Every finding on record at Gracewell, An Eventide Community

Based on observation, policy review, resident, and staff interview, the facility failed to prepare food that conserved flavor, appearance, and palatable for a lunch meal. The facility reported a census of 71. Findings include: Interview on 10/28/24 at 11:39 AM, Resident #15 stated the food is often overcooked and burnt at times, especially the meat. Interview on 10/29/24 at 9:33 AM, Resident #45 stated the food is bland, just didn't taste good. They described the meat as tough and unable to cut it. During continuous observation on 10/30/24 starting at 9:25 AM, Staff G, Cook, placed 5 pans of chicken nuggets into the oven to bake. At 9:40 AM they placed a pan of fish fillets into the oven to bake. At 9:50 AM, when Staff G checked the temperature of the chicken, it registered at 180 degrees Fahrenheit (F), and at 10:10 AM the fish fillet temperature registered at 174 F. Staff G left the chicken and fish in the oven. On 10/30/24 at 12:30 PM after the staff completed serving the lunch meal, the facility provided a test tray of sesame chicken, Asian blend vegetables, and fried rice. The sesame sauce appeared to soak through the breading of the nugget, no liquid sauce. The chicken nuggets too tough to cut with a fork only, but able to cut with a knife. The nuggets tasted dry with a moderate amount of work needed to chew the chicken thoroughly. The vegetables were mushy as able to mash all vegetables down to almost a puree consistency with a fork. They looked so overcooked couldn't differentiate the difference of each vegetable as the color of them all appeared the same greenish/brownish color. Interview on 10/30/24 at 1:30 PM, Resident #15 described the lunch meal as not good. Resident #15 reported he had the sesame chicken. He detailed the chicken as over cooked, very dry, with no sesame sauce on the chicken, and overcooked, mushy vegetables. Interview on 10/31/24 at 10:30 AM, the Dietary Manager agreed the vegetables served for the lunch meal the day before were very mushy and stated they expected the staff to provide residents a palatable meal. The facility policy, Food Preparation Guidelines dated 2/1/24, instructed food shall be prepared by methods that conserve nutritive value, flavor, and be palatable.

Based on resident record review, facility policy review, staff, resident, and family interviews, the facility failed to verify a resident's Advanced Directives choice for 2 of 24 residents reviewed (Residents #8 and #58). The facility reported a census of 71 residents. Findings include: 1. Resident #58's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of Alzheimer's and bipolar disorder. Resident #58's Free Choice of Health Care Services signed by his sister on [DATE], marked he wanted cardiopulmonary resuscitation (CPR) should his heart stop beating. The Physician telephone order dated [DATE] and signed by the physician on [DATE] reflected an order for Resident #58 to be a do not resuscitate (DNR) per family wishes. The Care Plan Focus dated [DATE] reflected Resident #58's Advanced Directives as DNR. Upon revision on [DATE], the Care Plan indicated DNR [DATE] CPR per Resident #58's wishes. The Interventions revised [DATE] directed to honor Resident #58's wishes: [DATE] - DNR per Resident #58's and family's wishes. On [DATE] CPR per Resident #58's wishes. Interview on [DATE] at 11:07 AM, Resident #58's sister, with Resident #58 in attendance, reported his Advanced Directive as CPR when he was admitted . The facility approached them about Resident #58's code status and his siblings chose for him to be a DNR. Resident #58's sister reported being up in the air with CPR or DNR. She explained CPR and DNR to Resident #58 and he stated he wanted CPR. Resident currently has a BIMS of 15. Interview on [DATE] at 3:18 PM, Staff F, Nurse Manager, stated she spoke with Resident #58's sister earlier that day. She reported Resident #58 wanted CPR for his Advanced Directives status. Staff F stated that during a care conference in the past, the siblings spoke to the facility and wanted the advanced directive changed from CPR on admission to DNR status. Staff F stated the facility's protocol is to fill out a physician telephone order slip with the code status change for the physician to sign. Staff F also stated they don't redo the initial form filled out on admission and signed by the resident or family. Staff F acknowledged Resident #58 had a BIMS of 15, and the facility didn't have a physician's note deeming him as incompetent to make his own decisions, they didn't have any documentation that someone talked to the family or Resident #58 about his code status. The facility only had the physician's order slip signed by the physician that documented the DNR per family's wishes, and should have something signed by family. 41785 2. Resident #8's MDS assessment dated [DATE], identified a BIMS score of 5, indicating severe cognitive deficit. Resident #8 required substantial assistance with dressing, hygiene, transfers and toileting. The MDS included diagnoses anemia (low blood iron levels), peripheral vascular disease (impaired blood circulation) and non Alzheimer's' dementia. The Care Plan Focus revised [DATE] reflected Resident #8 wanted DNR as their Advanced Directive wishes. The Intervention instructed the staff to provide education as requested or needed regarding Advanced Directives and maintain a copy of her code status in the chart. The Care Plan Focus revised [DATE] indicated Resident #8 had impaired cognitive function and impaired thought processes related to dementia. Resident #8's Free Choice of Health Care Services form signed by her niece on [DATE], indicated she wished for CPR, should her heart stop. The Communication - with Physician dated [DATE] at 10:17 AM identified Resident #8's family changed Resident #8's code status to DNR. The chart lacked a second form for the change in code status on [DATE]. On [DATE] at 6:40 AM, the Director of Nursing (DON) said they reviewed code status wishes with families at the quarterly care conferences. She pointed out a separate line on the form titled: Review Advanced Directive, where it was documented CPR or DNR. Another line on the form was titled; Phone Call to, where they documented the name of the resident's representative and phone number. A Care Conference note dated [DATE] identified the Review of Advanced Directives box indicated CPR. The form included Resident #8's Representative's name and phone number, the document lacked a signature of the representative. A Care conference note dated [DATE], reflected the Review of Advanced Directives box unchecked and documented; DNR per family. The line titled; Phone Call To, included the name of the representative with several phone numbers. The form lacked documentation that they could to talk to the family representative. The form lacked a signature of the representative. On [DATE] at 4:10 PM, Staff F, Unit Manager, said they put the phone numbers on the care conference line for the family member so they could contact them during the care conference. She acknowledged they didn't document if they actually got ahold of the family. She acknowledged they should follow up and get a signature especially when they had a code status change. The Residents' Rights Regarding Treatment and Advance Directives policy, dated [DATE], directed the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.

Based on observation, interview, and record review the facility failed to identify new skin issues in a timely manner for 2 of 4 residents reviewed (Residents #29 and #66). Resident #29 had an abdominal pressure ulcer, their clinical record lacked documentation until the area showed signs of infection. Resident #66 had bruising and a skin tear on her lower leg. The facility didn't discover or document the skin tear until after it scabbed over. The facility reported a census of 71 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. 1. Resident #29's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He required substantial assistance with dressing and hygiene. The MDS listed him as totally dependent for transfers, toileting, and turning in bed. The MDS included diagnoses of heart failure, basal cell carcinoma (cancer) of skin, and type 2 diabetes mellitus. The MDS indicated Resident #29 didn't have pressure injures. According to a Wound Clinic note, dated 2/27/24, Resident #29 had 2 unstageable pressure injuries at that time; 1 to the right heel and 1 on the anterior (front) of the right foot. The Care Plan included the following Focuses dated: a. 8/14/24 identified Resident #29 had a terminal prognosis related to chondrosarcoma and received system management of his terminal illness by hospice services. b. 1/31/23 indicated Resident #29 had an activities of daily living (ADLs) self-care performance deficit related to heart failure, diabetes mellitus measured by activity intolerance, weakness, impaired balance, and new placement. The Interventions directed the staff to: i. Follow skin prevention protocols. He had self care performance deficit related to heart failure diabetes mellitus and impaired balance. ii. Inspect the skin and observe for redness, open areas, scratches, cuts bruises, and report to the charge nurse. C. Revised 8/16/24 reflected Resident #29 took Lantus related to diabetes mellitus. The Interventions directed the staff to: i. Check all of his body for breaks in skin and treat promptly as order by the physician. ii. Inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. On 10/29/24 at 10:51 AM, observed Staff A, Registered Nurse (RN), provide Resident #29's wound treatments. Witnessed Resident #29 had a blackened ulcer on his right heel, an open oozing wound on the top of his right foot, and a deep ulcer under the abdominal fold on his right side. Staff A said the injury under the folds presented first as a pimple, then suddenly opened up, and had extensive drainage. After Staff A completed Resident #29's treatments and wrapped his right foot, she learned he had a spot under his right leg on the lower calf area. She said didn't know of the spot and proceeded to measure the abrasion. A nursing note on 10/29/24 at 12:06 PM, showed that the abrasion to the lower calf measured 0.5 centimeters (cm) x 0.5 cm, circular and red in the center. The resident was unsure how he got it. Resident #29's clinical record identified the first reference of a developing skin issue under the right abdominal fold in a nursing note created on 3/8/24 at 8:20 AM, for the date of 3/7/24 at 11:53 AM. The documentation described the skin issue as an area to the right groin having small drainage. The chart lacked description of the source of the drainage. The Health Status Note dated 3/8/24 at 3:30 AM, reflected Resident #29 had drainage of white, greenish pus, and bloody discharge in his right groin area, area harden 2 inches into the groin/scrotum area. The Physician/Nurse Communication Report dated 3/8/24, documented Resident #29's right groin crease had a lot of drainage. The drainage went from greenish to pus then bloody. Resident #29 had facial grimaces with cleansing. The staff couldn't keep the area dry due to the amount of drainage. The doctor replied with orders for a warm moist pack to her right thigh area for 15-30 minutes four times a day for seven days and Cephalexin 500 mg 1 by mouth 3 times a day, or every 8 hours for 7 days. They would see her on 3/11/24. Resident #29's Nursing Notes from 3/7/24 3/11/24 included the amount of drainage in the groin wound and their response to the antibiotic. The chart lacked measurements and further descriptions of the wound. The handwritten Physician's Orders and Progress Notes dated 3/11/24 reflected the provider rechecked Resident #29's right groin abscess, following the order of warm packs and antibiotic. Resident #29's wound culture remained pending. They denied fevers, chills, or increased pain in the right groin area. He complained of itching in his left groin that appeared to have excoriation (red irritated skin). The right groin exam revealed an area of firmness down into the right inner thigh. The groin had a small opening where the abscessed drained. Only a scant amount of bloody drainage observed. The provider gave orders for Lortisone cream to the affected red itchy areas twice a day as needed for dermatitis/yeast. The orders included to place a 4 by (x) 4 in the right groin over the abscess area and apply a paper towel to the left groin area. The nursing note from 3/11 3/18 made a reference to antibiotic reaction and continued drainage, but lacked compete documentation of size and color of the wound. A review of a form titled: Wound Documentation from 3/18/24 to 4/15/24, showed the first detailed description of the right groin wound 3/18/24. The form described the wound as an abscess measuring 1 cm x 0.5 cm with bloody drainage, and a purplish surrounding base. The wound edges denudation (denuded wound is an injury that occurs when the protective top layer of the skin is gone, leaving the underlying tissue exposed.) The documentation lacked staging. A Wound Clinic note dated 4/1/24, indicated Resident #29 had a right groin ulcer, described as a Stage II blister with bloody drainage. Upon inspection the base appeared boggy with an appearance of old instant blood return. The wound had ecchymosis (bruising) around the opening. It appeared as if the skin had gotten pinched or rubbed. The anticoagulant medications caused increased bleeding. The wound measured 1.4 cm. length x 0.7 cm. width x a depth of 0.5 cm. The area appeared boggy, with a peri wound with ecchymosis. On 10/31/24 at 8:34 AM, the Wound Clinic RN said something caused the area to break open and started the drainage from under the surface. She said deep tissue injuries could first present as bruising, especially when a resident used anticoagulants, the medication helps to feed the wound. She said given the wound oozed, he may have had bruising before the break in the skin. Resident #29's March 2024 Medication Administration Record (MAR) listed an order for Apixaban (anticoagulant) 5 milligrams (mg) twice a day. On 10/30/24 at 3:09 PM, Staff D, RN, said they didn't have scheduled skin assessments but documented when they identified an issue. Once they found new area they would complete weekly assessments. She said that they didn't do scheduled full body skin assessments and relied on recognizing areas through daily observation during cares. On 10/31/24 at 11:12 AM, Staff F, Unit Manager, described the Certified Nurse Aides (CNA's) as the eyes and ears of the nurses. They did regular monitoring for any new skin issues and reported them to the nurses. She said the nurses often helped with daily cares and they always watch for any concerns. She maintained the groin issue originated with a pimple and just exploded. Staff F said that on 3/7/24 someone came to her about it and they contacted the doctor, the next day it started oozing. She said they didn't document it on a skin sheet because it didn't seem like a concern at that time. She acknowledged they didn't start a wound documentation sheet until 3/18/24. She said they started the wound sheets on Mondays. 2. Resident #66's MDS assessment dated [DATE], identified a BIMS score of 6, indicating severely impaired cognition. She required substantial assistance with dressing, showers, and moderate/partial assistance with sit to stand and toilet transfers. The MDS included diagnoses of arthritis, osteoporosis, cerebrovascular accident (CVA or stroke) and non Alzheimer's dementia. The Care Plan Focus dated 6/13/24, indicated Resident #66 had the potential for excess bruising and/or bleeding related to the use of aspirin for her history of cerebral infarction (stroke). The Interventions directed the staff to monitor for excess bruising/bleeding with cares. Resident #66 admitted to hospice for system management of her terminal illness. A nursing note dated 10/28/24 at 3:00 AM, reflected a CNA reported a new area to Resident #66's left lower leg. The bruise measured 5.5 cm x 4.0 cm. On a side of the bruise had 2-line scabs each measuring 1.0 cm. The second bruise above measured 1.5 cm x 1.0 cm. Resident #66 couldn't recall what happened. On 10/30/24 at 2:43 PM, observed Staff C, RN, take Resident #66 to her room and pull up her pant leg to reveal two small scabbed areas. Around the scabs, the skin looked purple and slightly raised. She couldn't describe how it happened. On 10/31/24 at 11:12 AM, Staff F said that she didn't know why the bruising and skin tears on Resident #66's left leg didn't get discovered sooner, because by the time they found them, they scabbed over. On 10/30/24 at 4:10 PM, the Administrator and the Director of Nursing (DON) said the staff did a good job of watching for new skin issues. They said the CNAs didn't do assessments, but alerted the nurses to any concerns. They indicated the nurses help with a lot of the resident cares so they also have eyes on the resident's skin to monitor on a regular basis. A facility policy dated October 2023 titled: Skin Care, described the purpose of the policy as to give immediate assessment and treatment to all areas of the skin where tissue damage occurred and to prevent further skin damage. The direct care staff completed daily skin care through observance of any red, open, discolored areas and immediately reported the change in skin to the charge nurse. The assigned nurse would complete the weekly skin care documentation for a specific area on all residents with current and/or potential problems.

Based on observation, interview and record review the facility failed to practiced adequate hand hygiene for 1 of 4 residents reviewed (Resident #3) for infection control measures. As the nurse administered Resident #3's medications via a feeding tube, she failed to change her gloves after she had contact with several surfaces. The facility reported a census of 71 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS listed Resident #3 as totally dependent on staff for toileting, dressing, sit to lying, chair to bed transfer, and toilet transfers. The MDS included diagnoses of aphasia (difficulty speaking), cerebrovascular accident (CVA or stroke), neurogenic bladder (trouble with urinating either too much or not enough) and anemia (low iron in the blood). The Care Plan Focus dated 7/25/24, indicated Resident #3 required enhanced barrier precautions related to a history of C-diff (clostridium difficile bacterial infection in the large intestine) and a feeding tube. The Care Plan Focus revised 8/26/24 reflected Resident #3 had a nutritional risk. She couldn't have anything by mouth due to a history of dysphagia (difficulty swallowing) and receiving 100% of her nutrition and hydration by her G-tube. On 10/29/24 at 8:48 AM, Staff A, Registered Nurse (RN), prepared Resident #3's medications for administration into the PEG (Percutaneous Endoscopic Gastrostomy or feeding tube) tube. As Resident #3 laid in bed on her back, Staff A stood on one side of the bed and a nursing student on the opposite side. They each grabbed the protective pad under Resident #3 and slide her up in bed. Once up in the bed, Staff A failed to change her gloves or complete hand hygiene as she prepared the water and medications to administer. On 10/31/24 at 11:12 AM, Staff F, Nurse Manager, said she taught the staff to change their gloves and practice hand hygiene after touching surfaces that could possibly be contaminated. She said Staff A should have removed her gloves and performed hand hygiene before preparing the medications. A facility policy for PEG Or G Tubes, dated October 2023, indicated that residents with G Tube feeding would be cared for as ordered per physician, with emphasis on infection control and resident comfort. The Hand Hygiene policy dated February 2024, directed all staff to perform proper hand hygiene procedures to prevent the spread of infection.

Based on staff interviews the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 73 residents. Findings include: On 9/18/23 at 9:29 AM Staff B, Dietitian, reported that she is at the facility one day a week. Staff B stated the facility did not currently have a Certified Dietary Manager (CDM) at the facility. Staff B stated the Administrator is covering as the kitchen manager at this time and Staff C did the ordering. Staff B stated the Administrator did not have a CDM certificate either. Staff B stated that she and the facility knew of the regulation about the need for a CDM. Staff B said it is not always possible to have a CDM, but the facility is actively taking steps to hire a CDM. On 9/19/23 at 10:28 AM the Administrator stated the facility is aware of the regulation that a CDM is required at the facility. The Administrator stated the facility is actively taking steps to hire a CDM. The Administrator stated she is covering as the kitchen manager at this time. Request for documentation from the Administrator of qualifications for dietary manager revealed no certification or documentation. On 9/21/23 at 10:00 AM the Administrator stated the facility has no policy for employment of a Certified Dietary Manager or Kitchen Manager.

Based on observation, staff interview, and policy review the facility failed to store and prepare food in accordance with professional standards. The facility reported a census of 73 residents. Findings include: On [DATE] from 9:29 AM through 10:10 AM during a continuous observation during the initial kitchen tour revealed: a. The two door refrigerator had beef base chicken base, and gluten free bread open and undated. b. The dry storage had two packages of hamburger buns best if used by [DATE], one package of white sandwich bread best if used by [DATE], seven packages of white dinner rolls best if used by [DATE], one package of white dinner rolls best if used by [DATE], a large storage container of chocolate candy open and undated, a large storage container of graham cracker crumble open and undated, and a 10 pound bag of noodles open and undated. On [DATE] at 10:10 AM observed Staff C, Cook, remove eight hamburger buns from a package to puree. Staff C put four hamburger buns and seven pork patties in the blender with milk. Three more hamburger buns were added and blended together. One hamburger bun fell on the floor. Staff C picked the hamburger bun off the floor and put the hamburger bun onto the stainless table. Without completing hand hygiene, Staff C returned to the blender and used her index finger to push food off the side of the blender into the blender. Staff C did not wear gloves or do any hand hygiene prior to or after blending the food for pureed diets. Staff C returned to the stainless table and picked up the hamburger bun and threw it into the garbage. On [DATE] at 12:06 PM observed the lunch service for the Traditional wing. Witnessed Staff D, Dietary Aide, remove all the foil from pans. Staff D then obtained all the temperatures for all the food served on the Traditional wing. When Staff D served the carrot cake she applied a glove to her left hand. Staff D supported the side of the cake pan with her left gloved hand and touched the top of every piece of cake to support when cake was plated for the residents. Staff D repeated supporting the cake pan with gloved hand and supporting the cake with gloved hand for every piece plated. The Food Storage policy dated [DATE] instructed that food should be dated as it is placed on the shelves if required by state regulation. Date marking should be visible on all high-risk food to indicate the date by which the ready to eat, TCS (time/temperature controlled food for safety) food should be consumed or discarded. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk food or opened packages. All containers or storage bags must be legible and accurately labeled and dated. The undated Hand Washing Techniques policy directed that staff are to wash hands before and after resident contact, after contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated, and after removing gloves). Gloves should be used as an adjunct to, not a substitute for, washing hands. Gloves should be worn for hand contaminating activities. On [DATE] at 9:45 AM Staff B, Dietitian, stated she expected all opened food items have an open date on the package. Staff B added that she expected that all expired food be thrown away and would not be used. On [DATE] at 3:26 PM the Administrator said the facility's expectation is that hand hygiene would be completed prior to and after any handling of food. The Administrator stated when a task is completed with food there would be no cross contamination.

Based on observation, record review, document review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing adequate hand hygiene when assisting 4 of 8 residents reviewed (Residents #23, #68, #70, and #174). Finding include: 1. Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) of 5, indicating severe cognitive impairment. On 9/20/23 at 7:20 AM observed Staff E, Registered Nurse (RN), give medications to Resident #23. Staff E completed hand hygiene and placed the blood sugar machine on a clean field. Staff E applied a glove to her right hand but not the left hand. Staff E used her left hand to support Resident #23's left hand index finger. Staff E used a lancet (enclosed needle that moves out to puncture the skin to obtain blood for a blood sugar check) to obtain blood from Resident #23's left hand. Staff E used her left hand to milk (squeeze and push) Resident #23's finger to obtain a blood sample. Staff E cleaned the blood sugar machine, put blood sugar strips away, threw away the lancets and completed hand hygiene. 2. On 9/20/23 starting at 7:20 AM observed Staff F, RN, complete the following medication administrations: a. Staff F accessed the computer to open the Medication Administration Record (MAR), then opened the medication cart drawer. Staff F retrieved Resident #70's medications from the medication cart. Without completing hand hygiene, Staff F applied gloves, and administered Refresh eye drops to Resident #70's bilateral eyes. After Staff F administered Resident #70's inhaler, they returned to the medication cart. Staff F completed no hand hygiene upon return, opened drawers to the medication cart, and returned the medications to the drawers. Then Staff F completed hand hygiene. b. Without completing hand hygiene, Staff F obtained Resident #174's medications and administered them to her. Staff F returned to the medication cart and without completing hand hygiene, Staff F grabbed paper work for another resident's dental appointment from the medication room. Then Staff F returned to the resident's room and dropped off the paper in the resident's room. c. Without completing hand hygiene, Staff F returned to the medication cart and obtained Resident #68's Ocusoft lid scrub (used to clean the eyelids). Staff F entered Resident 68's room, applied gloves, wiped her eyes, removed their gloves, and left the room. Staff F completed hand hygiene upon returning to the medication cart. The undated Hand Washing Techniques policy directed that staff are to wash hands before and after resident contact, after contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated, and after removing gloves). Gloves should be used as an adjunct to, not a substitute for, washing hands. On 9/20/23 at 3:20 PM the Director of Nursing (DON) said that the facility's expectation is for the staff to complete hand hygiene between every resident and every task. The DON stated hand hygiene should be completed before and after entering a resident's room as well. The facility's expectation is for the person completing the blood check to wear two gloves. On 9/20/23 at 3:26 PM the Administrator said the facility's expectation is for the staff to complete hand hygiene prior to and after any resident cares.

Based on electronic record review, policy review, and staff interviews the facility failed to provide a comprehensive Care Plan that included diuretic (medication used to remove excess fluid from the body) therapy for 1 of 5 residents reviewed (Resident #71). Resident #5's Care Plan lacked the information on what signs and symptoms to watch for when using a high risk medication (diuretic), such dehydration. Finding include: Resident #71's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) of 13, indicating no cognitive impairment. The MDS included a diagnosis of edema, unspecified. The MDS indicated that he used diuretics for seven out of seven days in the lookback period. Resident #71's September 2023 Medication Administration Record (MAR) listed an order for furosemide (diuretic) to give 20 milligrams (mg) by mouth one time a day for edema / fluid. The order lacked what to monitor for side effects for the use of a diuretic medication. Resident #71's Comprehensive Care Plan included a Focus dated 8/10/23 that he had an activities of daily living (ADL) self-care performance deficit related to pneumonia diagnosis and intellectual disability. The Care Plan lacked information related to the use of high risk medications and side effects related to the use of the medications. On 9/21/23 at 8:25 AM Staff A, Registered Nurse (RN) / MDS Coordinator, reported that she missed that Resident #71 received a diuretic. Staff A stated it is her expectation and the facility's expectation that use of a diuretic would be included in Resident #71's Care Plan. On 9/21/23 at 10:26 AM the Director of Nursing (DON) explained that the facility expected a Care Plan developed for Resident #71 included the use of a diuretic and appropriate interventions related to the use of a diuretic. Review of policy with copyright date of 2023, titled Comprehensive Care Plan directed the purpose of the policy for the facility to develop and implement a comprehensive person-centered Care Plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on clinical document review, staff interview, and facility policy review the facility failed to update Care Plans in a timely manner to reflect the resident's condition for 1 of 5 residents (Residents #5) reviewed. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of neurogenic bladder (bladder malfunction caused by an injury to the brain, spinal cord, or nerves), cerebrovascular accident (stroke, CVA), and vascular dementia (Problems with reasoning, planning, judgement, and memory due to the lack of blood that contains oxygen and nutrients to the brain). Resident #5's Care Plan Focus revised 3/27/18 indicated that she had an activities of daily living (ADL) self-care performance deficit related to a CVA with left-sided weakness with the need for assist with ADLs. Resident #5 can resist at times). The Intervention dated 4/29/21 directed the staff to see the Medication Administration Record (MARs) and (TARs) as part of the Care Plan. The Care Plan lacked the risks regarding the use of an indwelling catheter. The last update made to the Care Plan reflected a date of 7/3/23. Resident #5's Clinical Physician Orders included an order dated 8/11/23 to insert a Foley (urinary) catheter 16 or 18 French with 5 cubic centimeter (cc) balloon due to urinary retention. The Clinical Physician's Orders lacked directions on what to monitor due to the use of a urinary catheter. Resident #5's September 2023 MAR lacked directions on what to monitor related to the use of a catheter. On 9/21/23 at 8:04 AM with Staff A, Registered Nurse (RN) / MDS Coordinator, explained that she expected to update Care Plans in a timelier manner, and anything beyond 14 days is excessive. During an interview on 9/21/23 at 10:11 AM with the Director of Nursing (DON) explained that she expected indwelling catheters documented on the Care Plan. Review of a facility provided policy titled, Comprehensive Care Plans with a copyright date of 2023 instructed that qualified staff responsible for carrying out interventions specified in the Care Plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical document review, observation, resident interview, staff interview, and policy review the facility failed to assist residents with activities of daily living by not assisting with showers per resident's request for 1 of 1 residents (Resident #8) reviewed. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #8 needed total assistance from two persons for transfers, and extensive assistance from one person with dressing, toilet use, and personal hygiene. In addition, Resident #8 required total assistance of one person for bathing. The MDS listed a weight of 414 pounds (lbs.) with a height of 4 foot 3 inches (52 inches). The MDS included diagnoses of coronary artery disease (narrowing of the major blood vessels that supply the heart), heart failure (inadequate pumping of the heart), peripheral vascular disease (narrowing of the blood vessels outside of the heart and brain), diabetes mellitus, hyperlipidemia (elevated cholesterol), morbid obesity (excessive body fat with complications), and acquired absence of limb. On 9/18/23 at 12:18 PM Resident # 8 reported that he only gets bed baths once a week, due to him being larger. Resident #8 explained that he would like a shower twice a week. The POC Response History reviewed on 9/20/23 for the previous 30 days reflected that Resident #8 received a bed bath on 8/22/23, 8/25/23, 8/29/23, 9/5/23, 9/15/23, and 9/20/23. In addition, the document indicated that Resident #8 refused a bath 9/1/23, 9/8/23, and 9/12/23. The Weights and Vitals listed his last weight as 414 lbs. on 7/26/23. The Health Status Note dated 9/20/23 at 2:19 PM indicated that Resident #8 did not want to go to his vision appointment on 9/21/2023 due to him not getting a bath. The Tasks reviewed on 9/20/23 listed that Resident #8 could shower in shower chair only if greater than 400 lbs., or in the whirlpool if below 400 lbs. The note indicated that from 11/23/22 - 11/30/22 - No baths post-surgery - Shower only document with each bath if weighed or refused! On 9/20/23 at 2:43 PM with Staff A, Registered Nurse (RN)/MDS Coordinator) reported that Resident #8 is physically too heavy for the facility's shower chair. Staff A added that she expected Resident #8 to get showers when over 400 lbs. and baths/showers if under 400lbs. On 9/20/23 at 2:45 PM observed a sticker on top of the shower chair documenting a weight limit of 500 lbs. On 9/20/23 at 3:15 PM the Director of Nursing (DON) explained that she expected Resident #8 to have showers when requested and staff to document refusals of showers when bed baths are completed. The Resident Showers policy dated April 2022 directed that residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.

Based on observations, facility policy review, clinical record review, resident, and staff interviews the facility failed to maintain a safe environment for 1 of 1 resident reviewed (Resident #44). The facility reported a census of 71 residents. Findings included: Resident #44's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #49 needed assistance of supervision from one staff member walking in her room and moving in her wheelchair. Resident #49 had diagnoses of anxiety, other [CONDITION(S)] disease, other abnormalities of gait and mobility. The Progress Notes dated 6/30/2022 at 8:23 PM recorded Resident #44 obtained a skin tear to her left forearm measuring 3 centimeters (cm) by (X) 1 cm with a smaller skin tear to the right measuring 1 cm X 0.5 cm with a skin flap apparent. Resident #44 stated that she scraped her arm on the doorway while leaving the bathroom. The nurse cleaned the area with a wound cleanser and applied steri strips. Resident #44 received education on being aware of her arm placement when entering, exiting doorways, or when in small areas. On 7/19/22 at 11:13 AM, Resident #44 reported that she cut her mid forearm on a sharp wooden edge located under the bathroom sink. Resident #44 explained that she sat in her wheelchair and started to wheel herself past the sink to exit the bathroom, when she scraped her arm against the wooden corner causing the cut. Resident #44's arm contained a total of three steri-strips. Resident #44 added that the maintenance staff sanded the corner but it still felt sharp. On 7/20/22 at 11:55 AM, Resident #44 pointed to the wooden corner under the sink where she cut her arm. The area appeared to be altered but still felt sharp to the touch. On 7/20/22 at 12:00 AM, a tour throughout the building revealed that all resident bathrooms contained the same sink design, with a sharp wooden edge under the sink. The Safe and Homelike Environment policy revised 4/20 instructed in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes the residents' independence and does not pose a safety risk. On 7/21/22 at 12:44 PM, the Nurse Manager acknowledged that the wooden corner under Resident #44's sink still felt sharp despite the alteration. When asked if the design could cause other residents an injury as they passed by the sharp corner in their own bathroom she replied, yes. On 7/21/22 at 12:44 PM, the Chief Executive Officer (CEO) reported that she contacted the architect but for the time being planned to install clear rubber corner safety devices in all resident bathrooms.

Based on observation, clinical record reviews, facility policy review, resident, and staff interviews, the facility failed to serve food at a safe and appetizing temperature. The facility reported a census of 71 residents. Findings include: 1. During an observation of meal service on 7/20/22 starting at 11:47 AM, Staff A, Dietary Aide (DA), placed a serving of pasta salad into 12 dishes, covered them with saran wrap, and left them sitting out on the counter. Staff A took the temperature of the pasta salad at 69.4 degrees Fahrenheit (F). The dishes of pasta salad continued to remain sitting on the counter during the meal service. Nine residents received the pasta salad. At the end of the service at 12:46 PM, a remaining dish of pasta salad temperature measured at 69.3 F. The Record of Food Temperature policy revised 10/18, documented, potentially hazardous cold food temperature will be kept at or below 41 F and no food will be served that does not meet the food code standard temperatures. 2. On 7/21/22 at 8:26 AM, the Dietary Supervisor explained they expected the pasta salad's temperature to be at 41 F or lower and should have been placed on ice. On 7/19/22 at 1:20 PM Resident #38 reported that the food served at meal times didn't get as hot as it should have been. On 7/20/22 at 12:30 PM Staff D, DA, took the kitchen thermometer to test the hamburger meat and the pureed meat that got served to the residents. The hamburger temperature measured 120 degrees F and the pureed meat measured 124 degrees F. On 7/20/22 Staff D served the items to the following residents At 12:33 PM a hamburger to Resident #33 At 12:37 PM pureed meat to Resident #167 At 12:39 PM pureed meat to Resident #62 On 7/21/22 at 9:30 AM, the Dietary Manager said that she would expect the staff member to reheat the food when it temperature didn't measure at least 135 F. She said that didn't know of any problems with the steam table maintaining the heat of the food but she would have maintenance check on it. The Dietary Manager said that she would make sure that staff took the temperatures of the food before and after serving meals. The Record of Food Temperatures policy dated 10/18, indicated that hot food would be held at 135 degrees Fahrenheit. Ready-to-eat foods that required heating before consumption would be taken directly from a sealed container and heated to at least 135 degrees F for holding for hot service. No food would be served that did not meet the food code standard temperatures.

Based on clinical record reviews, staff and resident interviews, the facility failed to notify a resident's family after a fall for 1 of 4 residents reviewed (Resident #49). The facility reported a census of 71 residents. Findings include: Resident #49's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #49 could independently transfer, and move between locations in her room with a wheelchair. Resident #49 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/18/22 at 11:26 AM, Resident #49 said that she fell a couple nights ago when she tried to transfer herself from the recliner to the wheelchair. She said no one contacted her family about her fall until 7/18/22 when she went to the doctor for an X-ray. The Incident Note dated 7/12/22 at 11:37 PM indicated at around 11:00 PM the nurse noted Resident #49's call light on. When the nurse went into her room, she found Resident #49 on the floor. Resident #49 explained that she slipped when she tried to get into her wheelchair to go to the bathroom. The nurse didn't notify Resident #49's family due to the late hour. On 7/21/22 at 9:07 AM Resident #49's family member said that he didn't know about her fall on 7/12/22. On 7/21/22 at 10:07 AM, the Director of Nursing (DON) said that the night nurse didn't follow the procedure to pass the information to the next shift after Resident #49's fall. She said that the morning shift didn't know that the family didn't get notified.

Based on observations, clinical record review, facility policy review, resident, and staff interviews the facility failed to provide professional standards of practice when administering medications for 1 of 6 residents reviewed (Resident #55). Staff B, Licensed Practicing Nurse (LPN), prepared the morning medications for Resident #55 before the resident was up for the day. Staff B reported that she knew that Resident #55 likes to sleep in, so she stored them in the medication cart until she administered them at noon. The nurse stored the medications in an unmarked medication cup. The facility reported a census of 71 residents. Findings include: On 7/20/22 at 11:51 AM, Staff B took a container out of the drawer of the medication cart that contained a nebulizer reservoir, mouthpiece, tubing, and a medication cup containing pills. The reservoir of the nebulizer contained medication. On 7/20/22 at 12:01 PM Staff B said that Resident #55's didn't get her morning medications yet as she preferred to sleep in. Staff B acknowledged that she prepared the medications earlier that morning and placed them in the drawer in an unmarked cup. On 7/20/22 at 12:05 PM observed Staff B administer the medications in the unmarked cup to Resident #55. On 7/20/22 at 12:11 PM Resident #55 said that she liked to sleep in and she was okay with waiting until later in the morning to get her medications. On 7/20/22 at 12:45 PM the Director of Nursing (DON) said that if a resident refused to take morning medications and the nurse had already dished them into the cup, she would expect the nurse to dispose of those medications and get new ones when the resident was ready for them. She said that best practice was not to keep the medication in an unmarked cup in the drawer for later. The Medication Administration policy dated 11/19, documented that medications were administered in accordance with professional standards of practice in a manner to prevent contamination or infection.

Based on observations, staff interviews, and clinical record reviews the facility failed to provide adequate adaptive eating utensils to meet the needs of 1 of 3 residents reviewed (Resident #62). The facility reported a census of 71 residents. Findings include: Resident #62's Minimum Data Set (MDS) assessment dated [DATE] recorded that a Brief Interview for Mental Status (BIMS) could not be conducted due to the resident rarely or never understanding. In place of the BIMS score and a staff interview got conducted indicating Resident #62 had long and short-term memory problems. Resident #62 had moderately impaired daily decision making abilities. Resident #62 required extensive assistance from one person with eating. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62's diet consisted of a mechanically altered diet. The Care Plan Focus revised 7/18/22 indicated that Resident #62 had a nutritional problem or potential nutritional problem related to dysphagia and requiring a mechanically altered diet with thickened liquids. The included intervention revised 3/29/22 directed the use of adaptive silverware as ordered or recommended of a left handed black bent spoon or left handed white handled bent spork. On 7/18/22 at 1:04 PM observed Resident #62 sitting at the lunch table with food in front of him and a regular spoon in his hand. At 1:06 PM he tried unsuccessfully to bring it to his mouth. At 1:13 PM a staff member walked through the area but did not offer him any help. At 1:23 PM a staff member sat down with him and gave him a couple of bites. At 1:28 PM the staff member got up and helped other residents. At 1:33 PM Resident #62 remained in the dining room as the only resident without staff present in the dining room. At 1:35 PM a staff member took off his protective apron and took him back to his room. Resident #62's meal consisted of mashed potatoes, pureed vegetables, and pureed meat. When Resident #62 was taken back to his room, his plate had approximately 75 percent (%) of his meal remaining. On 7/18/22 at 2:56 PM witnessed Resident #62 sitting in his wheelchair in his room with a small dish of ice cream on the bedside table in front of him. Resident #62 used a regular spoon that contained some melted ice cream. While in the room with Resident #62, Staff C, Occupational Therapy (OT), moved his bedside table closer to him. Staff C explained that Resident #62 should have an adaptive spoon in his left hand. Staff C then went to the kitchen and got the black handled adaptive spoon. After Staff C placed the adaptive spoon in his left hand, he could scoop some ice cream out of the dish and into his mouth. Staff C said that when OT made a recommendation for adaptive ware they communicated the instructions to the kitchen and the staff on what tools the residents should use to help them be as independent as possible.

Based on observations, clinical record reviews, staff and resident interviews, the facility failed to answer a resident's call light within 15 minutes for 1 of 16 residents reviewed (Resident #49). On the evening of 7/12/22, Resident #49 fell in her room. As she could reach her call light from on the floor, she used the call light to alert staff that she needed help. During her interview, Resident #49 reported that it took a while before someone came to help but she couldn't remember how long. According to the call light report from that night, it took staff more than 20 minutes to respond. The facility reported a census of 71 residents. Findings include: Resident #49's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #49 could independently transfer, and move between locations in her room with a wheelchair. Resident #49 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Focus revised 10/26/21 indicated that Resident #49 had activities of daily living (ADL) self-care performance deficits. The Care Plan included the following interventions a. Revised 6/21/22 instructed that Resident #49 chose to sleep in her recliner and have her bed removed from her room. b. Dated 7/15/21 Resident #49 could be up ad lib (as desired), staff should assist as indicated. c. Dated 7/15/21 Ensure call light and personal items are within reach. Encourage Resident #49 to use the bell to call for assistance. The Care Plan Focus revised 3/24/22 indicated Resident #49 as a low risk for fall and/or injuries related to [CONDITION(S)], restless leg syndrome, poor balance and pain as she didn't ambulate. Resident #49 had a fall score of 11. The Care Plan included the following interventions a. Revised 3/17/22 indicated the 10/12/21 fall intervention as Resident #49 educated to lock both brakes on her wheelchair for transfers. Resident #49 BIMS score 15. b. Revised on 7/13/22 Resident #49 should ask for staff assistance when needed. On 7/19/22 at 11:15 AM, Resident #49 said that a couple of nights ago, she sat in her recliner with her wheelchair next to her left side. She said that she could transfer and use the toilet independently by getting into her wheelchair without assistance. Resident #49 said that she failed to engage both of the brakes on the wheel chair and it slid out from under her when she tried to get in. She said that she landed on the floor. Resident #49 said that the recliner had the call light attached to it so she could reach it from the floor so she pushed the button right after she fell . Resident #49 said that it took a while for the staff to come help her get off the floor but she couldn't say for sure how long. According to a nursing note dated 7/12/22 at 11:37 PM, the resident ' s call light had been turned on around 11:00 PM. When staff went to investigate, they found the resident on the floor by her recliner chair. She stated that she was trying to get to her wheelchair and slipped. The untitled electronic report of Call Light Responses for the dates of 7/12/22 and 7/13/22, room [ROOM NUMBER] bed A activated their call light on 7/12/22 at 10:39 PM. The response section indicated the call light remained on for 20 minutes and 19 seconds. Resident #49's Census tab indicated she lived in room [ROOM NUMBER] bed B. Upon further investigation on 7/20/22 at 11:04 AM, Staff E, Registered Nurse (RN), turned on the call light for room [ROOM NUMBER] bed B, but the monitor in the nurses station showed that it was 311 bed A. On 7/21/22 at 8:23 AM, the Director of Nursing (DON) stated that they did not have a policy for call light response. She said that the expectation of call light response time got reviewed at orientation and at the annual skills fair. The DON said that she expected call light response time to be within 15 minutes.

Based on facility menu review, observations, and staff interviews, the facility failed to ensure residents on a pureed texture diet received the proper portion size based on the planned menu for 5 of 5 residents and failed to follow the menu for 37 of 70 residents. The facility reported a census of 71 residents. Findings include: 1. Review of the facility's Week 4 menu, for 8/18/21, identified 1 serving (4 ounces (oz)) each pureed ham and potato bake, 6 fluid (fl) oz tomato juice, 1 serving (3 oz) pureed broccoli cuts, #8 scoop (SCP) lemon pudding, 1 serving puree bread/margarine and 8 fl oz beverages. Review of the facility's diet type report dated 8/16/21, documented 5 residents with puree diet. During an observation on 8/18/21 beginning at 10:08 AM, Staff F, Cook stated he was pureeing 6 servings for 5 pureed diets. Staff F placed 9 large spoonfuls (not measured scoops) of ham and potato bake in bowl and covered with saran wrap. Ham and potato bake heated to 177 Fahrenheit (F) in microwave, placed in blender with milk and 3 slices of buttered bread, pureed, and measured to 5 1/2 cups total pureed product. Staff F, Cook referenced a document titled Pureed Diet Portion Sizes/Scoops and stated #6 (5 1/3 oz) and #16 (2 oz) scoop for a total of 7 1/3 oz. Staff F, Cook failed to use a measurable scoop when measuring the 6 servings to be pureed. Staff F, Cook placed six 3 oz scoops of heated broccoli cuts, 3 slices buttered bread and milk, into robot coupe, pureed and measured to 4 cups. Staff F, Cook referenced a document titled Pureed Diet Portion Sizes/Scoops and stated #6 scoop. Observation showed on 8/18/21 at 11:55 AM, Staff F, Cook serve 1 pureed ham and potato bake portion with #6 and #12 (2 2/3oz) scoop (8 oz total) and 1 pureed broccoli portion with # 8 (4 oz) scoop,1 1/3 oz less than portion size. On 8/18/21 at 12:17 PM, Staff E, Cook stated he served 4 pureed meals and used a #8 scoop (4oz) , 3 1/3 oz less than portion size, for pureed ham and potato bake and #12 scoop, 2 2/3 oz less than portion size, for pureed broccoli with no pureed product left over. Review of undated facility policy titled, Puree Process documented: a. Measure out desired number of servings into container for pureeing. b. Puree the food. c. Add any necessary thickener or appropriate liquid of nutritive value and flavor to obtain desired consistency. d. Measure the total volume of the food after it is pureed. e. Divide the total volume of the pureed food by the original number of portions. (See Puree Scoop Chart) Review of untitled and undated facility policy revealed: It is the policy of the dietary department that any cook that does blending (puree) will use the puree chart and the puree scoop chart to determine what scoop size will be used for serving. It will also be the cooks responsibility to be sure that any dietary employee who will be serving from the food cart has the correct size utensils and knows what they are to be used for. 2. Review of the facility's Week 4 menu for 8/18/21, documented ham and potato bake, broccoli cuts, sliced tomatoes, fruit cocktail, bread and butter, and beverages for the main dinner menu. Observation on 8/18/21 starting at 12:15 PM, revealed bread and butter not offered or provided to the residents in the Main Dining Room. On 8/18/21 at 12:53 PM, Staff I, Dietary Aide confirmed she passed trays in the Main Dining Room and did not offer or provide bread and butter to 37 residents as all bread and butter prepared was taken to the other units. On 8/18/21 at 12:57 PM, Staff G, Cook stated he passed out all the bread and butter on other units and not Main Dining Room, due to not having any bread and butter left. During an interview on 8/19/21 at 12:55 PM, Resident #43, with a Brief Interview for Mental Status (BIMS) score of 14 (mild cognitive impairment), stated did not receive bread and butter the day before at dinner and would have taken it and Resident # 19, with BIMS score of 10 (moderate cognitive impairment), stated bread and butter was on the menu slip for lunch yesterday, she requested the bread and butter but did not receive. During an interview on 8/19/21 at 10:57 AM, the Dietary Supervisor stated expectation to follow and provide foods on the menu and to follow the puree process policy and serve proper portions/scoops.

Based on observation, policy review, and staff interview, the facility failed to serve and store food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 71 residents. Findings include: 1. An observation during the initial kitchen tour on 8/16/21 at 10:34 AM, revealed the following: a. walk in refrigerator with 1 glass of orange juice, milk, and mighty shake labeled resident name and AM, not dated. b. 69 glasses with juice, milk, water not dated. c. cherry pie marked 7/18. d. tub full of corn on the cob dated 7/28 with mildew on ears. e. 22 quart (qt) container with 8 qts rice, not dated. f. 22 qt container with 18 qts of powdered sugar, not dated. g. 50 pound (lb) container 1/3 full of cornstarch, not dated. h. 50 lb container ½ full of oatmeal, not dated. i. 50 lb container ½ full of sugar, not dated. j. 50 lb container ½ full of flour, not dated. k. four dispensing cereal containers 1/3 - 1/2 full, not dated. 2. During an observation on the initial kitchen tour on 8/16/21 at 10:34 AM, cook's refrigerator contained an empty Gatorade bottle, not labeled, and water bottle 1/2 full, not labeled, along with facility food items in the refrigerator. Staff E, Cook stated bottles were a water source and belonged to employees. 3. During an observation on the initial kitchen tour on 8/16/21 starting at 10:34 AM: a. trash can with dirty lid, with lid partially covering trash can, sitting beside shelved stand, with clean dishes, and under 3 compartment dish sink. b. pan lids, on shelved stand, with dried food product and splatters of dried food on wall beside clean dish shelved stand and above trash can. c. bucket, with dirty rags, under clean dish shelf with rags sticking out of bucket and touching clean pan lids. d. floor dirty with dry food particles all throughout kitchen and black buildup around edges of walls/tile. e. pad under cook's refrigerator, due to leaks at times per Staff E, Cook. f. steam table with dried food and black buildup around ledge above wheels and down sides of steam table. 4. During an observation on 8/19/21 at 10:40 AM Staff G, Cook, with gloves on, placed 16 slices bread and cheese on grill, and with same gloves touched oven doors, sanitizer bucket, spatula, tongs, and dirty mixing bowl. Staff G, Cook with same gloves placed 16 meat patties on bread/cheese on grill with tongs and with same gloves and placed 16 slices of bread on top of meat patties, removed sandwiches from the grill with a spatula, placed in pan and touched cart handles. Staff G, Cook with same gloves placed 12 more slices of bread and cheese on the grill. Review of facility policy titled, The Safe Food Handle, reviewed 7/9/20, documented: food handlers must change single-use gloves at all of these times: before beginning a new task. During an interview on 8/19/21 at 10:57 AM, the Dietary Supervisor stated expectation to wash hands before gloves, not touch food with bare hands, and gloves for 1 time use only. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: 1) Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation, 2) prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) and requires food employees to wash their hands immediately before engaging in food preparation, including before donning gloves for working with food, in order to prevent cross contamination when changing tasks. 5. During an observation on 8/18/21 starting at 12:45 PM, Staff H, Dietary Aide was preparing drinks, with 13 glasses of milk sitting on a counter and in a tub, with no ice in the tub and a gallon of milk sitting on cart, not on ice. Staff H, Dietary Aide stated the drinks are prepared and put in the cooler for the supper meal. Staff E, Cook took the temperature of a glass of the milk at 57.5 Fahrenheit. Staff H, Dietary Aide placed the tub of glasses of milk and drinks, dated 8/18 in the walk-in refrigerator. Review of facility policy titled, Record of Food Temperatures dated 10/2018, documented: a. potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. b. no food will be served that does not meet the food code standard temperatures. During an interview on 8/19/21 at 10:57 AM, the Dietary Supervisor (DS) stated expectation for gallon jugs of milk to be on ice when out of the cooler and preparing drinks for the next meal. .

Based on observations, policy review and staff interviews the facility failed to provide residents on a puree diet with a fresh diet like other residents in the facility received for 5 of 5 puree residents reviewed. The facility reported a census of 71 residents. Findings include: 1. During initial walk thru tour of the kitchen on 8/16/21 at 10:34 AM, approximately 10 containers marked with the food product and date in the walk-in freezer. During an observation on 8/18/21 at 10:08 AM, Staff F, Cook used ham and potato cheese bake from a container dated 7/20 for 5 pureed diets. Staff F, Cook placed product in plastic bowl, covered with saran wrap, and heated in microwave till reached 177 Fahrenheit (F), top of bake turning dark yellow and dry appearing. Staff F, Cook stated the food was frozen from the last time the meal was served and placed in the refrigerator Sunday to thaw. During an observation on 8/19/21 at 10:20 AM, in the walk-in refrigerator: a. 6.5 pound (lb) container with mac/cheese/bacon casserole, 3/4 full and dated 7/2. b. container with 6 slices of cooked bacon dated 7/21 c. 6.5 lb container 1/2 full of sausage patties dated 7/28 d. container 1/3 full of sausage links dated 8/6 e. container with 9 breaded pork patties dated 8/4 Review of facility policy titled, Policy: Leftovers, dated 1/19/08, documented: Leftovers used for blending will be the same menu item as listed on the menu. Leftovers will be taken out of the freezer to thaw no more than 3 days prior to service. Leftovers will be heated to 165 degrees F or greater in less than 2 hours. If thawed leftovers are not used within 3 days they will be discarded. Refrigerated items that are opened and not used will be discarded after 3 days. During an interview on 8/19/21 at 10:57 AM, the Dietary Supervisor (DS) stated the containers in the refrigerator and freezer is used for the puree diets from the last time the meal was served. The container of food is removed from the freezer and put in the refrigerator 3 days before it is to be used. The DS stated leftovers are not served to residents in the Main Dining Room, with a regular diet, as there is usually not that much left over and the facility has a policy to use left overs. The DS stated staff are trained to place 2 pieces of tape on the container, 1 with the date put in the freezer and mark 2nd piece of tape with date moved to refrigerator. During an interview on 8/23/21 at 11:55 AM, Staff F, Cook stated for the pureed diets the facility serves leftover food from the freezer most every meal, almost all the lunches are leftovers, and suppers depends on if it's a casserole, otherwise would be a leftover probably. During an interview on 8/23/21 at 12:05 PM, Resident # 16 stated the palatability of his pureed meal is ok and asked if satisfied with the taste of his food and stated it's alright. Unable to interview 4 other residents on puree diet due to impaired cognitive status.

Based on clinical record review and staff interview, the facility failed to refer a resident, who was identified with a newly evident mental disorder, to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for two of two residents reviewed (Resident #36, Resident #50). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #36 dated 6/23/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of PASARR Level I Screen Outcome for Resident #36 completed and dated 1/19/21, documented Anxiety Disorder and no documentation of Psychotic Disorder. 2. The Minimum Data Set (MDS) assessment for Resident #50 dated 7/8/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of PASARR Level I Screen Outcome for Resident #50 and dated 7/21/21, documented Anxiety Disorder and Depression/Depressive Disorder, with no documentation of Psychotic Disorder. On 8/18/21 at 5:15 PM, the Director of Nursing stated she expected PASARR status changes completed with new diagnosis.

Based on record review and family and staff interviews, the facility failed to provide adequate supervision to 1 of 3 residents allowed in an outdoor gated area without staff supervision (Resident #4). The facility reported a census of 83 residents; 18 of which resided in the dementia unit. Findings include: The document titled preadmission worksheet dated 6/22/16 indicated Resident #4 had a big elopement risk. The document indicated the nurse spoke with the family and interviewed the resident. The nurse determined the resident could benefit from the Memory Lane Unit and would be able to frequent outdoors when weather permitted. The nurse identified the resident as not a great risk for elopement and the unit would allow more freedom. The nurse ' s notes identified Resident #4 had an admitted into the facility Memory Lane Unit on 6/24/16. The Admission Assessment form dated 6/24/16 identified the resident as independently ambulatory and did not need the use of assistive devices. The assessment indicated the resident as forgetful and confused. The initial Care Plan dated 6/24/16 identified multiple problems to address. The resident had cognitive loss/dementia and the approaches directed the staff to monitor his/her whereabouts and redirect/direct as indicated. The Care Plan indicated a problem with an elopement Risk. The approaches directed the staff to keep the court yard secured at all times and monitor whereabouts frequently, especially as people come and go from the unit and to allow and encourage the resident to go out to courtyard as desires. The nurse ' s notes dated 7/3/16 at 7:35 p.m. indicated the certified medical assistant came to the nurse and asked if the resident was outside walking with someone. The nurse replied no. The certified medical assistant informed the nurse the resident had just walked by Room 10 ' s window and outside. On 7/5/16 at 12:34 p.m. the Administrator and Director of Nursing (DON) reported Resident #4 eloped on 7/3/16. They stated the resident climbed over a fence which surrounded the courtyard. The courtyard was directly outside the locked dementia unit. Staff C observed the resident walking outside the facility along the side of the building. Observation of the courtyard area identified the facility's locked (secured) dementia unit, located on the lower level of the facility. An exit door provided residents an opportunity to be outdoors in a fenced courtyard. A chain link fence with 2 gates surrounded the courtyard. The gates measured 70 in height. Observation from the courtyard identified a 4 lane highway at the bottom of a hill. On 7/6/16 at 3:10 p.m. observation of the outside door from the courtyard identified the door did not open when the outside handle was pulled. The observation was confirmed by Staff K, licensed practical nurse (LPN). The initial Activity assessment dated [DATE] indicated Resident #4 looked for an open door so he/she could walk home to his/her farm. A Fall Risk assessment dated [DATE] indicated Resident #4 scored 18. Scores of 16 or greater indicated the resident to be a fall risk. Risk factors identified included multiple (5+) falls within the prior 6 months, impaired memory, and daily wandering behavior. Functional gait analysis identified the following disturbances: loss of balance while standing/walking strays off straight path of walking and lurching/swaying or slapping gait. An Incident Report dated 7/3/16, indicated Staff C, certified nursing assistant (CNA) provided assistance to a resident when he observed Resident #4 outside. Staff C notified Staff A, registered nurse (RN). Staff A exited the facility and observed Resident #4 walking on the grass to the facility Door #7. Staff C opened the door and Resident #4 entered the facility. The resident could not state why he/she was doing or how had exited the gated Courtyard. On 7/5/16 at 1:34 p.m. Resident #4's family member stated the resident transferred from a facility due to frequent exit seeking behaviors identified. The facility encouraged Resident #4 be placed in a locked dementia unit for safety. The family member was not aware of an elopement while in the prior facility. The family member was uncertain if Resident #4 would be able to climb the fence. Observation on 7/5/16 identified the staff assisted Resident #4 outside to the courtyard. Resident #4 was unable to recall if he/she exited the facility. Resident #4 approached the gait and picked up the padlock, however, unable to open it. Resident #4 did not attempt to exit the courtyard at this time. Staff interviews identified the following: On 7/5/16, Staff A, registered nurse (RN) stated on 7/3/16 when she arrived for her evening shift, the door to the courtyard was open and Resident #4 and Resident #6 were sitting outside in the courtyard. Resident #4 and Resident #6 ambulated independently so were allowed to go outdoors to the courtyard without staff supervision. Staff A observed Resident #4 at approximately 7:10 p.m. outdoors in the courtyard looking at plants. Staff C stated he looked out the window and observed Resident #4 walking outside unattended at approximately 7:30 p.m. Staff A returned the resident to the unit and the resident had no injuries. The resident requested to go outdoors later in the evening, and staff assisted him/her to the courtyard. Staff A asked Resident #4 how he/she got out the locked gate, however the resident was unable to recall how he/she eloped. Resident #4 made statements such as I need to go however was easily redirected. During a follow up interview on 7/5/16 at 4:10 p.m., Staff A stated after the night shift arrived, the door was checked and it was unlocked. Staff A stated she thought she had locked the door after Resident #4 eloped, however, could not be certain. Staff A confirmed other residents could have exited the facility while the door was unlocked. Staff A stated residents that ambulated independently were able to be outdoors in the courtyard without staff supervision. On 7/6/16 at 12:20 p.m. Staff C, CNA, stated he returned from break at approximately 7:15 p.m. and proceeded to provide bedtime cares to residents. At approximately 7:30-7:35 p.m. he looked out a resident's window and observed Resident #4 walking outside. Staff C stated he observed Resident #4 exit seeking and had asked how to leave before. Staff C stated he had not allowed Resident #4 outside alone, and was not sure if he/she required supervision while outside. Staff C stated normally the door to the courtyard is locked. If residents are outside, staff prop the door open because if the door closes it does not open from the outside. Staff C stated residents were not to be outside without staff supervision. On 7/5/16 at 7:17 p.m. Staff D, domestic aide (DA) was interviewed and stated on 7/3/16 at approximately 5:30 p.m. she returned from break. Resident #4 approached her and asked how to exit the facility. The resident indicated he/she wanted to get to the street. Staff D redirected Resident #4. At approximately 6:45 p.m. she observed Resident #4 open the door to the courtyard. Staff B informed her Resident #4 could go to the courtyard without staff supervision and it may relax him/her. Staff B then went to break. Staff D went outside to visit with the resident. Staff D stated at approximately 7:00 p.m. the evening snack cart arrived, and she proceeded to pass (distribute) snacks to residents. Resident #4 came inside with Staff B and accepted a snack and juice. Staff D stated she did not observe Staff B lock the courtyard door. Staff D stated she continued to pass snacks to residents in their rooms when she observed Staff A enter the dementia unit with Resident #4. Staff A informed her the resident had jumped over the fence. Staff D recalled Resident #4 had exit seeking behaviors after supper and walks from door to door. She observed Resident #4 shake the door in attempt to open the door and exit the facility. Staff D stated usually the door to the courtyard is closed and locked; however, someone informed her the door was unlocked during the afternoon. Staff D was not aware where the key to the courtyard door was kept, however, knew the door was to remain locked. She stated staff prop the door open with a towel when residents are outside. Staff D did not think residents were to be outside without staff supervision. On 7/5/16 at 3:55 p.m. Staff B, CNA, stated she went on break at approximately 7:14 p.m. and observed Resident #4 standing up from a chair near the unit's entrance door. When she returned from break she was notified Resident #4 eloped. Staff B stated staff were required to be with residents while outside in the courtyard. She had not observed residents outside unattended before. On 7/6/16 at 9:32 a.m. Staff J, RN, stated she worked the day shift on 7/3/16. She indicated she unlocked the door to the courtyard for Resident #4 at approximately 11:45 a.m. Staff J stated the resident went in (courtyard) and out as desired. Staff J left the facility at approximately 2:45 p.m. and observed Resident #4 outside with the door propped open. Staff J stated residents that are up ad lib may go outside, unsupervised to the courtyard as long as the conditions are ok. If the resident exhibits increased confusion they require supervision. Residents that are too high of a fall risk may require staff supervision for safety. Staff J expected nursing staff to use their judgement because demented residents can change daily. She stated residents in the dementia unit do not have wander guards (devices placed on residents to alert staff when leaving) because they are in a locked unit. (A wander guard is a bracelet like device worn by residents at risk to elope. Staff J stated she was not aware of a specific policy to direct which residents were able to be outside and unsupervised because that would not be fair to all residents. On 7/6/16 at 10:05 a.m. Staff P , CNA, was interviewed and stated she worked at the facility for 7 years, and typically worked in the dementia unit. Staff P stated she worked the day shift on 7/3/16. Staff P stated she observed Staff J unlock the door, but did not observe if the door was open or closed after dinner because she provided resident care. Staff P stated at approximately 1:00-1:30 p.m. she observed Resident #4 outside with his/her sister. Staff P stated Resident #4 independently ambulated with a limp. The resident got a little shaky at times which required staff assistance. Staff P stated she did not think Resident #4 could go outside unsupervised and had not observed Resident #4 outside alone before. On 7/5/16 at 10:27 a.m. Staff G, CNA, stated she had been employed by the facility for [AGE] years, primarily in the dementia unit. Staff G was told residents that were up independently were able to go outside alone; however, the door should be left open so staff can observe as able. Resident #4 had stated he/she wanted to go home before, but typically accepted redirection. Staff G indicated she checked the courtyard and padlock prior to allowing residents outside. On 7/6/16 at 10:55 a.m. Staff H, housekeeper was interviewed and stated she had not observed the outside door open unless residents were outside. Staff H stated typically a towel is placed under the door to prop it open when a resident was outside. Staff H stated she had not observed any resident outside alone before. She had not observed Resident #4 outside alone before, however indicated he/she asks to get out. The resident had requested she assist him/her to exit the facility quite often and earlier in the shift on 7/6/16. On 7/6/16 at 10:59 a.m. Staff I, LPN, stated she was informed residents that were up ad lib were able to be outside alone, however, if the resident was a fall risk, he/she would require supervision. Staff I stated whoever lets the resident outside is to let the resident inside. Staff I stated the staff would prop the outside door open when residents were outside. On 7/5/16 at 4:18 p.m. Staff F, domestic aide, stated she was employed by the facility for [AGE] years and had only worked in the dementia unit. Staff F stated typically residents that were up ad lib were able to go outside unsupervised, weather permitting. A few weeks prior, Staff F discovered the outside door unlocked. She locked it after she checked outside. On 7/6/16 at 3:10 p.m. Staff K, LPN, stated she was employed since 1994 and worked in the dementia unit. Staff K stated the residents that independently ambulate are able to go outside independently, however, the domestic aide monitors residents and periodically checks the residents while outside. If a resident was a fall risk she would be hesitant to allow them outside alone, and would send the domestic aide outside with the resident for safety. Staff K stated when residents are sitting outside, the staff prop the door open. On 7/5/16 at 8:33 a.m. the DON was interviewed and stated no elopement risk evaluation was completed on residents residing in the dementia unit because typically they do not get out and the exit door to the court yard is typically locked when not in use. Note: At the time of the complaint/incident investigation, the complaint was coded at a J, immediate and serious jeopardy. By 7/4/16, the facility had self corrected the immediate jeopardy with implemented measures to adequately addressed the jeopardy and the grid placement was lowered to a D. The facility had self corrected by assessing each resident in the Memory Lane Unit for elopement risk (climbing over fence/gait) and providing one to one supervision to Resident #4. The door leading to the courtyard will be locked and not propped open. All residents will be supervised in the courtyard.

Based on observation, record review, and interviews, the facility failed to implement interventions and provide adequate supervision to prevent accidents for one of four residents (Resident #1). Resident #1 fell when turning to the bathroom and fractured his/her left hip. A staff member did not use a gait belt, proper footwear and the care plan lacked safety intervention to provide contact guard assist (CGA) when transferring Resident #1. Interviews identified Resident #1 normally received CGA when staff transferred the resident for his/her safety. The facility reported a census of 90. Findings include: An undated Preadmission Worksheet documented Resident #1 had been admitted from home. He/she transferred with the assistance of 1 at times and at times independent. He/she took a few steps with a walker. He/she had short term memory problems. The worksheet documented Resident #1 had fallen at home. An Admission assessment dated [DATE] documented Resident #1 oriented to person, disoriented, and forgetful/confused. Resident #1 had impaired hearing, and had a hearing device, but didn't wear it. Regarding limited range of motion, Resident #1 had degenerative joint disease of the left knee, and shoulders bilaterally. Resident #1 had no pain. A Medical history and physical examination [REDACTED]. Resident #1's [DIAGNOSES REDACTED]. The admission orders [REDACTED]. A Fall assessment dated [DATE] scored Resident #1 at 20, with a score of 16 or more indicating a risk of falling. The assessment indicated Resident #1 had no history of falling the previous 6 months. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 12 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Resident #1 required extensive assistance of 2 plus persons with bed mobility, transfer, ambulation, and toilet use. Resident #1 demonstrated unsteadiness with moving from a seated to a standing position, walking with an assistive device, turning around and facing the opposite direction while walking, moving on and off the toilet, and surface to surface transfer. Resident #1 used a walker and a wheelchair. A Review of Indicators of Fall Risk dated 9/12/12 documented Resident #1 had no history of falls. The review documented Resident #1 demonstrated weakness, especially of the knees, and was off balance when transitioning from positions. Policy A facility Transfer Training policy identified: a. SBA, the resident requires a gait belt, do not touch the gait belt, stand close to the person, and may require verbal cues for assistance. They do not physically help the person but stay close to the person just in case they need help. b. CGA, the resident requires a gait belt. Hold on to the gait belt at all times. The resident may require voice cues for assistance. They do not help the person, but have a hold of the gait belt just in case they may need help. An Incident/Accident Report dated 9/24/12 at 5:45 p.m. documented Resident #1 transferred him/herself from his/her wheelchair to the bathroom. The alarms sounded. Staff noted Resident #1 sitting on the floor in front of the wheelchair on the bathroom entrance. Resident #1's head rested in front of the sink. Resident #1 denied pain. Resident #1 performed active range of motion in the upper and lower extremities. No open areas were noted. He/she did have some redness on the back of his/her head. A Physical Therapy Discharge Note dated 9/28/12 documented a summary of significant functional progress in the last week of care. Resident #1 did sit to stand with SBA and ambulated 100 feet times 2 with the 4 wheeled walker and CGA. A summary of care provided from evaluation to discharge documented Resident #1 SBA with sit to stand and ambulated 100 feet times 2 with the 4 wheeled walker with SBA and additional illegible documentation (see interview with the Physical Therapist). Care Plan The Resident Care Plan dated 09/19/12 identified Resident #1 with a problem of communication/dementia related to hard of hearing and diagnosis. The approaches included: a. Monitor for acute changes in mental status and report. b. Monitor and report any mood/behavior indicators. c. Cue as needed. d. Keep instructions short and simple. e. Explain all procedures prior to starting. f. May need to speak up or repeat. The care plan identified Resident #1 with a risk of falls related to degenerative joint disease and dementia manifested by weakness in the knees, and off balance when transitioning position. The approaches included: a. Ensure use of safe, comfortable footwear. b. Activity as ordered. c. Follow Physical Therapy (PT) recommendations. d. Monitor for changes in gait/transfer abilities, refer as needed. e. Anti-slip strips on bathroom floor, 09/24/12. f. Per therapy stand by assist (SBA), 10/01/12. g. Encourage family to ask for assistance with transfers and not leave Resident #1 alone, 10/14/12. h. Gripper socks at night, 10/27/12. i. 1/2 rail up when in bed. j. Call light in reach. k. Alarms on and functioning to bed, wheelchair and recliner. The care plan failed to address the resident ' s need for contact guard assistance (CGA) when walking. The Care Plan dated 11/14/12 identified Resident #1 with a risk of falls. The approaches included to ensure use of safe, comfortable footwear, gripper socks when up. An Incident/Accident Report dated 10/14/12 at 5:05 p.m. documented Resident #1's family member took him/her out of the building for a car ride. Two certified nursing assistants assisted Resident #1 in to the truck. Upon return, the family member left Resident #1 in the truck to get a wheelchair. Resident #1 laid on the floor on his/her right side when the family member returned. The family member assisted Resident #1 up and into the wheelchair then notified staff. A Incident/Accident Report dated 10/27/12 at 7:25 p.m. documented Resident #1 walked to the bathroom, and while turning left to go into the bathroom he/she fell directly on his/her left hip. Resident #1 went to the hospital by ambulance at 7:50 p.m. A hospital Consultation Report dated 10/27/12 documented Resident #1 resided at the nursing facility and fell going to the bathroom. He then had pain in his/her left hip. Another hospital saw Resident #1 and found a left hip fracture. The X-rays showed an obvious displaced femerol neck fracture on the left side. The hospital Progress Notes dated 10/28/12 documented Resident #1 had left hip hemi-arthroplasty. A Major Injury Determination Form dated 10/29/12 documented Resident #1 fell and fractured his/her left hip. A Certified Nursing assistant walked Resident #1 to the bathroom with a walker. While turning left to go into the bathroom, Resident #1 fell directly on his/her hip. Resident #1's previous functional ability was : Up with assistance. A Readmission assessment dated [DATE] documented Resident #1 had pain in the left hip at an 8 on a scale of 0 to 10. Resident #1 described the pain as hurting badly at 12:05 p.m. Resident #1 had 22 by 20 centimeters (cm) of bruising to the left hip, and a 17 cm incision with 21 staples. The hospital records documented Resident #1 received Vicodin (pain pill) 2 tabs on 11/02/12 at 9:37 a.m. An Occupational Therapy Evaluation dated 11/04/12 documented Resident #1 was previously independent with self-feeding and CGA (contact guard assistance)/stand by assistance (SBA) with ADL's, transfers, grooming, and toileting, and maximum assistance with dressing and bathing. Resident #1 had a recent decrease in ADL's and functional mobility following hospitalization for open reduction and internal fixation of a left hip fracture. The evaluation documented Resident #1 demonstrated significant decrease in strength/endurance, balance and coordination, ability to complete ADL's and functional mobility. Observation During an observation on 12/05/12 at 4:53 p.m. Resident #1 sat at the dining room table with an alarm box on the arm of the wheelchair. Resident #1 had TED stockings on bilateral feet. Resident #1 did not have gripper socks on. Interviews: During an interview on 11/07/12 at 10:10 a.m. Resident #1's family member said Resident #1 did have falls at home. When the family member heard Resident #1's lift chair he/she would go to assist him/her. The family member said Resident #1's feet did not work right, and he/she did not walk very well. The family member said Resident #1 had not for a long time. The family member said the therapy Resident #1 received before he/she fell and fractured may have helped a little. The family member said Resident #1 would try to do things him/herself. Resident #1 would push the walker way ahead and then run to keep up with it. The family member said Resident #1 was not safe to be up on his/her own. The family member said at home Resident #1 wore slippers and thought that was what he/she wore at the facility before the fall and fracture. The family member said Resident #1 did not wear shoes. The family member said it was like the information did not get from Resident #1's brain to his/her feet when he/she walked. During an interview on 12/05/12 at 1:39 p.m. Staff D CNA stated he worked with Resident #1 when he/she fell and fractured his/her hip. Staff D stated around 7 or 8 p.m. Resident #1 had his/her call light on and he went to the room to assist him/her. Staff D stated he normally put the gait belt on when Resident #1 needed to go to the bathroom. Staff D did not remember if Resident #1 said he/she needed to go to the bathroom or if he asked him/her if he/she needed to go. Staff D put the side rail in position so Resident #1 could get out of bed. Staff D turned off the alarms, and put the walker in front of him/her after assisting him/her to sit up on the side of the bed. Resident #1 just got up and started walking to the bathroom. Staff D stated he did not have time to put the gait belt on before Resident #1 stood up. Staff D stated he was right beside Resident #1. He did not ask Resident #1 to wait because he/she was already going. Staff A said he had his hands on Resident #1's hips. Staff A said he did not think he should try to put the gait belt on while Resident #1 walked. Staff D said when Resident #1 went to turn left he/she had trouble with his/her left foot and he/she just went down. Staff D said he did not think he could stop the fall if Resident #1 had the gait belt on him/her because it happened too fast. Staff D said Resident #1 had bare feet. Staff D stated he took CNA training in September of this year(2012). He started working at the facility in October and worked on his own about a week when the incident occurred. During subsequent interview on 12/06/12 at 4:45 p.m. Staff D said he normally put gripper socks on Resident #1, or he/she normally had them on. Staff D did not know why Resident #1 did not have gripper socks on. Staff D stated he did not know Resident #1 would get up that fast. Staff D stated he could have put the gripper socks on before he shut the alarms off. Staff D said Resident #1 did not have a shirt on and he did not know if he could put the gait belt on without it. He thought it maybe an infection control issue. He said he did not have time to put the shirt and gait belt on. Staff D said he did not tell Resident #1 to turn when he/she walked to the bathroom. Staff D stated now he would just put the gait belt on the resident. During an interview on 12/06/12 at 2:18 p.m. Staff K LPN stated when Resident #1 fell she was in another room with a resident. The CNA called for her. Staff K stated Resident #1 had nothing on his/her feet when he/she fell . She said Resident went to bed with nothing on but a brief. Staff K stated they usually put Resident #1's slippers on when getting him/her up to the bathroom. Staff K said Resident #1 would try to get up fast. When he saw someone come in he/she would try to go. Staff K said the first thing you did when you went in the room was put the slippers on. Staff K said Resident #1 did not have a gait belt on. Staff D told her he didn't know if he could put it on Resident #1 because he/she didn't have a shirt on. During an interview on 12/06/12 at 8:38 a.m. Staff G CNA stated she worked the day Resident #1 fell . She said she assisted Resident #1 up for breakfast. She said he/she ambulated per normal. Staff G said Resident #1 definitely needed someone there when he/she ambulated. She said Resident #1 needed verbal cues to slow down, to turn, and not to sit too soon. Staff G stated she used the gait belt and held on to it out of habit. Staff G said Resident #1 would go really fast and she told him to slow down. Resident #1 would try to get up him/her(self) before staff got to his/her room. Staff G said if Resident #1 was not already up she would put slippers on his/her feet. During an interview on 12/05/12 at 4:29 p.m. Staff E Certified Medication Aide (CMA) CNA stated she worked the night Resident #1 fell and fractured his/her hip. Staff E walked Resident #1 to the bathroom earlier in the shift. Staff E put the gait belt on Resident #1 and placed the walker close. Resident #1 unlocked the walker and walked to the bathroom. Staff E held on to the gait belt. She said she held on to it with everyone. Staff E said Resident #1 was in a hurry to get to the bathroom. Staff E said SBA meant they did not need to hold on to the gait belt, but she did with everyone because she felt safer. During an interview on 10/05/12 at 1:15 p.m. Staff C Certified Nursing Assistant (CNA) stated Resident #1 was SBA which meant they put the gait belt on, but they did not touch the gait belt unless he/she had difficulty, like getting unsteady, then staff could grab (the gait belt) to assist. She thought she could grab it quick enough to help him/her from falling or ease him/her to the ground. Staff C said Resident #1 would try to get up and go on his/her own, and try to shut the alarms off, but he/she did not mind the gait belt. She said Resident #1 walked pretty good, he/she may have gotten off balance every once in a while. During an interview on 12/18/12 at 9:01 a.m. the Occupational Therapy Aide (OTA) stated she worked with Resident #1 prior to the fall fracture. She said Resident #1 was never independent and his/her abilities varied day to day. She said when she worked with Resident #1 she usually always had her hand on his/her back. She said there was a fine line between SBA and CGA. She said residents needed a gait belt unless they were independent. She said she had her hand on the gait belt when she walked Resident #1 to the bathroom. She said Resident #1 could be impulsive and she did not know day to day how he/she would do. During an interview on 12/5/12 at 12:32 p.m. the Physical Therapist stated Resident #1 was steady on his/her feet on discharge and she knew he/she fell on [DATE] just prior to discharge from PT. The PT stated Resident #1 was SBA assist on discharge from PT, but wanted to review the discharge summary. During subsequent interview on 12/13/12 at 8:16 a.m. the PT said she received a copy of her Discharge Summary for Resident #1. She said Resident #1's discharge status was SBA to CGA because he/she was unsafe at times. During an interview on 12/05/12 at 12:15 p.m. Staff A Physical Therapy Aide (PTA) stated stand by assist (SBA) meant staff were to be close to the resident. The resident wears a gait belt, but staff did not have to hold on to it. They were close enough to the resident that they could grab the gait belt if the resident experienced difficulty. Staff A said the staff could grab the gait belt to steady the resident or ease his/her fall. She said it would be possible staff would be unable to grab the belt in time to help. Staff A did not work with Resident #1 prior to his/her fall and fracture. During an interview on 12/05/12 at 12:47 p.m. Staff B PTA stated she worked with Resident #1 prior to his/her fall. She said Resident #1 walked fine. She said she always used the gait belt and she always had her hands on the gait belt when she walked with Resident #1. Staff B stated she felt safer with a hand on the gait belt. During an interview on 12/06/12 at 1:31 p.m. Staff I LPN stated Resident #1 was impulsive and would try to get up quickly. During an interview on 12/06/12 at 8:17 a.m. Staff F Licensed Practical Nurse (LPN) stated residents wore gripper socks, slippers or shoes when up walking. During an interview on 12/06/12 at 1:09 p.m. Staff H said safe, comfortable footwear meant non-skid and residents should wear when ambulating. During an interview on 12/06/12 at 1:23 p.m. Staff M Registered Nurse (RN) stated residents were to have gripper socks, slippers or shoes on when ambulating. During an interview on 12/13/12 at 8:35 a.m. the MDS Coordinator stated she thought Resident #1's spouse told them prior to admission he/she had falls. She said when the facility admitted Resident #1 she thought another family member said they did not think he/she had fallen at home. She did not clarify this with the resident ' s spouse. The MDS Coordinator said she knew Resident #1 was impulsive and would get up quickly. She said the first time staff told her that she was really surprised. She said she did not care plan this because this did not happen every time Resident #1 got up. She said she put SBA on Resident #1's care plan and obtained that information off a therapy note, probably the discharge summary. She said she did not know when Resident #1 went to bed at bedtime, he/she did not wear a shirt. The MDS Coordinator did not know that a gait belt did not get put Resident #1 because the resident didn't have a shirt on and a new CNA didn't know he could put the gait belt on Resident #1's bare skin; and Resident #1 got up too fast to put a shirt and the gait belt on. The MDS Coordinator said she would recommend just putting the gait belt on the bare skin. During a concerns and findings meeting on 12/7/12 at 11:30 a.m. the DON and Administrator stated the intervention to ensure safe, comfortable footwear did not necessarily mean the resident/(s) had to wear footwear when ambulating instead it meant if the resident had footwear on his/her feet, the footwear should be safe and comfortable. Facility Protocol The facility Protocol for Prevention of Falls identified nursing actions for residents at risk for falls included: a. Maintaining close supervision of confused residents, b. Ensuring residents had properly fitting shoes/slippers with non-skid surfaces, c. Socks should have non-skid surfaces, d. Staff training would be done as needed to assist staff in recognizing and eliminating environmental hazards, e. How to provide adequate supervision to prevent falls.