Every finding on record at Greenfields of Geneva

Based on interview and record review, the facility failed to ensure that a resident (R1) was properly and safely transferred with the use of a gait belt to help prevent or minimize the risk of fall. This failure affected one of three residents (R1) reviewed for falls in the sample of 3. The findings include:R1's face sheet documented an admission date of 12/06/2025 with a past medical history not limited to strain of right quadricep muscle, encounter for orthopedic aftercare, difficulty in walking, osteoarthritis and fall.Review of R1's fall risk assessment dated [DATE] indicated resident is at risk for falls.R1's Minimum Data Set (MDS) dated [DATE] under section GG-functional abilities showed R1 is dependent with toilet transfer. Per the same MDS, dependent means the helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity.R1's care plan created/initiated on 12/12/2025 reads in part: at risk for falls and activities of daily living (ADL) self-care performance deficit related to limited mobility, weakness, fall with tendon tear and repair, arthritis. Resident had a fall during transfer on 12/21/2025.R1's care plan interventions included but were not limited to assist with toileting; intervention for 12/21/25-staff and therapy to use gait belt during transfers to aide in stabling resident (initiated 12/23/2025); requires extensive assistance by one staff for toileting. Update post fall transfer, requires extensive assistance by one staff to move between surfaces with gait belt.R1's physical therapy progress report signed 12/18/2025 at 01:07 PM documented supervision or touching assistance with toilet transfer. No documentation noted that use of gait belt was not required.Care Plan Summary Note with effective Date of 12/19/2025 at 11:03 AM, documented toileting- CGA with one person but did not indicate the meaning of CGA. No documentation noted that use of gait belt was not required.R1's occupational therapy note dated 12/21/2025 at 10:24 AM indicated that the therapist performed toileting task with CGA but did not indicate the meaning of CGA. No documentation noted that use of gait belt was not required.R1's fall incident report dated 12/21/2025 and skilled nursing note dated 12/21/2025 at 11:56 PM (23:56) indicated at approximately 08:45 PM, writer heard the sound of fall and meanwhile [aide] on the duty called for help. Writer observed resident (R1) on the bathroom floor in an upright position with both legs straight and hands were on the floor. Aide was standing in front of the resident and witnessed the fall. When asked what happened, R1 said he was unsure because it happened so fast.On 01/10/2026 at 10:42 AM, observed R1 sitting in wheelchair at table in the unit dining room on second floor. Noted R1 wearing a full length brace to his right leg. R1 said he had a fall a few weeks ago in his bathroom. R1 said a female aide came in his room and helped him stand and pivot in the bathroom then helped him sit on the raised toilet seat with handles to both sides. R1 then said that he does not recall the aide putting a gait belt on him prior to standing up. R1 said after he finished using the toilet, the aide helped him to stand up. R1 added that he then became lightheaded and fell to the floor.On 01/10/2026 at 11:43 AM, V3 (Certified Nursing Assistant) said gait belts are usually hanging in the resident's bathroom but if one was not available, he would still transfer the resident without using the gait belt and would be extra careful. V3 then said he works as needed for the last six months and did not recall the last in-service on resident transfers other than upon hire.On 01/10/2026 at 12:32 PM, observed V3 (Certified Nursing Assistant) place a gait belt on R4 then ambulate resident into the bathroom. At 12:36 PM, V3 ambulated R4 back to his recliner chair in his room from the bathroom. Gait belt was in place to R4's waist. At 12:40 PM, R4 said staff do not always use a gait belt when ambulating him and was surprised that V3 used one.On 01/10/2026 at 12:49 PM, R1 said he had urinated on the bathroom floor on day of fall but did not recall whether the aide cleaned the floor prior to assisting him off the toilet.On 01/10/2026 at 02:42 PM, V6 (Certified Nursing Assistant) was observed wearing a gait belt around her waist. V6 indicated she was informed during previous transfer in-services to use a gait belt for transfers then indicated that she would never transfer a resident without using a gait belt for their safety if they did not require the use of a mechanical lift.On 01/10/2026 at 03:11 PM, V4 (Registered Nurse) said on night of R1's fall on 12/21/2025 at approximately 08:45 PM, she was close to R1's room and heard a noise that sounded like someone fell and the aide (V5) yelled out for help. When V4 entered R1's room, she saw him sitting on the bathroom floor, next to the toilet, in an upright position with both legs extended forward. R1 did not have a gait belt on. V4 then said R1 was a one assist transfer with 1 assist, and per physical therapy, R1 only needs minimum assist with transfers. V4 added that a gait belt is now used since the fall, but he did not need one prior to the fall per therapy. V4 then said staff should use a gait belt for transfers if a resident does not require a mechanical lift, but sometimes per resident need or therapy recommendations, they don't need a gait belt. V4 added that if a resident is dependent with transfers, a gait belt should be used.On 01/10/2026 at 04:00 PM, V5 (Certified Nursing Assistant) said on the day of R1's fall on 12/21/2025 at around 08:30-9:00 PM, R1 called to go to the bathroom. R1 was in the bathroom when V5 entered his room. She stood next to R1 during the transfer onto the toilet but indicated that R1 did all the work by himself with the use of the grab bar. V5 said after R1 finished, she was wiping him while he was standing up. R1 was leaning forward then began falling forward. V5 indicated there was some urine on the floor by the toilet, but it was away from R1's feet. V5 added that she did not put a gait belt on R1 prior to the transfer. V5 then said R1 was a one assist at the time of fall and that staff are supposed to use a gait belt with transfers unless the resident is independent per previous transfer in-services. V5 added that she was never told by anyone that R1 did not require the use of a gait belt. On 01/10/2026 at 04:48 PM, V7 (Physical Therapist) said he has never worked with R1 and was not familiar with his plan of care. V7 then indicated that CGA means contact guard assistance which is used with residents who have some independence but are showing that they still require some contact assistance. With CGA, staff are there to help residents and guide them without touching them but can make contact if needed. V7 added with CGA, the resident is not independent yet and does still require the use of a gait belt with transfers. V7 then said a gait belt is used for safety purposes in case a resident falls, and should always be used with transfers unless the resident uses a mechanical lift.On 01/10/2026 at 04:57, V2 (Director of Nursing) said it depends on therapy recommendations whether a gait belt is used for transfers.Review of R1's medical record on 01/10/2026 revealed no therapy documentation that a gait belt is not required to transfer R1 to and from the toilet.Undated Safe Resident Handling/Transfers policy provided by V2 on 01/10/2026 reads in part: it is the policy of this community to ensure its residents are handled and transferred safely to prevent or minimize risks for injury. Our goal is to provide and promote a safe, secure, and comfortable experience for the residents while keeping the team members safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the team members that assist them.Handling aides may include gait belts, transfers boards, and other devices.Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on observation, interview, and record review, the facility failed to post EBP (Enhanced Barrier Precautions) signs outside of resident rooms and wear appropriate PPE (Personal Protective Equipment) while providing care to residents. This applies to 4 of 4 residents (R14, R50, R60, R61) in a sample of 17.The findings include: 1. On 12/21/22 at 9:29 AM, R14 was observed with ongoing tube feeding running at 75 ml/hour with 50 ml of water flush every hour. R14 said she has a J-tube (jejunostomy tube). On 12/21/25 at 9:30 AM, V3 (Licensed Practical Nurse/LPN) came inside R14's room. He said he was going to discontinue the feeding. V3 was not wearing a gown and was only wearing gloves. With gloves on, V7 moved R14's personal belongings on top of her bedside table to the side to make room for supplies needed. With same gloves, he continued to disconnect J-tube feeding and flushing J-tube with 50 ml of water before covering the port. V7 proceeded to leave R14's room with same gloves on. On 12/22/2025 at 1:47 PM, V13 (Infection Control Nurse/Assistant Director of Nursing) stated that any time you flush or start the formula through the J-tube, you need to follow enhanced barrier precautions where you sanitize your hands, wear gloves and gown. On 12/23/25 at 9:40 AM, V2 (Director of Nursing) said before discontinuing tube feeding, staff should observe and perform proper EBP (Enhanced Barrier Protection) Precaution before they start the procedure. She said because the feeding tube is an indwelling device, without proper PPE (Personal Protective Equipment) staff is putting the resident at risk for infection. R14's face sheet documents diagnosis of dysphagia. R14's POS (Physician Order Sheet) documents order for Enhanced Barrier Precaution for J-tube. R14's care plan for tube feeding documents need for Enhanced Barrier Precaution. Facility's Policy on Enhanced Barrier Precaution dated 4/25/23 and revised on 4/5/24 documents the following: Purpose: To provide basic guidance on the implementation of Enhanced Barrier Precautions for infection prevention and control.Procedures: 1. Enhanced Barrier Precautions (EBP) will be implemented for the following (including new admissions).Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization.4. All team members will wear appropriate PPE (gown and gloves) for high-contact resident care but not limited to peri care, device care (central line, urinary catheter, feeding tubes, tracheostomy/ventilator, ostomy) 2. On 12/22/25 at 9:54 AM R50's door had no EBP sign on the door. V17 (Registered Nurse/Wound Coordinator) went to R50's room without a gown and performed a pressure dressing change to R50's sacrum. R50's POS (Physician Order Sheet) had no order for EBP Precautions. There was an order for Wound Care for Sacrum. Review of R50's care plans show no care plan for EBP. On 12/22/2025 at 1:47 PM, V13 (Infection Control Nurse/Assistant Director of Nursing) stated at this time, they don't have wounds that require enhanced barrier precautions. She stated any open wound or pressure sore that has so much exudate requires EBP precautions. Facility's policy titled Enhanced Barrier Precautions (4/15/24) shows 1. EBP will be implemented for the following.wounds. This generally includes residents with chronic wounds, and not those with only shorter—lasting wounds, such as skin breaks or skin tear covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers.Clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE will be in place. All team members will wear appropriate PPE (gown and gloves). 3. On 12/22/2025 at 1:13 PM, V16 (Certified Nursing Assistant) stated that R60 was ready for incontinence care and transfer from bed to wheelchair for therapy. V16 asked V18 (Certified Nursing Assistant) for assistance, and both staff entered R60's room without performing hand hygiene and without gloves. Both V16 and V18 donned gloves without first performing hand hygiene. Neither staff member wore a gown. V16 provided incontinence care while V18 assisted by positioning R60 in a right side-lying position. After completion of incontinence care, V16 removed gloves and donned new gloves without performing hand hygiene, then proceeded to transfer R60 from bed to wheelchair using a mechanical lift. A review of R60's medical record by V14 (Wound Physician), dated 12/16/2025, showed that R60 had a pressure injury to the right buttock that was unstageable due to necrosis and full-thickness in nature. V14 documented that the wound had been present for greater than 38 days and had moderate serous exudate. V14 further documented that a surgical excisional debridement was performed and stated, slough and biofilm were removed. 4. On 12/22/2025 at 9:20 AM, V16 (Certified Nursing Assistant) was observed in R61's room providing incontinence care. V16 was wearing gloves and was not wearing a gown. R61 had a right stump dressing in place. V16 did not perform hand hygiene prior to donning gloves and did not perform hand hygiene after glove removal. A review of R61's medical record by V14 (Wound Physician), dated 12/16/2025, showed that R61 had a post-surgical wound to the right upper leg that was full-thickness in nature. V14 documented that the wound had been present for greater than 57 days and had moderate serous exudate. V14 further documented that a surgical excisional debridement was performed and stated that excision of devitalized tissue including slough, biofilm, and non-viable muscle tissues were removed. On 12/22/2025 at 1:24 PM, V16 and V18 stated that there were no residents on their assigned hallway who required Enhanced Barrier Precautions (EBP). At that time, R60 and R61 did not have Enhanced Barrier Precautions signage posted outside their rooms, and personal protective equipment (PPE) was not available or set up outside their rooms or in the immediate vicinity. On 12/23/2025 at 11:00 AM, V2 (Director of Nursing) stated that Enhanced Barrier Precautions (EBP) are required for residents with chronic wounds, which she defined as wounds present for greater than 30 days in duration and/or wounds without the presence of biofilm.

Based on observation, interview, and record review, the facility failed to provide a resident with a clothing protector during meals to maintain her dignity. This applies to 1 of 3 (R15) reviewed for dignity in a sample of 17.The findings include:On 12/21/2025 at 9:30 AM, R15 was in the dining room eating her pureed breakfast. R15 was severely cognitively impaired and unable to be interviewed. R15 was fatigued and had difficulty feeding herself. As a result, R15 had multiple food residue spills on her shirt and pants. R15 was not provided a clothing protector.On 12/21/2025 at 12:25 PM, R15 was served her lunch in the dining room. R15 was feeding herself, but at times had unsteadiness when using her utensils. Which caused her pureed food to spill on her shirt and pants. R15 was again not provided a clothing protector during her meal.On 12/23/2025 at 11:35 AM, V6 (Certified Nursing Assistant) said she routinely cared for R15. V6 said R15 was able to feed herself but required prompting and cueing with her meals, especially when fatigued. V6 said R15 required the use of a clothing protector to protect her clothing from food spillage. V6 said R15 was cognitively impaired and dependent on staff to provide her with a clothing protector for her meals.On 12/23/2025 at 9:40 AM, V2 (Director of Nursing) said she expected staff to provide resident-centered care during meal services. V2 said she expected staff to round during meal services and provide residents with clothing protectors to prevent spillage on their clothing.R15's MDS (Minimum Data Set) dated 11/24/2025 said she was severely cognitively impaired and required staff to provide set-up and clean-up assistance with her meals.R15's care plan said she was at risk for complications due to her cognitive impairment. The care plan said she was dependent on staff for her care, and staff was to anticipate her care needs.The facility's policy titled Resident Rights, dated 2001, said employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to assess residents for self-administration of medications. The facility failed to obtain physician orders for medication to be at the bedside. This applies to 2 of 2 residents (R54, R56) reviewed for medications in a sample of 17.The findings include:1. On 12/21/25 at 10:32 AM, during initial tour, the following medications were observed to be on R54's bedside table: Systane optimal dry eye relief lubricant eye drops and Systane ointment lubricant eye ointment.On 12/23/25 at 10:57 AM, R54 stated that no one educated her on how to take the medications. She said she already knows how to take the medications. R54 stated the medications are always kept in her room.R54's face sheet shows a diagnosis of exudative age-related macular degeneration, bilateral, with active choroidal neovascularization.R54's MDS (Minimum Data Set) dated 11/24/25 shows she is cognitively intact.Review of R54's POS (Physician Order Sheet) shows an order for Systane Ophthalmic Gel 0.4-0.3% (Polyethylene Glycol-Propylene Glycol)-Instill 1 drop in both eyes every 24 hours as needed for dry eyes PRN (As Needed).There was an order for the medication for the medication to be at the bedside.Review of R54's medical record shows no self-administration of medication assessment uploaded.R54 did not have a care plan regarding self-administration of medication.2. On 12/21/25 at 10:40 AM, R56 had the following medications on her bedside table: 1 tube of (brand name topical analgesic) 1.76 oz (ounces) and another tube of (brand name topical analgesic) 3.53 oz. There was 1 tube of (brand name topical antibiotic medication) 0.50 oz.R56 stated that she puts the (brand name topical analgesic) on her knees for arthritis pain and she applies the (brand name topical antibiotic medication) on the sides of her nose where her eyeglasses rest because sometimes she has pain. She stated the medications are always kept in her room and no one educated her on how much she can apply in a day.R56's face sheet shows a diagnosis of multiple sclerosis, unsteadiness on feet, and primary generalized osteoarthritis.R56's MDS dated [DATE] shows moderate impairment in cognition.Review of R56's POS shows no orders for the (brand name topical analgesic) and (brand name topical antibiotic medication).Review of R56's medical record shows no self-administration of medication assessment uploaded.R56 did not have a care plan regarding self-administration of medication.On 12/23/2025 at 9:44 AM, V2 (Director of Nursing) stated she currently doesn't have residents that self-administer medications. She stated that nurses should do an assessment to see if the resident can safely self-administer medications. The resident should demonstrate to the nurse that they can take the medication. She said this is necessary because nurses have to ensure the resident can self-administer according to doctor's orders and see if they are correctly getting the right medication. She stated there should be doctor's orders for the medications to be at the bedside.Facility's policy titled Self-Administration of Medications (Revised 2/2021) shows: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on observation, interview, and record review, the facility failed to reconcile controlled substances. This applies to 2 of 3 (R67 and R68) reviewed for narcotics in a sample of 17.The findings include:1. On 12/22/2025 at 11:45 AM, the facility's Birch unit medication cart storage observation was done with V2 (Director of Nursing/DON). R67's Hydrocodone-Acetaminophen oral tablet 5-325 mg (milligrams) medication card with 30 tablets was stored in the narcotic box with its controlled inventory sheet attached. V2 said R67's inventory sheet was not maintained in the cart's controlled inventory binder for count because she was discharged from the facility.R67's EMR (Electronic Medical Record) showed she was discharged from the facility on 12/16/2025.R67's Order Summary Report showed she had an as needed order for Hydrocodone-Acetaminophen oral tablet 5-325 mg started on 12/03/2025 and discontinued 12/08/2025.2. On 12/22/2025 at 11:45 AM, the facility's Birch unit medication cart also had R68's Alprazolam 0.25 mg card with 14 tablets and Tramadol HCL 50 mg with 15 tablets stored in the narcotic box. R68's medications had their individualized controlled inventory sheets attached to them. V2 said R68's inventory sheets were not maintained in the cart's controlled inventory binder for count because he had also discharged from the facility. V2 said the individual controlled count sheets should be maintained in the narcotic binder to ensure all stored narcotics were accounted for during shift-change to ensure accuracy. V2 said narcotics should be destroyed per policy when a resident discharges from the facility to prevent diversion.R68's EMR (Electronic Medical Record) showed he was discharged from the facility on 12/20/2025.R68's Order Summary Report showed he had as-needed orders for Alprazolam oral tablet 0.25 mg and Tramadol HCL oral tablet 50 mg.The facility's policy titled Controlled Substances, dated 2001, said the facility complied with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. The policy said nursing staff was responsible for counting controlled medications inventory at the end of each shift, using the narcotic records to reconcile the inventory count. The controlled substance inventory was monitored and reconciled to identify loss of potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.

Based on observation, interview, and record review, the facility failed to secure and contain resident medications. This applies to 2 of 2 residents (R57, R62) reviewed for medications in a sample of 17. The findings include: 1. On 12/21/25 at 10:50 AM, on R57's bedside table, the following medications were observed: Breztri aerosphere inhaler and Airsupra (Albuterol and Budesonide) inhaler. R57 stated that was admitted to the facility yesterday. She said both medications have been in her room since yesterday (12/20/25). She said the nurse administered the Airsupra inhaler to her and then left the medication in her room. R57 stated the Breztri inhaler needs to be approved by the respiratory therapist. R57's face sheet shows an admission date of 12/20/25. R57's face sheet shows a diagnosis of other specified chronic obstructive pulmonary disease. R57's MDS dated [DATE] shows she is cognitively intact. R57's POS (Physician Order Sheet) shows orders for Breztri Aerosphere Inhalation Aerosol 160-9-4.8 MCG (Micrograms) /ACT (Actuation) (Budesonide—Glycopyrrolate—Formoterol Fumarate 2 puffs inhale orally two times a day. Airsupra inhalation aerosol 90-80 MCG/ACT (Albuterol—Budesonide) 2 puffs inhale orally every 6 hours as needed for wheezing. There was no order for the medications to be at the bedside. On 12/23/2025 at 9:44 AM, V2 (DON—Director of Nursing) stated if residents bring medications from home, they should be given directly to the nurse. She stated that nurses shouldn't leave the medications in the resident's room. It should be locked up in the medication cart or medication room. Facility's policy titled Medication Labeling and Storage (Revised 2/2023 shows the following: The facility stores all medications and biologicals in locked compartments.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 2. On 12/21/25 at 11:00 AM, R62's had 3 tubes of (brand name topical analgesic) 1% on her tray table. R62 was unable to comment on the medication due to impaired cognitive function and thought processes secondary to dementia as stated in her care plan dated 12/18/2025. R62' face sheet shows an admission date of 12/17/2025. R62's face sheet includes diagnoses of cognitive communication deficit, unspecified dementia, and major depressive disorder. R62's MDS dated [DATE] shows she has moderate cognitive impairment. R62's POS does not contain any order for (brand name topical analgesic) 1%. There was no order for any medication to be at the bedside.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, store items, remove expired items, and wear hair restraint while serving food from facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 42 residents. On [DATE] at 3:20 PM, V2 (DON/Director of Nursing) said there is only 1 NPO (Nothing by Mouth) resident; all other residents eat from the facility kitchen. On [DATE] starting at 10:29 AM, the facility kitchen was toured in the presence of V3 (Interim Dietary Manager) and V4 (Executive Chef) and the following was found: In single door reach in cooler: 1. Package labeled Canadian Bacon with expiration date of [DATE]. 2. Opened, not sealed large tube of ground beef labeled [DATE]. V4 said the meat is only good for 3 days once opened and expired [DATE]. Red juices dripping from package. 3. Tubes of ground beef are stored on bottom of refrigerator, not on a pan/tray. Red/brown juices from meat leaked all over the bottom of the cooler. Red liquid dripping on floor of kitchen when expired ground beef was taken out of cooler. In the walk-in Cooler: 4. 2 thawed oven roasted beef pot roasts with pack date of [DATE]. V3 (Interim Dietary Manager) looked up the expiration date of beef roast said they expired 1 month from pack date- [DATE]. 5. Cooked beef in a medium silver bin, not covered/sealed with expiration date of [DATE]. 6. Medium sized silver bin of what V4 says are chicken thighs. Not labeled, dated, or sealed. 7. Medium sized silver bin of shrimp. Not labeled or dated. 8. 2- 16 ounce packages of mozzarella slices with use by date of [DATE], expired. 9. 10.5 ounce package of goat cheese best by [DATE], expired. 10. 2- 5 pound bags of smoked roasted bacon with expiration date written as [DATE], expired. 11. A medium sized bin of dark red sauce that appears to be cocktail sauce. Not labeled, dated, or sealed. 12. Medium plastic bin of what appears to be yogurt. V4 says he thinks it is frosting. Not labeled or dated. 13. A medium sized silver bin of white cream sauce labeled line sauce not sealed. Sauce appears congealed. 14. A small silver bin of what V4 says is white wine tomato sauce, not labeled and not sealed. 15. A medium silver bin of cooked pasta, not sealed and dated [DATE]. 16. A small silver bin of asparagus, not sealed and wilted, dated [DATE]. 17. Half an onion, not labeled or dated. In the Dry Storage: 18. Small black flies seen flying around by the canned foods 19. Large plastic container on wheels of white sugar with broken lid. The back half of the lid is missing, so half of the container is not covered. No date or label on the white sugar. 20. Large plastic container on wheels of brown sugar with lid left opened about an inch, exposing the sugar to contaminants. 21. 32 fluid ounce bottle of browning and season sauce opened and sticky on the outside with expiration date of [DATE]. Small black flies flew off the bottle when it was lifted off the shelf. V3 (Interim Dietary Manager) touched the bottle and commented, sticky and wiped her hands on her pants. 22. 1 gallon Apple Cider Vinegar with use by date of ,d+[DATE], expired. Outside of gallon is sticky. 23. 10 pound bag of seedless raisins opened, not sealed. Small black flies flying around the bag. 24. 5 pound bag of toasted couscous opened, not sealed. 25. Dishes stored on rack in dry storage are sticky/dusty and stored right side up instead of upside down. V4 said this is extra storage for our dishes and they do not use these dishes as often. Then 1 minute later, a cook came into the dry storage room and removed two trays from the top of the rack to use for food preparation. 26. Behind the dishes on the storage rack, 3 sweet potatoes were found in a small bowl labeled with expiration date of ,d+[DATE]. One onion was also found behind the dishes on the rack and V4 said, that's odd, because we keep our onions in the cooler. 27. 6.37 pounds can of sliced water chestnut on circulation rack dented in 3 different spots- 2 dents around the rim and 1 large dent in the side of the can. V3 (Interim Dietary Manager) said we cannot serve that. 28. Opened bag of vanilla wafers, no label or date. 29. 2 boxes of individual zero calorie sweetener packets with expiration date of [DATE]. In the double door reach in cooler: 30. Medium sized plastic bin of prepared coleslaw with expiration date [DATE], expired. 31. 6 prepared bowls of Mediterranean salads with expiration date of [DATE]. Lettuce has turned brownish red. 32. On [DATE] at 12:10 PM, V5 (Server) was seen in kitchenette on the unit serving meals to residents with hairnet only covering half of her head. V5's bangs and hair on the front top half of her head was not restrained and could be seen blowing in the breeze when she walked around in the kitchenette. On [DATE] at 10:46 AM, V4 (Execute Chef) said all food items, including items that are prepared in the kitchen, need to be labeled and dated for food safety. V4 said servers who handle resident food in the kitchen areas on the unit are supposed to wear hair restraints covering all the hair on their heads to minimize the risk of contamination from hair falling into the food. V4 said expired foods should be thrown away by or on their expiration date for food safety; to prevent an expired food item from being served to residents with the potential to jeopardize their health. V4 said we don't want any residents getting sick, especially in this environment where many residents are compromised. V4 said all opened food items in the dry storage and coolers should be sealed/covered to avoid cross contamination and debris from getting into the food with the potential to make the residents sick. V4 said dented cans should be removed from the circulation rack because if food is served from a dented can there is a risk for botulism. V4 said if the cans are dented, there is the possibility there is a tiny hole in the can and that creates risk for contamination. V4 said all sticky food packaging should be wiped down prior to being returned to storage because sticky food items can attract bugs/flies that carry diseases and potential to contaminate food items they land on. V4 said cleaned dished should be stored upside down so they don't risk dust particles or any other contaminants falling into the pans. V4 said opened packages of meat should be sealed before being placed back into the cooler to maintain the best quality of the meat and prevent the meat from spoiling quicker. V4 said meat should not be stored on the bottom of the cooler, but instead on a tray or pan to prevent cross contamination of other boxes or food items in the cooler. The facility's policy titled, Food and Supply Storage last revised ,d+[DATE] states, Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Procedures: .Foods past the use by, sell-by, best-by. Or enjoy by date should be discarded. Cover, label and date unused portions and open packages . Discard food past the use-by or expiration date . Dry Storage: . Maintain designated area for items that are damaged (such as dented cans) that are to be returned for credit .Store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight-fitting lids. Label both the bin and the lid .Refrigerated Storage: . Store bulk materials in NSF approved containers that have tight fitting lids. Label both the bin and the lid . Foods that are stored on .racks must be fully covered to prevent contamination from airborne contaminants as well as from dripping condensation. Either use a bag that covers the entire cart or cover each tray individually . Sort produce daily to remove spoiled pieces. The facility's policy titled, Storage of pots, dishes, flatware, utensils last revised ,d+[DATE] states, Policies: Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means. Procedures: . Store all pots, glasses, and cups in an inverted position on a clean storage surface. Invert the top plate, bowl, or dish of any stacks of dishes . The facility provided undated training papers titled, Personal Hygiene and Uniforms: Important information for all associates states, .Hair Restraints: Associates must wear hair restraints such as hats, hair coverings or nets, beard/mustache restraints, and clothing that covers body hair. Hair restraints must be worn so that hair effectively keep from contacting exposed food, clean equipment, utensils, linens, and single-service articles . The facility's undated policy titled, Cleaning and Sanitation states, Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from littler, rubbish and protected from rodents, roaches, flies and other insects .4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily . 5. Inspections will be conducted but not limited to the following areas: a. Dry Storage .c. Refrigerators .

Based on observation, interview, and record review, the facility failed to safely store medications for residents who were not assessed or ordered to have medications kept at bedside. This applies to 4 of 4 residents (R24, R13, R7, R19) reviewed for medication storage in a sample of 17. The findings include: 1. On November 6, 2024 at 11:31 AM, R24 had an eye drop bottle of Prednisolone Phosphate 1% Moxifloxacin 0.5% Bromfenac 0.075% on his bedside table. R24 said he was having cataract surgery on November 7, 2024 and needed to apply one drop four times a day. R24 said the nurses set the appointments up for his surgery, but he was not sure if they were aware he was putting the drops in. R24 said he had muscular dystrophy, and he may miss the first drop but there was enough liquid in the bottle to keep trying until he was able to administer the drop. R24's face sheet showed he was admitted to the facility with diagnoses including muscular dystrophy and cognitive communication deficit. R24's MDS (Minimum Data Set) dated September 4, 2024 showed R24 was cognitively intact. R24's POS (Physician Order Sheet) did not show an order for the Prednisolone Phosphate 1% Moxifloxacin 0.5% Bromfenac 0.075%, to self-administer medications, or to store medications at bedside. The Evaluations section of the EMR (Electronic Medical Record) did not have an assessment to show R24 was safe to self-administer medications or to store medications at the bedside. 2. On November 6, 2024 at 11:26 AM, R13 had Nystatin topical powder 100,000 units per gram, Chlorhexidine gluconate liquid solution 4%, and Triamcinolone acetonide topical aerosol 0.147 mg/gm (Milligram/Gram) with spray on his side table. R13 said the supplies were for his ostomy but the Chlorhexidine was seldom used and was probably for his bed sores. The Chlorhexidine gluconate liquid solution was dated May 17, 2024. On November 7, 2024 at 11:57 AM, the medications were still observed at the bedside. R13's face sheet showed he was admitted to the facility with diagnoses including ileostomy status. R13's MDS dated [DATE] showed R13 was cognitively intact. R13's POS did not have an order for the Chlorhexidine gluconate liquid solution 4%, and no orders to keep the Nystatin powder and Triamcinolone aerosol spray at the bedside. The POS showed the Chlorhexidine gluconate liquid solution was discontinued on June 20, 2024. The Evaluations section of the EMR did not have an assessment to show R13 was safe to self-administer medications or to store medications at the bedside. 3. On November 6, 2024 at 10:39 AM, R7 had a bottle of Phenol 1.4% oral spray on her tray table dated October 16, 2024. R7 said she had the bottle for a while and the facility staff had given it to her. R7 said she would spray it onto the right side of her mouth every once in a while. R7 said the last time she took it as a few weeks ago. R7 said she was not sure if she really needed the medication. On November 7, 2024 at 12:13 PM, R7's tray table did not have the spray on it and she said she did not know where it went. R7 then opened her side dresser drawer, and the Phenol 1.4% oral spray was in the top drawer of her side dresser. R7 said she had used it since the surveyor had asked her about it. R7's face sheet showed she was admitted to the facility with diagnoses including a cough, mood disorder, osteoarthritis, major depressive disorder, and cognitive communication deficit. R7's MDS dated [DATE] showed R7 was cognitively intact. R7's POS did not show an order for Phenol 1.4% oral spray, nor did it show orders for R7 to self-medicate or store medications at the bedside. The Evaluations section of the EMR did not have an assessment to show R7 was safe to self-administer medications or to store medications at the bedside. 4. On November 6, 2024 at 10:24 AM, R19's side dresser table had an unopened tube of hydrocortisone 2.5% cream with adaptor. R19 said she was not sure how or when the cream came to her room. On November 7, 2024 at 12:11 PM (during the survey), R19's tube of hydrocortisone 2.5% cream was no longer in her room. R19's face sheet showed she was admitted to the facility with diagnoses including constipation. R19's MDS dated [DATE] showed R19 was cognitively intact. R19's POS showed an order dated October 29, 2024 for Anusol-HC External Cream 2.5% (Hydrocortisone (Rectal)). R19's POS did not show any orders for R19 to have medications kept at bedside. The Evaluations section of the EMR did not have an assessment to show R19 was safe to self-administer medications or to store medications at the bedside. On November 8, 2024 at 10:18 AM, V6 (Registered Nurse/RN) said if a resident was allowed to self-medicate or store medications at the bedside, they needed an order from the doctor after an assessment for safe administration was done by the resident. V6 said he only had one resident who was allowed to store medications at bedside and self-administer. V6 said if there was a medication at the bedside, there should be an active order for the medication. V6 said the medications should be put in the drawer in their original packaging, and not kept out as another resident could take it or housekeeping could accidentally throw it away. V6 said if the medications did not have orders, it should be kept in the nurse's locked medication cart. On November 8, 2024 at 10:25 AM, V7 (RN) said she did not have any residents who were allowed to have medications at the bedside. V7 said the doctor needed to give an order after the resident demonstrated they were safe to store and self-administer medications. V7 said it was not the facility's practice to keep medications at the bedside. V7 said if a medication was found, there should be an active order for the medication, as well as orders to keep the medications at the bedside. V7 said it was the facility's preference that the nurses were the only ones to administer medications to the residents. V7 said the medications should be stored in the nurse's cart, but if they have an order to keep the medications at the bedside, they should be kept in a locked drawer in the rooms. On November 7, 2024 at 3:45 PM, V2 (Director of Nursing) said residents are allowed to have medications at the bedside if they have been educated on how, a return demonstration was done to show they were able to safely administer and ordered by the doctor. V2 said there was an assessment that gets filled out and an order needed to be put into the POS. V2 said there should be an order for a medication if it is at the bedside. The facility's Medication and Treatment policy dated February 1, 2024 showed An order for medication or treatment must be dated, signed by the prescriber and must be current and consistent with the resident's assessment. The facility's Medication Labeling and Storage policy revised February 2023 showed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls.

Based on observation, interview, and record review the facility failed to administer medications as ordered. There were 30 opportunities with 2 errors resulting in a 6.67 % error rate. This applies to 1 of 5 residents observed in the medication pass. Finding include: R3 admitted to the facility with diagnoses that includes fracture of left femur, hyperlipidemia, hypertension, anxiety, obstructive sleep apnea, (COPD) chronic obstructive disease and asthma. R3's physician orders includes fluticasone-salmeterol 250/50 MCG/ACT (Micrograms/ Actuation) one puff daily for COPD and Metoprolol Succinate 50 MG (Milligrams) on capsule by mouth daily for hypertension. R3's care plan states Actuation/he has asthma/COPD, sleep apnea and will display optimal breathing patterns. Interventions include to give aerosol or bronchodilators as ordered. R3 has hypertension and will remain free of signs, symptoms and complications related to hypertension. Interventions include to give anti-hypertensive medications as ordered. On 11/07/24 at 09:32 AM, during the medication observation V6 (Registered Nurse/RN) did not administer fluticasone-salmeterol 250/50 MCG/ACT one puff daily or Metoprolol Succinate 50 MG to R3. Review of the EMR (Electronic Medical Record) showed V6 (RN) documented fluticasone-salmeterol 250/50 MCG/ACT (Micrograms/Actuation) one puff and Metoprolol Succinate 50 MG (Milligrams) one capsule was administered to R3 that was not administered during the medication pass observation. On 11/08/24 at 11:40 AM, V2 (Director of Nursing) stated nurses should not document a medication was administered if was not administered. If it was not administered, it should be documented appropriately. The outcome for missing a medication depends on the medication. If Metoprolol is missed the resident could have an elevated heart rate or blood pressure. If fluticasone-salmeterol is missed the resident could have increased wheezing and shortness of breath after missing the medication. The facility policy Administering Medications dated April 2019 states medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to discontinue an antibiotic for a resident who did not meet criteria to continue antibiotics. This applies to 1 of 3 residents (R242) reviewed for antibiotic stewardship in a sample of 17. The findings include: On November 7, 2024 at 1:06 PM, V8 (Infection Preventionist/Registered Nurse) said R242 was admitted to the facility from the hospital on antibiotics on October 9, 2024. V8 said he had started Augmentin 875-125 MG (Milligrams) on September 28, 2024, while he was in the hospital. V8 said when R242 was first admitted to the facility, a McGeer's assessment was completed on October 9, 2024, which showed R242 did not meet criteria to continue the antibiotics. V8 said there was no evidence of infection, and his cultures were negative. V8 said she was not sure the doctor saw R242 since he was off the antibiotic by the time she came to the facility. V8 said she was not sure where the Infectious Disease note was. V8 said R242 had only received two days of the antibiotics. R242's POS (Physician Order Sheet) showed an order for Amoxicillin-Pot Clavulanate Tablet 875-125 MG with instructions to Give 1 tablet by mouth two times a day for bacterial infection for 5 days. R242's October 2024 MAR (Medication Administration Record) showed R242 received the following doses: On October 10, 2024 at 9 AM and 6 PM. On October 11, 2024 at 9 AM and 6 PM. On October 12, 2024 at 8 AM and 8 PM. On October 13, 2024 at 8 AM and 8 PM. On October 14, 2024 at 8 AM. R242's Infection Control Data Collection- McGeer tool dated October 9, 2024 at 6:49 PM showed on October 8, 2024 Blood cultures- no growth October 8, 2024 Urine Culture- no growth. Under the comments section, V8 wrote [Patient] has an ileostomy [due to] a colonic obstruction. No evidence of infection, does not meet McGreer's criteria for [antibiotic] stewardship, [Medical Director] referred to [Infectious Disease], will follow up with Infection Control on Thursday, October 10, 2024. R242's Progress Notes were reviewed from October 9, 2024 through October 25, 2024. No note was written by the Medical Director. On November 8, 2024, the facility provided a late entry note created on November 7, 2024 at 6:56 PM (during the survey) by the Infectious Disease Nurse Practitioner, which was backdated to October 10, 2024 at 6:55 PM. The Progress Note documented the following: Patient was admitted from [Hospital] on Augmentin 875 MG BID (Twice Daily) x 5 days. Hospital records are limited. Antibiotics are for bowel obstruction per [discharge] paperwork. Will complete course. Nursing to continue to monitor. R242's face sheet showed he was admitted to the facility on [DATE] and discharged from the facility on October 25, 2024, with diagnoses including ileostomy status, malignant neoplasm of colon, and intestinal obstruction. The facility's Antibiotic Stewardship policy revised December 2016 showed Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. Training and education will include emphasis on the relationship between antibiotic use and: gastrointestinal disorders, opportunistic infections (e.g., C. Difficile, candida albicans, etc.); medication interactions, and the evolution of drug-resistant pathogens. The facility's Unnecessary Drugs-Without Adequate Indication for Use revised February 2023 showed A medication initiated as a result of a time-limited condition .will be discontinued when the condition has resolved, or there is documentation indicating why continued use is relevant.

Based on observation, interview, and record review the facility failed to identify an area of pressure prior to it becoming unstageable in a resident (R27) at high risk for pressure injury. This failure resulted in R27 needing to be hospitalized with osteomyelitis (bone infection) which required antibiotics. This applies to one of three residents reviewed for pressure in the sample of 12. The findings include: The facility face sheet for R27 shows diagnoses to include adult failure to thrive, pressure ulcer of the sacral region and osteomyelitis of the sacral region and was admitted into the facility on [DATE] after a hip fracture. The facility assessment dated [DATE] shows R27 to have severe cognitive impairment and requires moderate assistance from staff for all activities of daily living. The facility scale for predicting pressure risks completed on admission, dated 9/15/23 shows R27 to be at high risk. The skin evaluation dated 9/21/23 shows no areas of concern to the sacral area of R27's body. The nursing progress note dated 9/27/23 for R27 shows a note stating R27 [has developed an unstageable pressure injury to her sacrum]. The measurements of the pressure injury were recorded as 4 by 8 CM (Centimeters) with 75% slough (dead cells in the base of a wound) that was yellow and a red perimeter around the wound. On 12/13/23 at 1:10 PM, V3 (Wound Care Nurse) said R27 was admitted to the facility for rehab after a hip fracture. V3 said R27 developed a facility acquired unstageable pressure injury to her sacrum. V3 said R27 was seeing an outside wound clinic for this wound and was sent from the clinic to the hospital when it became infected. On 12/14/23 at 9:00 AM, V3 said she expects the staff to find a pressure injury before it becomes unstageable. On 12/14/23 at 9:15 AM, V2 (Director of Nursing) said a pressure injury should be reported to the nurse before becoming unstageable. On 12/14/23 at 10:03 AM, V9 (R27's Physician) said R27 has a pressure injury to her sacrum and treatment to a wound should begin as soon as it is found. V9 said finding the wound is dependent on the cooperation of the resident and any pre-existing conditions. On 12/14/23 at 10:17 AM, V11 (Certified Nursing Assistant) said R27 is always compliant with her care. On 12/14/23 at 11:00 AM, V7 (Registered Nurse) said a wound should be found by staff prior to it becoming an unstageable wound. V7 said R27 is compliant with her care. The facility assessment dated [DATE] for R27 shows no rejection of care has been observed. The Physician Progress note dated 11/15/23 shows R27 was seen after her re-admission into the facility after a hospital stay. The note shows she was treated for an infected pressure skin injury and osteomyelitis to her sacral area pressure injury. R27 is to continue with intravenous antibiotics. The facility care plan dated 9/18/23 shows to monitor/document/report any changes in skin status. The facility policy with a revision date of April 2018 for pressure ulcer/skin breakdown shows nursing staff will assess and document a resident's significant risk factors for developing pressure ulcers The nurse will describe and document the following: full assessment of pressure sore, pain assessment, resident's mobility status

Based on observation, interview, and record review the facility failed to ensure a resident was assessed for safety prior to the use of a motorized wheelchair for 1 of 2 residents (R6) reviewed for safety in the sample of 12. This failure resulted in R6 being sent to the emergency room and receiving 30 stitches to the right lower leg. The findings include: R6's face sheet printed on 12/14/23 showed diagnoses including but not limited to dementia, cognitive communication deficit, altered mental status, anxiety, osteomyelitis (bone infection), absence of right toe, foot pain, and history of falls. R6's facility assessment dated [DATE] showed moderate cognitive impairment. The assessment showed substantial/maximal staff assistance needed for toilet transfers and the use of a walker for ambulation. R6's activities of daily living care plan showed an intervention dated 11/17/23 for: TRANSFER-The resident is able to transfer with 1-assist, gait belt, walker. R6's impaired cognitive function care plan showed an intervention dated 11/26/23 for: Cue, reorient and supervise as needed. On 12/13/23 at 8:50 AM, R6 was lying in bed and covered with a light blanket. R6 was awake but sleepy. R6 was slightly confused and refused to be interviewed. At 10:43 AM, V17 (R6's daughter) was at the bedside and R6 was asleep. V17 stated R6 had a recent toe amputation and is on IV antibiotics for an infection. V17 stated R6 had a motorized wheelchair in her room for a few days and accidentally ran it into the side of the bed. V17 said the right lower leg was ripped open and she had to go to the emergency room for stitches. V17 said R6 is somewhat confused at times, but especially recently, due to the toe amputation and medications being given to treat the infection and pain. On 12/14/23 at 10:36 AM, R6 was seated in her room next to her bed. R6 lifted her right pant leg and a C-shaped area with multiple sutures was observed on the right lower leg. A baseball size dark, purple bruise was covering the area. The leg wound was at the same level as the metal mattress platform on her bed. R6 was asked what happened and stated she took herself to the bathroom using a motorized wheelchair. R6 said she got off the toilet and pushed the button on the wheelchair. R6 said she ran super hard into the side of her bed and hit a metal rail. R6 said she had been using the wheelchair for a couple of days, including back and forth to the group dining room. R6 said her daughter brought it in for her and the staff knew she was using it. R6's progress note dated 12/6/23 stated: At 19:25 (7:25 PM) heard resident scream. CNAs and RN rushed to check on resident and noted resident on motorized wheelchair next to bed, stated she hit her right leg on the bed. Resident just came out of bathroom, stated she ran into the bed while using motorized wheelchair. Resident (complains) of severe pain to right shin. When checked blood gushing out on a laceration. Applied pressure to stop bleeding. Resident screaming in pain, does not want anybody look under her pants due to tightness of clothing rubbing into wound. RN needed to cut pants open to look at injury. Noted large flap of skin and bleeding a lot. Applied pressure to stop bleeding. Notified MD and ordered for resident to be sent to hospital for eval and treat. 911 was called for transport. Daughter (name omitted) and notified of incident. DON/ADON notified of incident. Paramedics took resident to hospital at 19:45 (7:45 PM). On 12/13/23 at 2:47 PM, V12 (Certified Nurse Assistant/CNA) stated R6 rammed her motorized wheelchair into the side of her bed and needed sutures. V12 said she had no idea how long it was in her room or why she was using it. V12 said R6 was able to walk with one assist prior to the incident and had no need for a wheelchair. On 12/13/23 at 2:59 PM, V13 (CNA) stated he had no knowledge of a motorized wheelchair being used by R6. On 12/14/23 at 8:20 AM, V15 (Occupational Therapist) stated R6 should not be using a motorized wheelchair. She (R6) had one in her room that her daughter had brought into the facility and R6 ran into the bed with it. V15 said she thought the chair had been in the room about 24 hours before the incident occurred. V15 said residents need an assessment done prior to use to ensure they can operate it safely. V15 said R6 should have definitely been trained on it first. V15 said the wheelchair was taken away as soon as the therapy department found out about the incident. V15 said R6 is sleepy and not always alert. V15 said R6 is confused at times and cannot be wheeling herself around safely. V15 said R6 can stand and pivot therefore there was no need for a motorized wheelchair. V15 said it would not have been recommended for use until it was determined she could operate it safely and that has never been done. V15 said it is not appropriate for R6 to use a motorized wheelchair now or prior to the incident. R6's family just brought it in one day and she was never assessed on it. On 12/14/23 at 8:35 AM, R6's motorized wheelchair was in the corner of the therapy gym. A piece of paper was taped to the back of it with handwritten instructions on how to use the chair and a contact phone number for the family member. V15 stated the paper was put there by her family member when the chair came it. V15 said it is irritating the nursing staff never told the therapy department she had it in the room. She needed training on it before they let her use it. On 12/14/23 at 10:47 AM, V17 (R6's daughter) stated she did bring the motorized wheelchair in for her mother. V17 stated R6 was able to get herself in and out of it alone. V17 said it was in R6's room for about one week. R6 used it several times and even went out on a doctor's appointment in it. V17 said her and another family member showed R6 how to use it. V17 said they left an instruction manual for the staff to use. V17 said she was told staff would be sure to tell the therapy department she had it and also show R6 how to use it. V17 said she was not sure if that was ever done, and the wheelchair has been taken out of the room since the incident. V17 said the staff all knew R6 had it. The wheelchair was in her room and in plain sight. On 12/14/23 at 10:57 AM, V16 (Physical Therapist) stated R6 is very hazy and lethargic. She would not be able to operate a motorized wheelchair safely. R6 has safety deficits, is weak, and lethargic at most times. Residents need to be assessed first by the therapy department. Check off forms are used to assess for safety going forward, backward and turning. Residents need to be assessed for the ability to judge distances and obstacles. They need to be able to get on and off it correctly. The assessment ensures the resident is safe to use the motorized chair appropriately. V16 stated R6 was never assessed prior to her using the chair and it was never reported to the department that she had it in her room. V16 stated R6 was physically able to transfer in and out of a chair by herself, but not mentally able to do it safely by herself. On 12/14/23 at 11:17 AM, V2 (Director of Nurses) stated the incident with R6, and the chair never should have happened. Staff have no idea how long the motorized wheelchair was in her room prior to the incident. It is not appropriate for family to just bring in equipment as they feel. There is the risk the resident may not be ready to operate it. R6 was never assessed or trained to use it safely before she jumped on it. It should never have been left in the room and staff should have removed it. R6 was never reviewed to use it safely. Nursing staff should have been aware it was in there. Nursing probably just assumed therapy okayed it. No one realized she would just jump on it and take off. R6's emergency room note dated 12/6/23 at 9:04 PM states: Patient presents from (facility name), was in her electric wheelchair when she lost control and hit the bed with her right shin. EMS reports an approximate 6-inch avulsion to the right shin. R6's most recent skin/wound note dated 12/13/23 at 8:00 AM showed: 1. Dressing changed to RLE (right lower extremity) laceration C shaped 17 cm (centimeters); area around the sutures/laceration gently cleansed with wound cleanser and pat dry. Dry gauze placed and secured with paper tape. No drainage, no c/o pain, no odor. Sutures in place. Peri wound with ecchymosis appears fragile. Currently the flap appears to be adhering and viable. The facility's Motorized Mobility Device (MMD) Use in Health Centers policy revision dated 10/31/20 states under the resident assessment due to medical condition section: A. In the event a resident has a medical condition that would interfere with the resident's ability to operate a MMD, nursing or therapy team members, including therapy vendors providing services to the resident, in consultation with the administrator, shall perform an assessment to determine whether the resident demonstrates evidence of sufficient skills/ability to follow all community safety rules and operate the MMD safely. The assessment shall be included in the resident's medical record. The facility was unable to provide a Motorized Wheelchair/Cart Skills Assessment form for R6.

Based on observation, interview, and record review, the facility failed to ensure food was kept off the floor, failed to maintain food storage areas in a clean and orderly manner, failed to ensure ice cream freezer temperature was monitored, failed to maintain cleanliness of ice cream freezer, and failed to discard expired food items. These failures have the potential to affect all residents in the facility. The findings include: The facility's resident roster dated [DATE] showed 42 residents currently residing in the building. On [DATE] at 9:58AM, The facility's refrigerator had multiple pans of food and boxes of food stacked on top of each other. There were boxes filling all racks of the refrigerator, some boxes filled with plastic bags that were packed tightly into each box. Due to the large amount of food stored within the refrigerator, surveyor was unable to move food around to determine what food was present in the refrigerator. A pan of meat was also located on the floor of the refrigerator under a cart. On [DATE] 10:05AM, The facility's freezer had 12 boxes of food placed on the floor and the shelves were piled with boxes of food so tightly and disorganized that surveyor was unable to move boxes around. On [DATE] at 10:12AM, The facility's dry storage room had 2 bags of corn tortillas with an expiration date of [DATE], an open container of cherries with no open or use by date, and 6 cans of diced peaches sitting directly on the floor. On [DATE] at 10:20 AM, The facility's ice cream freezer area had a bottle of raspberry sauce with an expiration date of [DATE] and a bottle of caramel topping with an expiration date of [DATE]. Surveyor requested to visualize the thermometer for the ice cream freezer and V5 (chef) had to remove 8 containers of ice cream to locate the thermometer that had a large chunk of ice cream stuck to it on the bottom of the freezer. The ice cream freezer had several large scoops of ice cream sitting on the bottom of the freezer surround by crumbs, ice buildup around the entire top portion of the freezer, and large areas of dried, previously melted ice cream located all around the top of the freezer. On [DATE] at 10:30AM, V5 stated the temperature for the ice cream freezer is not checked routinely and there is no temperature log for it. V5 stated the kitchen staff have a cleaning list for their respective areas but the ice cream freezer is not on any of those lists. V5 also stated that he is aware that the food storage areas area a bit of a disaster and that is something he will be working on in the near future. The kitchen cleaning schedules were reviewed and showed no schedule for cleaning the ice cream freezer. On [DATE] at 11:40AM, V6 (Interim Dietary Manager) stated, I have been the interim director for about a week. I am aware that there are issues in the kitchen and storage is on the top of my list to start working on. We don't have a lot of room for food storage but it's an absolute mess in there right now. There should not be any food or pans on the floor as that is not our policy for food storage. I agree that the food storage situation is chaotic, and I have no idea how they even find anything in there or keep the foods rotated for a first in first out rotation. The ice cream freezer should have the temperature checked every day because that is a dairy product and if it's not kept at the right temperature, it could cause illness potentially. We should be cleaning that freezer out at least weekly and as needed when we identify concerns. The facility's policy titled, Storage of Food and Supplies dated [DATE] showed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date .discard food past the use-by, sell-by, best-by, or enjoy-by date .arrange items neatly on the shelves in the same order as the inventory book .date and rotate items; first in, first out. Discard food past the use-by or expiration date .Refrigerated foods: Space foods on shelves to allow for air circulation. Do not crowd food .store items 6 above the floor, 2 from the walls, and 18 from the ceiling, consistent with local food protection codes .keep all food products at least 6 inches off the floor .Dry Storage: Store dry and staple items at least 6 above the floor and 2 from the walls and 18 from ceiling.

Based on observation, interview, and record review, the facility failed to provide evening snacks for 5 residents (R4, R19, R25, R26, R28). This applies to 5 of 5 resident's outside of the sample reviewed for frequency of meals and snacks. The findings include: On 12/13/23 at 10:00AM, A resident council meeting was held with R4, R19, R25, R26, and R28 who have no cognitive impairment. All resident's stated they do not receive snacks at the facility, and they have not been offered snacks prior to going to bed at night. All residents stated they are not diabetic and do not require any special diet that would prevent them from getting a snack. On 12/13/23 at 1:42PM, V2 (Director of Nursing) stated, We have a snack list posted in the dining area for resident's that want to ask for a snack. We don't routinely pass out snacks or offer them. They know they are there and should ask for them if they want them. We do pass water every shift though. If a resident has an order to receive a snack, then we offer them. I have never heard of a facility offering snacks to residents. The facility's policy titled, Frequency of Meals dated December 2009 showed, Each resident shall receive at least three meals and at least one snack daily .1. The facility will serve at least three meals or their equivalent daily at scheduled times .The following mealtimes have been established by our facility for residents: Breakfast 7:30am-9:30am, Lunch 11:30am-1:30pm, Dinner 4:30pm-6:30pm .6. Evening snacks will be offered routinely to all residents not on diets prohibiting bedtime nourishment .

Based on observation, interview, and record review the facility failed to ensure peri care was performed in a manner to prevent cross contamination for 1 of 1 resident (R100) reviewed for incontinence in the sample of 12. The findings include: R100's computerized face sheet printed on 12/13/23 shows diagnoses including but not limited to heart disease, malignant breast and liver cancer, chronic kidney disease, diarrhea, and urinary tract infection. R100's facility assessment dated [DATE] shows no cognitive impairment and staff supervision or touching assistance required for toileting hygiene. The same assessment shows R100 is always incontinent of urine and bowel. R100's December 2023 Physician Order Sheet (POS) shows an order start dated 12/11/23 that states: Lomotil tablet 2.5-0.025 milligram (Diphenoxylate-Atropine) Give 1 tablet by mouth every 6 hours as needed for diarrhea. R100's POS shows an order start dated 12/6/23 that states: Azo tabs oral table (Phenazopyridine HCI) Give 2 tablets by mouth as needed for urinary pain for 3 days twice daily. On 12/12/23 at 1:45 PM, R100 was seated on the toilet in her room. R100 said she has been having terrible diarrhea lately and her chemotherapy medication is the cause. R100 said her buttocks skin is sore and irritated from having to go the bathroom so often. R100 said she needs staff to help clean her and put on a protective cream after each episode. At 1:47 PM, V14 (Certified Nurse Aide) entered the bathroom and said R100 has been having watery diarrhea for several days. She needs frequent toileting, and we use an extra absorbent pad inside the brief to keep her skin drier. V14 donned gloves and assisted R100 to a standing position. V14 used peri-wipes to clean R100's buttocks then wiped the vaginal area. V14 wore the same diarrhea contaminated gloves to wipe the vaginal area. V14 applied a barrier cream to R100's buttock then put a fresh brief on her. V14 pulled up her pants and assisted her back into the room recliner. V14 laid a blanket across her lap, then placed the call light, tissues, and coffee cup within reach. V14 was still wearing the dirty gloves. V14 bagged up the garbage in R100's bathroom. V14 exited the room with the same diarrhea contaminated gloves on, walked down the hallway, and coded herself into the soiled utility room to dump the garbage bags. On 12/14/23 at 9:25 AM, V2 (Director of Nurses/Infection Control Preventionist) stated gloves need to be changed after peri care is performed and before a new brief is put on. Aides should be changing gloves between dirty and clean areas. V2 said dirty gloves should never be worn when exiting a resident room. Dirty gloves can cross contaminate clean items, clothing, and skin. It is an infection control concern. Germs can pass from one resident to another resident. Peri care should always be done from the front to the back. Feces can contaminate the urinary tract and cause infections. The facility's Perineal Care policy revision dated 2/2018 states under the steps for procedure section: 1.) b.) Wash perineal area, wiping from front to back . 10.) Remove gloves and discard into designated container. The facility's Glove Use policy dated 2019 states: Sterile gloves and examination gloves are removed: a. As soon as practical when contaminated. d. Before touching uncontaminated surfaces or other area of the same resident's body that may be uncontaminated.

Based on observation, interview, and record review the facility failed to ensure a physician order was obtained and a care plan was in place prior to oxygen administration for 1 of 1 resident (R96) reviewed for oxygen in the sample of 12. The findings include: R96's face sheet printed on 12/13/23 showed diagnoses including but not limited to acute respiratory failure, acute pulmonary edema, atrial fibrillation, shortness of breath, and dependence on supplemental oxygen. The face sheet showed an admitted [DATE]. R96's facility assessment dated [DATE] showed the use of continuous oxygen on admission and within the last 14 days. On 12/12/23 at 10:44 AM, R96 was seated in a wheelchair in her room. Oxygen was running via nasal cannula into her nose. The oxygen setting was at 1 liter per minute. At 12:24 PM, R96 was asleep in bed. The oxygen setting was at 1 liter per minute. On 12/13/23 at 8:36 AM and 12:05 PM, R96 was in bed and the oxygen was running at 2 liters per minute. On 12/14/23 at 8:40 AM, V8 (Registered Nurse) was applying a portable oxygen tank to the back of R96's wheelchair and set the oxygen level to 2 liters per minute. V8 stated she sets the oxygen at the level stated on the daily paper report or per the physician order. This surveyor and V8 viewed the daily report and electronic physician orders together. There were no orders for the use of oxygen. V8 said R96's oxygen needs to be running at the correct level. Too low can cause her to desaturate and not maintain 95% oxygen saturation levels. Too high can over oxygenate her. V8 said there should be orders and a care plan to show how to care for the oxygen system. On 12/14/23 at 9:20 AM, V2 (Director of Nurses) stated oxygen is a medication and needs a physician order. Orders should include the rate, if continuous or intermittent, liters, and oxygen saturation range. Orders should include how to care for the tubing system. V2 said a care plan is a good idea too. It directs staff how to provide that care. Lack of orders and a care plan have the potential for infection control issues and can affect the resident's overall health. Respiratory status can be negatively impacted. V2 reviewed R96's electronic medical record and stated she did not see any orders or care plan for R96's oxygen administration. The facility's Oxygen Administration policy revision dated 10/2010 states under the preparation section: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview, and record review, the facility failed to document and maintain an accurate count of narcotic medications for 1 resident (R6) in the sample of 12 and 1 resident (R95) outside of the sample reviewed for pharmacy services. The findings include: On 12/12/23 at 9:30AM, V8 (Registered Nurse) administered Norco 5/325mg to R6. V8 documented the medication administration on R6's narcotic count sheet but did not record the administration on R6's medication administration record. On 12/14/23, R6's medication administration record contained no documentation that V8 had administered any Norco to R6. (The only documented dose of Norco for R6 on 12/12/23 was 7:15PM) On 12/13/23 at 1:44PM, Surveyor performed a narcotic count with V8. R95's Norco 5/325mg narcotic count sheet showed R95 had 52 doses remaining. R95's Norco pill card showed 50 tabs remaining. V8 stated she must have forgotten to sign out a dose she gave to R95 earlier in the day. On 12/14/23 at 9:23AM, V8 stated, When we administer any medication to a resident, we are to document it in the medication administration record so there is confirmation that the medication was given. When we administer narcotics, we also have to sign out on the resident's narcotic record, so our counts are accurate. If we don't do both of these steps, our count could be off, and we also can't be sure when a resident last received their medications and that could lead to a medication error. On 12/14/23 at 11:44AM, V2 (Director of Nursing) stated, When staff are administering narcotics, they should first double check the count sheet to make sure the count is correct. After confirming correct count, they should document the amount removed on the count sheet, administer the medication, and then sign off on the resident's electronic medication administration record (EMAR). If a medication is not signed off on the EMAR, that's a problem because we need to know when the medication was last administered. If all of these steps are not followed, there could end up being a medication error. The facility's policy titled, Administering Medications dated April 2013 showed, Medications shall be administered in a safe and timely manner, and as prescribed .19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones . The facility's policy titled, Medication Administration dated 12/1/21 showed, Controlled Substances: Each medication is to be accounted for according to the Agency's procedure as it is removed from the container and before it is administered to the client.

Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 25 opportunities with 3 errors resulting in a 12% medication error rate. This applies to 1of 5 residents (R145) outside of the sample reviewed for medication administration. The findings include: R145's medication administration record for December 2023 showed R145 is to receive memantine 5mg, metformin extended release 500mg, and metoprolol 50mg at 9AM and 5PM. On 12/12/23 at 10:57AM, V7 (Registered Nurse) administered R145's memantine, metformin, and metoprolol. (1 hour and 57 minutes past the scheduled administration time). V7 stated she got a late start on her medication pass today because they were short staffed, and she had to help with patient care. On 12/14/23 at 11:44AM, V2 (Director of Nursing) stated, I wasn't aware that we were short staffed on Tuesday. I would expect the nurses to reach out to me if they are having trouble getting their medications administered in a timely manner or if there are staffing concerns. If a medication is not given within 1 hour before or after the scheduled administration time, then that is technically a medication error. The facility's policy titled, Administering Medications dated April 2013 showed, Medications shall be administered in a safe and timely manner, and as prescribed .4. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on observation, interview, and record review, the facility failed to store medications per manufacturer's directions and facility policy for 2 of 2 residents (R11, R37) outside of the sample reviewed for medication storage. The findings include: R11's physician's orders for December 2023 showed R11 receives Lantus 23 units daily. R37's physician's orders for December 203 showed R37 receives Insulin Glargine 38 units every evening. A review of V8's (Registered Nurse) medication cart on 12/13/23 at 1:44PM showed R11's Lantus pen was unopened with a label stating, Refrigerate until opened. R37's Insulin Glargine pen showed the insulin pen had been accessed and had no opened or use by date. V8 stated she believes that insulin is supposed to be refrigerated until use and that all insulin that has been opened is to have an open and use by date on it per facility policy. On 12/14/23 11:44AM, V2 (Director of Nursing) stated, Unopened vials of insulin should be refrigerated until they are put into use per manufacturer's directions. It should be dated with open date & use by date to ensure we discard it after 28 days. If these directions are not followed it could affect the efficacy of the insulin. The facility's policy titled, Medication Labeling and Storage dated February 2023 showed, The facility stores all medications and biologicals in a locked compartment under proper temperature, humidity and light controls .6. Medications requiring refrigeration are stored in a refrigerator locked in the medication room at the nurse's station or other secured location .5. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorts or longer date for the open vial.

Based on observations, interviews, and record reviews the facility failed to supervise a resident to prevent a resident's fall. This failure resulted in R1 sustaining a displaced fracture of the left distal femoral shaft requiring surgery. This applies to 1 of 4 residents (R1) reviewed for falls. Findings include: R1's electronic health record showed that on July 3rd, 2023, R1 was left on the commode in her bathroom, and she fell to the floor while trying to self-transfer to her wheelchair. R1's 7/3/23 hospital X-ray report showed that R1 has sustained a fracture to her left femur. R1's 7/3/23 - 7/7/23 (after visit summary) hospital records showed that R1 had a 4-day hospital stay. R1's 7/4/23 Operative Report showed R1 had an open reduction internal fixation of the left distal femur. On 7/21/23 at 10:00am V10 (Certified Nurse's Assistant) said that on 7/3/23 he found R1 on the floor of her bathroom. V10 said that R1 should never be left alone on the toilet because she will try to self-transfer to her wheelchair and fall. On 7/21/23 at 9:43am V9 (Certified Nurse's Assistant) said that on 7/3/23, R1 needed to be toileted, and she placed her on the commode chair in her bathroom and then left her there unattended to go assist another resident. V9 said that she did not want to leave R1 alone because she felt that she was a fall risk, but V8 (Nurse) told her she would be okay to be left alone. On 7/20/23 at 3:01pm V8 (Nurse) said that on 7/3/23 R1 fell off the commode in her bathroom. V8 said R1 told her she fell while trying to self-transfer back to her wheelchair. On 7/21/23 at 11:21am V11 (Director of Nursing) said on 7/3/23 R1 was unsupervised and fell while on the toilet and it caused a fracture to her left femur. V11 said that her expectations would be that R1 be supervised while in the bathroom. On 7/21/23 at 1:09pm V12 (R1's Primary Care Physician) said on 7/3/23 R1 fell while on the toilet and it caused a fracture to her left femur. V12 said that his expectations would be that R1 would be supervised while in the bathroom. On 7/21/23 at 3:36pm V13 (Administrator) said on 7/3/23 R1 was unsupervised and fell while on the toilet and it caused a fracture to her left femur. V13 said that his expectations would be that R1 be supervised while in the bathroom. R1's 7/10/23 MDS (Minimum Data Set) Sect. G showed that R1 is an extensive assist with toileting and transfers and section C shows that R1 cognition is severely impaired. R1's progress notes showed that in the last 12 months R1 has been found on the bathroom floor after falling while attempting to self-transfer 8 times, 7/3/23, 5/20/23, 1/12/23, 12/26/22, 12/31/22, 11/10/22, 11/6/23, and 9/20/22. A review of the progress notes showed that R1 was alone when she fell . R1's 7/9/23 care plan showed that R1 is a high risk for falls related to gait/imbalance problem and right-side paralysis with interventions including encourage use of safety devices, anticipate needs, and call light within reach. R1's 7/9/23 care plan showed that R1 has impaired cognitive function, judgement and decision making with interventions including supervision with all decision making.

Based on observation, interview, and record review, the facility failed to identify an environmental fall risk and ensure smooth floor transitions between resident bathrooms and resident rooms to prevent falls. This failure resulted in a resident tripping on the wheel on her walker in her bathroom doorway and falling, sustaining a [MEDICAL CONDITION]. This applies to 1 of 6 residents (R1) reviewed for fall risk. The findings include: R1's Minimum Data Set (MDS) history showed she was admitted to the facility on (MONTH) 14, 2019 and was transferred to the hospital on (MONTH) 6, 2019 after a fall. The MDS history showed R1 was readmitted on (MONTH) 9, 2019. R1's (MONTH) 21, 2019 MDS showed R1 was cognitively intact. R1's (MONTH) 6, 2019 Nursing Progress Note from 2:00 AM showed Heard a loud noise .resident noted on the floor in the doorway of her bathroom. The note showed left upper scalp with moderate amount of blood .Resident stated was trying to use the bathroom and tripped on walker when transferring herself back from the bathroom. R1's note continued .unable to move left leg, left leg shorter than right leg and left foot positioned outward upon assessment . On (MONTH) 2, 2019 at 4:00 PM, V9 RN (Registered Nurse) stated she was the nurse assigned to care for R1 the night she fell . V9 stated R1 told her R1 tripped on her walker. V9 stated she did not ask what R1 meant by that, or why and how she tripped on her walker. V9 stated she did not notice the threshold (in R1's room) per se and added R1 was using her walker when she fell . R1 no longer resides at the facility, and R3 now resides in the room where R1 lived when she fell and fractured her hip. On (MONTH) 2, 2019 at 1:30 PM, V3 (Director of Building Services) measured the height of the threshold between the bathroom and the bedroom in R1's former room. V3 stated the bathroom floor is a half an inch lower than the threshold (going up to leave the bathroom), and the bedroom carpet is a quarter of an inch lower than the threshold. When asked about thresholds on (MONTH) 2, 2019 at 1:50 PM, V4 (Physical Therapist) stated Everybody complains about them. V4 stated she typically completes initial evaluations on residents and she has to teach residents how to get up and over the thresholds. V4 stated when R1 returned from the hospital on (MONTH) 9, 2019, (R1) blamed the threshold, or somebody did. When asked for clarification, V9 stated two of R1's family members were present during her evaluation, and someone blamed the threshold as contributing to R1's fall. When asked who blamed the threshold, V9 stated she recalled the family members and R1 were in agreement R1 caught her walker on the threshold, and added R1 did not disagree with the discussion's conclusion. R1's Fall care plan (initiated (MONTH) 14, 2019) showed an intervention of The resident needs a safe environment with .even floors . On (MONTH) 2, 2019 at 11:30 AM, R4 was in her recliner with a walker in front of her. R4 was alert and oriented and stated she uses her walker to get in and out of the bathroom. R4 stated it's kinda hard. R4 stated she does not try to roll over the threshold with the walker, and instead she lifts the walker over it. R4 stated it is harder to get out of the bathroom than to get in it. With permission, the surveyor used R4's walker to exit R4's bathroom. The surveyor approached the threshold with the walker's left wheel leading. When the left wheel hit the threshold, the wheel abruptly stopped the walker and the right wheel continued until it was also stopped by the threshold. On (MONTH) 2, 2019 at 1:25 PM, V3 (Director of Building Services) measured the height of R4's threshold going into and coming out of her bathroom. Going from the bedroom carpet to the threshold, the height of the threshold was an eighth of an inch higher; coming out of the bathroom, the threshold height was half an inch higher to exit (also going up to leave the bathroom). On (MONTH) 2, 2019 at 12:05 PM, R2 was in her recliner in her room and her walker was in front of her. R2 was alert and oriented and was asked about the ease of getting in and out of her bathroom. R2 stated she is just careful getting over it. Regarding using her walker, R2 stated I kind of have to pick it up. R2 stated she has to go up when she goes into her bathroom, and she has to look down here and pay attention. At 1:05 PM, V3 measured the height differences of the floors on both sides of R2's bathroom threshold. The height difference from the bedroom carpet and the threshold was half an inch (going up to go in), and a quarter inch from the bathroom floor to the threshold. R2 stated she can see how it would be a problem. On (MONTH) 2, 2019 at 8:50 AM, R5 was not in her room. The threshold in R5's bathroom doorway was checked for ease of transition with V6 CNA (Certified Nursing Assistant). V6 stated R5 is in a wheelchair and sometimes staff pull wheelchairs backwards over the thresholds (with the height difference). V6 stated they're all like that. At 3:00 PM, V6 stated some residents can manage better getting over the thresholds, depending on their abilities .different people have different abilities. On (MONTH) 2, 2019 at 1:15 PM, R5's bathroom/room threshold was measured by V3. R5's threshold measured half an inch higher than the bathroom floor (going up to leave the bathroom). On (MONTH) 2, 2019 at 1:30 PM, R3's bathroom/room threshold was measured by V3. R3's threshold measured a half an inch higher than her bathroom floor (going up to the leave the bathroom). On (MONTH) 2, 2019 at 1:20 PM, R6's bathroom/room threshold was measured by V3. R6's bathroom floor was three eighths of an inch lower than the threshold. On (MONTH) 2, 2019 at 1:00 PM, V3 stated everybody's needs are different. V3 stated in the Building Code, it says 'smooth transition' and no height is mentioned. V3 stated the rise of the facility's transitions in the doorway is definitely noticeable and described the height difference as a hump. On (MONTH) 3, 2019 at 10:30 AM, V12 (R1's physician) stated some residents may have troubles with the height of a threshold, and others will not. The facility's Fall Management Program (revised (MONTH) (YEAR)) showed C. Managers, Directors, Nurse Managers .2.ii Assist the nurse with the investigation of each fall to determine the cause . and E. 3. Observing resident rooms .and recommend or make corrections as permitted or required . The policy further showed I. All Management Staff .is responsible for .Conducting environmental assessments . The policy showed Post Fall Management, Interventions, and Planning .Every fall will be reviewed by an Interdisciplinary Team (IDT) within 72 hours of the fall . with the purpose of to identify possible contributing factors .and determine the root cause analysis . R1's (MONTH) 8, 2019 IDT Fall Meeting notes showed Resident stated that she was coming out of the bathroom and tripped herself on the walker. The Fall Meeting notes do not show why or how R1 tripped herself on the walker, do not address the specific effect of R1's raised threshold, and do not consider if R1 was wearing her glasses to recognize the presence of the threshold. The (MONTH) 11, 2019 report sent to Public Health showed Resident's vision is impaired; she utilizes glasses to enhance vision. The Conclusion section of the report showed R1's Environment was evaluated and there were no tripping hazards. The section showed R1 was using her walker and the bathroom light was on, yet it appears she was not fully awake, and upon leaving the bathroom, R1 misjudged/miscalculated how to ambulate safely with her walker .

Based on observation, interview and record review, the facility failed to follow physical therapy instructions for transferring and assisting residents to use the bathroom, and also failed to follow their policy for transferring residents. This applies to two of three residents (R1, R2) reviewed for falls. This failure resulted in R1 sustaining a cervical fracture and being hospitalized . The findings include: 1.) R1 was admitted to the facility on [DATE], discharged to a local hospital on [DATE] after a fall incident at the facility, and expired on [DATE] at the hospital. The facility's electronic medical record (EMR) showed [DIAGNOSES REDACTED]. R1's 5-day Minimum Data Set (MDS) completed [DATE] showed R1's cognitive skills for daily decision making as modified independence - some difficulty in new situations only and R1 required extensive assistance with one person physical assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, dressing and toilet use. R1's MDS also showed R1 was not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around and moving on and off the toilet and surface-to-surface transfer. The facility's comprehensive nursing admission assessment dated [DATE] showed R1 had a disturbed gait/balance, limited range of motion and a recent fall where R1 sustained pelvic fracture. R1's Fall Risk assessment dated [DATE] showed a score of 11, indicating R1 was a high fall risk with a score of 10 or above. E6's (RN-Registered Nurse) clinical notes for R1 dated [DATE] at 8:01 a.m. showed, 7:30 a.m., R1 up with walker, to bathroom with Certified Nursing Assistant (CNA). CNA in bathroom lifting toilet seat and patient started to fall, unable to catch the fall. R1 landed on her buttocks and then her head against the wheelchair wheel. R1 didn't seem in any acute increased pain, however when asked she said her head hurt. E6 called 911 due to R1 being on blood thinner/Lovenox daily and her [DIAGNOSES REDACTED]. The facility's interim care plan for R1 showed: New Admission Plan of Care: 1. Fall Risk. Interventions: Alarms in place for 72 hours, call light in reach, walkways free of clutter. The Physical Therapy Care plan for R1 started on [DATE] showed Problem: R1 is unable to perform functional transfers without assistance. Interventions: Transfer using the transfer board/lift devices (unspecified). Problem: R1 is unable to maintain (sitting/standing) balance without assistance and support. Hospital records for R1 showed R1 arrived at the local hospital on [DATE] at 8:09 a.m. Results of the CT scan of R1's cervical spine dated [DATE] showed: Findings: Type III base of dens fracture. Anterior displacement of 3.5 mm and on [DATE] showed, CT scan of C-spine showed C2 fracture. C2 fracture, in C-collar for at least ,[DATE] months. Hospital records showed R1 was admitted to the intensive care unit on [DATE] and expired on [DATE]. Z3's (MD-Neurosurgeon) documentation dated [DATE] showed R1 had a right frontal hypertensive intracranial bleed with extension into the ventricular system with acute [DIAGNOSES REDACTED] and acute ventricular hemorrhage and subarachnoid hemorrhage. On [DATE] at 2:15 p.m., E3 (CNA) said she transferred R1 to the bathroom with a walker. E3 said she brought a wheelchair in to transport R1 to the bathroom but R1 said she could walk with a walker. E3 said the CNAs can check the 24 hour shift report for resident transfer status, ask the nurse, or check the computer. E3 said she did not confirm R1's transfer status prior to transporting R1 to the bathroom. E3 said she did not place a gait belt on R1 during the transfer. E3 said she walked with R1 to the bathroom, and let go of R1 to adjust the toilet seat. When I let go of her, she fell . She fell on to her buttocks and then fell backwards and hit her head on the wheel of the wheelchair. On [DATE] at 10:10 a.m., E3 said, I should have had a gait belt on R1 while walking her to the bathroom. It is best to hold the gait belt all the time when transferring a resident if they are a one person assist. R1's Resident Care Instructions from the EMR, dated [DATE], showed ADL/Transfers: 1 person assist. Mobility: Wheelchair. The 24 hours shift report dated [DATE] lacked documentation to show the transfer status of R1. On [DATE] at 2:40 p.m., Z2 (Physical Therapist) said, Physical Therapy does the evaluation of the residents. We expect the nurse to put in our suggestions. Only if the resident is independent do I put in an order that states the resident is independent and does not need staff assistance with walking or transferring. On [DATE], R1 was assessed by physical therapy as a contact guard assist, which meant a staff member should have at least one hand on the resident at all times when transferring or standing. On [DATE] at 2:05 p.m., Z1 (MD) said Facility staff should follow the recommendations of the Physical Therapist for standing and transferring. On [DATE] at 8:25 a.m., Z3 (MD-Neurosurgeon) said R1's cervical fracture was called a Type II dens fracture. This fracture was caused by the fall R1 sustained on [DATE] when she hit her head. Z3 said R1 experienced a rapid hemorrhage, arterial in nature, in her brain on [DATE]. Three physicians consulted on the rapid nature of R1's brain hemorrhage. I doubt the brain hemorrhage was caused by the fall, but the cervical fracture definitely was. On [DATE] at 9:22 a.m., E1 (Administrator) said Nothing was documented on the 24 hour nursing report dated [DATE] regarding transfer status for R1. We found the nurses are not consistently filling out the transfer status on the 24 hour nursing report,or the Resident Care Instructions on the computer, and were not updating the transfer status per physical therapy's guidelines. 2.) R2 was admitted to the facility on [DATE]. The facility's face sheet dated [DATE] showed R2 had [DIAGNOSES REDACTED]. R2's quarterly MDS dated [DATE] showed severe cognitive impairment and R2 required extensive assistance by one person for transferring, ambulation, dressing and toileting, and was totally dependent on staff for bathing. R2 had fall risk assessments completed on [DATE] with a score of 17 and [DATE] with a score of 19, indicating R2 was high fall risk with a score of 10 or greater. On [DATE] at 10:00 a.m., E7 (RN-MDS Coordinator) said fall risk assessments are required to be completed quarterly on residents and R2's quarterly fall risk assessment completed on [DATE] was late. The facility's nursing documentation dated [DATE] at 4:30 p.m. showed: At 12:00 p.m. today R2 was lowered to the floor by CNA while transferring her from recliner to wheelchair. Per CNA R2's right knee gave way and R2's head ended up on CNA's chest. She added that she tried to keep resident in standing position but not able to, so she lowered her to the floor on her knees. A stat bilateral knee X-ray was ordered by the physician. The facility nursing documentation continued to show on [DATE] at 7:33 a.m. R2's right knee is bigger than the left knee, complains of pain when turning. At 3:57 p.m. on [DATE] the facility's documentation showed R2's spouse requested to send R2 to the local hospital and at 7:15 p.m. the local hospital reported R2 was admitted for fracture to right knee joint. On [DATE] at 12:37 am., the nursing documentation showed R2 was readmitted to the facility at 4:05 p.m. on [DATE] with [DIAGNOSES REDACTED]. R2 with knee brace intact and on at all times except during hygiene and skin checks. R2 is on bed rest with non-weight bearing to right leg. On [DATE] at 9:25 a.m. and again on [DATE] at 1:25 p.m., R2 was observed sitting up in a chair in her room, sleeping. The Resident Care Instructions for R2, dated [DATE] showed, Comments: Bed rest, non-weight bearing to right leg. The 24 hour nursing report for [DATE] lacked documentation to show the transfer status of R2. On [DATE] at 3:33 p.m., during a telephone interview, E5 (CNA) said I stood R2 up from the recliner. I was supposed to use a gait belt, but I did not. R2 will sometimes scratch you when you try to use a gait belt, so we will hold her hand instead. Then she started to lean on me so I lowered her to her knees on the floor. I called two other CNAs to help me and we put her back to bed. On [DATE] at 8:50 a.m., E1 (Administrator) said E5 put R2 back to bed before calling the nurse to assess R2, and did not use a mechanical lift to transfer R2 from the ground back to her bed, per the facility's policy. E1 also said R2 has been known to refuse the use of a gait belt with ambulation, and if R2 was refusing the gait belt for transfer, then E5 should have told the nurse before attempting to transfer the resident without a gait belt. E1 also said the facility does not have R2's rejection of care or the refusal of the gait belt addressed in a care plan. During the same interview, E7 (RN) said there was no care plan in place to address R2's high fall risk. The high fall risk score does not trigger a care plan. It only triggers after the resident falls. The Facility's policy and procedure entitled Safe Resident Handling revised on [DATE], showed Procedure: 1. Designation of method of transfer or handling: a. An initial screen is performed on all residents, by a Physical Therapist, to match the appropriate type of transfer. b. Therapy reports verbally to nurse level of assistance required - then is communicated via 24 hour report. 2. Gait belt usage is mandatory for all resident assists with exception of bed mobility and/or medical contraindications. 3. Transfer of resident off the floor: a. A resident observed on the floor will not be moved until assessed by a nurse. b. If it is found that the resident may be transferred from the floor, only a total mechanical lift will be used. NO other method of transfer may be utilized. The facility's policy entitled Safe Lifting and Movement of Residents revised [DATE] showed: Policy Interpretation and Implementation: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.