearing an incontinence brief with no clothing to cover his brief. R22 had no sheet or blanket covering him. On 8/14/18, at 3:57 p.m. R22's door was closed. After knocking, upon entrance R22 was observed on his bed, uncovered again wearing only an incontinence brief without any clothing covering the brief. At that time, R22 stated he does not wear pants due to staff preference, not his own. On 8/15/18, at 7:59 a.m. nursing assistant (NA)-A and NA-B were observed to assist R22 with changing his brief and washing up. NA-A and NA-B helped dress R22 with a shirt. NA-A and NA-B did not offer to help R22 put any pants, shorts or pajama bottoms, but did put a blanket over R22. On 8/15/18, at 3:14 p.m. the director of nursing (DON) reported she would look into why R22 was not wearing any type of clothing over his incontinence brief. The DON stated staff should offer to assist R22 with putting on lower extremity clothing unless directed otherwise by the care plan. On 8/15/18, at 2:45 p.m. registered nurse manager (RN)-A stated it was R22's preference not to wear pants. Then RN-A added, RN-A stated she had not seen R22 with clothing bottoms on but was not aware of a reason. RN-A stated if there was a concern or reason for R22 not to wear any clothing over his incontinence brief, it should be identified in the care plan or on the NA care sheets. RN-A reviewed the care plan and care sheets and verified there was nothing documented about R22 not wearing clothing over his incontinence brief. On 8/15/18, at 2:59 p.m. R22 again told the surveyor he would prefer to wear pants, especially if he was not covered by a sheet or blanket. R22's most recent admission minimum data set (MDS) assessment dated [DATE], indicated R22 was moderately cognitively impaired, did not refuse care and had no behaviors that were disturbing to him or others. The MDS further indicated R22 required extensive assistance from two staff to dress as his [DIAGNOSES REDACTED]. On 8/15/18, at 3:02 p.m. licensed practical nurse (LPN)-A stated, as far as I know it is his preference not to wear pants. LPN-A reported she had worked with R22 for three days and he was typically wearing incontinence briefs and not covered. On 8/16/18, at 9:44 a.m. NA-C stated R22 refuses to wear pants as he gets hot and will rip the blanket off. NA-C stated she had reported this to the nurse manager (RN)-A. On 8/16/18, at 9:47 a.m. RN-A reported the nursing assistants should offer R22 clothing for his lower body to cover the incontinence brief. On 8/16/18, at 3:28 p.m. NA-A reported staff were not in the habit of offering R22 clothing for his lower body because R22 refused. NA-A also stated R22 would remove blankets and sheets put over him. NA-A reported he'd informed RN-A about R22 not wearing lower body clothing yesterday. R22's care guide undated, included no directions related to R22 not wearing lower body clothing. R22's care plan last revised 4/19/18, included: Assist me to choose simple, comfortable clothing that is easy to put on. and Dressing: I require 1 staff participation to dress. There were no problems, goals or intervention related to R22 not wearing lower body clothing.

Based on interview and document review, the facility failed to provide a Notice of Bed Hold and Readmission for 2 of 2 residents (R22 and R112) who were transferred to a hospital. Findings include: R22's medical record, including progress notes and hospital documentation from 7/22/18 to 7/25/18, revealed R22 had been hospitalized related to a urinary tract infection. Further review of R22's record revealed no indication R22 or his resident representative had been provided with a copy of the facility's bed hold policy upon transfer. On 8/16/18, at 11:48 a.m., registered nurse (RN)-A reviewed R22's record and verified there was no evidence the facility's bed hold policy was provided to R22 or his resident representative upon transfer to the hospital. Further, RN-A stated the bed hold policy was provided at the time of admission, but stated she was unsure if it was provided at the time of hospital transfer. RN-A explained the facility would automatically hold the bed for 18 days for R22 since his care was paid for by the state's medical assistance program. R112's face sheet indicated the resident had [DIAGNOSES REDACTED]. Review of a progress note dated 5/8/18, indicated R112's temperature had increased and oxygen level decreased with labored breathing, and an order for [REDACTED]. Review of the progress notes lacked evidence of the facility providing R112 or the responsible representative bed hold information at the time of hospital transfer. During an interview on 8/16/18, at 12:10 p.m. licensed practical nurse (LPN)-B stated she expected the family to be notified of a bed hold, and that information should have been documented in the 5/8/18 progress note. On 8/16/18, at 1:17 p.m. the director of nursing (DON) confirmed the facility protocol was for staff to notify residents or their family of a bed hold. The facility's Bed Hold policy dated (MONTH) 2014 included: 1. Upon admission, resident or resident representative will sign Bed Hold and Readmission Policy . 3. Before a resident leaves for hospitalization or therapeutic leave, the facility will attempt to give the resident a copy of the bed hold policy . 5. Discussion regarding bed hold will be documented in the progress notes.