Every finding on record at Grove of Lagrange Park, The

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision to residents at high risk for falls due to poor cognition, poor safety awareness, impulsiveness, and a history of repeated falls. This failure applies to one of three residents (R4) reviewed for accidents and supervision and resulted in R4 sustaining multiple fractures. Findings include:R4's EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE]. R4 is currently [AGE] years old and has diagnoses that include vitamin D deficiency, altered mental status, mixed incontinence dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R4's care plan showed R4 was at high risk for falls related to a history of falls, dementia, behavior with psychotic disturbance, anxiety, altered mental status, incontinence and medication use. The interventions included use of a bed alarm when in bed, use of a chair alarm when up in wheelchair, non-skid pad to minimize risk of sliding out of chair and encourage R4 to participate in daily activities to minimize potential for falls while providing diversion and distraction. On April 13, 2026, at 12:35 PM, V5 (Registered Nurse) said on February 13, 2026, she was giving medication to another resident in the common area of the 3rd floor. V5 said she heard a commotion in the dining room and when she responded she saw R4 on the floor in the dining room in front of her wheelchair on her hands and knees. On April 13, 2026, at 12:45 PM, V2 (Director of Nursing) said R4 self-propels herself around the unit non-stop and staff can hardly keep up with her. V2 said the staff are to redirect R4 to sit back down when they see her attempting to get up on her own. On February 13, 2026, when R4 fell, she stood up too quickly from her chair and the staff could not reach her before she fell. V2 said R4 is very impulsive. R4's incident report dated February 13, 2026, at 7:15 PM, showed R4 was self-propelling around the unit and at 7:50 PM, R4 had an unwitnessed fall. R4 had gotten up from her wheelchair, lost her balance and fell, she was found on the floor in front of the wheelchair and was observed with a nosebleed. R4 was sent to the hospital for further evaluation and returned to the facility from the hospital with a diagnosis of a closed nasal bone fracture. R4's EMR (Electronic Medical Record) showed on March 28, 2026, at 9:02 AM, R4 had an unwitnessed fall. R4 was found sitting on the floor in her room at the foot of her bed. R4 had some swelling around her left eye and was complaining about pain in her left wrist. She was sent to the hospital and diagnosed with a left wrist fracture. R4's post fall investigation dated March 30, 2026, showed the root cause analysis factors that may have contributed to R4's fall included R4 getting up on her own and poor safety awareness. There was no mention of the bed alarm alerting staff that R4 had gotten out of bed. On April 09, 2026, at 12:52 PM, V9 (Certified Nursing Assistant) said the overnight staff will normally get R4 up, dressed, and in her wheelchair upon waking, but on March 28, 2026, R4 was still in bed. After R4 had finished eating breakfast, V9 said she was going to provide R4 with morning care to get her cleaned up, dressed, and up into her wheelchair. V9 said R4 prefers pullups but she didn't have any on her cart, so V9 said she went to the linen room to get one. V9 said R4 has a habit of getting up out of her bed or wheelchair chair unassisted, and on this day, V9 said it was less than a minute from when she left R4's room to get a pull up to the time she returned to R4's room. When she returned to R4's room, R4 was already on the floor right in front of the foot of her bed. V9 said R4's bed alarm was activated when she fell and could be heard at the nurse's station, The other aides were assisting other residents, and V7 (Registered Nurse) was on the phone at the nurse's station during this incident. V9 said you cannot see inside R4's room or see R4's bed from the nurse's station. V9 said she has worked with R4 for approximately six months and R4 has never used her call light and has always attempted to self-transfer without assistance. V9 said R4 frequently tries to stand up out of her chair and at times will attempt to walk saying she's packed up her belongings and is checking out of the facility. V9 said fall interventions for R4 include keeping an eye on R4 and redirecting her. V9 said monitoring R4 includes rounding and looking for R4 if you haven't seen her in 10 minutes, and all staff are responsible for monitoring the residents on the floor. On April 09, 2026, at 1:33 PM, V7 (Registered Nurse) said on March 28, 2026, they had just completed clearing breakfast trays, and she was passing her morning medications to the residents when an aide told her R4 was on the floor. V7 said R4 was sitting flat on her butt in front of the bed and had a bump on her head. V7 said R4 doesn't use her call light due to dementia and hasn't been since she's known her for at least two years. V7 said R4 frequently attempts to get up unassisted and has almost no safety awareness, R4's room cannot be seen from the nurse's station, and it's a big challenge to keep an eye on R4. R4 is moody and combative. V7 said R4 constantly wanders, and it is not good for R4 to be in her room when she's up. On April 09, 2026, at 3:59 PM, V2 (Director of Nursing) said R4 has a high probability of getting up on her own. If R4 refused to get up out of bed on March 28, 2026, when staff attempted to get her up, V2 said she would suggest staff stay with R4 until she's ready to get up. V2 said staff should always be aware of R4's whereabouts. V2 said on the day of this fall (March 28, 2026) R4 initially didn't want to get up so staff decided to let her eat breakfast in bed. The facility's policy regarding Routine Resident Checks, showed Nursing staff will make structured and regularly scheduled routine resident checks to help proactively maintain resident safety and wellbeing.To promote resident safety and wellbeing of our residents, nursing staff shall make a routine resident check on each unit at least every 2 hours and/or as often as needed concordant to the resident's needs. Rounding Tips; Individualized Care - tailor rounds to the specific needs of each patient.

Based on interview and record review the facility failed to provide care and services to a resident that had a change of condition for 1 of 4 residents (R2) reviewed for change of condition in the sample of 4.The findings includeR2's electronic face sheet show R2 had diagnoses that include alcoholic cirrhosis of liver with ascites, alcohol abuse and hepatic encephalopathy. R2's progress notes dated 12/27/25 timed at 2329 (11:29 PM) documents, Received resident lying on bed. Lethargic with vital signs of BP- 69/33, PR-59, T-97.2, Spo2- 81%. Started oxygen at 4LPM via nasal Cannula, rechecked spo2-97%. 911 was called and R2 was sent to a (local hospital).R2's progress notes documents, R2's admitting diagnosis of electrolyte imbalance.On 1/9/26 at 10:40 AM, V9 (Registered Nurse-RN) said he was R2's night shift Nurse. RV9 said he came to work at 11 PM, he got report from V11 (RN) and made his rounds after the shift report. At around 11:20 PM, he was in R2's room making rounds, R2 was in respiratory distress with an oxygen saturation of 81%. R2's blood pressure was very low at 69/33. V9 said he applied oxygen via nasal cannula at 4liters, R2's oxygen saturation went up to 94-95%. R2 was then sent to the hospital via 911. V9 said R2 was a full code.On 1/9/26 at 10:19 PM, V11 (RN) said she was the day and PM shift nurse on 12/26/25 and worked double shift. R2 remained in bed alert but weak. V11 said at the end of the morning shift, R2's vital signs were checked, R2's blood pressure (Bp) was low, (73/43). V11 said she did not notify R2's physician who visited R2 earlier to report R2's low bp. V11 said she did not check R2's vital signs again on PMs shift even though R2's bp on day shift was significantly low. V11 said R2 did not get his bedtime meds because R2 refused. V11 said R2 was normally alert but slow to respond and weak. V11 said she did not notify R2's physician that R2 did not get her bedtime medications.R2's vital signs dated 12/26/25 timed at 14:52 (2:52 PM) documented R2's BP was 73/43.On 1/9/25 at 12 PM, V7 (R2's Physician) said she saw R2 on 12/26/25 mid-day. R2 looked unwell but stable, weak but alert, yellowish (jaundiced) with ascites due to end stage liver disease. V7 said R2's vital signs during her visit were also stable. V7 said R2's bp of 73/43 was very low and that she should have been informed. V7 said Nurses know that systolic bp below 90's or 85's. The Physician should be informed for immediate intervention, like stat labs or sent out to the hospital sooner. V7 siad R2 had complex medical condition that the facility could not manage. V7 also said she was not notified of R2 not getting her bedtime meds.On 1/9/25 at 10:30 AM, V2 (Assistant Director of Nursing) said R2 was full code, R2 had low blood pressure and refused her meds. Resident's significant changes should be relayed to their physicians.The facility policy on Notification for change of condition dated 7/2/25 documents, the facility will provide care to residents and provide notification, or residents change in status. The facility must immediately consult with the resident's physician when there is a significant change in the resident's physical, mental or psychosocial status- deterioration in health either life threatening conditions or clinical complications.

Based on observation, interview, and record review, the facility failed to ensure residents received timely and adequate incontinence care and hygiene assistance.This failure applies to 4 of 4 residents (R1, R4, R5, and R6) reviewed for incontinence care.The findings include:1. R1 is a [AGE] year-old male who was admitted to facility on September 18, 2023.R1's face sheet includes the following diagnoses: : bilateral osteoarthritis of the knee, strabismic amblyopia, cataracts, difficulty walking, muscle wasting, gait and mobility abnormalities, dysphagia, diabetes mellitus, protein calorie malnutrition, benign prostatic hyperplasia, dementia with agitation, sleep apnea, repeated falls, gout, atherosclerotic heart disease, hyperparathyroidism, gastroesophageal reflux, post-traumatic stress disorder, AFIB (irregular heartbeat), congestive heart failure, cardiomyopathy, hypertension, and hyperlipidemia.R1's MDS (Minimum Data Set) dated September 23, 2025, shows R1 is cognitively impaired and requires extensive assistance of one staff member for activities of daily living tasks.On October 14, 2025 at 11:04AM V14 (Family Member) said R1 was left soiled for prolonged periods of time, and on September 25, 2025, they complained R1 had feces on his arms, hands, and under his fingernails and was not properly cleaned. V14 said that staff failed to promptly provide hygiene assistance for R1. V14 said that she informed the nurse and aide on duty as well as administrator at the time of this occurred.Review of grievances obtained on October 14, 2025, did not notate occurrence.2. R4 is a [AGE] year-old male who was admitted to facility on March 10, 2025.R4s face sheet includes the following diagnoses: Osteoarthritis, benign prostatic hyperplasia, bilateral knee stiffness, frequent falls, cardiac murmur, abnormal gait, and spondylosis.R5s current care plan dated August 15, 2025, shows a potential for skin integrity impairment due to incontinence of bowel and bladder and requires staff assistance for incontinence care.R5's MDS (Minimum Data Set) section C dated August 15, 2025 shows R4 is cognitively intact.On October 14, 2025 at 11:17 AM, R4 was lying in bed alert and oriented, wearing a hospital gown and watching television. R4's bed sheet and transfer pad had a large dark yellow ring on their surface, and a foul odor was present in the room. R4 said he had not been changed since the previous night and no aide had been in yet that morning. A green bag filled with soiled linen and a clear white bag containing soiled briefs were lying on the floor near the bed.On October 14, 2025 at 11:20 AM, V3(Certified Nurse Assistant) and V4(Certified Nurse Assistant) entered R4's room to provide care. V3 stated that this was her first time doing rounds on the unit and that she had not changed R4 during her shift, and assumed R4 was last changed around 5:00 AM by the overnight shift. V4 stated rounds are typically completed after breakfast and that if no one is available, CNAs (Certified Nursing Assistant) proceed to other duties such as showers.3. R5 is an [AGE] year-old female who was admitted to facility on May 04, 2021.R5's face sheet includes the following diagnoses: depression, insomnia, bilateral cataracts, presbyopia, protein calorie malnutrition, hypertension, falls, and osteoarthritis.R5's current care plan dated July 2025 shows R5 is at risk for impaired skin integrity due to incontinence. Clothes, linen, and adult brief are to be changed promptly when wet. R5's toileting care plan dated June 06, 2021, shows that R5 requires the assistance of one to two staff members for incontinence care and toileting needs.On October 14, 2025 at 11:50 AM, R5 stated that during the day shift on October 13, 2025, she had to wait approximately six hours before being changed. R5 stated she was soiled with feces and had informed her assigned CNA (Certified Nursing Assistant), who never returned, and she was ultimately changed by the evening CNA. R5 reported that she had not yet been checked or changed by the day shift and had last received care from the overnight shift at 5:00 AM. R5 reported that she needed to be changed. 4. R6 is an [AGE] year-old female who was admitted to facility on December 12, 2021. R6's face sheet includes the following diagnoses: atrial fibrillation, anxiety, overactive bladder, anemia, hypothyroidism, hypertension, and congestive heart failure. R6's current care plan dated February 10, 2024, shows a risk for skin impairment with a need for staff assistance for incontinence care. On October 14, 2025 at 12:10 PM, R6 was in bed with a meal tray next to her and a foul odor was present in her room. V3 (Certified Nursing Assistant) provided care and discovered that R6's adult brief was saturated with urine and feces. V3 said R6 had not been checked or changed prior to meals and that this was her first round of the day. V3 said she believed R6 was last changed around 5:00 AM by the overnight CNA. On October 15, 2025 at 1:11 PM, V6 (Certified Nursing Assistant) stated she was not present during the incident with R1 but confirmed that facility protocol requires residents to be checked and changed every two hours and before and after meals.On October 15, 2025 at 2:15 PM, V2 (Director of Nursing) stated that CNAs are expected to check and change residents at least every two hours and before and after meals. V2 said all CNAs receive orientation, competence, and computer training upon hire.The facility's General Care Policy (dated June 30, 2025) states: The facility will provide care to meet each resident's physical and psychosocial needs.The facility's Incontinence and Perineal Care Policy (dated June 30, 2025) states: Do rounds at least every two hours to check for incontinence during shift Provide perineal care to ensure cleanliness, comfort, and infection prevention.

Based on observations, interviews and record review the facility failed to follow interventions to prevent falls and use equipment as per policy and procedures. This applies to 2 (R1 and R3) of 7 residents reviewed for falls and safety. The findings include:1. R1 is a [AGE] year old male who was admitted to the facility on [DATE], with the following diagnosis: bilateral osteoarthritis of the knee, strabismic amblyopia, cataracts, difficulty walking, muscle wasting, gait and mobility abnormalities, diabetes mellitus, protein calorie malnutrition, benign prostatic hyperplasia, dementia with agitation, sleep apnea, repeated falls, atherosclerotic heart disease, post-traumatic stress disorder, AFIB (irregular heart beat),and congestive heart failure.R1's current care plan dated September 21, 2025, shows R1 has a self-care deficit and is on a restorative advanced range of motion program; R1 has impaired mobility and is at high risk for falls and requires extensive assistance with one staff member for bed mobility, toileting, and transfers.Report written by V7 (registered nurse) on September 23, 2025, shows R1 was being transferred to the toilet by V5 (Certified Nursing Assistant) when R1 lost his balance and slowly slid to the floor. Facility's Initial Incident report dated September 23, 2025, written by V8 (Assistant Director of Nursing) shows at approximately 8:15 AM staff were assisting R1 from the toilet to the wheelchair when R1 lost balance and slowly slid to the floor. A body assessment was completed with R1 verbalizing pain to right rib area. R1 was assisted back to bed using mechanical lift. Pain medication was given. Post Fall Investigation dated October 13, 2025 at 10:16 AM written by V9 (Restorative Nurse/Licensed Practical Nurse) shows R1 had a witnessed fall with injury on September 23, 2025 at 9:15 AM. Root cause analysis identified general weaknesses related to recent hospitalization, poor safety awareness, and impaired decision-making. History of multiple falls at home noted. On October 15, 2025 at 12:30PM, V5 (Certified Nursing Assistant) stated she was present when R1 had a fall in the restroom. V5 said she was transferring R1 from wheelchair to toilet when R1's foot slipped as he turned to sit. V5 said she guided R1 to the floor with her arms wrapped around his stomach. V5 said the gait belt was wrapped around her waist and not R1's waist, and stated R1's fall happened quickly and she didn't have a chance to tell him to hold on to him (facilities will refute quotes), V5 said she did not think she needed to put the gait belt on R1 because he was already seated in the chair. V5 said she had been trained that gait belts should be placed under the resident's breast area and that this was not done during R1's fall.On October 15, 2025 at 1:38PM, V7 (Registered Nurse) confirmed that V5 (Certified Nursing Assistant) informed her of the R1's fall incident on September 23, 2025. V7 stated she did not witness the fall but observed R1 on the floor, R1 denied striking his head but complained of right rib pain. On October 15, 2025, at 2:09PM V8 (Assistant Director of Nursing) said the use of gait belts depends on restorative evaluation and that R1's fall resulted in a therapy referral.On October 15, 2025 at 4:00PM, V9 (Restorative Nurse/Licensed Practical Nurse) said staff are trained on proper use of gait belts and that belts should be placed around the resident's waist with two-finger space between the belt and resident's body.On October 15, 2025 at 4:10pm, V10 (Restorative Nurse/Licensed Practical Nurse) said that it is unsafe for a CNA (Certified Nursing Assistant) to transfer a resident using a gait belt around their own waist. V10 said that the transfer belt should be secured around the resident's waist with adequate spacing and should always be used during transfers with unsteady residents. 2. R3 is an [AGE] year-old female with a diagnosis's history of Dementia, Anxiety Disorder, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Abnormalities of Gait and Mobility, and Lack of Coordination, and Unsteadiness on Feet who was admitted to the facility 07/17/2024.R3's current care plans-initiated July 2024 shows R3 has Impaired mobility and ADL (Activities of Daily Living) self-care performance deficit related to dementia, depressive disorder, psychotic disturbance, diabetes mellitus, hypertension, and is hard of hearing with interventions including extensive participation from one staff for transfers, assistance from staff for standing and walking, and use of a walker for ambulation. R3's current care plans initiated in September 2024 shows she is at risk for fluctuating blood sugars; she is at high risk for falls related to dementia, depressive disorder, psychotic disturbance, diabetes mellitus, hypertension, is hard of hearing and taking medications such as hypnotic, anti-hypertensive and hypoglycemics.R3's current care plan-initiated April 2025 shows R3 may have challenges secondary to declining vision, poor hearing or poor comprehension.R3's Functional Abilities assessment dated [DATE] shows she requires partial/moderate assistance from staff for moving from a sit to stand position and walking. R3's Restorative assessment dated [DATE] shows her gait is unsteady, she requires assistance with ambulation and one person assistance with transfers, is on a walking program, assumes standing position with assistance, and is forgetful.R3's Fall Incident Report dated 09/21/2025 shows she had an unwitnessed fall, while sitting in a chair in front of her room, she is forgetful, lacks safety awareness, and has cognitive impairment.Facility Post Fall Investigation report shows on 09/21 at 6 PM R3 had a fall with injury and based on the information gathered from staff, resident, and medical records reviewed the resident attempted to stand up unassisted and lost her balance.Facility Final Incident Investigation Report dated 09/22/2025 shows R3 had an unwitnessed fall that resulted in a left arm fracture; she was last observed at 5:20 PM sitting comfortably in a chair prior to the fall, R3 returned to the facility with a left arm immobilizer and with an order for ortho follow up.On October 14, 2025 at 1:38 PM, R3 stated her left arm is real sore all the way up her arm and hurts really bad, When asked if anything happened to her arm, R3 stated she fell.On October 16, 2025 at 2:38 PM V10 (Restorative Nurse/Licensed Practical Nurse) stated R3 has a history of suddenly or randomly stepping back and falling backwards, and has been educated not to do so because it would cause her to fall.On October 20, 2025 at 10:11 AM, V19 (Family Member) stated she noticed changes in R3's walking ability months ago, it seems like she needs a walker and she had a walker in her room but it hasn't been used. V19 stated R3 seems to walk slower and lean to the side and she has spoken to all R3's nurses including V16 (Registered Nurse) and was told she would need to talk to the doctor, it might be R3's medication, R3's up all night due to sundowning and in the day time she's tired. V19 stated she told all the nurses to have the doctor to call her because she hasn't encountered them when she was at the facility and the doctor still hasn't contacted her. V19 stated R3 had another fall 10/18/2025 and is currently in the hospital. V19 stated nobody's watching R3 and she has walking issues, R3's walker is always sitting in her room, and V19 has never seen R3 using the walker while visiting her at the facility. V19 stated R3 gets up and walks around a lot and walks real slow and V19 was told by the staff at night R3 walks fast however she has never seen R3 walking fast. V19 stated R3's coordination and balance has been off for months which is why she asked about R3's medications. V19 stated she has asked the staff about R3 using the walker and they said we have a walker for R3 and she could use the walker. V19 stated when R3 began walking different she asked the facility what can they give R3 to assist her with walking. V19 stated R3's is also hard of hearing and does need assistance with walking or needs a better walker. On October 15, 2025 at 3:42 PM, V18 (Certified Nursing Assistant) stated R3 is confused, would sometimes sit in a chair outside her room and would stand on her own a lot.October 15, 2025 at 4:02 PM, V10 (Restorative Nurse/Licensed Practical Nurse) stated R3 needs help with walking, has an unsteady gait, is a fall risk, needs supervision and cueing, and will get up unassisted from a chair. V9 (Restorative Nurse/Licensed Practical Nurse) stated on 09/21/2025 R3 stood up, turned around, began walking lost her balance and fell. Neither V9 or V10 were aware of R3 using a walker or why it was part of her care plan.On October 20, 2025 at 12:25 PM, V8 (Assistant Director of Nursing) stated R3 did not have a walker when she fell on [DATE] and she has never seen R3 with a walker.On October 20, 2025 at 11:07 AM, V12 (Medical Director/Physician) stated if patients are high risk and have multiple falls we use bed alarm all the time unless the resident frequently removes it. V12 stated if the resident has a change in condition and refuses to use bed alarm or frequently removes it this will be noted in their records. V12 states most residents have gait instability, history of falls, memory loss, coordination problems, and are taking certain medications that put them at risk for falls and those residents may need bed alarms. V12 stated an assessment by physical and occupational therapy determines if residents are safe to use a walker as well as day to day assessments from the nurses. V12 stated R3's mental status does not allow her to remember to use the walker, and we put the walker next to the residents and always remind them to use it. V12 stated whenever the staff notices R3 is out of her room they come right away with the walker and remind her to use her walker and our staff are always available to help residents change positions. V12 stated there should be an attempt to have R3 use a walker and no reason why this can't be done.The facility's Fall Occurrence Policy received 10/15/2025 states in part: It is the policy of the facility to ensure that interventions are put in place. Those identified as high risk for falls will be provided fall interventions.

Based on observation, interview, and record review the facility failed to provide nail care for 2 of 3 residents (R2, R3) reviewed for activities of daily living in the sample of 5. The findings include: 1. On 11/2/24 at 10:29 AM, R2 was lying on her back in bed with a hospital type gown on. R2's hands were contracted; the left hand was contracted more than the right. R2's fingernails were long and appeared dirty with something under the nails. R2 stated she would like her nails cut because she likes them short. R2 stated she had a stroke and her left hand doesn't open on its own. R2 stated she can't cut her nails herself. On 11/2/24 at 11:31 AM, V7 (Licensed Practical Nurse, LPN) stated the restorative CNA (Certified Nursing Assistant) or CNAs cut residents nails. The nurse cuts residents nails and toenails of residents that are diabetic. V7 stated residents can be seen by a podiatrist depending on their insurance. The nurse will send a request to social services, they will check the insurance and then add the resident to the podiatry list to be seen. On 11/2/24 at 2:39 PM, V2 (Director of Nursing, DON) stated nail care is done at the time of the resident showers. V2 stated there is no documentation to show that nail care is provided; they just know that it is done. On 11/2/24 at 3:07 PM, V9 (CNA) stated residents get showers three times per week. V9 stated on shower days the CNA providing the resident's shower will trim their nails. V9 stated the CNAs don't cut residents toenails. The Face Sheet dated 11/2/24 for R2 showed diagnoses including hemiplegia and hemiparesis of left side, anemia, protein-calorie malnutrition, insomnia, cerebral infarction, subarachnoid hemorrhage, orthostatic hypotension, and acute kidney failure. The Care Plan dated 8/26/24 for R2 showed, R2 has an ADL (activities of daily living) self care performance deficit and impaired mobility related to history of fall, orthostatic hypotension, cerebral infarction, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, insomnia, hemiplegia affecting left dominant side. Personal hygiene/oral care: R2 requires extensive assist of 1 staff with personal hygiene and oral care. R2's care plan also showed Bathing: I would like staff to check nail length and trim and clean on bath day and as necessary. Please report any changes to the nurse. 2. On 11/2/24 at 11:01 AM, R3 was lying on his side in bed with his legs hanging over the side of the bed. R3's fingernails were long and appeared dirty. R3's toenails were long and he had flaky dry skin to his feet. V5 (R3's POA, power of attorney) was at bedside and stated that he told the facility staff 2-3 days ago that R3 needed his nails cut and still has not been done. V6 (R3's family member) stated they were told that the facility doesn't trim/cut toenails and he needs it done. On 11/2/24 at 11:51 AM, V8 (RN, registered Nurse) stated nail care is done with the resident's showers. V8 stated CNA will tell the nurse if the resident refuses and the nurse will do the nail care. V8 stated if the resident is diabetic the nurse does the nail care. On 11/2/24 at 3:23 PM, V10 (CNA) stated everyone does nail care for residents. The nail care is done on showers days and can be done as needed. V10 stated most people don't chart that nail care has been done but can type a note in point of care that it was done. The Face Sheet dated 11/2/24 for R3 showed diagnoses including chronic obstructive pulmonary disease, pneumonia, hypoxemia, anxiety disorder, type 2 diabetes mellitus, protein calorie malnutrition, hypertension, paroxysmal atrial fibrillation, chronic respiratory failure, low back pain, dysphagia, solitary pulmonary nodule, congestive heart failure, mitral and aortic valve insufficiency, and atherosclerotic heart disease. The Care Plan dated 9/19/24 for R3 showed, R3 has an ADL self care performance deficit and impaired mobility related to chronic obstructive pulmonary disease, chronic respiratory failure, diabetes mellitus, hypertension, low back pain. R3's care plan also showed Bathing: I would like staff to check nail length and trim and clean on bath day and as necessary. Please report any changes to the nurse. The facility's Nail Care policy (8/1/24) showed, The purpose of this procedure are to clean the nail bed, keep nails trimmed, and prevent infections. Nursing staff shall check the residents for nail care which includes cleaning and regular trimming. Proper nail care can aid in prevention of skin problems around the nail bed. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. Refer to podiatrist for further interventions as indicated. Refer to podiatrist for podiatric care and trimming of toenails. Document procedure.

Based on observations, interview and record review, the facility failed to maintain sanitizer in dish machine during dish washing and failed to ensure that cold foods are stored properly per facility policy guidelines. This applies to 114 residents who receives meals prepared in the facility kitchen. The findings include: Facility provided information that the census on September 3, 2024 was 116 residents with 2 (two) residents on NPO (nothing by mouth) status. On September 03, 2024 at 9:49 AM, V11 (Dietary Aide) was washing dishes at the dirty side of the low temperature dish machine and stacking the dirty dishes on racks to pass through the dish machine. Some newly washed dishes that were placed on racks were seen on the clean side of the dish machine. On request, since V11's hands were soiled, V10 (Regional Director of Operations) tested the sanitizer well with a chlorine test strip and the test strip remained white color. V10 tested it again, and the test strip remained white color. V11 pointed to the sanitizer container on the floor which was connected to the dish machine, and which was nearly empty and stated that the test strip was probably not testing because the sanitizer is running low. When asked when she last tested the sanitizer, V11 stated that she usually tests it before starting the process of washing the dishes after breakfast and that she had tested the sanitizer at 9:00 AM. V11 stated that she does not test it again in between washing/sanitizing the breakfast dishes. V11 stated that she would test the sanitizer again before washing the lunch dishes as that is how it's marked on the log. The Low temperature Dish machine Sanitizer Log showed that on September 9, 2024 at 9:00 AM, the concentration (of sanitizer) was 100 ppm (parts per million). In the reach in freezer, spills of unknown substances were noted on bottom of a free-standing reach in freezer. There was a 3-gallon tub of strawberry flavored ice cream with a broken lid which was loosely placed over the tub and not closed properly. More than half of the ice cream in the container was used. V10 stated that the ice cream is served as a preference to residents that request for the same. V10 added that the ice cream container should have been closed properly. On September 04, 2024 at 10:21 AM, V12 (Dietary Aide) was at the dish machine washing dishes at the dirty side of the low temperature dish machine. At the clean side of the dish machine there were two racks of trays and one rack of cups that were just washed through the dish machine. V12 stated that she had already tested the sanitizer in the morning prior to washing the dishes and it tested okay. V12 was asked to test it again for verification and V12 hesitated and stated that the chlorine stopped coming out of the nozzle and that she will have to wait for it to come out. After 2-3 minutes of continuing to run the machine, V12 was asked again to test the sanitizer in the sanitizer well and when tested , the test strip showed white color. V10 came to the area and tinkered with the sanitizer container on the floor and the supply piping and V12 tested the sanitizer again and it showed a purple color registering between 50-100 ppm. V10 stated that she will notify the maintenance as the chlorine should be readily dispensing during sanitation process. V10 was notified that the earlier seen racks of washed dishes will have to be re-send through the dish machine to ensure that they are properly sanitized. Facility Policy titled Ware Washing (dated October 2019) included as follows: Policy Statement: It is the center policy that all dishware and service ware will be cleaned and sanitized after each use. The same policy showed, Low-Temperature Dish machine Sanitizer Log guidance (Dated May 29, 2024) included as follows: Chlorine concentration must be between 50-100 ppm. Facility policy titled Food Storage: Cold (dated October 2019) included as follows: Policy Statement: It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of FDA (Food and Drug Administration) Food Code. The same policy showed, 5. The Dining Service Director/Cook(s) insures that all food items are stored properly in covered containers .

Based on observation, interview and record review, the facility failed to prepare pureed consistency hamburger beef steaks to residents on pureed diet. This applies 6 of 6 residents (R1, R4, R24, R25, R50, R319) reviewed for pureed diets in the sample of 24. The findings include: On September 04, 2024 at 10:01 AM, during pureed meal preparation of pureed hamburger steak in the facility kitchen, V13 (Cook) stated that he is preparing for 6 residents. V13 measured six portions (about 3 oz/portion) of cooked hamburger beef steaks into the blender and added about 1 oz of beef broth and blended the product. The final product appeared granular and V13 transferred the pureed mixture into a container and stated that he is going to reheat the mixture prior to service. When the pureed meat was taste tested , there was granules of meat and fat that had to be chewed. V10 (Regional Director of Operations), who was in the vicinity was notified that the product was not safe to serve with current granular consistency. V10 also taste tested the pureed meat and agreed that its granular and instructed V13 to blend it again with an extra ounce of fluid. When blended again, the final product was smooth without any granules. On September 04, 2024 at 10:29 AM, V10 stated that the pureed consistency should be very smooth on the tongue with no textures detected and should not have any grinds. Facility policy titled Pureed included as follows: Description: This diet consists of pureed, homogeneous, and cohesive foods. Food should be pudding-like No coarse textures . Any foods that require bolus formation, controlled manipulation, or mastication are excluded. Facility diet order report showed that R1, R4, R24, R25, R50 and R319 were on pureed consistency diets.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices during provisions of incontinence and catheter care related to hand hygiene and gloving. The facility also failed to sanitize glucometer machine during blood glucose monitoring. This applies to 6 of 24 residents (R9, R15, R30, R65, R85, R105) reviewed for infection control in the sample of 24. The findings include: 1. On September 4, 2024, at 9:45 AM, V4 and V5 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R85 who had a bowel movement. V4 cleaned from front to back, applied incontinence brief, help straightened R85's clothing, and help with repositioning, while wearing same gloves, and did not perform hand hygiene in between tasks. 2. On September 4, 2024, between 11:22 AM to 11:30 AM, V7 (Nurse) checked R9 and R105's blood glucose level. V7 did not sanitized the glucometer machine prior to usage, and in between use of R9 and R105. After V7 used the glucometer, he placed it back in the medication cart without cleaning or sanitizing it. 3. On September 4, 2024, at 11:39 AM, V6 (CNA) rendered incontinence care to R30 who was heavily saturated with urine and had a bowel movement. V6 cleaned R30 from front to back of the perineum, while wearing same gloves she touched the curtain, then she continued to clean the buttocks. V6 removed her gloves and without hand hygiene, went to get more wet washcloths. V6 came back, donned new set of gloves and continued to clean the rectal and buttocks area of R30. After she completed the peri-care, V6 placed a new incontinence brief and put a set of clean pants on R30 and helped reposition R30 while wearing same soiled gloves. 4. On September 4, 2024, around 2:15 PM, V4 and V6 (Both CNA) rendered incontinence care to R15 who was wet with urine. V6 cleaned R15's perineum from front to back, applied new incontinence brief, helped assisted with R15's repositioning, and covered R15 with clean blanket while wearing same soiled gloves. 5. On September 5, 2024, at 1:26 PM, V19 (Restorative/CNA) rendered peri-care to R65 who had a bowel movement. V19 cleaned R65 from front to back of the perineum. V19 changed his gloves without hand hygiene, then he continued to clean R65's rectum and buttocks. While wearing the same gloves, V19 applied barrier cream to the back perineum, followed by placing a clean incontinence brief on R65. On September 5, 2024, at 1:48 PM, V3 (Assistant Director of Nursing) stated that staff must wash their hands prior to peri-care, don gloves, and proceed with the peri-care. The staff should change gloves and perform hand hygiene from dirty to clean tasks. In addition, V3 said, staff must sanitize the glucometer machine before and after use, and in between residents. These are to be done to prevent spread of infections. Facility's Hand Hygiene Policy and Procedure with a revision date of July 30, 2024, showed, Policy Statement: Hand hygiene is important in controlling infections. hand hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC Guidelines regarding hand hygiene. The same policy showed in-part under procedures, 1. Hand Hygiene using alcohol-based hand rub is recommended during the following situations: . g. Before moving from work on soiled body site to a clean body site on the same resident, h. After contact with blood, body fluids, or surfaces contaminated with blood and body fluids, i. After removing gloves including during wound dressing change. Facility's Glucose Meter Cleaning Policy and Procedure with revision date of 7/30/24 shows: Policy Statement: To ensure safe, convenient, and proper cleaning and disinfection of Blood Glucose Meters in accordance with CDC guidelines and manufacturer's instructions to help prevent device exposure to blood borne pathogens. The same policy showed in-part under procedures, 4. Clean and disinfect glucose meter with EPA-approved disinfectant including Clorox Healthcare Bleach Germicidal Wipes/ Micro kill Wipes/ Microdot Wipes/ Avert Wipes before after each resident use. 6. Always clean and disinfect the glucose meter before storing it with other clean equipment.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 7 of 7 residents (R19, R26, R30, R57, R71, R97 and R259) reviewed for ADLs (activities of daily living) in the sample of 24. The findings include: 1. R19 had multiple diagnoses including hemiplegia affecting left nondominant side, based on the face sheet. R19's quarterly MDS (minimum data set) dated August 17, 2024 showed that the resident was moderately impaired with cognition and required assistance from the staff with personal hygiene. On September 3, 2024 at 10:45 AM, R19 sitting in her bed, alert and verbally responsive. R19 had left sided weakness and was not able to open or extend the fingers on her left hand. R19 can only open and extend her right thumb and index finger while the rest of her right fingers were contracted. R19's fingernails were long, jagged and with black substances underneath the nails. The long fingernails on R19's left hand were touching the palm area. R19 stated that she wanted the staff to trim and clean her fingernails. On September 4, 2024 at 11:48 AM, R19's fingernails were long, jagged and with black substances underneath the nails. R19 was not able to open or extend the fingers on her left hand. The long fingernails on R19's left hand were touching the palm area. R19 stated that she wanted the staff to trim and clean her fingernails. V2 (Director of Nursing) was present during the observation and stated that R19 cannot trim and/or clean her own fingernails. According to V2, R19 needs the assistance of the staff with ADLs including cleaning and trimming of fingernails. R19's active care plan initiated on May 16, 2023 showed that the resident have ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance from the staff with personal hygiene. 2. R26 had multiple diagnoses including sudden visual loss of the left eye and dementia without behavioral disturbance, based on the face sheet. R26's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required assistance from the staff with personal hygiene. On September 3, 2024 at 12:19 PM, R26 was sitting in her wheelchair inside the unit dining room with other residents and staff. R26 was alert and verbally responsive. R26 had accumulation of long, curling chin hair and she was observed playing/pulling it. R26 stated, I am hoping for the staff to shave me. On September 4, 2024 at 11:57 AM, R26 was in bed, alert and verbally responsive. R26 had accumulation of long, curling chin hair. In the presence of V2, R26 stated that she wanted the staff to shave her chin hair. According to V2, R26 needs the staff assistance with shaving. R26's active care plan initiated on February 1, 2024 showed that the resident have an ADL self-care performance deficit. The same care plan showed multiple interventions including maximum assistance from the staff with personal hygiene. 3. R57 had multiple diagnoses including vascular dementia with other behavioral disturbance, based on the face sheet. R57's MDS dated [DATE] showed that the resident was moderately impaired with cognition and required assistance from the staff with personal hygiene. On September 3, 2024 at 12:02 PM, R57 was sitting in his wheelchair at the hallway outside his room. R57 had accumulation of long facial hair. R57 stated that he needs the assistance of the staff to shave. On September 4, 2024 at 11:52, R57 was inside the unit dining room. R57 had accumulation of long facial hair. V2 was present during the observation and stated that R57's facial were long and that the resident needed the assistance of the staff to shave. R57's active care plan initiated on May 30, 2024 showed that the resident had ADL self-care performance deficit. The same care plan showed interventions including extensive assistance from the staff with personal hygiene. 4. R71 had multiple diagnoses including dementia with other behavioral disturbance and dementia with psychotic disturbance, based on the face sheet. R71's quarterly MDS dated [DATE] showed that the resident was moderately impaired with cognition and required maximum assistance from the staff with dressing and personal hygiene. On September 3, 2024 at 12:13 PM, R71 was sitting in his wheelchair inside the unit dining room with other residents. R71 was alert and verbally responsive. R71 had accumulation of long facial hair and his gray shirt had lots of dried white flaky substances on the neck, shoulder, back and chest area. R71 stated that he wanted the staff to change his shirt and to shave him. V8 (Registered Nurse) was present during the observation. According to V8, R71 needs the staff assistance to shave and change his clothing. R71's active care plan initiated on January 10, 2023 showed that the resident have an ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance from the staff with personal hygiene. 5. R97 had multiple diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the left posterior cerebral artery, metabolic encephalopathy and type 2 diabetes mellitus, based on the face sheet. R97's admission MDS dated [DATE] showed that the resident was severely impaired with cognition and required assistance from the staff with personal hygiene. On September 3, 2024 at 11:03 AM, R97 was sitting by the side of her bed. R97 was alert and verbally responsive. R97's fingernails were long, jagged with black substances underneath the nails. According to R97, it has been a long time since her fingernails were trimmed and cleaned and she wanted the staff to do it. On September 4, 2024 at 11:54 AM, R97's fingernails were long, jagged with black substances underneath the nails. R97 stated that she wanted the staff to at least file and clean her fingernails. V2 was present during the observation and stated that R97 needs the staff assistance to trim or file and clean her fingernails. R97's active care plan initiated on May 28, 2024 showed that the resident have an ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance from the staff with personal hygiene. On September 4, 2024 at 12:00 PM, V2 (Director of Nursing) stated that providing ADL assistance to resident's including shaving/removing of unwanted facial hair and trimming and cleaning of fingernails are part of the facility's nursing care and service to ensure that the resident's personal hygiene and grooming are maintained. 29562 6. Face sheet shows R30 is [AGE] years old who has multiple medical diagnoses which include Alzheimer's disease and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R30's MDS shows that R30 requires assistance with hygiene and grooming. On September 4, 2024, at 11:35 AM, R30 was resting in bed, alert and oriented, she was able to verbalize her needs. R30 displayed overgrown hair in the chin which was thick and curly, and she has long fingernails with black/brown substances underneath the nails. R30 stated she knows she needs shaving and her nails to be clipped and she wants it done. R30's active ADL care plan shows; R30 have an ADL self-care performance deficit and impaired mobility related to recent fall, encephalopathy, unsteady gait. The same care plan shows multiple interventions which include R30 requiring extensive assistance with personal hygiene care. 36567 7. R259's EMR (Electronic Medical Records) showed that she was admitted on [DATE] with diagnoses including Parkinson's disease with dyskinesia, without mention of fluctuations, essential tremor, anxiety disorder, unspecified. Physician progress notes dated September 2, 2024 included that R259 has mobility and ADL dysfunction secondary to sepsis, acute kidney injury, hypernatremia, hypokalemia. The same progress notes documented that R259 needs assistance with personal care. On September 3, 2024 at 11:42 AM, R259 was seated in her bed in a hospital gown. R259 was noted to have very long nails with some of them jagged and with blackish and brownish substances caked underneath most of the nail beds. R259 was alert and oriented and able to communicate needs. R259 stated I came here 4 days ago. Regarding the nails, R259 stated They can be shortened and cleaned. I don't know if they will do it for me. This information was relayed V8 (Registered Nurse). R259's interim care plan initiated August 30, 2024 included that R259 requires assistance with ADL's including personal hygiene.

Based on observation, interview, and record review, the facility failed to provide perineum and indwelling urinary catheter care in a manner that would prevent urinary tract infection. This applies to 4 of 6 residents (R15, R30, R65, R85) reviewed for perineum and urinary catheter care in the sample of 24. The findings include: 1. On September 4, 2024 at 9:45 AM, R85 was resting in bed, she has an indwelling urinary catheter. V4 and V5 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R85 who had a bowel movement. V4 cleaned R85 from front to back of the perineum, however, V4 did not separate labia to clean the inner corners and the catheter right outside the urethra. 2. On September 4, 2024 at 11:39 AM, V6 (CNA) rendered incontinence care to R30 who was heavily saturated with urine and had a bowel movement. There was a strong urine odor coming from resident's bedroom. V6 used a wet washcloth to clean R30's perineum and wiped it in an up and down stroke on the outer labia. V6 did not open the labia to clean the inner corners, the urethra, and the inner groins. 3. On September 4, 2024 around 2:15 PM, V6 rendered incontinence care to R15 who was wet with urine. V6 used a wet washcloth to wipe the outer labia in an up and down stroke. V6 took another washcloth to clean the labia and wipe it again in an upward stroke. V6 did not separate the labia to clean the inner corners, and the inner groins. 4. On September 5, 2024, at 1:26 PM, V19 (Restorative CNA) rendered peri-care to R65 who had a bowel movement. R65 has a suprapubic catheter. R65 has redness all over the front and back perineum. Used a washcloth to clean V19's perineum from front to back. However, V19 did not clean the left side of the abdominal fold, penis, scrotum, and the inner folds of his groins. On September 5, 2024, at 1:51 PM, V3 (Assistant Director of Nursing) stated that when providing peri-care, the staff must clean the full perineum from front to back, which includes the folds of the genitals, pubic area, abdomen, and groins. If it is a female resident the staff should separate the labia to clean the inner corners of this area. If it is a male, this includes the penis and scrotum. This is needed to be done to prevent infection. Facility's Incontinent and Perineal Care Policy and Procedure with revised date of 7/31/24 shows: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition.

Based on observation, interview and record review, the facility failed to provide staff supervision during meal times to a resident with difficulty swallowing and staff failed to use a gait belt/transfer belt when assisting and transferring a resident. This applies to 2 of 4 residents (R75 and R98) reviewed for accidents and supervision in the sample of 24. The findings include: 1. R98's EMR (Electronic Medical Record) showed the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism of unspecified cerebral artery and dysphagia (difficulty swallowing). R98's MDS (minimum data set) showed the resident had severe cognitive impairment and required set-up assistance with meals. R98's care plan showed that the resident was at risk for choking or aspiration of food or liquid related to his diagnoses of cerebral vascular accident and dysphagia. R98 was also edentulous. The interventions the facility put in place included to instruct R98 to eat in an upright position, to eat slowly, chew each bite thoroughly, monitor for shortness of breath, labored respirations, or lung congestion. Staff are to observe R98 during mealtimes for signs and symptoms of aspiration such as coughing and throat clearing. R98's POS (physician order sheet) showed an order for mechanical soft texture diet with thin liquids. R98's hospital record for a nutritional assessment dated [DATE] showed the resident had chewing problems and dysphagia. Interventions included mechanical soft diet, aspiration precautions, and 1:1 feeding assistance. R98's Speech Therapy admission evaluation done on August 5, 2024 showed oral phase moderately impaired caused by prolonged mastication, increased transit time, and mild oral residue post-swallow. No pharyngeal symptoms observed; however, due to impaired oral phase [R98] is at risk of aspiration of non-masticated boluses. On September 3, 2024, at 11:55 PM, R98 was in the dining room eating lunch. R98 had mechanical soft chicken, macaroni and cheese, and spinach. Dietary staff were all the way across the dining room closest to the door where staff would come grab room trays to take to the residents in their rooms. Staff were coming and going and no one was monitoring or paying attention to the residents in the dining room. R98 started coughing and staff continued to come and go from the dining room. No one stopped to see if R98 was alright. Surveyor went to R98 and asked if he was ok, he was able to speak and said he's ok. R98 continued to cough. On September 4, 2024, at 12:00 PM, R98 was in his bed with his lunch tray in front of him on his over the bed tray table. R98 was sitting with the head of bed at a 45 degree angle. R98 started coughing after putting food into his mouth. No staff was in the room with R98. Surveyor asked R98 if he would like to sit up higher in the bed and he shook his head yes. He was eating a ground hamburger steak with mushroom gravy, pureed cream corn, pureed white rice, and orange sherbet. He was drinking juice. At 12:07 PM Surveyor went and asked V15 (Registered Nurse) to get some help to sit R98 up higher in the bed. V15 and V16 (Certified Nursing Assistant) went to R98's room and together they pulled R98 up in the bed and raised the head of the bed up so that he was sitting at a 90 degree angle. V15 said R98 should be sitting upright (90 degrees) to prevent aspiration. He has aspiration precautions in place. V15 asked V16 to watch R98 until he was done eating. On September 5, 2024 at 3:37 PM, V2 (Director of Nursing) said the residents in the dining rooms are to be monitored at all times for choking. On September 5, 2024, at 9:25 AM, V18 (Speech Therapist) said when R98 came to this facility she reviewed his chart and noted that R98 was on a mechanical soft diet. V18 said she observed R98 eating his mechanical soft diet with thin liquids and he tolerated it well. V18 said R98 had a stroke and he has dysphagia so he requires general aspiration precautions which include sitting upright and taking small bites at a time. V18 said she observed him this morning and he was in bed reclined at about a 45 degree angle. V18 said she had him attempt to eat regular solid food and he did cough, but cleared after he was offered some liquid to drink. V18 said that R98 should not be in a reclining position when eating and staff should be aware of that. 16746 2. R75 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side and dementia without behavioral disturbance, based on the face sheet. R75's significant change status MDS dated [DATE] showed that the resident was severely impaired with cognition. The MDS showed that R75 required moderate assistance from the staff with toileting hygiene, lower body dressing and from sitting to standing position. The same MDS showed that R75's ability to toilet transfer, including getting on and off a toilet or commode was not attempted due to medical condition or safety concerns. On September 3, 2024 at 12:25 PM, R75 was observed sitting on the toilet while V17 (Certified Nursing Assistant) was by the bathroom door. After R75 finished using the toilet, V17 held on to R75's left arm and asked the resident to stand and hold on to the grab bar that was attached on the wall, located on the right side of the resident, to clean R75's back area. R75 stood up and attempted to hold on to the grab bar using only his right hand. R75 was confused and V17 had to give the resident several instructions to hold on to the grab bar with both hands. When R75 was finally able to stand while holding on to the grab bar with both hands, V17 started cleaning R75's buttocks. While R75 was standing and V17 was cleaning the resident, R75's legs were observed to be slightly bent from the knee and his legs were slightly shaking. After V17 had cleaned R75, V17 assisted the resident to transfer and sit on his wheelchair. During the observation no gait belt or transfer belt was observed being used to assist R75, to stand and to transfer. After the procedure, V17 was asked if she has a gait belt/transfer belt with her and if she used it to transfer R75 from his wheelchair to the toilet. V17 responded that she does not have a gait belt/transfer belt with her and that she did not use a gait belt/transfer belt to transfer R75. V17 acknowledged that a gait belt/transfer belt will be useful to transfer and assist R75 to prevent fall incident and for resident's safety. R75's medical records showed that the resident had a history of fall with injury, when he stood up from his wheelchair, attempted to walk and lost his balance. R75's active fall care plan initiated on February 10, 2024 showed that the resident was at risk for fall related to recent fall, cardiovascular accident, unsteady gait and psychotic disturbance. On September 4, 2024 at 11:33 AM, V2 (Director of Nursing) stated that a gait belt/transfer belt should always be used when manually assisting a resident to transfer from bed to wheelchair and back, from wheelchair to toilet and vice-versa. V2 added that a gait belt/transfer belt should always be used when assisting any resident to stand, pivot and while a resident is standing even if the resident is holding on a grab bar, to ensure resident's safety and to prevent accidents including fall. The facility's gait belt policy and procedure last revised by the facility on July 26, 2024 showed. The facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers and walking.

Based on observation, interview and record review, the facility failed to request a re-evaluation for a PASARR II (Pre-admission Screening and Resident Review) screening for a resident with an SMI (serious mental illness) diagnosis within the required timeframe. This applies to 1 of 1 resident (R96) reviewed for PASARR in the sample of 24. The findings include: R96's EMR (Electronic Medical Record) showed R96 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and major depressive disorder. R96's MDS (Minimum Data Set) dated July 16, 2024 showed R96 had severe cognitive impairment. R96's care plan showed R96's bipolar diagnosis and signs and symptoms of depression caused the resident to have little interest in doing activities and has a self care performance deficit for ADLs (activities of daily living). R96's PASARR Level I was done on May 14, 2024. The PASARR I rationale showed a 60 day convalescent care approval - A 60 day or less stay in the nursing facility was authorized. Re-screening must occur by or before the 60th day if the individual is expected to remain in the NF (nursing facility) beyond the authorization on timeframe. R96 was due for a re-screen on July 15, 2024, making his re-evaluation seven weeks overdue. On September 4, 2024, at 9:02 AM, V1 (Administrator) provided a copy of PASARR I when she was asked about a PASARR II, V1 said the PASARR I did not indicate R96 needed a PASARR II. V1 said V14 (Admissions Director) is responsible for PASARRs. On September 4, 2024, at 11:07 AM, V14 (Admission Director) said when a resident is being admitted from the local hospital, she will log into (Electroninc web-based platform) system for the (Service Company) report PASARR (Preadmission Screening and Resident Review). V14 said she will review and upload the report into the EMR (Electronic Medical Record). Sometimes it will say the resident needs a PASARR II and sometimes it will say they do not have to have a PASARR II. If it says it is approved for 30 days or 60 days, it is because the resident is coming here for short term rehab and they may not need to have the PASARR II done. If the resident needs to stay in the facility longer than either the 30 days or 60 days on the PASARR I, then we need to do a PASARR II. Facility provided their policy titled, PASARR Screening of Residents with Mental Disorders or Intellectual Disability with a revision date of August 16, 2024, showed, Policy is to ensure residents with a Mental Disorder and those with Intellectual Disorder will receive a PASARR Screening within the timeframe allowed.

Based on observation, interview and record review the facility failed to implement fall interventions. This applies to 4 of 4 residents R3, R4, R5 and R6 reviewed for falls in a sample of 7. Findings include: 1. R3 was admitted to the facility on [DATE] with diagnosis that include Chronic Obstructive Pulmonary Disease and Dementia. R3's MDS (Minimum Data Set) dated 1/17/24 documents a BIMS (Brief Interview for Mental Status) score of 1 indicating he is cognitively impaired. R3 had a documented unwitnessed fall on 2/7/24. R3's care plan was updated on 2/7/24 to include floor mats / floor pads at the bedside. On 3/26/24 at 10:40 AM, R3 was lying in bed. There was no fall mat on floor to the right side of R3's bed. On 3/26/24 at 11:01 AM, V5 C.N.A. (Certified Nursing Assistant) exited R3's room but did not place the fall mat on the right of R3's bed. V5 stated R3's fall interventions include a bed and chair alarm, fall mat to the floor on both sides of the bed, and bed rails. Surveyor informed V5 she did not place the fall mat back on the right side of R3's bed. 2. R4 was admitted to the facility on [DATE]. R4 has diagnosis that includes Chronic Kidney Disease, Visuospatial Deficit and Anxiety. R4's MDS dated [DATE] documents a BIMS score of 15 indicating she is cognitively intact. R4 last documented fall was 2/16/24. R4's care plan for falls dated 1/25/24 included the use a bed alarm. 3. R5 was admitted to the facility on [DATE] with diagnosis that includes Congestive Heart Failure, Dementia and Hypertension. R5's MDS dated [DATE] documents a BIMS score of 5 indicating she is cognitively impaired. R5's had a documented fall on 2/8/24. R5's care plan was updated on 2/8/24 to include a bed alarm. On 3/26/24 at 3:45 PM, V8 C.N.A. assigned to care for R4 and R5 stated she had floated to the unit and did not know what fall interventions were in place for R4 and R5. On 3/26/24 at 3:52 PM, V8 and another staff member assisted R4 to the toilet. There was no bed alarm on R4's bed. On 3/27/24 at 10:35 AM, R4 did not have a bed alarm on her bed. On 3/27/24 at 10:36 AM, V6 RN (Registered Nurse) stated R4 and R5 should have bed alarms in place as part of their fall interventions. V6 stated it is the responsibility of Nurses, Managers and C.N.As to assure fall precautions are in place. On 3/27/24 at 10:43 AM, V10 C.N.A. was brought to R5's bedside to check the bed alarm and noted it was off. V10 was then brought to R4's bedside to confirm there was no bed alarm. 4. R6 was admitted to the facility on [DATE] with diagnosis that include Chronic Obstructive Pulmonary Disease, Hemiplegia, and Ischemic Optic Neuropathy. R6's MDS dated [DATE] documents a BIMS score of 8 indicating a moderate cognitive impairment. R6's care plan dated 2/2/24 includes fall interventions that include the use of a bed alarm. On 3/28/24 at 12:06 AM, R6's bed alarm did not have a green light indicating it was on and activated. On 3/28/24 at 12:15 PM, V12 C.N.A / Admissions Director was in R6's room providing feeding assistance to another resident. V12 stated she wasn't sure how the alarm worked because the facility used different types of alarms. On 3/28/24 at 12:18 PM, V5 C.N.A. assigned to R6 transferred R6 from the bed to a wheelchair. The bed alarm did not alert. V5 then repositioned the pressure sensing pad attached to the bed alarm and placed R6 back on the bed. The bed alarm indicator light flashed green and beeped. V5 stated if the resident is not positioned properly on the pressure sensing pad the alarm will not set and staff will not be alerted if the resident attempts to get up. R6 then shifted off the pad the indicator light turned red and alarmed. On 3/27/24 at 11:22 AM, V2 DON (Director of Nursing) stated it is the responsibility of Nurses, C.N.A, Managers and Activities personnel to assure fall interventions are in place. No staff should be walking away from residents without assuring measures are in place and working properly. On 3/27/24 at 11:55 AM, V1 Administrator stated the restorative nurse determines what fall interventions should be implemented. Any staff that go in a resident's room should assure fall interventions are in place. They should not walk away without making sure fall alarms are working, mats are on the floor and interventions are in place. The Fall Occurrence policy dated 7/17/23 states it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

Based on interview and record review, the facility failed to follow their policy to immediately notify residents' families of a change of condition. This applies to 2 of 3 residents (R1 and R2) reviewed for policy and procedure in the sample of 3. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including osteoarthritis, diabetes, chronic kidney disease, and a pressure ulcer of the sacral region. R1's MDS (Minimum Data Set) dated September 28, 2023, showed R1 had sever cognitive impairment and required extensive assistance from facility staff for bed mobility and transfers between surfaces. V7's (Wound Doctor) documentation dated June 28, 2023, at 8:27 AM, showed R1 had a sacral Stage 3 pressure ulcer and an unstageable pressure ulcer of the left buttock. The facility does not have documentation to show V8 (R1's Family) was notified of R1's pressure ulcers. V7's documentation dated August 30, 2023, at 8:46 AM, showed R1's sacral Stage 3 pressure ulcer, Wound progress: Exacerbated due to generalized decline of patient . The facility does not have documentation to show V8 was notified of R1's pressure ulcer exacerbation. V7's documentation dated September 13, 2023, at 8:35 AM, showed R1's sacral Stage 3 pressure ulcer, Wound progress: Exacerbated due to generalized decline of patient, patient non-compliant with wound care. The facility does not have documentation to show R1 was non-compliant with wound care. The facility does not have documentation to show V8 was notified of R1's pressure ulcer exacerbation or R1's non-compliance with wound care. V7's documentation dated October 18, 2023, at 8:27 AM, showed, Stage 3 Pressure Wound Sacrum .Dressing Treatment Plan, Add: skin substitute application, once weekly, do not remove or disturb the wound bed. Change the secondary dressing(s) with care as per recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indicated next visit . The facility does not have documentation to show V8 was notified of R1's change in treatment of her Stage 3 pressure ulcer. The facility's Wound Report dated October 20. 2023 showed R1 had an active sacral Stage 3 pressure ulcer identified in the facility on June 28, 2023. On October 20, 2023, at 11:48 AM, V8 (R1's Family) said she was not notified of R1's pressure ulcer until R1's care plan meeting which took place about two weeks ago. V8 continued to say the facility informed her at the care plan meeting R1's pressure ulcer was present since July. V8 said nobody from the facility contacted V8 regarding R1's pressure ulcer. On October 20, 2023, 2:20 PM, V3 (Wound Care Coordinator) said she does not have documentation to show R1's family was notified when R1's pressure ulcers were identified. V3 said she should have notified R1's family when R1's wound deteriorated on August 30, 2023, and September 13, 2023. V3 continued to say V3 did not notify R1's family of the change in treatment of R1's sacral Stage 3 pressure ulcer. V3 said she should have notified R1's family of the change in treatment of R1's sacral Stage 3 pressure ulcer. On October 20, 2023, at 2:45 PM, V2 (DON/Director of Nursing) said a resident's family should be notified as soon as possible if a resident acquires a pressure ulcer while residing in the facility. V2 continued to say facility staff should be documenting in the EMR if a resident's family was notified or if an unsuccessful attempt was made to contact the family. V2 said if a resident's pressure ulcer is deteriorating, the resident's family should be notified. 2. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including dementia, breast cancer, and stage 4 pressure ulcer of the left heel. R2's MDS dated [DATE], showed R2 had severe cognitive impairment. The MDS continued to show R2 was dependent on facility staff for toilet use, personal hygiene, bed mobility, and transfers. The facility's Wound Report dated October 20, 2023, showed R2 had a left heel Stage 4 pressure ulcer identified in the facility on August 3, 2023. The facility does not have documentation to show V9 (R2's Family) was immediately notified of R2's pressure ulcer. The facility's skin evaluation form was initiated by V3 on August 3, 2023 showed R2's family was notified of R2's pressure ulcer on August 7, 2023, four days after the wound was identified on August 3, 2023. On October 20, 2023, at 1:58 PM, V3 said she notified V8 of R2's left heel pressure ulcer four days after R2's pressure ulcer was identified. V3 continued to say she usually notifies families the day after the pressure ulcer is identified. On October 23, 2023, at 1:24 PM, V4 (ADON/Assistant Director of Nursing) said V3 is responsible for notifying resident families of newly identified pressure ulcers. V4 continued to say a resident's family should be notified as soon as possible or at lease within 24 hours. V4 said the notification of the family should be documented in the EMR. The facility's policy titled, Skin Care Treatment Regimen dated July 28, 2023, showed, Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. Procedures: .7. Notify the patient family/next of kin or POA (Power of Attorney) for any new sore that is identified during the course of stay at the facility . The facility's policy titled, Notification for Change of Condition, dated July 28, 2023, showed, Policy Statement: The facility will provide care to residents and provide notification of resident change in status. Procedures: 1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the residents legal representative or an interested family member when there is: . b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions); c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .

Based on observation, interview and record review the facility failed to handle and store bulk bin scoops in a sanitary manner. This failure has the potential to effect all residents in the facility. The findings include: The CMS 672 dated 9/18/23 shows the facility has 114 residents residing in the facility. On 9/19/23 at 9:41 AM, V4 (Cook) prepared puree crab cakes, puree spinach, and mashed potatoes for lunch. On 9/19/23 at 9:54 AM, V4 opened the food thickener bulk bin, grabbed the scoop from inside the bin, scooped food thickener into the scoop, and the food thickener to the puree spinach. When finished, V4 placed the used scoop back inside the food thickener bulk bin. On 9/19/23 at 10:02 AM, V4 closed the food thickener bulk bin with the used scoop still inside without washing it after use. On 9/19/23 at 10:03 AM, V3 (Food Service Director) said the scoops that are stored inside the bulk bins are washed once a week. V3 said this practice was okay but the scoops should ideally be washed after each use. On 9/20/23 at 9:15 AM, V6 (Registered Dietitian) said per the facility's ware washing policy, the scoops should be washed and sanitized after each use before storage. The facility's Ware Washing Policy dated 10/19/23 states, It is the center policy that all dishware and service ware will be cleaned and sanitized after each use.

Based on observation, interview, and record review the facility failed to ensure staff performed hand hygiene after direct care, failed to ensure enhanced barrier precautions were in place and failed to ensure staff wore PPE (Personal Protective Equipment) during direct care for residents on isolation to prevent cross contamination. This applies to 7 of 24 residents (R23, R1, R14, R76, R109, R270 & R267) reviewed for infection control in the sample of 24. The findings include: 1. On 9/18/23 at 10:30 AM, V10 (Certified Nursing Assistant) provided incontinence care to R23. R23's incontinent brief was soiled with urine and stool. V10 cleansed R23's peri-area and with the same contaminated gloves touched multiple surfaces including the bedding, R23's gown, and the bed control. She then removed her gloves and left the room without performing hand hygiene. On 9/19/23 at 1:59 PM, V11 (CNA) said staff should wash hands or hand sanitize after providing cares to prevent the spread of infections. The facility's Hand Hygiene Policy revised 7/23 states, Hand Hygiene is important in controlling infections. Hand Hygiene consists of either hand washing or the use of alcohol gel .Hand hygiene using alcohol-based hand rub is recommended during the following situations .before and after direct care .before moving from work on soiled body site to a clean body site on the same resident . 2. On 9/19/23 at 9:21 AM, R1 and R14's door had a sign posted with Enhanced Barrier Precautions. There was no isolation cart located outside of the room. Upon entering the room V2 (Director of Nursing) and V12 (CNA) were providing direct care to R1 without wearing gowns. R1 was observed in her bed with a gastric tube in place. In bed two, R14 was observed with a dressing to her sacrum. V8 (Activity Director) and V13 (CNA) were providing direct care to R14 without wearing gowns. On 9/20/23 at 10:10 AM, V2 said R1 and R14 are both on enhanced barrier precautions. R1 has a gastric tube and her roommate R14 has a wound. V2 confirmed she and V12 were not wearing gowns. We should have been wearing gowns when providing direct care for the protection of the resident. R1's face sheet shows she is a [AGE] year old female with diagnosis including gastrostomy status, hemiplegia affecting left non-dominant side and history of traumatic brain injury. R14's face sheet shows she is [AGE] year old female with diagnosis including pressure ulcer of sacral region, chronic kidney disease, hypertension and type 2 diabetes. The facility's Enhanced Barrier Precaution List provided on 9/19/23 shows R1 is on isolation for her gastric tube and R14 for her wound. 33760 3. On 9/18/23 at 10:35 AM, R76 who has a tube feeding and R109 who has indwelling foley catheter and pressure sore were both in room [ROOM NUMBER]. The room was not on any Enhance Barrier precaution. V15 (Certified Nursing Assistant) CNA provided care to both R76 and R109 without wearing any gown. V15 said R76 has a tube feeding and R109 has foley catheter but they are not on any precautions. On 9/19/23 at 9:20 AM, a sign was now posted in room [ROOM NUMBER] for Enhance Barrier Precautions There was no isolation cart outside the room. V10 (CNA) was in room [ROOM NUMBER] with no gown on. V10 saw the Enhance Barrier sign but said I have no idea what that meant. and said no one told her to wear a gown when in room [ROOM NUMBER]. V14 (Clinical Director) who was by the room [ROOM NUMBER] said there should be on isolation carts outside the room and staff should be wearing a gown and gloves when providing care to R76 and R109 due to both residents were on enhance barrier precautions. On 9/20/23 at 9:40 AM, V2 (Director of Nursing) said room [ROOM NUMBER] is on Enhance Barrier precautions for R76 who has a tube feeding and R109 who has wounds and catheter for additional precautions to prevent cross contamination. 34314 6. On September 18, 2023 at 10:50 AM, R267 was lying in bed watching television. She had a urinary drainage bag attached to the side of her bed. There was no sign on her door saying Enhanced Barrier Precautions. On September 18, 2023 at 11:05 AM, R270 was lying in bed. He had a feeding pump pole next to his bed. He also had a drainage bag attached to his bed. There was no sign on his door saying Enhanced Barrier Precautions. The facility's enhanced barrier precaution list (no date) shows, R267 is on enhanced barrier precautions for a wound (the list doesn't show she also has an indwelling urinary drainage tube). R270 is on enhanced barrier precautions for a wound (the list doesn't show he has a drainage bag and g-tube for his feeding). On September 19, 2023 at 1:50 PM, V20 Infection Control Nurse stated, they are using enhanced barrier precautions in addition to standard precautions for residents who have indwelling urinary drainage bags, wounds, central lines and any opening in the skin. We have to wear gowns, mask if there is splashing and gloves to protect residents from MDROs (multi-drug resistant organisms) because of openings in the body. Staff would know a resident is on enhanced barrier precautions by a sign on the door. The facility's Enhanced Barrier Precaution policy last revised July 26, 2023 shows, Policy: The facility will use Enhanced Barrier Precautions (EBP) to reduced transmission of infectious organisms. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Procedure: 1. EBP will be used for any resident in the facility with: an open wound/s, has indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheotomy/ventilator) regardless of MDRO colonization status for the duration of their stay, is colonized with multi-drug resistant organisms (MDROs) and contact precautions do not apply . 3. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but is not necessary in other situations. Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: a) dressing, b) bathing/showering, c) transferring, d) providing hygiene, e) Changing linens, f) Changing briefs or assisting with toileting, g) Device care of use: central line, urinary catheter, feeding tube, tracheotomy/ventilator, h) Wound care: any skin opening requiring a dressing .

Based on observation, interview and record review the facility failed to provide assistance to residents that needed extensive assist with activities of daily living (ADL's) to 5 of 24 residents (R70, R22,R23, R19, R65) reviewed for ADLs in the sample of 24. The findings include: 1. On 9/18/23 at 11am, R70 was in bed. A strong smell of stool was noted. Smears of stool was noted on R70's sheets and linens. V15 (Certified Nursing Assistant- CNA) was in R70's room and removed R70's incontinent pad full of dried stool. Dried stool was also noted in R70's back and thighs. R70 said he had been needing to be changed. V15 (CNA) said she had not had a chance to provide incontinence care or morning care to R70. R70's facility assessment dated [DATE] show R70 need extensive assist for ADL's for toileting and hygiene and is always incontinent of bowel functions. 2. On 9/18/23 at 10:15 AM, R22 was sitting in bed. A strong smell of urine was noted coming from R22. R22 asked this surveyor Are you here to change me? R22 said she had been needing to be changed and that she had not been changed since last night. R22 said this is uncomfortable. This surveyor asked V7 (Wound Nurse) to check on R22. V7 removed R22's incontinent pad totally soaked with urine. At 10:30 AM, V15 (CNA) said she had been so busy and has not given any care to R22. On 9/20/23 at 9:15 am V2 (Director of Nursing-DON) said residents should be provided morning care and incontinence care in the mornings then 3-4 times a day and as needed. R22's facility assessment dated [DATE] show R22 needs extensive assist with toileting. 34117 3. R23's Minimum Data Set assessment dated [DATE] shows she requires extensive assist with toileting and is freqeuntly incontinent. On 9/18/23 at 10:30 AM, R23 was lying in her bed. A strong permating smell of urine was present. At 10:41 AM, V10 (Certified Nursing Assistant-CNA) entered the room to provide care. V10 removed two incontient breifs from R23. Her incontient breif was saturated with urine and stool and redness to her peri-area. V10 said she had not changed R23 until now. 4. R19's Minimum Data Set assessment dated [DATE] shows she's cognitively intact, requires extensive assist with toileting and frequently incontinent. On 9/18/23 at 11:02 AM, R19's call light was on. She said she needed to be changed and told V10 (CNA) when V10 was in the room cleaning up her roommate. I've been waiting since 10:00 AM. R19 said she was last changed last night. V9 (Restorative Aide) entered the room to answer the call light. R19 told V9 she was soiled and needed to be changed. V9 said you'll have to wait, V10 is giving a shower to a resident. At 11:11 AM, V9 returned back to the room to provide incontinence care. R19 was wearing two incontinent breifs. Her incontinent breifs were heavily soiled with urine. On 9/19/23 at 1:59 PM, V11 (CNA) said residents should not be double briefed, we are not allowed to do that. Residents should be checked and changed every two hours for incontinence care. The facility's Incontinent and Perineal Care Policy revised 7/2023, states It is the policy to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation and to observe the resident's skin condition .1. Do rounds at least every two hours to check for incontinence during shift . 35174 5. R65's Facility assessment dated [DATE] showed R65 is an eighty year old cognitively impaired residents with diagnoses which include: unspecified dementia with other behavioral disturbances. This assessment also showed R65 needs extensive assistance with getting dressed. On 9/18/23 at 12:55 PM, R65 was walking in the hallway with V19 (R65 family). R65 had on a gray sweatshirt with red lettering and dark blue pants. V19 stated they had visited over the weekend, and R65 had been in the same clothes since Friday (9/15/23). R65 hoped would be changed today. On 9/19/23 at 11:20 AM, V16 (CNA) stated she had worked with R65 over the weekend. V16 described R65's clothing as a gray sweatshirt with red letters and blue pants. V16 stated R65 was in the same clothes yesterday morning (9/18/23). V16 stated R65 is unable to get dressed himself. R65 does not know how to dress himself anymore. On 9/19/23 at 1:30 PM, V2 stated the facility did not have a policy in regards to assisting a resident with getting dressed.

Based on observation and interview the facility failed to ensure a residents dirty linens were changed which applies to 1 of 24 residents (R54) reviewed for homelike environment in a sample of 24. The findings include: On 9/18/23 at 9:30 AM, R54 was in bed with the bottom quarter of the bed exposed. R54's fitted bed sheet had multiple reddish-brown marks which ranged from dime to golf ball in size. R54 stated the marks are from his scratch he had on his lower right leg. R54 had a dressing covering on his right ankle. On 09/19/23 at 10:35 AM, R54's sheet had the same marks on it along with additional pea sized reddish marks. R54 stated none of the staff offered to change his sheet. R54 stated he had several staff in and out of his room yesterday and this morning. R54 stated the nurse saw the sheet when she changed his ankle dressing. On 9/19/23 at 11:20 AM, V16 Certified Nursing Assistant stated if a residents bed linens are dirty they should be changed. On 9/19/23 at 12:00 PM, V2 Director of Nursing stated a residents linens should be changed if soiled. On 9/20/23 at 1:25 PM, V1 Administrator stated the facility has no policy in regards to changing a residents bed linens.

Based on interview and record review the facility failed to complete a comprehensive assessment after a hospice admission. This applies to 1 of 24 (R33) residents reviewed for comprehensive assessments in the sample of 24. The findings include: R33's facesheet dated 9/19/23 shows R33 has the following diagnoses: Sepsis, Methicillin Resistant Staphylococcus Aureus Infection, Anemia, Dementia, Hypertension, Chronic Respiratory Failure, Chronic Kidney Disease Stage 3, Gastro-Esophageal Reflux Disease, Cerebrovascular Disease, Enterocolitis due to Clostridium Difficile, Malignant Neoplasm of Lung, Protein-Calorie Malnutrition, Hypercholesterolemia, Anxiety Disorder, Depression, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Fracture of the Elbow, and Fracture of the Femur. R33's Physician's Order Report dated 9/19/23 shows R33 has an active order for, admitted to [Hospice Company] 8/20/23 . R33's Social Service Progress Note Dated 8/21/23 at 3:30 PM states, Notified by [Hospice Company] that hospice care started on 8/20/23 diagnosis: cerebrovascular disease. Care plan initiated for hospice care. SS to remain available to assist as needed. R33's Minimum Data Set (MDS) List shows on 8/12/23 a quarterly MDS was completed and on 9/19/23 a Significant Change MDS was initiated. On 9/19/23 at 11:54 AM, V5 (Clinical Care Coordinator) said that an MDS assessment must be completed within 14 days after admission to hospice. On 9/19/23 at 2:02 PM, V5 said there was an error and the Significant Change MDS for R33's hospice admission had not been completed or transmitted. The facility's Completion of Minimum Data Set (MDS) policy dated 3/22 states, . Any additional assessment such as Significant Change in Status, Quarterly assessments, IPA/NPE, or other required assessment will be completed per RAI guideline not unless it is an insurance payer which will only be 'completed'.

Based on observation, interview, and record review the facility failed to ensure the prescribed treatment order was in place for a resident with unstageable sacral pressure ulcer. This applies to 1 of 7 residents (R14) reviewed for pressure ulcers in the sample of 24. The findings include: R14's Wound Physician Progress note dated 9/13/23 documents she has a unstageable sacral pressure ulcer measuring 4.1 cm (centimeters) x 2.3 cm x 0.2 cm with treatment orders, include to apply calcium alginate and cover with foam dressing daily. R14's Treatment Administration Record for September 2023 shows orders to cleanse the sacrum, apply medihoney and cover with foam dressing daily. The T.A.R. shows the order was not changed until 9/19/23 (6 days later) to cleanse sacrum, apply calcium alginate and cover with foam dressing. On 9/19/23 at 9:21 AM, R14 was observed lying in bed with foam dressing to her sacrum. On 9/19/23 at 1:50 PM, V7 (Wound Nurse) said she rounds with the wound physician weekly and she transcribes the treatment orders. She confirmed the treatment order was not changed until today. We should follow the prescribed treatments orders by the wound physician. R14's wound should have been receiving calcium alginate instead of the medihoney. The facility's Skin Treatment Regime policy reviewed 7/2023 states, It is the policy of this facility to ensure prompt identification, documentation and to obtain topical treatment for residents with skin breakdown .charge nurses must document in the nurse's notes/and or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained form the the patient's physician.

Based on observation, interview and record review, the facility failed to identify/implement specific pressure ulcer prevention measures to prevent the development of multiple pressure ulcers. The facility also failed to implement interventions and/or provide treatments for pressure ulcers per resident plans of care and as ordered by the physician. This failure resulted in the development of facility-acquired unstageable, necrotic pressure ulcers on a resident's foot who had a recently fractured leg and impaired mobility. This applies to 3 residents (R1-R3) reviewed for pressure ulcers in a sample of 6. The findings include: Face sheet, dated 1/9/23, shows R1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], after a hospital admission from 7/9/22 to 7/14/22. R1 was discharged from the facility on 12/20/22. R1's diagnosis included nondisplaced oblique fracture of shaft of right tibia and right fibula, pressure ulcer of right heel and other site, pressure-induced deep tissue damage of right heel, abnormality of gait and mobility, senile degeneration of brain, vascular dementia, malignant neoplasm of the breast, diabetes Type 2, and cerebral infarction. Hospital record, dated 7/9/22, shows R1 was diagnosed with a right tibia and a right fibula fracture. On 1/10/23 at 5:14 PM with V2 (Director of Nursing), V1 (Administrator) referred to R1's care plan and stated the facility follows the plan of care for the residents regarding pressure ulcer prevention interventions. Skin Evaluation, dated effective 7/14/22 and signed by V11 (Wound Nurse) on 7/21/22, shows R1 had no alteration in skin integrity and R1's Braden Score was 14 indicating R1 was at moderate risk for pressure ulcers. The assessment shows R1 was readmitted to the facility with a soft cast to her right lower leg and had physician orders for non-weight bearing. The assessment shows R1 had difficulty repositioning herself and required staff to assist with redistributing body weight. The assessment shows R1 demonstrated capillary refill to her right great toe, R1's skin was intact, R1 was non-weight bearing, and staff will continue to monitor R1's skin integrity. No specific pressure ulcer prevention interventions were identified in the assessment. POS (Physician Order Sheet), dated 7/1/22-7/31/22, shows admission physician orders, dated 7/14/22, included Skin check/assessment every 1 hours as needed AND every shift every Saturday. The POS failed to show any specific pressure ulcer prevention interventions when R1 was readmitted to the facility with non-weight bearing status, impaired mobility, and a soft cast on her right leg. Review of R1's TAR documentation shows R1's skin was documented as monitored weekly on Saturdays. On 1/11/23 at 10:46 AM, V1 (Administrator) stated the facility did not have a specific pressure ulcer prevention policy and prevention of a resident's pressure ulcer would be based on the resident's Braden and nurse assessment. Orthopedic Physician Assistant Progress note, undated and signed by V8 (Orthopedic Physician Assistant), shows R1's plan included weight bearing as tolerated, right lower extremity in CAM boot during day, physical therapy, and follow up in four weeks (9/19/22). Review of R1's care plans, admitted [DATE], failed to show R1 had any specific care plan/interventions related R1's newly fractured leg, impaired mobility, or pressure ulcer prevention upon admission. The care plans show R1's first care plan/interventions related to R1's skin integrity related to her newly fractured leg was on 9/29/22 after identification of R1's pressure ulcers. Skin Evaluation, dated effective 9/28/22 and signed by Wound Nurse on 10/4/22, shows R1 had an alteration in skin integrity which included an unstageable pressure ulcer on R1's right outer foot measuring 2 cm x 2 cm, an unstageable pressure ulcer on R1's right achilles measuring 2.5 cm x 3.5 cm, and an unstageable pressure ulcer on R1's right dorsal foot measuring 3.5 cm x 3.5 cm. The evaluation shows R1 had a CAM (Control Ankle Motion) boot to her right lower leg as an immobilizer. The evaluation shows interventions initiated included heel protectors for pressure relief. Initial Wound Evaluation and Management Summary, dated 10/5/22, shows, R1 had: 1. Non-pressure wound of right dorsal foot full thickness trauma/injury greater than three days in duration and healing. Measured 3.2 cm x 2.0 cm x 0.1 cm with moderate serous exudate and 100% thick adherent devitalized necrotic tissue. The wound received surgical excisional debridement of devitalized tissue. 2. Stage 1 pressure wound of the right heel partial thickness greater than 2 days and measuring 2.3 cm x 3.5 cm not measurable and no exudate. Recommendations included off-load wound, reposition per facility protocol, and sponge boot. Wound Evaluation and Management Summary, dated 10/12/22, shows R1 had the following: 1. Non-pressure wound of the right dorsal foot full thickness (healing), Unstageable (due to necrosis) of the right heel, full thickness healing. Recommendations included off-load the wound. 2. Unstageable (due to necrosis) of the right heel was deteriorated. Recommendations included off-load wound, reposition per facility protocol, and sponge boot. 3. Newly-identified unstageable DTI (Deep Tissue Injury) of the right distal lateral foot. Recommendations included off-load wound, reposition pr facility protocol, sponge boot. Review of R1's nursing progress notes, dated 8/1/22 - 9/30/22, show no documentation of specific pressure ulcer preventions measures implemented to ensure R1 avoided the development of pressure ulcers. Review of R1's care plans, admitted [DATE], show R1 had new care interventions initiated 9/29/22 including staff to assist R1 with the application of her right CAM boot when up and remove the boot when in bed/sleeping, check for skin integrity and circulation, and check for motion before and after the removal of the boot noting the condition of the skin. No specific pressure ulcer prevention interventions were identified. Skin integrity impairment care plan, initiated 10/9/22, shows the following care interventions were initiated on the following dates: - 10/9/22 Apply heel protector when on bed. Offload heels. Use CAM boot when out of bed. Skin check every shift. Report abnormalities to the nurse - 10/10/22 Apply skin prep after NSS (Normal Saline) cleanse and wrap with Kerlix (right achilles, right dorsal foot, right lateral foot). Physician order dated 8/24/22 and discontinued on 9/29/22, which showed, Put on boot on right leg when up and may take off at night when sleeping. Review of R1's progress notes, MAR, TAR. and Monitoring Record, fail to show pressure relieving interventions for R1's lower extremities. Physician order, dated 9/28/22 and discontinued on 10/19/22, showing, Skin prep to right dorsal foot, right achilles, right lateral foot after NSS cleanse, wrap with Kerlix every day shift for treatment. Physician order on 9/28/22, showed Heel protector boots. Physician order, dated 9/28/22 and discontinued on 10/10/22 which showed, Heel protectors on when CAM boot is not on. The POS shows R1's 8/24/22 physician order was changed on 9/29/22 (and discontinued 10/11/22) to include, Put on CAM boot on right leg when up and may take off at night when sleeping. Staff to check for skin integrity before and after applying CAM boot every day and every evening shift. Wound assessment details report, dated 10/28/22, shows R1 had a newly identified deep tissue pressure injury on 10/26/22 to her right bunion measuring 2.2 cm x 1.5 cm. Physician order, dated 10/19/22, for Santyl External Ointment 250 Unit/gram to be applied to R1's right achilles, right dorsal foot, and right lateral foot topically every day shift. The POS also shows a new physician order dated 10/26/22 and discontinued 12/21/22 for, Skin prep to right bunion, after NSS cleanse, wrap with Kerlix every day shift for treatment. Physician order, dated 12/1/22 to 12/31/22, shows R1 had a physician order to be sent to the emergency room for a hemoglobin of 6.8 grams per deciliter. Nursing progress note, dated 12/21/22, shows R1 was admitted to the hospital due to a right foot infection. Hospital emergency room Physician note, dated 12/20/22, shows R1 complained of pain in her right foot and was observed to have tender right foot ulcers with purulent discharge. Hospital Physician note, dated 12/22/22, shows R1 was transferred to the hospital for a low hemoglobin and right foot pain. The note shows R1 was diagnosed with right foot cellulitis and osteomyelitis status post-surgery for debridement, sepsis due to cellulitis/osteomyelitis, and right foot pain. On 1/11/23 at 4:16 PM, V9 (Wound Care Physician) stated if a resident is fragile, such as having a decline in mobility, a resident can develop a pressure ulcer on their feet if protective boots are not utilized or the feet are not offloaded. V9 stated R1's mobility declined due to her fractured tibia/fibula. On 1/11/23 at 4:39 PM, V10 (Primary Physician) stated since R1 had limited mobility and was not getting out of bed, the limited mobility could have probably caused R1's pressure ulcers if the staff were not utilizing protective heel boots or offloading R1's feet. On 1/10/23 at 10:36 AM, V11 (Wound Nurse) stated after R1 broke her leg, R1 stayed in bed most of the time and most often refused to get up out of bed. V11 stated she became involved with R1 when staff identified a wound on her right foot. V11 assessed R1, and two necrotic wounds and one deep tissue injury were identified on R1's right foot. V11 stated at that time the facility ordered heel protectors to be placed on R1's right foot at night when the CAM boot was removed and placed on her left foot at all times. V11 stated R1 later developed a deep tissue injury on her right bunion while R1 continued to wear the CAM boot. V11 stated the facility reported the wounds on R1's right foot to V10 (Primary Physician) but not to V8 (Orthopedic Physician Assistant) as V12 (Family) chose not to return to the orthopedic physician office for a scheduled follow up 9/19/22. Review of R1's MAR/TAR/Monitoring, dated 11/1/22-12/21/22, show R1 had the following physician orders for pressure ulcer treatments: 1. Santyl ointment - apply to right dorsal foot, right lateral foot, and right achilles every day shift (all ordered 10/20/22 - 12/21/22) 2. Skin prep to right bunion, after NSS cleanse, wrap with Kerlix every day shift (ordered 10/26/22-12/21/22) The records show R1 failed to receive one or more pressure ulcer treatments on the following dates: Santyl External Ointment application to one or more wounds- 11/7/22, 11/10/22, 11/19/22, 11/21/22, 11/23/22-11/25/22, 11/28/22, 11/30/22, 12/2/22. Skin Prep, NSS cleanse, and wrap with Kerlix to right bunion - 11/1/22-11/4/22, 11/7/22, 11/10/22, 11/21/22, 11/24/22, 11/30/22 Review of the documents also shows multiple nurses, including V11(Wound Nurse), V12 (LPN- Licensed Practical Nurse)), V13 (RN), V14 (RN Supervisor), R15 (LPN), and R16 (Wound Nurse) all administered wound care treatments on R1 between 11/1/22-12/21/22. Facility Policy/Procedure, reviewed/revised 7/28/22, showed It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. Procedures 1. Charge nurses must document in the nurse's notes and/or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the patient's physician 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician 5. Refer any skin breakdown to the skin care coordinator for further review and management as indicated. 6. Residents who are not able to turn and reposition themselves will be turned and repositioned every 2 hours unless specified in the POS (Physician Order Sheet ) 9. Residents with Stage III and/or IV pressure ulcer will be placed in specialized air mattresses like Low Air Low Mattress with an incontinent brief if they are incontinent only, incontinence pad which will also act as repositioning aid, and either a flat sheet or a fitted sheet which are all necessary to prevent infection control issue. 2. MDS (Minimum Data Set), dated 11/25/22, shows R2 was cognitively intact and required the extensive assistance of two staff for bed mobility and was totally dependent on staff for transfers. Skin Evaluation, dated 12/19/22 and performed by V11, shows R2 had pressure ulcers of the right and left heels, left bunion, right lower leg, right inner ankle, lumbar back, and 3 pressure ulcers on her right ischium, right. Advanced Practitioner Nurse progress note dated 1/10/23 shows R2 was to be turned and repositioned every two hours. Impaired skin integrity care plan, initiated 11/21/22, shows R2's interventions include offloading of bilateral heels when in bed every shift and as needed - apply heel protectors and treatments as ordered. The care plan fails to state R2 was to be repositioned every two hours. On 1/10/23 at 4:28 PM, R2 was lying in her bed with a blue heel protecting boot on each foot. R2's heels were not offloaded and her blue heel protecting boots, calves, and knees were all were resting directly on the bed. R2 stated the facility staff did not usually offload her heels when in bed. R2 stated staff usually only apply the blue protective boots while in bed and may place a pillow under her knees/legs for comfort occasionally. R2 stated the staff turn and reposition her every two hours during the day but they fail to turn her consistently every two hours during the night shifts. R2 stated she sometimes did not receive her daily physician-ordered wound treatments as ordered for her wounds. R2 stated when her treatment is skipped for a day she complains and the staff perform the treatment the next day. On 1/11/23 at 3:11 PM, V11 stated if R2 had heel protectors on the staff were not required to place a pillow under her calves because heel protectors achieved the intervention of offloading. On 1/11/23 at 3:27 PM, V9 (Wound Physician) stated offloading resident heels involves putting a pillow under the calf of the resident and is not the same intervention as placing heel protectors on the resident heels. V9 stated they are two separate interventions. Review of R2's TARs, dated 11/21/22 -12/31/22, fails to show R2 was provided the following wound treatments: 1. Medihoney to lumbar, after NSS cleanse, cover with border dressing every day shift (ordered 11/22/22 - 12/5/22) - 11/22/22, 11/23/22, 11/25/22, 11/28/22, 12/2/22, 12/4/22 2. Skin prep to left bunion, after NSS cleanse, wrap with Kerlix every day shift (ordered 11/22/22 - 12/13/22) - 11/22/22, 11/23/22, 11/25/22, 11/28/22, 12/2/22, 12/4/22, 12/11/22 3. Skin prep to right inner ankle after NSS cleanse, wrap with Kerlix every day shift (ordered 11/22/22-12/13/22) - 11/22/22, 11/23/22, 11/25/22, 11/28/22, 12/2/22, 12/4/22, 12/11/22 4. Skin prep to right ischium after NSS cleanse, wrap with Kerlix every day shift (ordered 11/22/22-12/16/22) -11/22/22, 11/23/22, 11/25/22, 11/28/22, 12/2/22, 12/4/22, 12/11/22 5. Santyl Ointment to left heel every day shift for treatment for calcium alginate after NSS cleanse, wrap with Kerlix (ordered 11/24/22) - 11/25/22, 11/28/22, 12/2/22, 12/4/22, 12/11/22 6. Santyl Ointment to right heel every day shift for treatment with calcium alginate after NSS cleanse, cover with border dressing (ordered 11/24/22) - 11/25/22, 11/28/22, 12/2/22, 12/4/22, 12/11/22 7. Santyl ointment to right lateral leg for wound care with calcium alginate after NSS cleanse, wrap with Kerlix (ordered 11/24/22 - 1/10/23) - 11/25/22, 11/28/22, 12/2/22, 12/4/22, 12/11/22 8. Santyl ointment to left bunion after NSS cleanse wrap with Kerlix every day shift (11/22/22-12/13/22) - 11/22/22, 11/23/22, 11/25/22, 11/28/22, 12/2/22, 12/4/22, 12/11/22 9. Calcium Alginate with Silver to left ischium after NSS cleanse, cover with border dressing (ordered 11/24/22-12/12/22) - 12/2/22, 12/4/22, 12/11/22 10. Calcium Alginate with Silver to sacrum after NSS cleanse, cover with board dressing every day shift (ordered 11/24/22-12/9/22) - 12/2/22, 12/4/22) 11. Wet gauze with dakins solution to lumbar, after NSS cleanse, cover board dressing every day and evening shift (ordered 12/6/22-12/9/22) - 12/7/22 PM shift 12. Wet gauze with dakins solution to sacrum after NSS cleanse, cover with border dressing (ordered 12/9/22-12/14/22) - 12/11/22 PM Review of R2's MAR skin treatment documentation shows multiple nursing staff provided R2's daily treatments at the facility. On 1/10/23 at 11:39 AM, V11 (Wound Care Nurse) stated any staff documentation of completion of the POS skin treatments would be documented on R2's TARs. On 1/10/23 at 10:36 AM, V11 stated she and another treatment nurse were responsible for performing daily wound treatments on residents. On 1/11/23 at 3:11 PM, V11 stated floor nurses also perform resident wound treatments at the facility which may be on days V11 and V16 (Wound Nurse) may not be working. V11 stated she was not sure if she ever forgot to sign the TAR after performing resident wound care, however V11 stated her assigned wound care treatments were completed when she worked at the facility. On 1/10/23 at 5:14 PM, V1 stated the two facility wound nurses were in the building every day and performed the wound care on all the wounds in the facility every day. 3. Care plan, admitted d 1/4/23, shows R3's diagnoses include Alzheimer's disease, major depression, hypertension, and spinal stenosis. Wound Assessment Details Report, dated 1/5/23, shows R3 had a left trochanter pressure ulcer measuring 5 cm x 4.5 cm x 0.1 cm. Skin integrity impairment care plan, initiated 1/4/23, shows R3's interventions included applying wound treatment as ordered by the physician and turn and reposition at least every two hours as needed. Review of R3's TAR, dated 1/4/23 - 1/10/23, showed R3 had a physician order, dated 1/5/23 at 7:00 AM, for Santyl External Ointment to be applied to R3's left hip every day shift for treatment. The TAR showed the facility failed to provide R3's Santyl and skin prep wound treatments on 1/5/23 per physician order.

Based on observation, interview and record review, the facility failed to ensure a hazard free environment, and failed to use adequate supervision and safety devices while assisting a resident to ambulate after receiving a shower. This applies to 1 of 3 residents (R1) reviewed for falls. As a result R1 fell , sustained a left femur fracture and underwent a revision total left knee replacement. The Findings Include: 12/15/20 at 10:15AM, R1 was laying in bed ,with dark red discoloration to the mid right arm. R1 said, V4 (Certified Nursing Assistant) took me into the shower and gave me a shower. After my shower was complete V4 folded up a blanket, put it on the floor, placed my walker in front of me and told me to walk towards my walker. I told him I can't. He said yes you can. I stood up from the shower chair with the walker in front of me and I got caught on the walker with the blanket on the floor. He gave me a little push to reach the door. My knee buckled under me and I fell . V4 did not use anything on my waist. (No gait belt) I went down on my knee and broke my leg. I had to go to the hospital and I had surgery. I cannot walk now. I worked with V4 (CNA) before, I do not know if he pushed me intentionally. I told him twice I could not walk. I told the hospital what I am telling you. On 12/15/20 at 10:58 AM, V2 ( DON) said V4 (CNA) resigned on good terms. He worked here for two years. V2 said the facility does not have a policy on transferring residents from chair to bed, etc. V4 said the restorative aides will know how to transfer a resident. V2 said she spoke to V4 about the fall and V4 said after the shower R1 became weak and he assisted R1 to the floor. V2 said R1 is a bigger resident. V2 said V5 (Nurse) was in the hallway when V4 yelled for help. V5 came right away and R1 was transferred to bed. V2 said the root cause analysis was weakness. V2 said R1 uses a walker for short distances and a wheelchair to ambulate in the hallway. V2 said R1 told her after the shower she felt weak and V4 was with her and she lost her balance and fell . On 12/15/20 at 11:40AM, V8 (Restorative Nurse) and V9 (Restorative Nurse) said there is no policy on how to transfer a resident without the use of a mechanical lift. R1 requires extensive assist with activity of daily living skills except eating, meaning 50 % of weight bearing from staff. V8 and V9 demonstrated how a resident should be transferred and said always use a gait belt. On 12/15/20 at 11:53AM via telephone, V4 (CNA) said After I showered R1, I put the walker in front of her, the wheelchair was on the side. I put a blanket on the floor. The transfer was difficult. Surveyor asked V4 to explain difficult. V4 stated In the shower, R1 was quite heavy. When she was moving from the shower chair to the walker, she stood and lost her balance and I lowered her to the floor. This was the first time that I ever showered her. I was right behind her and asked her to walk. She could walk a little bit. It would have been easier with two people assisting herV4 stated he had been trained on transfers. You must use a gait belt and two people if you need it. She had a gown, shoes and no diaper and I did not use the gait belt and did not use two people. The nurse helped me transfer her from the floor to her bed. Shower Sheets were reviewed for R1 from 10/20 to 12/4/20. V4 signed that he gave R1 a shower on 11/9/20, 11/11/20 and 12/4/20. V2 said the root cause analysis was weakness.The Root Cause analysis did not mention the blanket on the floor, no gait belt use, the residents weight or one staff assist. On 12/15/20 at 4PM V7(Medical Doctor) said In my [AGE] years of practice I have never had to call anything in but this once. R1 came into the emergency room and told me she was shoved onto the floor after a shower. She was able to give me the aides name. R1 said V4 put blankets on the floor, told her to walk and gave her a shove and she said she fell . The fall caused a femur fracture. R1 is alert and cognizant, but a heavier resident. Not having two people assist her or using gait belt upon transfer or ambulation could possibly cause the fracture, but a shove can cause a fracture. On 12/16/20 at 10:11AM via telephone V1(Administrator), V2(Director of Nursing) and V3(Assistant Director of Nursing) were made aware of allegation of R1 being pushed. V1, V2 and V3 stated they were not aware that R1 said V4(CNA) shoved her. 12/16/20 V11 (Facility's Medical Director) said R1 had demineralization around the old hip replacement/knee replacements site and likely osteopenia. The doctor said she placed her hands on the walker why would the aide tell her to walk towards the walker. facility should The doctor began to discuss different scenarios about what occurred in the shower room but did say he was not physically there to see what happened. V11 said R1 was confused about being shoved. Upon informing V11 that R1 informed V7(Medical Doctor) in the emergency roiagnom on [DATE]. On 12/15/20 ,her statement did not deviate when she informed the surveyor. V11 had no response. Hospital Interdisciplinary Note dated 12/5/20 says R1 expressed to emergency room Physician that when she was attempting to transfer from the shower seat and step to her walker, there was carpeted tile on the ground and she did not feel she could safely step. V4 (CNA) told her she could do it and shoved her from behind causing her to fall. R1 has a new femur fracture. Hospital Record dated 12/4/20 to 12/11/20 says R1 was admitted for distal left femur peri-prosthetic fracture and revision of left TKA (Total Knee Arthroplasty). The record says R1 is an obese resident. The Facility's Shower Sheets, Progress Notes, Minimum Data Set and Physician order [REDACTED]. Summarized R1 sustained a left femur fracture after a shower on 12/4/20. R1 is alert and oriented with Brief Interview for Mental Status Scores of 15 indicating she is cognitively intact. R1 had 7 showers prior to 12/4/20 without injury. The functional status section on the minimum Data Set prior to R1's fall 11/18/20 shows that she was a extensive assist for transfers and bathing with one person physical assist.

Based on interview and record review, the facility failed to ensure that a resident with a known skin condition was transferred safely. As a result of an improper transfer, R1 sustained a laceration that required 62 sutures to close. This applies to 1 of 3 residents (R1) reviewed for safe transfers in the sample of 3. The findings include: R1's face sheet showed R1 has multiple [DIAGNOSES REDACTED]. R1's quarterly MDS (minimum data set) dated 2/16/19 shows a BIMS (Brief Interview for Mental Status) score of 15 which means that the resident is cognitively intact. The same MDS showed R1 required extensive assistance from the staff with regards for transfer with the assist of 2 persons. On 4/12/19 at 4:31 PM, hospital records showed R1 was received at the emergency room for a laceration of the lower left leg that required 62 sutures to close. On 4/12/19 at 4:02 PM, V8's (Nurse Practitioner) progress note showed R1 was observed to have a long skin tear to LLE (lower left extremity) with acute bleeding and exposed adipose tissue, complete tissue loss. Same progress note showed V8 was asked by staff to see the resident due to skin tear to LLE while transferring patient from recliner to her bed. Incident report completed on 4/9/19 showed R1 sustained a skin tear on the right lower leg. The progress note dated 4/9/19 at 9:04 PM showed while the CNA (certified nursing assistant) transfer the resident to the wheelchair, the resident was scooting back in the chair and scraped right calf on the wheelchair .steristrips were applied and covered with derma rite. R1's transfer assessments on 12/19/18 and quarterly assessment on 2/10/19 completed by V7 (restorative nurse) both showed based on the amount of yes answers to the questions in section 'Transfer Ability', R1 required assistance of two or more persons and required mechanical sit to stand lift. Those same reports showed R1 had not been observed for steadiness when moving from seated to standing position. R1's current transfer care plan shows that the resident required 2 staff physical assistance with transferring and to allow R1 to position her leg with one foot forward to promote balance as she comes to stand. R1's care plan did not indicate the use of mechanical lift for transfer. On 4/16/19 at 12:10 PM, V4 (CNA) stated she was assigned to R1 on 4/12/19 and asked V5 (CNA) for assistance to transfer R1 from the reclining chair to the bed. V4 stated she was positioned on the side of the recliner chair and V5 was in front of R1. V4 added that as R1 stood, V5 grabbed R1 under the arms, pivoted R1 and alone, transferred R1 to the bed. V4 stated she did not have her hands on R1 during the transfer. V4 stated gait belt was not used. V4 added that she had transferred R1 earlier in the shift using a mechanical lift, because it was easier and safer. On 4/16/19 at 1:20 PM, V5 stated he assisted putting R1 back to bed by lifting underneath R1's arms, pivoting R1 and sat R1 on the bed. V5 added the moment R1 sat down, R1 said my leg, my leg. V5 stated they looked down to check R1's right leg because they were aware of the right leg injury, Then, R1's left leg noted dripping blood from underneath R1's black pant leg. On 4/17/19 at 3:00 PM in the presence of V1 (administrator), V7 (Restrorative Nurse) stated R1 should not have been transferred from a recliner chair and there should be more communication with staff during transfers to ensure everyone, including the resident, will know what will take place and what assistance is needed. On 4/17/19 at 1:35 PM, V9 (physician) stated R1 has a skin condition that puts her at risk for injury. V9 stated the facility is aware and has measures in place: putting R1 on a special mattress, elevating R1's legs when in bed, bathing R1 with soft towels to prevent skin injuries and wrapping R1's legs with gauze as a preventative measures. V9 acknowledged he was aware that R1 has sustained a skin tear to the opposite leg during transfer on the 4/9/19 and no new interventions were put into place to prevent future occurrences. V9 added that, in hindsight, R1's care should have been updated o include; placed in a padded chair, with padding on the leg extenders and gauze around legs to protect R1.

Noncompliance resulted in two deficient practices. A. Based on interview and record review, the facility failed to initiate fall prevention interventions, failed to consistently implement fall prevention interventions, and failed to provide adequate supervision to prevent falls for four of 22 residents (R3, R4, R7 and R16) reviewed for falls in a sample of 22. These failures resulted in R16 falling, sustaining a fractured leg on two separate occasions. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] documents R16 requires extensive assistance of two people for transfers, bed mobility, and toileting. The MDS also documents R16 is sometimes incontinent of bowel and frequently incontinent of bladder. A care plan dated 12-11-13 documents R16 is at, "high risk for falls...follow facility fall protocol...bed in lowest position with floor mat to side of bed." R16's care plan also states, "...requires two staff participation to reposition..." A fall protocol (prevention program) dated 8/2013 says, "...implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary." The fall protocol also says, "All assigned personnel are responsible for ensuring ongoing precautions are put into place and consistently maintained...," and instructs staff, " Use of mechanical lifts during transfer," as a fall prevention intervention. An incident report form dated 1-04-14 documents R16, "...was being transferred by CNA (Certified Nurse Aide) to wheelchair when R16 lost balance and was lowered to the floor...R16 complained of right knee pain." The incident report documents R16 received an X-ray which indicated R16 had sustained a fractured leg. The incident report documents, "CNA instructed on proper way to determine mode of transfer for R16." An X-ray report dated 1-03-14 documents R16 sustained, "Suspicious transverse incomplete fracture of the proximal shaft of the tibia and fibula." On 8-13-14 at 2:15p.m. E14 (Registered Nurse) verified during interview being R16's nurse on 1-03-14 when R16 was lowered to the floor by a CNA. E14 stated that R16 was totally dependent on staff for mobility and required a mechanical lift with two staff members for transfers. E14 also verified R16 was transferred by only one staff member at the time of the fall, and without the use of a mechanical lift. E14 stated, "It was an inappropriate transfer by the CNA." An incident report dated 3-06-14 documents R16 fell to the floor while, "trying to switch sides of the bed." The incident report documents R16's bedside floor mats, "Not in use at the time of fall." The incident report concludes, "Based on the root cause of the incident...continue with prior intervention which is to ensure that the bed is on the lowest position and floor mats on the floor next to R16's bed." On 8-13-14 at 8:50a.m., E2 (Director of Nurses) verified the findings of R16's 3-06-14 incident investigation which indicated R16's floor mats were not in place at the time of R16's fall. An incident report dated 5-21-14 documents, "Observed R16 on the floor...limited ROM (range of motion) on right knee." The incident report also documents R16 was, "...sent out to ER (emergency room )...returned from ER with a soft cast on R16's right leg." The incident report documents under, "Time resident last toileted...incontinent," and the section asking, "Was the resident toileted as required..." was left blank. The incident documents R16, "...needs assistance to use the bathroom." The incident report does not include the last time R16 had been monitored for toileting needs or observed in bed prior to the fall. A nurses' note dated 5-21-14 at 4:45p.m. documents R16 returned from the ER with the [DIAGNOSES REDACTED]." On 8-13-14 at 8:50a.m., E2 (Director of Nurses) verified R16's fall 5-21-14 resulted in another fracture to R16's right leg. An X-ray report dated 5-21-14 documents R16 sustained, "Acute incomplete fracture of the right distal femur...after fall trauma." 2. A Nurse's Notes for R7 dated 2/13/14 at 10:00 PM documents, "Taken after CNA (Certified Nursing Aide) reports resident self propelled wheelchair from entrance of room to the bedside, stood up, alarm sounded, didn't put brakes on and lowered self to floor rubbing back on wheelchair feet..." On 8/13/14 at 11:10 AM, E2/DON (Director of Nursing) verified there was no evidence that a fall investigation/analysis had been completed for R7's fall on 2/13/14 or that the care plan had been updated. E2/DON stated E2 does not update the resident care plans for falls, the Care Plan Coordinator updates the care plan. On 8/13/14 at 11:40 AM, E5/MDS (Minimum Data Set)/Care Plan Coordinator stated that E5 is not responsible for updating falls on the care plans, the Restorative Nurse is responsible for updating the falls on the care plans. On 8/13/14 at 12:20 PM, E12/Restorative Nurse stated that E12 is not responsible for updating falls on the care plans, the DON is responsible for updating the falls on the care plans. 3. Incident Accident Reports for R3, dated 8/14/13, 8/17/13, 1/13/14, 2/19/14, 3/27/14 and 5/2/14 documents R3's falls with interventions that were to be put into place for future fall prevention. An Incident/Accident Report for R3, dated 2/19/14, documents R3 is to wear non skid slipper socks as a fall intervention, but is not listed on R3's Fall Care Plan. The current care plan for R3, dated 7/7/14, does not include fall interventions for R3's falls on 8/14/13, 8/17/13, 1/3/14, 2/19/14, 3/27/14 and 5/2/14 which has resulted in repeated falls. On 8/11/14 through 8/13/14, R3 was sitting up in (R3's) wheelchair without non skid socks on and no hip protectors. On 8/13/14 at 1:45 pm, E2 DON/Director of Nursing stated (E2) is unsure why R3's fall interventions were not added to (R3's) Care Plan. 4. The Physician order [REDACTED]. The facility was unable to provide an incident report upon request. R4's Nurses Notes do not document R4's fall on 7/26/14. The current care plan for R4, dated 6/23/14 does not document R4's 7/26/14 fall and does not include new fall interventions. On 8/13/14 at 1:45 pm, E2 DON stated E2 is unsure why Nurse's Notes for R4 do not include documentation regarding R4's fall on 7/26/14 and unsure why the current care plan for R4 does not include fall care plan revisions. B. Based on observation, interview and record review, the facility failed to secure medications within a medication cart. This failure has the potential to affect two of 22 residents (R3 and R4) reviewed for safety in a sample of 22 and two residents (R38 and R39) on the supplemental sample. Findings include: On 8/12/14 at 9:10 AM, E17/LPN (Licensed Practical Nurse) prepared medications for R38 including: aspirin (blood thinner), amlodipine (blood pressure medication), zoloft (antidepressant), multivitamin, bupropion (antidepressant) and magnesium oxide (supplement). E17/LPN then left the cup of R38's medications, blister cards and bottles on the medication cart and walked down the resident hallway looking for R38, leaving the medication unattended and out of sight. The following residents were in close proximity of E17's medication cart: R3, R4 and R39. The MDS (Minimum Data Set) dated 6/17/14 for R3 documents a BIMS (Brief Interview for Mental Status) score of one indicating cognitive limitations. The MDS (Minimum Data Set) dated 6/11/14 for R4 documents a BIMS (Brief Interview for Mental Status) score of seven indicating cognitive limitations. The MDS (Minimum Data Set) dated 6/16/14 for R39 documents a BIMS (Brief Interview for Mental Status) score of five indicating cognitive limitations. The facility policy titled "Administration of Medications" dated 8/13 states, "The medication cart is kept in visual control. If unable to unable to maintain visual control, the cart must be locked. No medications are kept on top of the cart." On 8/13/14 at 11:10 AM, E2/DON verified that medication should be secured when not maintained in direct visual contact.

Based on record review and interview, the facility failed to provide adequate, safe and acceptable monitoring for one of five sampled residents (R5) reviewed for adequate supervision. The lack of monitoring resulted in an avoidable incident of another resident (R2) giving (R5) a donut with no staff intervention; and (R5) choking on it and being sent out emergently to the hospital. R5 was identified as having problems eating regular textured food. Findings include: On [DATE] at 7:05pm, R5 was noted to be coughing on a donut that R5 had received from a peer (later to be determined as R2). R5 coughed up and spit out the donut; the remainder of the donut was removed from R5's hand. Resident appeared fine with no distress noted. The Resident was given liquids which were tolerated well. Resident was taken to room by RN to access further. Upon entering room, resident became cyanotic. Code Blue called; 911 notified, according to the facility incident report form. The final report, (occurrence resolution) stated, resident admitted to LaGrange Hospital with [DIAGNOSES REDACTED]. On [DATE]th, resident's family decided to remove patient from ventilator. Resident expired at (Z5/hospital) on [DATE] th. The accompanying nurse's notes written by E16 (nurse) indicated the same information as above with additional details which were the liquids given to R5 was thickened and RN initiated Heimlich maneuver. The E11 (nurse) and E16 (nurse) were seated in the nurse's station when the incident occurred; the incident took place outside the nurse's station in the hallway. A review of the most recent Nutrition Assessment presented by the facility (annual) is dated [DATE] which indicated R5 had chewing problems. Minimum data Set (MDS) date [DATE], section K. swallowing/nutritional status depicts R5 receiving Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food. thickened liquids). The current physician order [REDACTED]. A review of (hospital records/Z5) Progress Notes page 36 of 483 states in part, the patient is a [AGE] year old with bipolar disorder and diabetes who was admitted from Z6 ( facility) on [DATE]. R5 was eating a donut when R5 choked and had a respiratory leading to cardiac arrest. Upon arrival to emergency room R5 was noted to have fixed and dilated pupils, not breathing over vent. R5 was placed on hypothermia protocol. The Medical Examiner/Coroner Certificate of Death stated, date of death is [DATE] and the cause of death part 1. a. Complications of Asthma b. Choking on Food Bolus. Review of a hand written interview dated ([DATE]) by E17 (nurse's aide) who is no longer employed by the facility is, "walk out of room 304. Look at resident, R5 were coughing informed the nurse. I (E17) was told to give R5 water, I (E17) did. R5 spit donut out of R5's mouth. R5 look ok A couple of seconds went by and we could tell something was still wrong with R5, so informed the nurse again." E4 (nurse aide) was interviewed on [DATE], at 4:50pm, about the choking incident involving R5. E4's written statement as written in part is, " I (E4) wasn't working on the third floor, was on the first floor. The two aides I (E4) know that were working on the third was E15 (nurse aide) and E17 (nurse aide). E11 (nurse) was interviewed via telephone on [DATE], at 11:03am, about the choking incident. E11's statement as stated in part is, "I (E11) don't work that often, but I (E11) do remember that they were giving R5 thick liquids in R5's cup. This usually means that person have difficulty swallowing. I (E11) was inside the nurse's station untill I (E11) came out for choking incident. No, I (E11) didn't see any resident with any donuts. The documentation was done by (E16) nurse who was R5's nurse for the day. I (E11) never saw R2 give R5 a donut until I (E11) went to R5 when someone said R5 was choking. E15 (nurse aide) said, R5 was choking, that's when I (E11) got up went over to R5. When R5 was in the hallway, R5 was trying to cough up whatever R5 had in R5's mouth." On [DATE] at 12:04pm, E16 (nurse) was interviewed via telephone about the incident. E 16' s' statement as stated in part is, "I (E16) was assigned to R5 on the day R5 choked. R5 should not have that donut because R5 was on a mechanical diet with nectar thick liquids. I (E16) was in the nurse's station with E11 (nurse), but I (E16) didn't see anyone give R5 a donut that's because the nurse's station counter is high and the medicine carts are on the corner. R5 was blocked by the counter top and medication carts. I (E16) am assuming R5 got the donut from another resident (R2)." [DATE] at 2:21pm, E13 (nurse's aide) was interviewed via telephone about the incident. E13's statement as stated in part is, "R2 has been known to try to give R5 regular water, R5 has to have thick water. We (staff) have actually had to stop R2 from trying to give R5 water is what I've (E13) seen. R5 was on a pureed diet. Myself (E13) and E15 (aide) was in the room with another resident. When we (E13 and E15) made it back to the nurses station, R5 was already choking. One of the other nurse's aide (E17) alerted the nurses that R5 was choking. E11 (nurse) and E16 (nurse) were in the nurse's station, E11 came out. R5 was not far from the room, but there were medication carts there. So, maybe, that's why they (E11 and E16) didn't see." E15 (nurse's aide) was interviewed on [DATE] at 3:34pm about the same choking incident. E15's written statement in part is, "I (E15) was walking out of my (E15's) room and I (E15) seen R5 in R5's wheelchair and R5 was eating a cake donut. Me (E15) and my (E15) co-workers realized R5 was choking. So, the nurse informed my co-worker (E17) to give R5 some water, so, E17 gave R5 some thickened water from the nurse cart." On [DATE] at 10:38am, Z2 (physician) was interviewed via telephone about the incident. Z2 stated, "It's possible that if the circumstances described that R5 ate a donut, then choked on the donut. If that fact is certain, it's ascertain to be true. Then it's possible the donut caused respiratory deterioration. As a physician, we like to keep our differential [DIAGNOSES REDACTED]."

Based on record review, interview and observation the facility failed to develop, implement, monitor, modify and care plan for pain management interventions for two residents (R11 and R6) who were exhibiting and verbalizing signs of pain. The facility also failed to have pain management protocols to guide and educate staff in the proper evaluation and management of pain. This applies to two of 10 residents with pain in the sample of 24 This failure resulted in R11 experiencing severe levels of pain (8/10) and recurrent [MEDICAL CONDITION] and R6 not getting out of bed due to fear of experiencing pain. The findings include: Review of most recent full MDS (minimum data set) dated 5/2/13 shows that R11 is [AGE] years old and requires extensive physical assist with all activities of daily living. R11 was observed to be lying in bed on her right side in a fetal position 7/23/13 at 10:15 am. Both hands were clenched closed and all fingers curled and deformed. R11 stated during interview that she was having a lot of pain in the right shoulder that she was laying on and also in her hips. R11 stated the pain is very unpleasant and she often cannot help it when she screams out in pain when staff attempt to move her because she knows it is going to hurt. R11 states she hates to get out of bed because the pain is so bad and she only gets up once or twice a week now. R11 stated that her pain is usually around 8 on a scale of 10, with 10 being the worst. R11 said her pain keeps her up at night. When asked what measures are taken to manage her pain, R11 stated she takes 1 [MEDICATION NAME] every 8 hours and is afraid of becoming addicted. R11 said the [MEDICATION NAME] does not do much for her and she has been thinking of trying pot, having heard that it can be very effective for some types of pain. During the entire interview, R11 was observed to be grimacing and making small adjustments to her positioning in an attempt to relieve the areas of pain to her shoulder and hips. On 7/24/13 at 12:20pm, E5 (nurse's aide) entered R11's room to feed her lunch. E5 stated R11 is unable to feed herself because of her pain and hand contractures. E5 proceeded to raise R11's head using the bed control. As she did, R11 pleaded for E5 to stop because it was hurting her hips even though E5 did not even raise R11's head to a 45 degree angle. E5 stated that (E5) has fed R11 her meals for the past year and that " every movement we do for her (R11) is painful. " Prior to having dressing change to her wounds on 7/24/13 at 1:30pm, R11 stated " This is going to hurt. My skin even hurts. When anyone bumps me it hurts and then I yell. It's miserable. I try to be pleasant so people will come around. They don't like it when I yell. It makes them nervous and afraid and then they don't want to take care of me. They think I'm mean and I don't need to yell but I do. It relieves the pain a little. " R11 stated E6 (wound and restorative nurse) had recently told her if she yells out during the treatment they will have to stop the procedure. E6 entered the room to perform the wound treatments and when asked why she (E6) thinks R11 yells during care, E6 stated it is because R11 anticipates pain even before anyone touches her and that R11 has [MEDICAL CONDITION] arthritis and receives [MEDICATION NAME] every 8 hours and Tylenol in between. Upon review of the current MAR (medication administration record) for July/ 2013, it shows R11 has been administered Tylenol 2 tabs, one time during the month of July on 7/24/13, shortly before the dressing change was being observed. When asked if any other interventions to manage R11's pain have been attempted including non-pharmacological measures, E6 stated, "No, but we are open for suggestions. " Review of R11's pain flow sheet located in the MAR book was totally blank. This form is for documenting pain intensity, pain statements, action taken, side effects and results of medication, including effects on physical or social function. Review of Pain Screening Form with quarterly assessments dated 10/10/12, 11/13/12, 12/20/12, 2/2/13 and 5/2/13 are inaccurate: #4 shows R11 assessed for effectiveness of pain meds to be effective and #8 shows no observations of pain for R11. It is unclear how this could be accurate as multiple direct care staff stated (as referenced above) R11 is in pain most of the time and even screams out in pain. The total score is 5, with the instructions stating " Score 5 or greater indicates comprehensive assessment needed. " A Comprehensive Pain Assessment form was located in the medical record but was totally blank. E2 (Director of Nursing) states there had not been a comprehensive pain assessment completed for R11. Review of R11's pain care plan is not specific or individualized to R11's pain issues. E4 (MDS/care plan) on interview stated on 7/25/13 at 10:30am, R11 did not trigger for pain on the MDS and therefore she (E4) does not write a specific and individualized pain care plan. 2. R6 was observed on 7/23/13 at 12:45 PM to be lying in bed with her lunch on the table positioned over her. R6 was observed to be in a bariatric bed and states she does not get up for meals usually because she is too tired. After further discussion, R6 stated during interview she does not like to get up at all because it is too painful for her and that she would like to take an axe and chop off her left leg at times, from her hip to her toes. R6 then asked if surveyor could get a pillow for under her left knee. R6 was observed to be transferred via total body lift with E5 and E6 present along with E2 on 7/26/13 at 1:50pm. R6 yelled and displayed signs of pain as she was being transferred, complaining her left leg and knee were painful when being touched or moved. E8 (nurse's aide) stated, on 7/24/13 at 12:20pm, R6 has been refusing to get up for at least the past several weeks, saying that everything hurts, especially her left leg and hip. E12 (nurse's aide) stated, on 7/25/13 at 10:10am, that R6 complains of pain to her left leg and hip when ADL's are performed while R6 remains in bed. E6 stated she was not aware R6 verbalized pain as one of the reasons given for refusing to get out of bed. Review of Pain Screening Form with dated 12/20/12, 3/18/13 and 6/11/13 are inaccurate: #4 shows R6 assessed for effectiveness of pain meds to be effective and #5 shows no frequency of pain for R6. It is unclear how this could be accurate as multiple direct care staff stated (as referenced above) R6 experiences pain with movement. R6's care plan dated 6/11/3 states R6 yells out in pain during transfers but offers no specific interventions or measurable goals. E4 (MDS/care plan ) stated on 7/25/13 at 10:30am that R6 did not trigger for pain on the MDS and therefore she (E4) does not write a specific and individualized pain care plan. E1 (Administrator) and E2 (Director of Nursing) stated on 7/24/13 at 3:15pm the facility does not have pain protocols or policy and procedures to guide and educate staff in the proper evaluation and management of pain.