Every finding on record at Ledgewood Rehabilitation and Nursing Center

Based on observations, record reviews, and interviews, the facility failed to ensure residents admitted with an indwelling catheter were assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated continued catheter use is necessary, for one Resident (#110) out of a total sample of 23 residents. Findings include:According to the Resident Assessment Instrument (RAI- a manual used to for the guidance for the Minimum Data Set assessment, which is required by the Centers for Medicare and Medicaid recipients in skilled nursing facilities): -Indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of an indwelling catheter, the anticipated duration of use, and consideration of complications resulting from the use of an indwelling catheter. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding. Resident #110 was readmitted to the facility in July 2026 with diagnoses that included dementia and a left femur fracture. Review of Resident #110's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident had severe cognitive impairment. The MDS further indicated that the Resident was frequently incontinent and required maximum assist for toileting transfers. On 7/7/26 at 7:30 A.M., 7/7/26 at 1:01 P.M., and 7/8/26 at 6:42 A.M., the surveyor observed Resident #110 in bed with a catheter bag hanging on the side of the bed. Review of the physician's order, dated 7/2/26, indicated: Foley catheter #16 with 10 mL (milliliter) balloon. Review of Resident #110's plan of care related to catheter use, updated 7/3/26, indicated: Has an indwelling foley catheter related to surgery. Review of Resident #110's medical history and diagnosis lists failed to indicate a diagnosis for the continued need for a catheter. Review of Resident #110's medical record indicated that he/she was hospitalized from [DATE]-[DATE]. The hospital paperwork, dated 7/2/26, failed to indicate the reason the catheter was inserted or a plan for removal. During an interview on 7/9/26 at 8:20 A.M., Unit Manager #1 said a resident admitted with a catheter should have a voiding trial to establish if he/she is able to void without a catheter and then if he/she is unable to void, he/she should have a follow up with urology. Unit Manager #1 said that if the resident has a need for a chronic catheter, there should be an approved diagnosis documented. She said that the risk of continued use of a catheter is developing a urinary tract infection. Unit Manager #1 also said that sometimes if a resident is receiving hospice services, they will recommend leaving the catheter in place related to the resident having limited mobility, but that she would expect that to be documented and included in a progress note and/or care plan. During an interview on 7/9/26 at 10:05 A.M., the Director of Nursing (DON) said if a resident is admitted or readmitted with a catheter, she/he should have an order to have a voiding trial; if unsuccessful, then the resident would need to have an order to follow up with urology. The DON said if a resident has a chronic indwelling foley catheter, then there should be an approved diagnosis. The DON said that sometimes, if the resident is a hospice patient, hospice prefers to keep the catheter in for comfort, but she would expect documentation to be in place to support this decision. During an interview on 7/10/26 at 9:16 A.M., the DON said she did not know why Resident #110 had a catheter inserted in the hospital and that there had not been any plan since his/her return to have it removed; Resident #110 is now on hospice and if they had wanted him/her to keep the catheter in place then she would have expected that to be documented.

Based on observations, record review, and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice for three Residents (#9, #38, and #15) out of a total sample of 23 residents. Specifically, the facility failed to: 1.Ensure Resident #9's oxygen administration included humidification in accordance with the medical plan of care. 2a. Ensure Resident #38's nebulizer equipment was changed in a timely manner. 2b. Ensure Resident #15's nebulizer equipment was cleaned, bagged, and dated. Findings include: 1. For Resident #9, the facility failed to ensure the administration of oxygen included humidification in accordance with the medical plan of care. (An oxygen humidifier adds moisture to supplemental oxygen, preventing dryness and irritation in the respiratory tract during oxygen therapy). Review of the facility policy titled Respiratory Equipment, dated August 2017, included but was not limited to the following: Policy: 8. Oxygen therapy is administered only on order of the physician. 10. Physician's order shall include liters of flow and vehicle of administration. 18. Oxygen delivery devices (i.e. mask, nasal cannula) and humidifier bottles should be used when indicated. 19. Be sure there is water in the humidifying jar and that the water level is high enough the water bubbles as oxygen flows through. 20. Periodically re-check water level in humidifying jar. Resident #9 was admitted to the facility in April 2026 with diagnoses that include but are not limited to chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypercapnia (elevated carbon dioxide in the blood). Review of the most recent Minimum Data Set assessment, dated 6/4/26, indicated Resident #9 scored a 15 out of 15 on the Brief Interview for Mental Status exam, signifying he/she as cognitively intact, requires substantial/maximal assistance for daily care, is receiving hospice services and respiratory treatment including oxygen therapy. On 7/7/26 8:35 A.M., the surveyor observed Resident #9 with his/her eyes closed in bed with a nasal cannula administering oxygen from a concentrator. Review of Resident #9's medical record indicated the following active physician's orders: -Change oxygen tubing, change O2 (oxygen) humidification bottle as applicable and clean filter (wash, rinse, pat dry filter) and change storage bag every week every night shift every Tue. (Tuesday), dated 4/27/26. -Check humidification level q (every) each shift on oxygen concentrator change when low every shift, dated 5/1/26. -Titrate O2 1-3 liters via NC (nasal canula) to maintain 02 sats 85-92% every shift, dated 4/30/26. Review of Resident #9's care plans indicated the following: -Care plan focus: Resident has emphysema/COPD r/t (related to) smoking date 4/28/26. Goal: Resident will display optimal breathing patterns daily through review date 9/16/26. Review of interventions failed to indicate Resident #9 uses supplemental oxygen with humidification. On 7/8/26 at 10:31 A.M., the surveyor observed Resident #9 in bed wearing a nasal cannula administering oxygen from an oxygen concentrator next to his/her bed. The oxygen concentrator was not equipped, nor was it administering humidification. On 7/8/26 at 12:38 P.M., the surveyor observed Resident #9 sitting up wearing a nasal cannula administering 3 liters of oxygen. The oxygen concentrator was not equipped, nor was it administering humidification. On 7/8/26 at 3:32 P.M., the surveyor observed Resident #9 up in his/her chair wearing a nasal cannula administering 3 liters of oxygen. The oxygen concentrator next to Resident #9's bed was not in his/her view. Resident #9 said he/she uses CPAP (continuous positive airway pressure) at night and oxygen during the day and that humidification is used. The oxygen concentrator was not equipped with humidification. On 7/8/26 at 4:48 P.M., the surveyor observed Resident #9 wearing a nasal cannula administering oxygen. The oxygen concentrator was not equipped with a humidification bottle. On 7/9/26 at 6:54 A.M., the surveyor observed Resident #9 in bed wearing a nasal cannula administering oxygen. The oxygen concentrator was not equipped with a humidification bottle. Review of the Medication Administration Record (MAR) dated for July 2026 indicated the order to change oxygen tubing, change O2 humidification bottle as applicable was signed off as completed on 7/7/26. Further, the MAR indicated Resident #9's O2 saturation rate was 92% and was administered oxygen at 3 liters on the 7/7/26 day shift, O2 saturation rate was 90% and was administered oxygen at 3 liters on the 7/7/26 evening shift, and O2 saturation rate was 92% and was administered oxygen at 2 liters on the night shift 7/7/26-7/8/26. During an interview on 7/9/26 at 7:02 A.M., Nurse #4 said Resident #9 is on oxygen therapy for COPD, and the nursing staff monitor his/her oxygen saturation rate to be within the range per the physician's orders. Nurse #4 said that humidification is an added therapy and used for residents with COPD. Nurse #4 reviewed Resident #9's physician's orders and said the humidification should be provided as ordered. Nurse #4 and the surveyor went to Resident #9's room and Nurse #4 said there was no humidification being administered to Resident #9. During an interview with on 7/9/26 at approximately 7:05 A.M., Unit Manager #2 said the physician's order for humidification for Resident #9's oxygen should be provided. Unit Manager #2 and Nurse #4 proceeded to look in the unit storage area for the needed supplies and Unit Manager #2 said they would need to get the 'tree' adapter for the humidification bottle. 2a. Review of the facility policy titled Respiratory Equipment, dated August 2017, indicated the following: -Purpose: To prevent the transmission of infection associated with respiratory therapy tasks and equipment. -Policy: Disposable cannulas, masks and tubing is used. Change every 7 days, or as needed. Keep PRN (as needed) tubing and equipment in plastic when not in use. >Nebulizers should be rinsed and dried after each use. Wipe mouthpiece with a damp gauze or paper towel. Save the equipment in clean plastic bag between treatments. Discard the administration set every 7 days. Resident #38 was admitted to the facility in June 2026 with diagnoses including interstitial pulmonary lung disease (a progressive lung disease that causes inflammation and/or scarring), congestive heart failure, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/28/26, indicated that Resident #38 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, and required assistance with activities of daily living. On 7/7/26 at 11:01 A.M., the surveyor observed Resident #38 lying in bed. A nebulizer was located on the bedside table; the tubing was dated 6/23/26 and the mouthpiece was hanging on the wall inside a clear plastic bag that was undated. On 7/7/26 at 2:43 P.M., the surveyor observed Resident #38 lying in bed. Resident #38 said he/she has trouble with breathing and needs to use the nebulizer regularly. The Resident said he/she last used the nebulizer yesterday, 7/6/26. A nebulizer was located on the bedside table; the tubing was dated 6/23/26 and the mouthpiece was hanging on the wall inside a clear plastic bag that was undated. During an interview on 7/8/26 at 11:49 A.M., Resident Representative #2 said he/she visits the Resident #38 daily. Resident Representative #2 said the Resident uses a nebulizer regularly for difficulty breathing, but has not seen staff change the nebulizer equipment since his/her admission. Review of Resident #38's physician orders indicated the following: -Ipratropium Bromide Inhalation Solution 0.02%, 2.5 milliliters inhale orally via nebulizer every 6 hours as needed for wheezing or dyspnea; start date 6/22/26, discontinued 7/5/26. -Ipratropium Bromide Inhalation Solution 0.02%, 2.5 milliliters inhale orally via nebulizer three times a day for wheezing; start date 7/5/26. -DuoNeb Solution 0.5-2.5 (3) milligrams/3 milliliters (Ipratropium-Albuterol), 1 application inhale orally every 6 hours as needed for SOB (shortness of breath)/wheeze; start date 7/8/26. Review of the nursing progress note, dated 6/23/26, indicated Resident #38 received a PRN (as needed) neb (nebulizer) tx (treatment) with good effect. Review of Resident #38's Medication Administration Record (MAR) for July 2026 indicated the Resident received nebulizer treatments on the following days, or a total of nine times since 6/23/26: -7/4/26 at 3:49 P.M. (PRN) -7/5/26 at 2 P.M. and 8 P.M. -7/6/26 at 8 A.M., 2 P.M., and 8 P.M. -7/7/26 at 8 A.M., 2 P.M., and 8 P.M. Further review of the medical record failed to indicate physician orders were in place to change/date the nebulizer equipment. During an interview on 7/8/26 at 11:54 A.M., Nurse #2 said Resident #38 receives both standing and PRN nebulizer treatments for wheezing. Nurse #2 said nursing is responsible for maintaining nebulizer equipment, including changing the tubing, but she was unsure how often it needs to be changed. During an interview on 7/8/26 at 12:13 P.M., Nurse #3 said Resident #38 receives both standing and PRN nebulizer treatments. Nurse #3 said nursing is responsible for maintaining nebulizer equipment, including changing the tubing. Nurse #3 said nebulizer equipment should be changed weekly and there should be a physician's order. Nurse #3 said Resident #38's nebulizer equipment should have been changed weekly but was not, and there should have been a physician's order in place to change/date the nebulizer equipment. During an interview on 7/8/26 at 12:18 P.M., the Director of Nursing (DON) said nursing is responsible for maintaining nebulizer equipment, including changing the tubing. The DON said nebulizer equipment should be changed weekly and there should be a physician's order. The DON said Resident #38's nebulizer equipment should have been changed on 6/30/26 but was not, and there should have been a physician's order in place to change/date the nebulizer equipment. 2b. Resident #15 was admitted in May 2023 with diagnoses including, acute bronchitis, morbid severe obesity due to excess calories, essential primary hypertension and anxiety. Review of Resident #15's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had no cognitive impairment. On 7/7/26 at 8:52 A.M., the surveyor observed Resident #15 sitting up in a chair in his/her room. A nebulizer was located on the bedside table. The mouthpiece and tubing were undated and placed directly on top of the bedside table. On 7/7/26 at 10:52 A.M., the surveyor observed Resident #15 sitting up in a chair in his/her room. A nebulizer was located on the bedside table. The mouthpiece and tubing were undated and placed directly on top of the bedside table. On 7/8/26 at 7:13 A.M., the surveyor observed Resident #15 sitting up in a chair in his/her room. A nebulizer was located on bedside table. The mouthpiece and tubing were undated and placed directly on top of the bedside table. During an observation and interview on 7/8/26 at 11:43 A.M., the surveyor observed Resident #15 sitting up in a chair in his/her room. The nebulizer was now dated 7/7/26 and placed in a bag inside the Resident's bedside table. Resident #15 said someone came in and placed the nebulizer in the bag, but he/she was not sure why. During an interview on 7/9/26 at 10:29 A.M., Resident #15 was sitting up in a chair in his/her room. Resident Representative #1 said Resident #15 is still using his/her nebulizer daily because he/she still has shortness of breath but is getting better. Review of Resident #15's active physician orders indicated the following: -DuoNeb Solution 0.5-2.5 (3) MG/3ML (Ipratropium- Albuterol) 1 vial inhale orally three times a day for cough for 5 Days. Start Date 7/1/26. -DuoNeb Solution 0.5-2.5 (3) MG/3ML (Ipratropium- Albuterol) 1 vial inhale orally every 6 hours as needed for SOB (shortness of breath), wheezing for 3 Days. Start Date: 6/29/26. Further review of the medical record failed to indicate physician orders were in place to change/date the nebulizer tubing. Review of Resident #15's medical record including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of July 2026 indicated Resident #15 received the medication as ordered. During an interview on 7/8/26 /26 at 10:30 A.M., Nurse #1 said the nebulizer mouthpiece and tubing should be changed and dated weekly. Nurse #1 reviewed Resident #15's physician orders and said he/she does not have any orders in place and said staff should be changing the tubing weekly and rinsing the equipment after each use. Nurse #2 said respiratory equipment must be labeled, dated and stored in a bag. Nurse #1 said Resident #15 is using the nebulizer daily for shortness of breath. During an interview on 7/9/26 at 10:32 A.M., Unit Manager #1 said orders must be in place for changing and dating the nebulizer tubing and said staff must be cleaning and storing the nebulizer tubing and mouthpiece appropriately. During an interview on 7/9/26 at 11:07 A.M., the Director of Nursing said respiratory equipment must have orders in place and for cleaning and storage and said the nebulizer mouthpiece must be rinsed after use, the tubing must be changed weekly, and the equipment must be dated and stored in a bag. The DON said Resident #15's nebulizer orders fell off the MAR and said Resident #15 receives nebulizer treatments daily and should have orders in place for administration, cleaning and storage.

Based on observation, record review and interview, the facility failed to ensure residents were treated with dignity on one resident care unit, out of three units. Specifically, three Certified Nursing Assistants (CNAs) wore earbuds (a small headphone worn inside the ear) while providing care to residents. Findings include: Review of the facility policy titled 'Quality of Life-Dignity,' version 9/2025, indicates: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Residents shall be treated with dignity and respect at all times. On 7/8/26 the surveyor made the following observations on the Farms Unit: -At 6:56 A.M., Certified Nursing Assistant (CNA) #4 exited a room occupied by two residents. The surveyor observed CNA #4 with an earbud in one ear. A resident in the room said the CNA had emptied his/her bag (urinary drainage bag). During an interview on 7/8/26 at 7:00 A.M., CNA #4 said she worked the 11:00 P.M.-7:00 A.M. shift. CNA #4 said she should not be wearing an earbud and had it on because she is in school and does work during the night. CNA #4 said she had the earbud in when she started changing residents around 5:30 A.M. -At 3:36 P.M., CNA #5 had an earbud in one of her ears while standing behind the nursing desk, facing the resident 'lounge.' At 3:38 P.M., she walked into the resident lounge, spoke to a resident, then pushed the resident's wheelchair to the nearby bathroom and entered the bathroom with the resident, while wearing an earbud in one ear. -At 4:58 P. M., CNA #5 and CNA #6 were in the hallway, both wearing an earbud in one ear. When the meal truck arrived, the nurse on the unit passed a tray to CNA #5, who then entered a resident room, set up the tray for the resident, and then exited the room. The nurse then passed CNA #6 a meal tray and she entered a resident room and left the meal tray with a resident. During an interview on 7/9/26 at 7:25 A.M., CNA #2 said staff are not supposed to use cell phones, and he thinks it would include earbuds too. CNA #2 said if someone is using an earbud then they are not truly present with the resident. During an interview on 7/9/26 at 7:30 A.M., CNA #3 said staff should not use earbuds around residents because you need to hear the residents and focus on the resident. During an interview on 7/9/26 at 9:03 A.M., the Administrator said staff should not be wearing earbuds when providing care to residents.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), whose comprehensive plan of care indicated interventions included that he/she required two staff member assistance with use of the Hoyer lift for all transfers, the Facility failed to ensure staff consistently implemented and followed his/her comprehensive plan of care, when staff transferred him/her without the assistance of another staff member.Findings include:The Facility Policy, titled Comprehensive Person-Centered Care Plan, dated as reviewed 09/2024, indicated the comprehensive, person-centered care plan would describe the services that would be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being.The Facility Policy, titled Mechanical Lift, dated as reviewed 09/2024, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift.A Hoyer Lift is a device that allows caregivers to safely transfer an individual between a bed, wheelchair, shower chair, or another surface. A sling lift is comprised of a base on casters, a boom, and a cradle that supports the sling.Resident #1 was admitted to the Facility in October 2022, diagnoses included dementia, anxiety, and adult failure to thrive.Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her quarterly Minimum Data Set (MDS) assessment on 06/18/25, indicated he/she required full mechanical lift transfers with two person assist (date initiated 11/10/2022).Review of Resident #1's handwritten individualized resident Care Card indicated he/she required two or more staff member assistance using the Hoyer Lift for all transfers.Review of the Report submitted by the Facility via the Health Care Facilities Report System (HCFRS) Report, dated 07/18/25, indicated that during an incident investigation, Certified Nurse Aide (CNA) #1 and CNA #2 reported that they had each independently transferred Resident #1 using the Hoyer Lift.During a telephone interview on 08/06/25 at 11:53 A.M., Certified Nurse Aide (CNA) #1 said that on 07/12/25 and 07/13/25 she transferred Resident #1 using the Hoyer Lift without assistance from any other staff member, and said she had transferred Resident #1 using the Hoyer Lift on other occasions (exact dates unknown) without the assistance of any other staff member. CNA #1 said she knew it was the Facility's policy that all Hoyer Lift transfers required two or more staff members for the safety of the resident, and said she knew Resident #1's plan of care included two staff members for all transfers, using the Hoyer Lift.During an interview on 08/05/25 at 12:08 P.M., CNA #2 said that on 07/11/25, and on other occasions (exact dates unknown), she transferred Resident #1 using the Hoyer Lift without assistance from any other staff member. CNA #2 said she knew she wasn't supposed to transfer using the Hoyer Lift without assistance from another staff member, and said she knew Resident #1's plan of care included that he/she required two staff members assistance with Hoyer Lift transfers.During an interview on 08/05/25, the Regional Clinical Consultant Nurse, who was filling in for the Director of Nurses, said CNA #1 and CNA #2 should have had a second staff member to assist with all Hoyer Lift transfers, per Facility policy and Resident #1's Plan of Care and Care Card, but did not.On 08/05/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 08/03/25, which addressed the areas of concern as evidenced by:A. 07/18/25, The Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, and ensure that residents who required two staff members assistance with Hoyer Lift transfers were provided the necessary level of assistance by staff.B. 07/18/25, The Facility Nursing staff conducted skin assessments and pain assessments on all residents whose transfer status required use of the Hoyer Lift.C. 07/18/25, Director of Nurses (DON)/designee began daily random audits of Hoyer Lift transfers to ensure two staff members were present. Audits will be ongoing daily on the 07:00 A.M., to 03:00 P.M., and 03:00 P.M., to 11:00 P.M. shifts for 30 days.D. 07/30/25, The Assistant Director of Nurses (ADON)/designee educated all licensed staff, CNAs, and therapy staff of the Facility policy and the requirement to always have two staff members present for all mechanical sling lift transfers.E. 08/03/25, The Assistant Director of Nurses (ADON)/designee conducted Hoyer Lift and gait belt transfer competencies with all CNAs which included review of the Care Card to determine how to safely transfer the resident and to get assistance as needed. F. The DON/designee will present the results of the daily Hoyer Lift transfer audits to the monthly Quality Assurance meeting, at which time further actions will be determined.G. The DON/designee are responsible for ongoing compliance.

Based on records reviewed and interviews, the Facility failed to ensure that Certified Nurse Aide (CNA) #1 had completed competency training prior to use of the Hoyer Lift for resident transfers.Findings include:The Facility Policy, titled Mechanical Lift, dated as reviewed 09/2024, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift, and staff must be trained in and demonstrate competency in the use of lift devices.A Hoyer Lift is a device that allows caregivers to safely transfer an individual between a bed, wheelchair, shower chair, or another surface. A sling lift is comprised of a base on casters, a boom, and a cradle that supports the sling.Review of The US Department of Labor Wage and Hour Division Fact Sheet #52, Hazardous Order No. 7 prohibits minors under 18 from operating or assisting in the operation of power-driven hoists, including those designed to lift and move patients. The Wage and Hour Division has, however, adopted an enforcement position effective July 13, 2011, that allows certain properly trained 16- and [AGE] year-old nursing aides or nursing assistants, to assist trained adults in the operation of certain power-driven patient/resident hoists/lifts under certain conditions. Review of Certified Nurse Aide (CNA) #1's Certified Assistant Competency and Education Check off list, completed upon hire, dated 04/17/24, indicated she was under [AGE] years of age at the time of her orientation, and where her preceptor would have dated and signed off that she was competent for the use of the Hoyer Lift, a line was drawn.Additionally, further review of CNA #1's Personnel File indicated there was no documentation to indicate that she had any further training or competencies for the use of the Hoyer Lift.During a telephone interview on 08/06/25 at 11:53 A.M., Certified Nurse Aide (CNA) #1 said she had assisted with Hoyer Lift transfers regularly throughout her employment at the Facility, and said she turned 18 in April 2025, but had not had any further training or competencies on the use of the Hoyer Lift for resident transfers. CNA #1 said she was never formally trained on how to use the Hoyer Lift controls, but had used them.During an interview on 08/05/25 at 01:47 P.M., the Assistant Director of Nurses (ADON) said upon hire, CNA #1 was under 18 and therefore, (per Facility protocol) was not permitted to work the controls for the Hoyer Lift, but was permitted to act as an assistant with Hoyer Lift transfers along with a trained staff member who was 18 or over. The ADON said CNA #1 should have been oriented to and been signed off as competent for assisting with Hoyer Lift transfers upon hire, and once she turned 18 should have completed another competency for the use of the Hoyer Lift controls, but had not.On 08/05/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 08/03/25, which addressed the areas of concern as evidenced by:A. 07/18/25, The Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, and ensure that residents who required two staff members assistance with Hoyer Lift transfers were provided the necessary level of assistance by staff.B. 07/18/25, The Facility Nursing staff conducted skin assessments and pain assessments on all residents whose transfer status required use of the Hoyer Lift.C. 07/18/25, Director of Nurses (DON)/designee began daily random audits of Hoyer Lift transfers to ensure two staff members were present. Audits will be ongoing daily on the 07:00 A.M., to 03:00 P.M., and 03:00 P.M., to 11:00 P.M. shifts for 30 days.D. 07/30/25, The Assistant Director of Nurses (ADON)/designee educated all licensed staff, CNAs, and therapy staff of the Facility policy and the requirement to always have two staff members present for all mechanical sling lift transfers.E. 08/03/25, The Assistant Director of Nurses (ADON)/designee conducted Hoyer Lift and gait belt transfer competencies with all CNAs which included review of the Care Card to determine how to safely transfer the resident and to get assistance as needed.F. The DON/designee will present the results of the daily Hoyer Lift transfer audits to the monthly Quality Assurance meeting, at which time further actions will be determined.G. The DON/designee are responsible for ongoing compliance.

Based on record reviews and interviews, for one of three sampled residents (Resident #1), who was totally dependent on staff for his/her Activities of Daily Living (ADL) care needs, the Facility failed to ensure staff consistently provided necessary services to meet his/her ADL care needs, when on 5/16/25 Resident #1's request to nursing for care during the evening shift were not met and he/she was not provide care until the next morning. Findings include: Review of the Facility's Care and Treatment for ADL Care Policy, dated September 2024, indicated ADLs are provided in accordance with resident preference and needs. The Policy indicated that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, oral care), mobility, and toileting. Review of Resident #1's clinical record indicated diagnoses included morbid obesity, Type 2 Diabetes with Polyneuropathy, and Acquired Absence of Right Leg Below Knee. Review of Resident #1's Care Plan Report, updated on 04/15/25, indicated he/she had self care and mobility deficits related to muscle weakness and activity intolerance. The Care Plan Report indicated he/she was nonambulatory, required a two person assist with a mechanical lift for transfers, was dependent for bathing needs, required an assist of two for repositioning in bed, dependent for use of bedpan and incontinent care, and to provide a sponge bath when full bath not tolerated. Review of Resident #1's Resident Profile (CNA care plan), dated 04/22/25, indicated Resident #1 did not ambulate, required a mechanical lift with two or more staff for transfers, was incontinent of bladder and bowel, and was totally dependent with a two person assist for bathing, grooming, positioning and toileting. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/24/25, indicated he/she was dependent on staff for personal hygiene, toilet hygiene, bathing, upper body dressing, and lower body dressing. The MDS indicated he/she had intact cognitive functioning and was frequently incontinent of bladder and bowel. During an interview on 06/17/25 at 11:45 A.M., Resident #1 said there was a day recently (exact date unknown) that around 11:00 P.M., he/she had been incontinent and requested staff to provide care. Resident #1 said CNA #1 told him/her that there was no other staff member there to assist him (CNA #1) to provide his/her care, and that he (CNA #1) needed to wait for the other CNA to come on the unit. Resident #1 said he/she had been incontinent of bowel and remained in bed without incontinence care for a total of nine hours until the 7:00 A.M. shift CNA arrived. During a telephone interview on 06/23/25 at 12:50 P.M., Nurse #1 said around 9:00 P.M. on 05/16/25, Resident #1, who was lying in bed, asked for assistance. Nurse #1 said Resident #1 did not specifically request incontinent care, but asked for assistance to get ready for bed for the night. Nurse #1 said she reminded Resident #1 that his/her assigned CNA had offered to provide care before she left at 9:00 P.M. Nurse #1 said she told Resident #1 that she would try to find assistance for Resident #1 from another CNA, and if they were unable, he/she would receive care from the CNAs that arrive at 11:00 P.M. for the evening (11:00 P.M. to 7:00 A.M.) shift. Nurse #1 said at the time of Resident #1's request, the CNA on the side of the unit she had been working on was assisting another resident, and that she did not know what the other CNA on the unit was doing. Nurse #1 said Resident #1 did not receive care prior to the end of her shift (11:00 P.M.) that night. Nurse #1 said when Nurse #2 arrived for the start of his shift (at 11:00 P.M.), she told Nurse #2 that they had not been able to provide care to Resident #1 on the last part of their shift (from 9:00 P.M. to 11:00 P.M.) and that he/she needed care. Nurse #1 said Resident #1 should not have had to wait until the next shift for care. Nurse #1 said she should have ensured Resident #1 received care after his/her request by either assisting an available CNA herself or asking the other Nurse working on the unit to help her. During a telephone interview on 06/23/25 at 9:10 A.M., Nurse #2 said he told CNA #1 that based on the change of shift report he received, Resident #1 had not received care as requested on the preceding shift and that they needed to provide it. Nurse #2 said since Resident #1 was incontinent of bowel, he assumed the care he/she had requested after 9:00 P.M. was for bowel incontinence. Nurse #2 said Resident #1 required a two person assist with care in bed. Nurse #2 said two CNAs were scheduled for the night shift (on 5/16/25 from 11:00 P.M. into 5/17/25 until 7 :00 A.M.) that night, however one CNA did not report to work as scheduled. Nurse #2 said at no time during the shift did CNA #1 indicate that he/she needed assistance to care for Resident #1. Nurse #2 said he assumed CNA #1 went to another unit to obtained assistance from a CNA for Resident #1 and that Resident #1 had received care. Nurse #2 said a CNA from another unit was sent to his unit to assist with care around 5:00 A.M. that day. Nurse #2 said he had provided Resident #1 with drinks during the shift and administered him/her medication at 6:00 A.M., and that Resident #1 never said he/she was still waiting for staff to provide care. During a telephone interview on 06/23/25 at 12:00 P.M., CNA #1 said upon his arrival to the unit at 11:00 P.M. on 05/16/25, Nurse #2 told him Resident #1 had not received care during the preceding shift. CNA #1 said at the start of the shift Resident #1 rang his/her call light, and asked him for incontinent care. CNA #1 said he told Resident #1 that he was waiting for the other CNA to arrive to provide assistance. CNA #1 said he told Nurse #2 around 11:15 P.M. and again at 12:00 A.M. that the other CNA scheduled had not come to work on the unit, and that Nurse #2 told him to wait until someone arrived. CNA #1 said at around 5:00 A.M. a CNA from another unit came to provide assistance with resident care on the unit. CNA #1 said Resident #1's care needs were not provided before the 7:00 A.M. shift arrived. During a telephone interview on 06/17/25 at 3:05 P.M., Nurse #3 said she was scheduled for the day shift (7:00 A.M. to 3:00 P.M.) on 05/17/25. Nurse #3 said at around 8:00 A.M. she responded to Resident #1's call bell light, and Resident #1 stated he/she had been waiting since 11:00 P.M. to be changed but no one came to his/her room. Nurse #3 said with Resident #1's bed sheet pulled down, she could see that he/she had a bowel movement. Nurse #3 said she immediately coordinated care for Resident #1. During a telephone interview on 06/11/25 at 2:50 P.M., CNA #2 said at around 8:00 A.M. on 05/17/25 Resident #1 told her that he/she had a bowel movement, the previous night, had been waiting to be changed and asked her to provide care. CNA #2 said Nurse #3 was made aware and care was immediately provided. CNA #2 said the stool on Resident #1 was dry in appearance, like it had been there for many hours. During an interview on 06/11/25 at 2:00 P.M., the Director of Nurses (DON) said staff should ask a resident specifically what care is needed to determine if additional assistance is needed. The DON said Resident #1 should have received the care he/she requested in a timely manner in accordance with his/her plan of care with the assistance of nurse(s) and/or CNA(s). The DON said communication between staff needed to be clearer, that assistance with care was needed to provided at that time, so the resident(s) were not left to wait.

Based on observations and interviews, the facility failed to properly store food items to prevent the risk of foodborne illness and in accordance with professional standards for food service safety. Findings include: The surveyor made the following observations during the initial kitchen walkthrough on 7/30/24 at 7:10 A.M.: - In the walk-in refrigerator, a container of unlabeled, undated sliced meat. - In the walk-in refrigerator, a container labeled as mushrooms with a use by date of 7/29 written on it. The container was partially open. - In the walk-in refrigerator, an opened bottle of Gatorade belonging to a staff member was stored with resident food. - In the walk-in freezer, numerous boxes containing resident food were stored directly on the ground. During the revisit walk-through of the kitchen on 7/31/24 at 11:27 A.M., the surveyor observed the following: - In the walk-in refrigerator, an opened bottle of Gatorade (a different bottle than the day prior) belonging to a staff member was stored with resident food. - In the reach-in refrigerator, an opened bottle of water with a staff member's name written on it was stored with resident food. During an interview on 7/31/24 at 11:50 A.M., the Food Service Director (FSD) said all food needs to be labeled and dated and should be thrown out after three days or as written on the food's label. During an interview on 8/1/24 at 8:30 A.M., the FSD said opened drinks belonging to kitchen employees should not be stored in areas where resident food is stored.

Based on interview, record review and observation, the facility failed to develop individualized, person-centered care plans for two Residents (#1, #104) out of a total sample of 25 residents. Specifically: 1. For Resident #1, the facility failed to develop an individualized, person-centered care plan related to dementia. 2. For Resident #104, the facility failed to develop an individualized person-centered care plan related to nutritional care. Findings include: Review of the facility policy titled Care Plan, revised and dated September 2023, indicated the following: - Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. - A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). 1. Resident #1 was admitted to the facility in December 2018 with diagnoses including unspecified dementia with agitation and adult failure to thrive. Review of Resident #1's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of Resident #1's MDS indicated that he/she has a diagnosis of non-Alzheimer's dementia and requires assistance with all activities of daily living. Review of Resident #1's active care plans failed to indicate an individualized, person-centered care plan relating to dementia care. During an interview on 8/1/24 at 7:40 A.M., Nurse #2 said she would expect all residents with a dementia diagnosis to have an individualized care plan as each resident requires different types of care. During an interview on 8/1/24 at 8:15 A.M., the Director of Nursing (DON) said she would expect Resident #1 to have an individualized dementia care plan. The DON and the surveyor reviewed Resident #1's medical record together and the DON said no dementia care plan had been developed. 2. Resident #104 was admitted to the facility in April 2024 with diagnoses including urinary tract infection, hyperlipidemia, and unspecified dementia. Review of Resident #104's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 7 out of a possible 15 indicating that the Resident has severe cognitive impairment. Review of Resident #104's active care plans failed to indicate an individualized, person-centered care plan relating to nutrition care. During an interview on 7/31/24 at 8:32 A.M., Resident #104 said he/she does not remember speaking with a Registered Dietitian/Nutritionist. During an interview on 8/1/24 at 7:58 A.M., the Registered Dietitian (RD) said she works in the building four days per week. The RD said when there is a new admission, we assess the resident and develop an individualized care plan for their nutritional needs to get their baseline nutrition status. The RD continued to say she missed completing Resident #104's initial nutrition assessment and developing his/her nutritional care plan upon admission to the facility. During an interview on 8/1/24 at 8:21 A.M., the Director of Nursing said an individualized nutritional care plan should be developed when a resident gets admitted to the facility, and she continued to say Resident #104 should have a nutrition care plan.

Based on observation, record review and interview, the facility failed to ensure staff followed physicians' orders for two Residents (#47 and #23) out of a total of 25 sampled residents. Specifically: 1. For Resident #47, the facility failed to document the external length of a peripherally inserted central catheter (PICC) line (a long thin tube that's inserted into a vein in the arm and passed through to the larger veins near the heart) and failed to document the urine output of his/her Foley catheter, as ordered by the physician. 2. For Resident #23, the facility failed to document the output from his/her negative pressure wound therapy (NWPT; also called a wound vac, is a suction pump and tubing used to remove excess exudate and promote healing in acute or chronic wounds), as ordered by the physician. Findings include: 1. Resident #47 was admitted to the facility in July 2024 with diagnoses including bacteremia, chronic obstructive pulmonary disease, and urinary retention. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #47 scored an 8 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating moderate cognitive impairment. The MDS also indicated he/she requires assistance with bathing and dressing and is receiving IV antibiotics. The MDS also indicated that Resident #47 has a Foley catheter. Review of Resident #47's physician's orders indicated: - 7/15/24: Change dressing of PICC every week and measure and document external length of catheter every day shift. Review of the Medication Administration Record (MAR) for July 2024 indicated that staff did not document Resident #47's external length of the catheter. Additional review of Resident #47's physician's orders indicated: - 7/10/24: Indwelling urinary catheter; measure and record output every shift. Review of the July 2024 MAR indicated that staff did not record Resident #47's output on the following shifts/days: - 7:00 A.M. to 3:00 P.M., on 7/12/24, 7/20/24 and 7/29/24 - 3:00 P.M. to 11:00 P.M., on 7/11/24 and 7/17/24 - 11:00 P.M. to 7:00 A.M. on 7/10/24, 7/14/24, 7/16/24, 7/18/24, 728/24, 7/29/24 and 7/30/24. During interviews on 7/31/24 at 8:50 A.M. and at approximately 9:00 A.M., the Director of Nursing (DON) said that it is expected for external lengths of PICC lines to be measured to ensure the line has not migrated. The DON reviewed Resident #47's July 2024 MAR with the surveyor and was not aware that staff had not completed the measurements for the PICC line or catheter output. 2. Resident #23 was admitted to the facility in June 2024 with diagnoses including encounter for surgical aftercare following surgery on the digestive system, and chronic pulmonary disease with acute exacerbation. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #23 is cognitively intact and requires assistance with bathing, dressing and transfers. Review of Resident #23's physician's orders indicated: - 6/27/24, NPWT (negative-pressure wound therapy) document amount of drainage. Call MD if > (greater than) 100 mls (milliliters) in 8 hours OR if [NAME] red blood is in the canister The order indicated document drainage every shift. Review of the July 2024 Medication Administration Record (MAR) indicated staff did not document the drainage amount per physician's order on the following days/shifts: - 7:00 A.M. to 3:00 P.M. on 7/2/24, 7/5/24, 7/8/24, and 7/25/24 - 3:00 P.M. to 11:00 A.M. on 7/1/24, 7/3/24. 7/4/24, and 7/13/24 - 11:00 P.M. to 7:00 A.M. on 7/14/24, 7/29/24, and 7/30/24. During an interview on 7/31/24 at approximately 9:00 A.M., the Director of Nursing (DON) reviewed Resident #23's July 2024 MAR with the surveyor. The DON said she was not aware that staff had not been documenting the NPWT drainage, as ordered.

Based on observation, policy review and interview, the facility failed to ensure nursing staff followed infection control practices during the administration of intravenous (IV) medication for one Resident (#47) out of a total of 25 sampled residents. Findings include: Review of the facility's Enhanced Barrier Precautions policy dated 7/1/24 indicated: Purpose: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Device care or use: central line; urinary catheter, feeding tube, tracheostomy/ventilator. Resident #47 was admitted to the facility in July 2024 with diagnoses including bacteremia, chronic obstructive pulmonary disease, and urinary retention. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #47 scored an 8 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS), indicating moderate cognitive impairment. The MDS also indicated he/she requires assistance with bathing dressing and is receiving IV antibiotics. Review of Resident #47's care plans indicated: - Problem: [Resident] is on IV medications ABTX (antibiotic treatment) related to bacteremia. Type of IV: PICC (peripherally inserted central catheter) rt (right) upper arm. Interventions: IV dressing as ordered. Monitor intake and output. Dated 7/21/24. - Problem: [Resident] has catheter. Interventions: EBP (enhanced barrier precautions) as indicated. Monitor and document intake and output as per facility policy. Dated 7/15/24. Review of Resident #47's physician's orders dated 7/9/24 indicated: Penicillin G Potassium Injection Solution Reconstituted (Penicillin G Potassium). Use 3 million units intravenously every 4 hours for bacteremia. On 7/30/24 at 12:40 P.M., the surveyor observed Resident #47's empty IV bag hanging from the IV pole. The physician order's written on the bag indicated: Infuse 50 ML (milliliters) IV every four hours at 100 ml/hr (hour) over 30 minutes. On 7/31/24 at 8:19 A.M., the surveyor observed Nurse #1 administer Resident #47's ordered intravenous antibiotics. Nurse #1 exited the medication room and walked to the medication cart to gather supplies. Nurse #1 then donned gloves that she obtained from the hallway, without first performing hand hygiene, potentially contaminating the gloves, and then entered Resident #47's room. A sign on the door indicated that Resident #47 was on enhanced barrier precautions and staff were to perform hand hygiene and don gloves and a gown during care. Nurse #1 did not don a gown. Nurse #1 then adjusted the privacy curtain with her gloved hands, set the infusion rate on the IV pump and then removed a bag of IV solution/antibiotic from her pocket, potentially contaminating her gloves. Nurse #1 then proceeded to connect the IV bag to Resident #47's PICC line cite, while still wearing the same gloves, potentially contaminating the IV tubing and PICC line insertion cite. During an interview on 7/31/24 at 8:29 A.M., Nurse #1 said that staff have to wear a gown when providing care to Resident #47. Nurse #1 said she did not have to wear a gown because she was administering medications. During an interview on 7/31/24 at 8:50 A.M., the Director of Nursing said that Nurse #1 should have worn a gown, performed hand hygiene, and not kept the IV solution bag in her pocket.

Based on observation, and interview the facility failed to maintain proper sanitation practices related to food labeling and storage in the kitchen. Review of the facility policy, revised September 2022, titled Food Storage and Preparation, indicated the following: *All foods will be shelved and rotated using the older foods first and based on the use-by or expiration dates. *All food items will be wrapped properly and tightly, or stored in clean, covered containers clearly marked, including the preparation date and discard date. *All temperature control for safety foods (TCS), ready-to-eat foods (RTE) or leftover foods will be labeled and dated with the date the food was prepared and the discard date. *All ready to eat salads (ex. Tuna salad, seafood salad etc.) or leftovers will be discarded within 5 Calendar days from the preparation date including day 1. During the initial kitchen walk-through on 6/13/23, at 7:05 A.M., the following observations were made: *A container of mandarin slices in the reach-in refrigerator, labeled as prepared on 5/7 and use by 5/9 *A cut tomato in the reach-in refrigerator with visible signs of decomposition wrapped and undated. *A piping bag filled with whipped cream in the reach-in refrigerator, dated use by 04/10. *An open bag of Mozzarella cheese in the reach-in refrigerator, undated. *Two pots containing soup in the walk-in refrigerator, undated and unlabeled. *Cooked carrots wrapped in a bowl in the walk-in refrigerator, undated and unlabeled. *Two prepared, ready to eat salads, wrapped and undated. *A case of squash, with significant signs of decomposition including the growth of a wispy, white and gray substance. *A tomato with visible signs of decomposition including the growth of a wispy, white and gray substance. During an interview on 6/13/23 at 7:13 A.M., the Food Service Director (FSD) said all food should be labeled and dated when the food item was prepared or opened. The FSD said all foods that have not been labeled or dated, including the soups stored in pots, should be discarded as the date of preparation is unknown. During an interview on 6/15/23 at 10:17 A.M., the Registered Dietitian (RD) said foods that have surpassed their use-by date pose a food-safety risk by introducing the potential for foodborne illness into the high-risk population of this skilled nursing facility.

Based on observation and interview, the facility failed to provide a dignified dining experience for the residents on the Fields Unit. The following was observed during the breakfast meal on 6/14/23: *At 8:21 A.M., 8:26 A.M. and 8:52 A.M., staff members were referring to residents who require assistance with meals as feeds in the unit hallway where residents were able to hear them. *At 8:31 A.M., a staff member was observed standing over a resident, not at eye level while feeding the resident while he/she was sitting up in bed. *At 8:52 A.M., a resident was observed with his/her tray open and untouched in front of him/her while he/she was sleeping in bed. Thirty-seven minutes later, a staff member was observed standing over the resident, not at eye level while feeding the resident, while he/she was sitting up in bed. On 6/15/23 at 12:11 P.M., a staff member was observed standing over a resident, not at eye level while feeding the resident while he/she was sitting up in bed. During an interview on 6/15/23 at 12:52 P.M., the Director of Nursing said staff should be assisting residents with feeding while sitting down at eye level with the resident. She also said that staff should not be referring to residents who require assistance with meals as feeds.

Based on observation, record review, interview and facility policy review, the facility failed to complete a restraint assessment for one Resident (#66) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Restraints reviewed and dated September 2022 indicated the following: *Prior to initiating a restraint, the interdisciplinary team must determine that alternatives to restraints have been tried and determined not to have been effective. The team will assess the resident for the least restrictive device/method. Re-assessments will be done at least quarterly. Resident #66 was admitted to the facility in November 2022 with diagnoses that include vascular dementia, anxiety disorder, history of falling and insomnia. Review of Resident #66's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 11 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the Resident's MDS indicated that he/she requires extensive assistance with activities of daily living, was coded for wandering behavior and had no indications of a restraint being used. During an observation on 6/13/23 at 7:54 A.M., the surveyor observed Resident #66 lying in bed, the sides of the bed were raised with pillows, with the side facing the hallway being higher than the other side of the bed. Resident #66 was attempting to get out of bed on the side stuffed with pillows, but could not do so. During an interview on 6/13/23 at 7:54 A.M., Resident #66 said he/she was trying to get out of bed but could not. During an observation on 6/14/23 at 6:52 A.M., Resident #66 was observed sleeping in bed, there were bolsters on both sides of the mattress from the Resident's head of the bed to the foot of the bed. Review of Resident #66's care plan for falls related to unsteady gait, the following intervention was implemented on 4/7/23: *Resident #66 needs Air Mattress Bolsters to prevent slippers [sic] from bed. During an interview on 6/14/23 at 11:41 A.M., Unit Manager #1 said Resident #66 has bolsters on his/her bed so he/she does not roll out of the bed, he continued to say that the Resident cannot get out of bed. During an interview on 6/15/23 at 7:32 A.M., Certified Nursing Assistant (CNA) #1 said we use the bolsters so Resident #66 does not get out of bed and we also use pillows on the other side of the bed, so he/she does not fall out of bed. He continued to say that Resident #66 tries to get out of bed but cannot, he/she sometimes almost slides out of the bed because he/she tried to get out of bed. Review of Resident #66's clinical record failed to indicate a restraint assessment was completed. During an interview on 6/15/23 at 7:41 A.M., the Director of Nursing said we do not have a restraint assessment for Resident #66.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with showers, for three Residents (#7, #29, and #57) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, reviewed and dated September 2022, indicated the following: *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. *Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support assistance with: Hygiene (bathing, dressing, grooming, and oral care). 1. Resident #7 was admitted to the facility in February 2022 with diagnoses that include hypertensive heart and chronic kidney disease with heart failure, and acute respiratory failure. Review of Resident #7's most recent completed Minimum Data Set (MDS) dated [DATE], revealed that the Resident has a Brief Interview for Mental Status score of 9 out of possible 15, indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that Resident #7 requires extensive assistance of one person for bathing. During an interview on 6/13/23 at 8:19 A.M., Resident #7 said he/she does not receive a weekly shower and can't remember when he/she last received one. Resident #7 was asked if he/she would like a weekly shower, he/she said yes. Review of Resident #7's care card (a form that shows all resident care needs) indicated he/she required physical assistance from staff for bathing tasks. Review of the shower schedule for the unit indicated Resident #7 was scheduled to have a shower weekly on Wednesday mornings and Saturday evenings. Record review on 6/13/23 at 2:37 P.M. for the past 30 days failed to indicate Resident #7 has received a shower. During an interview on 6/15/23 at 8:00 A.M., CNA #3 said she follows the shower schedule and if a Resident refuses care, she documents it under the bathing task on the ADL care card (a form of all activities of daily living) and reports it to the nurse. CNA #3 was asked if Resident #7 refuses care, she said no. During an interview on 6/15/23 at 9:52 A.M., the Director of Nursing said there is a shower schedule on the daily assignment sheet and if a resident refuses care, the nurse should be notified, and it should be documented. The Director of Nursing was informed Resident #7 has not received a shower in the past 30 days. The Director of nursing said she had not been made aware that Resident #7 had not received his/her weekly shower or that he/she was refusing care. Review of Resident #7's behavior care card (a form that shows all residents behaviors) and daily nursing documentation failed to indicate Resident #7 refused care. 2. Resident #29 was admitted to the facility in February 2023 with diagnoses that include spinal stenosis, low back pain and chronic Atrial Fibrillation (abnormal heart rhythm). Review of Resident #29's most recent completed Minimum Data Set (MDS) dated [DATE], revealed that the Resident has a Brief Interview for Mental Status score of 14 out of possible 15, indicating that he/she is cognitively intact. Further review of the MDS indicated that Resident #29 requires extensive assistance of one person for bathing. During an interview on 6/14/23 at 7:49 A.M., Resident #29 said he/she only receives a shower about once or twice a month. Resident #29 said when he/she lived at home he/she showered every day. Resident #29 was asked if he/she would like to receive a weekly shower, he/she said yes. Review of Resident #29's care card (a form that shows all resident care needs) indicated he/she required physical assistance from staff for bathing tasks. Review of the shower schedule for the unit indicated Resident #29 was scheduled to have a shower weekly on Wednesday mornings and Saturday evenings. Record review on 6/14/23 at 8:32 A.M., indicated Resident #29 has received 3 showers in the past 30 days. During an interview on 6/14/23 at 12:01 P.M., Resident #29 was asked if he/she had received a shower this morning, he/she said no. During an interview on 6/15/23 at 8:00 A.M., CNA #3 said she follows the shower schedule and if a Resident refuses care, she documents it under the bathing task on the ADL care card (a form of all activities of daily living) and reports it to the nurse. CNA #3 was asked if Resident #29 refuses care, she said no. During an interview on 6/15/23 at 9:52 A.M., the Director of Nursing said there is a shower schedule on the daily assignment sheet and if a resident refuses care, the nurse should be notified, and it should be documented. The Director of Nursing was informed that Resident #29 has received 3 showers in the past 30 days. The Director of nursing said she had not been made aware that Resident #29 has not received his/her weekly scheduled shower or that he/she was refusing care. Review of Resident #29's behavior care card (a form that shows all residents behaviors) and daily nursing documentation failed to indicate Resident #29 refused care. 3. Resident #57 was admitted to the facility in July 2022 with diagnoses that include chronic diastolic congestive heart failure, spinal stenosis unspecified, and unspecified osteoarthritis. Review of Resident #57's most recent completed Minimum Data Set (MDS) dated [DATE], revealed that the Resident has a Brief Interview for Mental Status score of 15 out of possible 15, indicating that he/she is cognitively intact. Further review of the MDS indicated that Resident #29 requires extensive assistance of one person for all Activities of Daily Living including bathing and did not exhibit any behaviors. Review of Resident #57's care card (a form that shows all resident care needs) indicated Resident #57 required physical assistance from staff for bathing tasks. Review of the shower schedule for the unit indicated Resident #57 was scheduled to have a shower weekly on Thursday mornings and Sunday evenings. Record review on 6/14/23 at 7:59 A.M., indicated Resident #57 has received 3 showers in the past 30 days. During an interview on 6/15/23 at 8:00 A.M., CNA #3 said she follows the shower schedule and if a Resident refuses care, she documents it under the bathing task on the ADL care card (a form of all activities of daily living) and reports it to the nurse. CNA #3 was asked if Resident #57 refuses care, she said no. During an interview on 6/15/23 at 9:52 A.M., the Director of Nursing said there is a shower schedule on the daily assignment sheet and if a resident refuses care, the nurse should be notified, and it should be documented. The Director of Nursing was informed that Resident #57 has received 3 showers in the past 30 days. The Director of nursing said she had not been made aware that Resident #57 has not received his/her weekly scheduled shower or that he/she was refusing care. Review of Resident #57's behavior care card (a form that shows all residents behaviors) and daily nursing documentation failed to indicate Resident #57 refused care.

Based on record review and interview, the facility failed to identify and address a significant weight loss for 1 Resident (#46) out of a total of 25 sampled residents. Findings include: Review of the facility policy revised September 2022, titled Weight Assessment and Intervention, indicated the following: *Any change in weight 5 pounds or more over 1 month will be re-taken for confirmation. If the weight is verified, nursing will notify the dietitian. *The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (past weight - actual weight)/(past weight) x 100. - a. 1 month - 5% weight loss is significant; greater than 5% is severe 3 month - 7.5% weight loss is significant; greater than 7.5% is severe 6 months - 10% weight loss is significant; greater than 10% is severe *if the weight change is desirable or expected, this will be documented and no change in the care plan will be necessary. Resident #46 was admitted to the facility in June 2022 with a diagnosis of dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #46 scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. Review of the Weights and Vitals Summary indicated the following: -7/20/22: 200 lbs. (pounds) -7/26/22: 197.6 lbs. -8/12/22: 202.1 lbs. -9/8/22: 201.3 lbs. -9/21/22: 186 lbs. -10/07/22: 190 lbs. -11/01/22: 187.4 lbs. Review of the weights indicated Resident #46 experienced a clinically significant weight loss from 9/8/22 to 9/21/22 of 15.3 lbs. or a loss of 7.6% of the Residents total body weight within one month. Review of the weights also indicated that the Resident's weight was not re-checked or confirmed until over two weeks following the initial weight loss recording. Review of Resident #46's clinical record indicated the weight loss was not addressed until 11/29/22, two months after the weight loss occurred when the Nurse Practitioner (NP) indicated the Resident experienced weight loss in a progress note. Resident #46's clinical record failed to indicate the Registered Dietitian (RD) or NP were notified of the weight loss. During an interview on 6/15/23 at 10:17 A.M., the RD said if a resident experiences a weight change of 3 or more pounds the resident's weight will be re-checked within 48 hours for confirmation. The RD said the expectation is to assess any resident that experiences a significant weight loss within 48 hours, and that Resident #46 should have been assessed at the time of the Resident's initial weight loss. The RD said nursing should notify the NP and RD of any significant weight changes, and that she is unaware if this occurred at the time of Resident #46's weight loss.

Based on observations, policy review and interviews the facility failed to ensure expired medications were unavailable for administration, medications once opened were dated according to manufacturer's guidelines and medications were stored separately from food on 1 out of 2 observed medication rooms and 3 out of 4 observed medication carts. Review of the facility policy titled, Storage of Medications revision date April 2007 included the following: - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. - Medications requiring refrigeration must be stored and monitored in a refrigerator located in the drug room at the nurse's station or other secured location. Medication must be stored separately from food and must be labeled accordingly. On 6/15/23 at 8:36 A.M., [NAME] Farms Medication Cart 2 the surveyor observed the following: -Two bottles of opened atropine eye drops, undated. -A bottle of LiquaCel opened and undated. During an interview on 6/15/23 at 8:38 A.M., Unit Manager #1 said LiquaCel should have an open date once it's opened. On 6/15/23 at 8:48 A.M., on the Cove unit Medication Room the surveyor observed the following: - An opened bottle of tuberculin (Tb) solution dated 4/4/23. - A can of soda. - A container of yogurt. During an interview on 6/15/23 at 8:51 A.M., Nurse #4 said food items should not be in the medication fridge and was unsure how long the tuberculin solution lasts once opened. On 6/15/23 at 9:36 A.M., on the Pride Unit Medication Cart 1 the surveyor observed the following: - A bottle of fiber caplets with an expiration date of 5/23. - A bottle of Magnesium caplets with an expiration date of 5/23. During an interview on 6/15/23 at 9:36 A.M., Nurse #5 said it was nursing's responsibility for checking the medication carts for expired medications. On 6/15/23 at 9:50 A.M., on the Pride Unit Medication Cart 4 the surveyor observed the following: - A bottle of Senna Plus with an expiration date of 2/23. - A bottle of magnesium with an expiration date of 5/23. During an interview on 6/15/23 at 9:53 A.M., the Director of Nursing said expired medications should not be in the medication cart, Tb solution is only good for 30 days once opened, and there should be no food items in the medication fridge.

Based on observation, record review and interview, the facility failed to ensure an air mattress was at the correct setting to help prevent the development of pressure ulcers for one Resident (#66) out of a total sample of 25 residents. Findings include: Resident #66 was admitted to the facility in November 2022 with diagnoses that include vascular dementia, anxiety disorder and insomnia. Review of Resident #66's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 11 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the Resident's MDS indicated that he/she requires extensive assistance with activities of daily living and is at risk for developing pressure ulcers. During an observation on 6/13/23 at 10:53 A.M., Resident #66 was observed sleeping in bed with his/her air mattress set to 150 pounds. During an observation on 6/15/23 at 6:58 A.M., Resident #66 was observed sleeping in bed with his/her air mattress set to 100 pounds. Review of Resident #66's physician's orders indicated the following: *Discontinued date of 6/13/23: Air Mattress when in bed setting of 200 lbs. (pounds) check function Q (every) shift. *Order date of 6/13/23 at 3:25 P.M.: Air Mattress in when in bed setting of 150 lbs. check function Q shift. Review of Resident #66's weight summary report indicating that his/her last reported weight on 6/6/23 was 136.8 pounds. Review of Resident #66's nursing progress notes from 3/31/23 indicate the following note: *Resident #66 has a new stage 2 area noted on coccyx. Now has air mattress and therapy replaced his/her cushion. Review of Resident #66's weekly skin check dated 4/5/23 indicated that a coccyx wound was present. Review of Resident #66's assessment titled [NAME] Plus Pressure Ulcer Risk Scale (an assessment used to assess the risk of developing pressure ulcers) dated 11/13/22, 2/8/23 and 5/3/23 revealed that the Resident was at a high risk for developing pressure ulcers. During an interview on 6/14/23 at 11:42 A.M., Unit Manager #1 said Resident #66 is at risk for pressure ulcers on his/her bony areas and had a facility acquired pressure ulcer recently but it had recently healed. He continued to say that the Resident uses an air mattress to help prevent pressure injuries. During an interview on 6/15/23 at 7:21 A.M., Unit Manager #1 and the surveyor observed Resident #66's air mattress set to 100 pounds, he said it should be set to 150 pounds. Unit Manager #1 then said physician orders should be followed for Resident #66's air mattress settings. During an interview on 6/15/23 at 7:41 A.M., the Director or Nursing said Resident #66 is at high risk for pressure ulcers and air mattress settings are determined by the Resident's weight. She continued to say that physician's orders should be followed for the correct air mattress setting.

Based on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions, resulting in the development of a pressure ulcer, for 1 Resident (#47) out of a total sample of 26 residents. Findings include: Review of facility policy titled 'Wound and Skin Care Protocols/ Definitions', reviewed 9/21, indicated the following: *Purpose: -To prevent pressure ulcer/ injury formation by identifying those residents who are at risk for pressure injuries/ ulcers and to develop appropriate interventions. *Definitions: -A pressure injury/ulcer is defined as any lesion caused by unrelieved pressure resulting in damage to underlying tissue. Pressure ulcers usually occur over bony prominences and are staged to classify the degree of tissue damage observed. (Agency for Health Care Policy and Research 1994). -Staging Classification adapted from National Pressure Ulcer Advisory Panel (NPUAP) *Stage 2- Partial thickness tissue of dermis presenting as shallow open ulcer with a red/pink wound bed without slough. The ulcer is superficial and presents clinically as an abrasion, blister (clear fluid filled blister) or shallow crater. Resident #47 was readmitted to the facility in August 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS further indicated the Resident requires extensive assistance with physical assistance for care activities and that the Resident did not have any pressure ulcer or injury and is at risk for developing pressure ulcers/injuries. On 5/04/22 at 12:44 P.M., Resident #47 was observed sitting in his/her wheelchair in his/her room. The Resident said he/she has an open area on his/her buttocks that he/she thinks opened a few days ago and that the area is sore. Resident #47 said nursing staff has been putting a treatment on the area. The Resident's wheelchair had no pressure relieving cushion in place and there was not one visible in his/her room. Resident #47 said he/she used to have one, but it was discolored, and he/she didn't want to use a discolored cushion so he/she gave it to the Occupational Therapist (OT). Resident #47 said the OT told him/her that the facility did not have another cushion of that type, but they would order another one for him/her. Resident #47 said this happened sometime in February and that he/she has not had a cushion since then. Review of Resident #47's medical record indicated the following: -A care plan initiated 9/04/2018 for a potential for pressure ulcer development related to medication use, pain, incontinence of bowel and bladder, weakness and history of pressure impairment with interventions for a pressure reducing mattress on bed and cushion in wheelchair. -A Norton Plus Pressure Ulcer Risk Scale dated 3/10/22 which indicated a score of 11 and a high risk of developing pressure ulcers. -A Physical Therapy (PT) treatment note dated 1/26/22 which indicated the Resident was provided a new wheelchair cushion. -A weekly skin check dated 4/30/22 which indicated skin issues were identified as follows: sacrum-wound note; broken blister right shin; skin tear forearm; skin tear right forearm. Further review of Resident #47's medical record failed to indicate any additional documentation of the Resident's wound or missing wheelchair cushion. During an interview on 5/05/22 at 8:07 A.M., Unit Manager (UM) #1 said he was notified by nursing staff that the Resident has a new open area on his/her buttocks. UM #1 said he thinks that it opened within the previous two days and said the new wound is a pressure injury. UM #1 said the Resident has had issues in the past with his/her skin having open areas. During an interview on 5/05/22 at 8:44 A.M., UM #1 reviewed Resident #47's Electronic Health Record (EHR) and said there were no notes indicating the Resident had a new open area on his/her buttocks and no wound notes for this area. UM #1 said the expectation would be that nurses would include any skin issues in their notes and complete an incident report. UM #1 said that he was told about the new pressure injury by nurses yesterday but hasn't had a chance to assess the area. On 5/05/22 at 9:40 A.M., the surveyor observed Resident #47's skin with UM #1 and observed an open area on his/her left buttock. The area was pink with some slough (yellow/white material in the wound bed consisting of dead cells) with darker pink skin surrounding the wound. Unit Manager #1 said that this area will need a treatment. Review of Resident #47's medical record on 5/05/22 at 10:50 A.M. indicated the following: -A Pressure Ulcer weekly observation dated 5/05/22 which indicated the Resident had a facility acquired Stage 2 pressure ulcer to his/her left buttock measuring 2 centimeters (cm) x 2 cm with 10 percent slough tissue present. - A Nurse's Note dated 5/05/22 which indicated Resident with an open wound to left buttock, treatment orders obtained: wound gel to wound bed, skin prep to surrounding wound, then cover with a protective dressing daily and as needed. -An order dated 5/05/22- to left buttock wound: clean, pat dry, apply wound gel to wound bed, skin prep to surrounding wound bed then cover with protective dressing every day shift and as needed. During an interview on 5/05/22 at 11:01 A.M., the Director of Rehabilitation (DOR) and the OT said that any resident in the facility who has a wheelchair will get a cushion to sit on. They both said the standard cushion provided to residents is a gel cushion, but the facility also has specialty cushions to offload pressure from areas while sitting. The DOR said nursing will complete a form and send to the rehab department if a resident needs a cushion evaluation or needs a new cushion. The DOR said the facility keeps a supply of different cushions in house. The DOR said that Resident #47 should have a cushion for his/her wheelchair and that he/she would have been issued one. On 5/05/22 at 11:12 A.M., the DOR accompanied the surveyor to Resident #47's room and observed there was no cushion on his/her wheelchair. Resident #47 was sitting in his/her wheelchair and told the DOR his/her wheelchair cushion had been missing since February after he/she asked the OT for a new one. During an interview on 5/05/22 at 11:19 A.M., UM #1 said every resident is supposed to have a wheelchair cushion and they get it upon admission. UM #1 said therapy would determine if anyone needs a specific type of cushion. UM #1 said the cushion is used to help prevent pressure ulcers from forming and acknowledged Resident #47 was assessed to be a high risk for pressure ulcer/injury, had a care plan intervention for a cushion to his/her wheelchair, did not have a cushion in place on her wheelchair and has now developed a Stage 2 pressure injury to his/her buttocks. During an interview on 5/05/22 at 12:43 P.M., the Director of Nursing (DON) said that Resident #47 should have a cushion for his/her wheelchair and that he/she used to have a cushion. During an interview on 5/05/22 at 12:54 P.M., the DOR said Resident #47 was issued a new cushion by Physical Therapy in January. The DOR said her department will get referrals for all missing equipment and they didn't get anything about a missing cushion for this Resident. The DOR acknowledged a cushion was issued on 1/26/22 and the Resident reported giving it to staff in February and requesting a replacement cushion. The DOR said staff did not remember removing the cushion from the Resident's wheelchair.

Based on observation, record reviews and interviews, the facility failed to maintain acceptable parameters of nutritional status by providing adequate interventions to maintain usual body weight and prevent significant weight loss or gain, for 2 Residents (#2, and #57) out of a total sample of 26 residents. Findings include: Review of the facility policy titled, Weight Assessment and Intervention, undated, indicated the following: *Any weight change in 5 pounds or more over 1 month will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian. *The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe 3 moths - 7.5% weight loss is significant; greater than 7.5% is severe 6 months - 10% weight loss is significant; greater than 10% is severe 1. For Resident #2, the facility failed to provide interventions to prevent a significant weight loss. Resident #2 was admitted to the facility in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's most recent quarterly Minimum Data Set, dated dated dated [DATE] revealed the Resident had a Brief Interview for Mental Status score of 14 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated Resident #2 is independent with self-feeding. Review of Resident #2's weights indicated the following: *On 09/29/21, 200 lbs (pounds) *On 10/13/21 189.5 lbs. This is a significant 5.25% weight loss in a 1-month time frame. *On 11/12/21 177.5 lbs. This is an additional significant 6.33% weight loss in a 1-month timeframe. *On 12/01/21 177 lbs. *On 01/12/22 167 lbs. *On 02/22/22 160.5 lbs. This is an additional significant 9.58% weight loss in a 3-month timeframe. On 03/15/22 164 lbs. On 04/13/22 162 lbs. Review of the facility census indicated Resident #2 was hospitalized for 5 days in March, however the significant weight loss happened prior to the hospitalization . Review of Resident #2's medical chart indicated the following: *The physician notes from December 2021 to March 2022 failed to indicate he was notified of Resident #2's significant weight loss. *A physician order written [MEDICAL RECORD OR PHYSICIAN ORDER] . *There were no reweights obtained after each significant weight loss was recorded. *A weight change progress note written on 1/7/22 by the Dietitian identifying the significant weight loss and recommending an increase in Resident #2's [MEDICATION(S)] (an anti-depressant and appetite stimulant). There is no documentation that this was discussed with the physician and followed. *Resident #2 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . *Physician orders failed to indicate any new dietary interventions were put in place after November 2021. Review of Resident #2's nutritional care plan last revised 9/23/21, indicated an intervention to monitor weight, intake, skin, s/s (signs and symptoms) of aspiration. During an interview on 5/5/22 at 8:50 A.M., Unit Manager (UM) #1 said the nurses and dietitian are both responsible for identifying significant weight changes in residents. UM #1 said that if a significant weight change occurs, the interdisciplinary team works together to find appropriate interventions. UM #1 said he was unaware of Resident #2's weight loss. During [NAME] interview on 5/05/22 at 9:46 A.M., the Dietitian said she receives information regarding significant weight changes by attending morning meeting, clinical rounds and printing out the weight report. The Dietitian said there is no formal at risk meeting for residents at risk of significant weight loss. The Dietitian said her expectation if to assess any residents with a significant weight change on the day the weight change was identified or within a few days at the most. She said she would also expect a reweight to be obtained with any significant change in weights to verify its accuracy. The Dietitian said Resident #2's food intake has been okay and that she is unable to speak to the weight loss that occurred in December 2021 and January 2022 since she has only been working at the facility since January 2022. When asked what interventions the facility had put in place for the significant weight loss for the 3-month timeframe of November 2020 to February 2022, the Dietitian said there were no interventions put in place in January or February. 2. Resident #57 was admitted in 12/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan for Resident #57 indicated the following: -Problem: Resident #57 has predicted suboptimal intake related to intake <75%, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Weight Report indicated the following: - 1/28/22 : 114.4 lbs (pounds) - 2/4/22: 115 lbs - 2/11/22: 107.6 lbs - 2/12/22: 108.7 lbs - 2/25/22: 107.9 lbs (5.7% weight loss in one month) Review of the weights indicated that Resident #57 had a 7.1 lb (5.7%) weight loss in one month and a 7.4 lb weight loss from 2/4/22 to 2/11/22, which is a 6.4%, clinically significant, weight loss. Review of the clinical record does not indicate that the weight loss was addressed until 3/29/22 when additional interventions were implemented, which was 46 days after the initial weight loss was identified. On 3/29/22, Ensure plus was changed to 2 P.M. and every night to avoid getting full and impacting meals. During an interview on 5/5/22 at 9:46 A.M., the Dietitian said that she would expect to see a resident with significant weight loss the same day or within a few days to address it.

Based on observation, interview and facility policy review, the facility failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness. Findings include: Review of the facility policy titled, Preventing Foodborne Illnesses-Employee Hygiene and Sanitary Practices indicated the follow: Policy Statement: -Food and Nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent spread of foodborne illnesses. Policy Interpretation and Implementations: Employees must wash hands: *Before coming in contact with any food surfaces. *After handing soiled equipment or utensils. *During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands. -Gloves are considered single use items and must be discarded after completing the tasks for which they are used. The use of disposable gloves does not substitute for proper hand washing. During an observation of the kitchen on 05/03/22 at 7:15 A.M., the following was observed: *Food Service Employee #1 was preparing breakfast and was wearing gloves as the surveyor entered the kitchen. He was observed touching slices of strawberry cake to place on trays. The food service employee then touched serving utensils before touching additional slices of strawberry cake to place on plates. While wearing the same pair of gloves, the food service employee was observed touching the side and tops of plates with gloved hand while plating food. During an observation of the lunch line on 5/04/22 at 11:25 A.M., the following was observed: *Food Service Employee #1 was observed touching a pan cover handle with gloved hands, then grabbed stack of plates touching the top of the plates where food was placed. The food service employee was then observed opening and closing kitchen draws and then touching the top of plates where food was placed. While wearing the same gloves the food service employee was observed touching utensils, then handling 2 slices of bread and cheese. The food service employee was then observed lifting a box of saran wrap then plating a grilled cheese sandwich with his hands. During an interview on 5/05/22 at 1:40 P.M., Food Service Employee #2 said clean gloves should have been worn before handling food.

Based on observation, record review and interviews, the facility failed to provide adequate supervision to prevent falls with injuries for 1 resident (#72) out of a total sample of 27 residents, by leaving the resident unsupervised on 2 occasions. Findings include: On 5/8/18, Resident #72, who was cognitively impaired, identified as being at high risk for falls, required the assistance of 2 people for transfers and ambulation and the assistance of one person for toileting, was left unattended in the bathroom, fell and fractured his/her right hip. On 9/2/18, Resident #72 was left unattended in front of the nurses station, fell out of the wheelchair, resulting in hospitalization and extensive facial bruising, as well as a left frontal hematoma. Resident #72 was admitted to the facility in 3/2018 with a fractured humerus and a history of falls. A falls assessment conducted on 3/4/18 indicated the resident was at high risk for falls, scoring a 20 (A score over 10 indicates a high risk for falls). A care plan for falls, initiated on 3/4/18, indicated the resident was at risk for falls due to a history of falls and poor balance. Interventions included the following: - bed/chair alarm in place as ordered. - Monitor/document/report pain, bruises, change in mental status. A care plan, for self care deficit, initiated 3/4/18, related to activity intolerance and deterioration in Activities of Daily Living (ADLs) included the following interventions: - Encourage resident to ambulate to the bathroom, staff to follow with wheelchair. - Resident requests privacy while toileting, leave door slightly ajar. An admission Minimum Data Set ((MDS) dated [DATE] indicated the resident had severe cognitive impairment, scoring a 5/15 on the Brief Interview for Mental Status (BIMS) and needed extensive assistance with transfers, ambulation and toilet use. In addition, the resident had a history of [REDACTED]. Review of a nurse's note dated 5/8/18 at 10:53 A.M., indicated the resident was found sitting on the bathroom floor in front of the sink. The resident had tried to self transfer off of the toilet. The resident complained of right hip pain. The physician was notified and ordered a right hip and pelvis x-ray. The x-ray showed a right [MEDICAL CONDITION] and the resident was sent to the hospital for a total hip repair. Review of the facility's incident report, dated 5/8/18, indicated Nurse #3 reported she stepped out of the bathroom to provide privacy and gave the resident the call bell. Nurse #3 went back 2 minutes later and found the resident on the floor. Review of Nurse #3's statement, dated 5/8/18, indicated the resident was on the toilet. Nurse #3 gave the resident the call bell and left to get a medication, came back 2 minutes later and the resident was on the bathroom floor in front of the sink. Nurse #3 stated the resident got up by himself/herself despite given the call bell with instructions that Nurse #3 would be right back to help him/her. (Resident #3 may not have been able to comprehend or retain this instruction with a BIMS score of 5 out of 15, indicating severe cognitive impairment.) An interview was conducted with Nurse #3 on 9/25/18 at 1:50 P.M. Nurse #3 stated the resident self transferred to the bathroom and hen Nurse #3 came to the resident's room with medications, she found the resident on the floor in the bathroom. When the surveyor mentioned that her statement written on the day of the fall differed, Nurse #3 stated she should have read her statement before answering questions about the fall. When asked if the resident was able to left alone in the bathroom, Nurse #3 stated she thought the resident was a lot more alert at that time. Review of an admission MDS dated [DATE] (the resident was discharged and readmitted to the facility) indicated the resident had short and long term memory problems and needed extensive assistance with transfers and ambulation. Review of the nurse's note dated 9/2/18 at 10:40 P.M., indicated the resident was sitting in the wheelchair, stooped down and fell . Review of the facility's incident report, dated 9/2/18, indicated the resident fell from the wheelchair and was found on the floor. The resident was assessed for injury and sustained a bump on the forehead. The resident was sent to the hospital for further evaluation where she was admitted with a urinary tract infection. Nurse #4, who was working on the night the resident fell , was interviewed on 9/24/18 at 3:40 P.M. When asked if the resident is usually up that late at night, Nurse #4 stated they usually keep the resident out in front of the nurse's station at night to watch him/her as the resident is at high risk for falls. The night of the fall, the resident was in front of the nurse's station. The resident made multiple attempts to stand up setting off the chair alarm. Nurse #4 as well as other staff members where attending to other resident's needs and when Nurse #4 came out of a resident's room, she found the resident on the floor. The resident was unsupervised. The resident was hospitalized from [DATE] - 9/5/18. Review of the hospital discharge summary dated 9/5/18 indicated the resident did not have any fractures or intercranial bleeding, but was being treated for [REDACTED]. The resident was observed on all days of survey. The resident was in the day room across from the nurse's station sitting in a wheelchair with a chair alarm attached. The resident's face had extensive bruising with a hematoma on the left forehead.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure Resident #2 was free from a significant medication error. On 9/11/2015, Resident #2's plan of care was updated to include the following: [MEDICATION NAME] (a medication used to prevent blood clots) to be discontinued and Xarelto (a medication used to thin blood and prevent blood clots) 15 mg (milligrams) everyday with the evening meal was ordered. The order, for the Xarelto, was incorrectly transcribed to read: Xarelto 15 mg everyday and with the evening meal, Resident #2 received 6 extra doses of Xarelto in 6 days; presented with low blood pressure and bloody stools on 9/17/2015, was sent to the hospital and admitted with a [DIAGNOSES REDACTED]. Findings include: Resident #2's Minimum Data Set (MDS), dated [DATE], indicated Resident #2 was alert, oriented, and his/her Brief Interview for Mental Status (BIMS) score was 15 (score range 00 - 15), which indicated he/she was cognitively intact. Resident #2's MDS indicated he/she required extensive assistance with dressing, bathing, transfers and mobility. A handwritten physician's orders [REDACTED].#2's [MEDICATION NAME] was to be discontinued and Xarelto 15 mg everyday with evening meals was to be administered. A Nursing Note, dated 9/11/2015, indicated the nurse documented the physician's orders [REDACTED]. Resident #2's Medication Administration Record [REDACTED]. Resident #2's MAR indicated [REDACTED]. A Facility Medication Variance Report, dated 9/18/2015, indicated a significant medication error had occurred with the incorrect transcription of Xarelto 15 mg resulting in Resident #2 hospitalized with a GI bleed. The Surveyor interviewed the Director of Nursing (DON) at 3:30 P.M. on 3/2/2016. The DON said the Facility found the physician's orders [REDACTED].#2 receiving extra doses of Xarelto in error and Resident #2 was subsequently hospitalized with a GI bleed. The DON said the nurse was educated and the Facility implemented a Process Improvement Plan which included audits of all residents on any type of anticoagulant medications, education of all nursing staff and implementation of a triple check system of all new orders. The Surveyor interviewed the Physician at 3:55 P.M. on 3/2/2016. The Physician said he ordered Xarelto 15 mg to be administered by mouth with the evening meal and the Xarelto should have only been given once per day not twice. The Physician said Xarelto was being ordered for blood clot prevention for Resident #2 and the only time Xarelto 30 mg would be ordered is to actively treat a blood clot. The Physician said the ordered was transcribed incorrectly. On 3/2/2015, the Facility provided the Surveyor with a plan of correction with an implemented performance improvement plan as evidenced by: A) A review of the Medication Incident and Interventions to ensure Resident #2's health and safety. B) Audits of all residents prescribed any anticoagulant medication to ensure no other residents were or could be affected, audits began 9/18/2015 and continued to be conducted as of survey 3/2/2016. C) On 9/23/2015, the Facility implemented a systemic change of a triple check system of all new orders, the triple check consisted of two nurses checking the order and the Unit Manager completing a third check for three months (October 2015 through December 2015), as of survey 3/2/2016, the Facility was still conducting random triple checks. D) Random daily audits, started 9/23/2015, by the Unit Managers of all anticoagulants orders for three months and presented at the Facility's Quality Assurance Performance Improvement Committee. E) Education provided by the Staff Development Coordinator and Pharmacy Consultant, to all nurses, dated 9/21/2015 through 9/30/2015, regarding the implementation of the triple check system for new orders and atypical anticoagulant medications. F) Monitoring to sustain system compliance, responsibility of the Director of Nursing and/or Executive Director results of audits presented to the Facility's Quality Assurance Performance Improvement Committee for three months October through December 2015. G) As of 3/2/2015, the Facility was continuing to monitor all anticoagulant medications and orders. The Director of Nursing presented the surveyor with audits she had conducted in January and February 2016. H) On 3/2/2015, the Facility's Medical Director, was aware of and in agreement with, the Facility's Performance Improvement Plan for new orders and anticoagulant medication monitoring I) The Facility's Performance Improvement Committee will continue to review findings of new orders and anticoagulant medications.

Based on record review, observation and interview, the facility failed to provide effective interventions to prevent falls for 5 of 16 residents (#6, #9, #11, #18 and #21) in a total sample of 23 residents. Three of the five residents sustained injuries. Findings include: 1. For Resident #6, who had a history of [REDACTED]. The resident experienced 2 falls after his/her admission to the facility, resulting in two fractures. Resident #6 was admitted to the facility in 7/2013 with admitting [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] identified the resident as having a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident's cognition was moderately impaired. It also identified him/her as requiring extensive assistance in transfers, requiring extensive assistance in ambulation in his/her room, and having had no falls since admission. Review of the plan of care for falls upon admission and through 9/27/13 indicated interventions including the following: *Anticipate and meet pt's (patient's) needs *Assess risk for falls *Be sure the call light is within reach and encourage pt. to use it for assistance as needed. Pt. needs prompt response to all requests for assistance. *Educate pt./family/caregivers about safety reminders and what to do if a fall occurs. *Follow facility fall protocol. *Lock bed brakes. *Monitor pt. for safety if using side rails.... *Provide non-skid footwear. *PT(physical therapy) evaluate and treat as ordered or PRN (as necessary). *Pt. needs safe environment with: (Specify:even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach.) *Pt. needs activities that minimize the potential for falls while providing diversion and distraction. A nursing note dated 7/27/13 indicated the resident was awake at 3:30 A.M. attempting to get out of bed, restless. Denied pain, 1:1 with good re-direction, snack declined. Positioned in bed for comfort. Slept in long naps the rest of the night. The following intervention was added to the care plan on 7/29/13: *Pressure pad alarm to both bed and chair to alert staff of pt attempts to self transfer/ambulate. A 7/30/13 nursing note indicated the resident exhibits no safety awareness, does not ask for assistance and sets motion alarms off. An 8/15/13 nursing note written at 7:12 A.M. indicated the resident was receiving gait training with the therapy department. A review of the 8/20/13 nursing note written at 6:44 A.M. indicated the resident was alert with confusion, had increased anxiety/restlessness and made multiple attempts to get out of bed. Alarms were ringing and he/she was found ambulating without the rolling walker to the bathroom. The resident was holding onto the furniture, his/her gait was unsteady and stated, "I got to go to work." Medicated with Ativan 0.5 mg at 4:00 A.M. with fair effect. Nursing notes written on 8/27/13 at 10:34 P.M. and 8/30/13 at 6:16 A.M., indicated the resident continued to get out of bed without assistance and lacked safety awareness. A nursing note written on 9/01/13 at 8:24 P.M. indicated the resident made multiple attempts to try and stand-up by himself/herself and lacked safety awareness. A review of the 9/28/13 Resident Event Report indicated the resident was found on the floor at 10:15 P.M. The resident had impulsively got up out of bed that evening and removed his/her personal alarm and attempted to ambulate. Probable cause given: weakness, unsteady, confusion, no safety awareness. Preventative measures implemented: bed alarm was working, personal alarm was disconnected, pulled off. The resident had been sleeping until 10:00 P.M., when he/she was toileted. The resident stated his/her slipper socks had tripped him/her when he/she was trying to get up to straighten his/her sheets. The resident was admitted to the hospital and readmitted back to the nursing home on 10/02/13 with a 6 millimeter (mm) parenchymal hemorrhage (bleed) of the left thalamus (a midline symmetrical structure of two halves within the brain) and an acute-on-chronic (re-injured) left intertrochanteric hip fracture. The care plan interventions continued to remain unchanged, despite that the resident was hospitalized for [REDACTED]. Nursing notes written on 10/09/13 at 6:20 A.M., 10/10/13 at 6:17 A.M. and 10/11/13 at 6:12 A.M. indicated the resident attempted to get out of bed multiple times without assistance. The Significant Change MDS dated [DATE] identified the resident as having a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident's cognition was severely impaired and requiring extensive assistance in transfers and extensive assistance in ambulation in his/her room. A weekly nursing note dated 10/16/13 indicated the resident was alert with baseline confusion. The resident made multiple attempts to get out of bed unassisted and did not use the call light. A nursing note on 10/20/13 at 10:30 P.M. indicated the resident was found on the floor inside the doorway of his/her room. All safety measures were in place. The resident stated he/she was going for his/her shoes. He/she had turned off his/her alarm. Further record review indicated the resident suffered a left medial tibia plateau fracture, which was the second major injury he/she sustained in 22 days. A review of the 10/20/13 Resident Event Report included the following statement by Certified Nurse Assistant (CNA) #1: The resident knows how to shut off (his/her) bed alarm and always unclips (his/her) personal alarm, if we can move it or hide it from her I think it will be more effective." A statement was also written by Nurse #3. It stated, "(resident) is forgetful, non-compliant and requires frequent redirection. (Resident) understands and becomes annoyed when (his/her) alarms sound and has learned to turn them off." On 1/15/14 at 1:30 P.M., an interview was held with Nurse #3 in regards to the resident. Nurse #2 said that the resident had a pressure alarm pad on his/her bed prior to his/her 2 falls and that the resident had been shutting it off a lot. She further said the resident had learned how to shut off this alarm as well as his/her clip alarm. "She knew how to do that." The surveyor said that neither the nursing notes nor the care plan identified this issue and that the care plan was not revised to include interventions to address the resident's ability to shut off his/her alarm. Nurse #2 said she did not document the fact that the resident had been turning off his/her alarms since their implementation. On 1/15/14 at 3:30 P.M. the surveyor and the Assistant Director of Nursing (ADON) observed the resident lying in bed with the pressure alarm box attached to the bed rail next to the resident's head where he/she could reach for it. The surveyor then spoke to the ADON about the 10/20/13 Resident Event Report regarding the statement written by Nurse #2 and CNA #1 pertaining to the resident's ability to shut off his/her alarms. The ADON said she was unaware of these written statements. On 1/16/14 at 9:00 A.M., an interview was held with CNA #1. The CNA said the resident knows how to shut off both his/her pressure pad alarm and clip alarm and has done so many times. The facility failed to properly and safely supervise this confused and high risk resident who experienced significant injuries due to falls prior to admission. The facility also failed to revise the resident's care plan and implement effective interventions for the resident, who subsequently suffered 2 more major fractures from falls within a 22 day period. 2. For Resident #21, the facility failed to ensure that the resident was appropriately supervised to prevent falls. The resident fell and sustained a fracture to the right hip. The clinical record was reviewed on 1/17/14. Resident #21 was admitted to the facility in 10/2013 with [DIAGNOSES REDACTED]. Medical [DIAGNOSES REDACTED]. The resident had an invoked health care proxy as of 10/23/13. On admission, Resident #21 made multiple attempts to ambulate without assistance. The Discharge Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as having moderately impaired cognitive skills for daily decision making. The resident required extensive assistance for transfer, walking, dressing, toileting, personal hygiene and bathing. The resident was continent of urine and infrequently incontinent of bowel. The resident was independent for feeding. According to the care plan implemented on 10/23/13, measures for falls risks prevention indicated the resident was at moderate risk for falls. The goals established were the resident was to be free of minor and major injury. Interventions included: *Educate/remind Patient to request assistance prior to transfer/ambulation. *Encourage/remind patient to use recommended assistive devices in ambulating. *Follow facility fall protocol. *Monitor for gait changes. *Provide non-skid footwear. *Remind patient and reinforce safety awareness: lock brakes on bed, chair before transferring. When rising from a lying position, sit on side of the bed for a few minutes before transferring. *Use bed and chair alarms. Review of a Facility Event Report and investigation, dated 11/4/13 indicated that Resident #21 was confused, anxious and made multiple attempts to get up from the wheel chair on 11/4/13. The chair alarm was active. Staff placed Resident #21 behind the nursing station for increased observation at approximately 8:00 P.M. During interview on 1/21/14 at 2:40 P.M., the Assistant Director of Nursing said that Nurse #4 directed Certified Nursing Assistant (CNA) #1 to watch Resident #21 because she/he was so restless and needed increased supervision while she passed medications. CNA #1 directed another staff person (CNA #2) to supervise the resident while she went on break. CNA #1 did not inform Nurse #4 that she did not continue supervising Resident #21. CNA #2 left Resident #21 alone at the nurse's station while she went to attend to another resident. At 8:15 P.M., staff responded to resident's chair alarm sounding and found the resident on the floor. The fall was unwitnessed. Review of the Transfer sheet indicated that Resident #21 was transferred to the emergency room for evalution. Resident #21 was diagnosed with [REDACTED]. 3. For Resident #11, the facility failed to utilize effective interventions consistent with the resident's impaired cognitive status and, therefore, protect the resident from repeated falls including 1 fall with injury. The clinical record was reviewed on 1/14/14 and 1/15/14. Resident #11 was admitted to the facility in 7/2012. [DIAGNOSES REDACTED]. The Falls care plan in place at time of review included: Goal: Will not sustain a fall related injury by utilizing fall precautions by next review. Interventions: * Gripper socks for safety. Pressure mat alarm on bed. Personal alarm on at all times. * Floor alarm. Re-educate resident on not disconnecting any of the safety alarms and to ask for assistance before exiting the bed or chair. * Low platform bed, call light within reach, adequate glare free lighting, free of clutter. * Reinforce safety awareness. Lock brakes on bed, chair before transferring, sit on side of bed for few minutes before transferring or standing, educate/remind resident to request assistance prior to ambulation. * Provide family with education re: safety measures. * Provide rest breaks. Urinal at bedside. Rolling walker within reach. * Do not leave in bathroom alone. * Activity Dept. to inform staff when resident returns to his/her room. * Winged mattress, bed strip sensor alarm. * Two hour toilet schedule. The resident was also identified as being "non-compliant" with routine care including ambulation. A care plan intervention was in place to discuss with the resident the implications of not complying with therapeutic or medical regime. According to the facility Event Report and Investigation, the resident sustained [REDACTED]. * On 11/26/12 at 3:30 P.M., the resident was found on the bathroom floor by a Certified Nurse Aide (CNA) having lost balance and fell by the sink. The call light was ringing. At this time, two interventions, do not leave in bathroom alone and transfer with assistance, were added to the above care plan. * On 2/22/13 at 1:00 P.M., the resident was found sitting on the floor. Activity staff had returned resident to the room and did not inform staff, per care plan. Call bell was not within reach, alarms were not in place and the resident was left in the chair, not the bed as per plan of care. Activity staff was re-educated. * On 4/30/13, at 3:30 P.M., the resident was sitting on the edge of the bed and the resident slipped to the floor when attempting to self-transfer. The resident had been identified as non-compliant, unclips personal alarms and does not remember to use the call light. A strip alarm was placed on the bed and the resident was reminded to use the call light even though the resident had been identified as not remembering to do so. * On 7/10/13 at 9:15 A.M., the resident again slipped from bed to floor when attempting to self-transfer after removing a personal alarm. Once again, the resident did not use the call light, per the care plan, in order to request assistance to return to bed. The Quarterly Minimum Data Set (MDS) of 8/27/13 identified the resident as having a Brief Interview of Mental Status (BIMS) of 13 indicating cognitively intact and forgetful. The resident required extensive assistance of 1 for all activities of daily living including transfer and ambulation. The resident was frequently incontinent of urine requiring extensive assistance of 2 and utilized a diuretic. * On 10/31/13 at 11:30 P.M., the resident was attempting to go to the bathroom, removed alarm and did not use call light. The resident was found on the floor, having fallen backwards and hit his/her head on floor resulting in a moderate size hematoma requiring 3 staples in the emergency room . According to physician's orders [REDACTED]. The Significant Change MDS of 11/11/13 identified the resident as having a Brief Interview of Mental Status (BIMS) of 9, indicating a moderately impaired mental status and forgetfulness. The resident required extensive assistance of 1 for all activities of daily living including transfer and ambulation. The resident was frequently incontinent of urine requiring extensive assistance of 2 and utilized a diuretic. * On 1/5/14 at 8:00 P.M., the resident was trying to get to the bathroom independently, tuned off the alarm and slipped and fell to the floor. Even though the resident could not remember to use the call bell and not turn off the alarms, the resident was re-educated in both areas. No new interventions were developed. During observation of the resident on two days of survey, 1/14/14 at 1:00 P.M., 2:15 P.M. and 3:05 P.M. and 1/15/14 at 2:00 P.M. and 3:30 P.M., the resident was in bed sleeping. Interview with Nurse #2 on 1/16/14 at 3:15 P.M., confirmed the use of ineffective interventions which relied on the resident to prevent falls when the resident was identified as being a high risk for falls, having impaired cognition/memory loss, and identified as non-compliant with safety measures. Nurse #2 said that the facility continued to utilize ineffective interventions such as: re-educate the resident to call for assistance, not to self-transfer and not to remove alarms when documentation throughout the investigation indicated the inability of the resident to follow-through in these areas. Nurse #2 said that "We need to become more creative with our interventions." 4. For Resident #18, the facility failed to utilize effective interventions consistent with mental status to protect the resident from repeated falls. The clinical record was reviewed on 1/16/14. Resident #18 was admitted to the facility in 5/2013. [DIAGNOSES REDACTED]. The Falls care plan in place at time of review included: The resident is a high risk for falls relative to dementia, confusion and diminished safety awareness. Goal: Will not sustain serious injury through next review. Interventions implemented, dated 5/12/13: * Anticipate needs. * Personal alarm at all times for safety. * Call light within reach and encourage resident to use for it for assistance as needed. * Chair alarm while in wheelchair. 7/22/13 * Educate resident and family and caregivers about safety reminders. * Educate and remind the resident to request assistance prior to transfer and ambulation. 6/19/13 * Floor mats for side of bed. 7/22/13 * Winged mattress. 10/10/13 * Falling Star program. * Resident to use chair/bed pull alarm. Ensure the device is in place. Educate staff regarding placement. * Physical Therapy (PT) evaluate and treat as ordered or as needed (PRN). 5/12/13 * Toilet after dinner. Walk and place into bed no earlier than 7:30 P.M. 10/14/13 * Use pull alarm when in bed. * Use bedside impact absorbing floor mat next to bed when in bed. 7/22/13 * Use chair pull alarm when in chair/wheelchair. According to physician's orders [REDACTED]. According to the facility Event Report and Investigation, the resident sustained [REDACTED]. * On 6/19/13 at 4:45 A.M., the resident who was described as alert and confused, tried to get out of bed. The bed strip alarm was not on the bed. The resident had removed the personal alarm and was re-educated despite dementia, confusion and diminished safety awareness. * On 7/22/13 at 3:30 A.M., the resident was found rolled in his her blankets having rolled out of bed. This resulted in a swollen left ankle sprain. A new right impact absorbing floor mat was initiated. The intervention was already on the care plan for the same date was: Chair alarm while in wheelchair and Floor mats for side of bed. * On 8/4/13 at 6:00 P.M., (witnessed) the resident was trying to pick something up from the floor. The personal alarm was not on the chair and therefore, an alarm did not sound. The foot-board was not on the wheelchair. It was in the resident's room. The Certified Nurse Aid (CNA) Care Card had as an intervention, foot-board to be used at all times when in the wheelchair. There was no date to indicate when this intervention was initiated. * On 10/10/13 at 9:00 P.M., (witnessed) the resident who was described as confused but pleasant, slid out of bed onto the floor. The alarm was heard. A resident winged mattress was requested. Three staff statements were blank. * On 10/14/13 at 8:00 P.M., the resident was trying to get up and fell . A slight red mark across the resident's bilateral breasts was found secondary to the gait belt used when trying to lift the resident off the floor. There was no indication on the Event Report that staff were re-educated on placement of gait belt when lifting a resident. This fall was the second event in one week. The resident was currently receiving Physical Therapy. Other interventions documented were already in place on the care plan. * On 1/6/14 at 6:00 A.M., the resident was seated across from the Nurse's station and although not witnessed, it was concluded that the resident was reaching down to the floor. The resident was found face down on the floor with the wheelchair tipped over. The alarm was sounding. There was an abrasion noted on the right side of the resident's forehead. New interventions were: alarm on, which was already on the care plan and supervision, which at the time of survey, was not documented on the care plan. The most current Quarterly Minimum Data Set (MDS) of 1/13/14 identified the resident as having a Brief Interview of Mental Status (BIMS) of 10 indicating cognitively intact but memory impaired. The resident required extensive assistance of 2 to ambulate and total assistance of 2 to transfer. The resident was always incontinent of urine requiring extensive assistance of 2 and utilized anti-anxiety medication. * On 1/15/14 at 12:45 P.M., (witnessed) the resident was in the TV room and slid out of the wheelchair. Although it was already on the care plan, a personal alarm was not in place. Intervention documented on Event Report was personal alarm in place. One staff person included in staff statement in response to what may have contributed to the event., "The resident is non-compliant." During observation of the resident on, 1/16/14 at 1:30 P.M., 2:00 P.M. and 3:00 P.M., the resident was in bed sleeping and/or seated in a chair in day room with eyes closed. Alarm was observed to be on bed and wheelchair. Interview with Nurse #2 on 1/16/14 at 3:15 P.M., confirmed the use of ineffective interventions which relied on the resident to prevent falls when the resident was identified as being at risk for falls, having impaired memory loss, and identified as non-compliant. Nurse #2 said that similar to other residents at risk, we cannot rely on impaired residents to follow-through with safety measures. She added that appropriate interventions already in place need to be consistently enforced. 5. For Resident #9, the facility failed to utilize effective interventions consistent with the resident's ability to comply with safety measures secondary to impaired memory, high fall risk and failure of staff to follow-through with safety interventions. The clinical record was reviewed on 1/14/14. Resident #9 was admitted to the facility in 4/2013. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) of 4/25/13, identified the resident as having a Brief Interview of Mental Status (BIMS) of 14 indicating cognitively intact but memory impaired. The resident required extensive assistance of 2 to transfer and extensive assistance of 1 to ambulate. The resident was always incontinent of urine and utilized no psychoactive medications. The Falls care plan in place at time of review included: The resident is high risk for falls secondary to [DIAGNOSES REDACTED]. Goals: Will not sustain serious injury through next review and will comply with safety measures. Interventions: * Anticipate and meet resident's needs. * Call light within reach and encourage to use it for assistance as needed. Needs prompt response to all requests. Box of tissues on bedside table within reach. * Educate resident/family/caregivers about safety reminders and what to do if a fall occurs. * Educate/remind resident to request asstance prior to transfer/ambulation. * Encourage participation in activities and physical activity for strengthening. * Encourage resident to request assistance in ambulating. * Keep adjustable bed in low position for safe transfers. * Evaluate for appropriate adaptive equipment or devices as needed. * Needs safe environment: even floors, glare free light, working and reachable call light, low bed at night, siderails as ordered, handrails on walls, personal items within reach. * Extra blanket when in bed. * Re-educate family relative to safety measures. * Use pressure pad alarm, personal alarm and sensor in bed. According to physician's orders [REDACTED]. According to the facility Event Report and Investigation, the resident sustained [REDACTED]. * On 6/12/13 at 4:30 A.M., the resident was trying to get out of bed without assistance to get bathrobe and fell . The resident was found to be confused and weak. Intervention put in place was to ensure that pressure alarm is working appropriately. A nursing progress note of the same date, indicated that the resident was "up and down all night. The resident has a tendency of removing bed alarms. Is very confused." * On 6/13/13 at 8:45 A.M., (witnessed) the resident took off non-skid socks and slid to floor. Had been told not to get up by self despite documented lack of safety awareness. Probable cause: inability to use call-light secondary to increased anxiety and lack of safety awareness. Second fall within two days. * On 6/16/13 at 3:50 P.M., the resident was brought to the bathroom by a certified nurse aide (CNA) without non-skid socks on and no gait belt. Having had a history of [REDACTED]. The resident tried to stand up with pants to ankles and was soiled and wet. The resident fell secondary to no safety awareness. This fall resulted in a "tennis ball size red area on upper posterior of head." Staff was educated and the resident was to be placed in view of nurse's station when exhibiting no safety awareness and anxiety. This intervention was not added to the care plan. For the above three falls, there was no evidence that the care plan was reviewed or updated. * On 8/26/13 at 9:15 P.M., the resident was left in his/her room alone by a family member and stood up to get a bottle opener and fell . Intervention: The resident was not to be left in room alone unless with staff, family or sleeping. This intervention, although on the Event Report, was not added to the care plan. * On 9/9/13 at 5:30 A.M., the resident was looking for tissues and was found on floor. Intervention added to the care plan: The residents box of tissues was to be placed on bedside table within reach. * On 12/23/13 at 12:15 A.M., the resident rolled out of bed and was found kneeling by bed with skin tear/bruise noted on both knees. Interventions: Mat on floor and mattress with wings. These interventions, although on the Event Report, were not added to the care plan. The Quarterly Minimum Data Set (MDS) of 1/6/14, identified the resident as having a Brief Interview of Mental Status (BIMS) of 15 indicating cognitively intact but memory impaired. The resident required extensive assistance of 2 to transfer and did not ambulate. The resident was always incontinent of urine and utilized a hypnotic for insomnia. During observation of the resident on 1/14/14 at 2:00 P.M. and 3:30 P.M., the resident was seated with other residents in the day room and on 1/16/14 at 1:30 P.M., 2:00 P.M. and 3:30 P.M., the resident was seated in a wheelchair in day room with eyes open and responded when spoken to. However, there was evidence of confusion in the resident's responses as the intent of the response was not clear or intelligible. Interview with Nurse #2 on 1/16/14 at 3:15 P.M., confirmed that the resident, although having had a BIMS of 15, was increasingly confused, forgetful and anxious. Reminders were ineffective for this resident secondary to the above. There was evidence of lack of follow- through with documented safety interventions which contributed to this resident's repeated falls and injury.