Every finding on record at Legacies Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the temperature for the dish machine was at the appropriate temperature of 120 degrees Fahrenheit during the wash cycle according to the manufacturer's guidelines to sanitize dishes appropriately on 03/01/26 through 3/17/26. This failure could place residents who eat from the kitchen at risk of foodborne illnesses.Findings included: During initial kitchen observation on 03/16/2026 at 9:05 am, Dietary Manager was observed running dishwasher and the temperature did not go above 110 during testing. The dietary manager said it had been like that. She said they had the same issues last year. The temperature log hanging next to dishwasher was observed to have multiple temperatures less than 120 F. The dietary manager said the temperature was 118 this morning. There was a label observed on the front of the dish machine which read: .Dishwasher operating requirements 1. Water temp. 120 F. minimum. Chemical test strip tested at 200 ppm, which was within the guidelines. During an observation on 03/16/2026 at 3:33 PM the Maintenance man was observed in the kitchen to check dish machine temperature. He ran machine 4 times before temperature was up to 120.4. During an observation on 03/17/2026 at 9:00 AM the dietary manager was observed checking temperature on dish machine. Temperature came up to 120 after 3 attempts. She said she thought it was ok to run it at a lower temp as long as it was close to 120 F and the chemicals were testing ok. She said she thought the combination of the chemicals and the temp being close enough would sanitize the dishes. Record review of a facility form titled Dish Machine Temperature & Chemical Log dated March 2026 indicated the following below minimum dishwasher temperatures:3/1/26 - Breakfast - 116; Lunch - 116; Dinner - 1153/2/26 - Breakfast - 117; Lunch - 116; Dinner - 1163/3/26 - Breakfast - 116; Lunch - 117; Dinner - 1173/4/26 - Breakfast - 115; Lunch - 116; Dinner - 1163/5/26 - Breakfast - 117; Lunch - 116; Dinner - 1153/6/26 - Breakfast - 115; Lunch - 116; Dinner - 1153/7/26 - Breakfast - 116; Lunch - 116; Dinner - 1163/8/26 - Breakfast - 115; Lunch - 116; Dinner - 1163/9/26 - Breakfast - 116; Lunch - 115; Dinner - 1153/10/26 - Breakfast - 114; Lunch - 1153/11/26 - Breakfast - 114; Lunch - 112; Dinner - 1183/12/26 - Breakfast - 115; Lunch - 116; Dinner - 1163/13/26 - Breakfast - 114; Lunch - 116; Dinner - 1163/14/26 - Breakfast - 116; Lunch - 116; Dinner - 1163/15/16 - Breakfast - 115; Lunch - 115; Dinner - 1153/16/26 - Breakfast - 117; Lunch - 117; Dinner - 1163/17/26 - Breakfast - 115and the bottom of the form read .low temperature machines: >120 F. & 50ppm (minimum) . During an interview on 03/18/2026 at 10:23 am the dietary manager said she had done an in-service with dietary staff, and they would now be expected to run the dishwasher until it reached 120 degrees Fahrenheit or above. She said if they cannot get it above minimum temp, she expected staff to notify maintenance or administrator. She said maintenance would be working on fixing the backflow issue which was what they believed was causing the problem. She said if minimum temperature was not reached, the dishes may not be clean or sanitized, and residents could be at risk of contamination. During an interview on 03/18/2026 at 10:30 am the Administrator said she expected her staff to run the dishwasher until the temperature was at least 120 degrees. She said going forward, the dietary staff were expected to notify her or maintenance if minimum temperature was not reached. She said residents could be at risk of infection if dishes were not properly sanitized. Record review of a facility policy titled Cleaning Dishes/Dish Machine dated 2017 read: .All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing . and .Prior to use, verify proper temperatures and machine function . and .Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation . and .low temperature dishwasher spray type dish machines using chemicals to sanitize .wash temperature .120 F . Record review of the manufacturer's instructions retrieved at https://www.autochlor.com/commercial-dishmachines/ on 3/17/26 for Auto- Chlor Dishwasher operating requirements for low temp dish machine indicated the wash cycle is supposed to reach 120 degrees. Low Temperature Dishwasher (chemical sanitization): Wash - 120 degrees F.

Based on observations, interviews, and record review, the facility failed to ensure that each resident had a right to privacy during medical care for 1 of 6 residents (Residents #73) observed for privacy.The facility failed to ensure full visual privacy during incontinent care for Resident #73 on 03/16/2026. This deficient practice placed residents at risk of loss of privacy and dignity.The findings were:Record review of a facility face sheet dated 03/16/2026 indicated Resident #73 was an [AGE] year-old female and admitted to the facility on [DATE] with a diagnoses of dementia (severe memory loss), anxiety disorder (nervousness), and Alzheimer's disease (severe cognitive decline causing memory loss).Record review of an annual MDS assessment dated [DATE] indicated Resident #73 had a BIMS score of 04 indicating severe impairment of cognition and was incontinent of urine and bowel requiring total assistance with toileting.Record review of the care plan dated 02/20/2026 indicated Resident #73 had an ADL (activity of daily living) function disorder and to assist with ADLs as needed. During an observation of incontinent care on 03/16/2024 at 9:43 am this state surveyor knocked on the door and asked permission to enter. Permission was granted. Resident # 73 was being prepared for incontinent care by CNA A. The privacy curtain was pulled around Resident #73. Resident #73 was unclothed from the waist down exposing her buttocks. NA B knocked and asked to enter the room, she left the door open and drew back the curtain to speak with CNA A. She stood at the open doorway with the curtain pulled back potentially exposing resident #73 to the hallway while other staff members walked down the hallway. During an observation and interview on 03/16/26 at 10:00 am NA B knocked and asked to enter the room, she left the door open and drew back the curtain to speak with CNA A, for the second time. She stood at the doorway with the curtain pulled back exposing resident #73 to the hallway. CNA A made big eyes (a disapproving facial expression) at NA B. CNA A said that NA B should have come into the room and shut the door due to having the door open and the curtain pulled back was exposing Resident #73 to the hallway and any possible passersby. CNA A said that it was a dignity and privacy issue having the door open, the curtain pulled open. CNA A said she had been trained in privacy and dignity and realized NA B had not maintained privacy for Resident #73. NA B said she was a new nurse aide in training and had only worked at the facility for a few weeks. NA B said she had received training on dignity and privacy during her orientation. NA B said that it could make Resident #73 feel bad if her privacy was not maintained. During an interview on 03/17/2026 at 2:30 pm the DON said if privacy was not maintained, and a resident was exposed during personal care it could cause embarrassment. The DON said NA B was trained on resident rights and privacy during her orientation in February. During an interview on 03/17/2026 at 2:45 pm the Administrator stated she expected everyone in the facility to be trained, follow resident rights, treat all residents with dignity, and maintain privacy. She stated by not doing so could cause resident embarrassment. During an interview on 03/17/2026 at 3:00 pm the ADON said she was responsible for competency checks for the nurses and aides. She said that NA B had been trained on resident rights to include providing privacy during personal care by closing the window covering, pulling the curtain, and closing the door to the room. She said if privacy was not maintained, and a resident was exposed during personal care it could cause embarrassment. Record review of training and orientation logs indicated NA B received resident rights, dignity and privacy training on 02/18/2026. Record review of a facility policy titled Dignity revised February 2021 indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 11). Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) and 1 of 7 staff (MA C) reviewed for infection control. The facility failed to ensure MA C followed contact precautions for Resident #1 on 3/16/2026. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings include: Record review of Resident 1's facility face sheet, dated 3/18/2026, indicated Resident #1 was an [AGE] year-old female, readmitted [DATE], with diagnosis of diabetes. Record review of Resident #1's quarterly MDS assessment, dated 01/30/2026, revealed a BIMS score of 09 that indicated Resident #1 had moderately impaired cognition. She was dependent on staff for all ADLs and was always incontinent of bowel and bladder. Record review of Resident #1's comprehensive care plan, revision date 02/16/2026, indicated Resident #1 had a history of recurrent urinary tract infections, required contact precautions and to ensure PPE was worn prior to entering room. Record review of Resident #1's order summary report, dated 3/18/2026, indicated Resident #1 had an order dated 3/16/2026 for contact precautions for urinary tract infection. During an observation on 3/16/2026 at 12:30 pm, Resident #1 had a sign posted on her door indicating contact isolation and PPE gloves and gown were required before entering the room. MA-C was present in the room, sitting on Resident #1's bed assisting with her meal. MA C was not wearing PPE. During an interview on 3/16/2026 at 12:33 pm, LVN D said that Resident #1's urine culture came back that morning and was positive and contact isolation was initiated. She said that the staff and visitors were made aware of the isolation requirement using the sign posted on the resident's door. She said that PPE of gloves and gown should be applied prior to entering the room and removed prior to leaving the room. She said that by not following the infection process for contact isolation could cause the spread of infections. During an interview on 3/16/2026 at 1:58 pm, MA-C said that when a resident was in contact isolation a gown and gloves should be put on before entering the residents room. She said she had overlooked the sign on Resident #1's door because the order had come in that morning. She said she should have had on PPE and not sat on the resident's bed to prevent cross contamination in the facility. During an interview on 03/18/2026 at 11:06 am, the DON said that she was the infection preventionist and responsible for the infection control program in the facility. She said that when a resident required isolation the nurse was notified, biohazard boxes were placed in the room, and a sign was posted on the door notifying all staff and visitors of the isolation. She said she then would verbally notify the staff working. She said it was the staff's responsibility to recognize the isolation sign on the door and follow the guidelines for that type of isolation. She said MA C had been trained on infection control measures and following contact precautions. She said with contact isolation the staff were to put on a gown and gloves before entering the resident's room, remove the gown and gloves and wash their hands prior to leaving the resident's room. She said by not following the contact isolation process infections could spread. During an interview on 03/18/2026 at 11:57 am, the Administrator said the DON was responsible for the infection control program to include training on hire, annually and as needed as things changed. She said the staff should recognize the isolation sign on the door and follow the guidelines set for that isolation to prevent the spread of infections. She said she expected the facility's policy and procedures for infection control always be followed. Record review of a facility policy titled Isolation -Categories of Transmission-Based Precautions dated September 2022 indicated, .Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.7. Staff and visitors wear gloves (clean, non-sterile) when entering the room.a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves are removed and hand hygiene performed before leaving the room c. staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Record review of a facility policy titled Isolation - Initiating Transmission-Based Precautions dated August 2019 indicated, .Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. 3.When transmission-based precautions are implemented, the infection preventionist (or designee): a. clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used; b. explains to the resident ( or representative) the reason( s) for the precautions; c. provides and/or oversees the education of the resident, representative and/or visitors regarding the precautions and use of PPE; d. determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions: (I)The sign age informs the staff of the type of CDC precaution ( s ), instructions for use of PPE, and/or instructions to see a nurse before entering the room.

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 2 of 12 residents reviewed for accident hazards. (Resident #50 and #63). 1.The facility failed to develop and implement a policy and procedure to properly handle the care of mechanical lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service for Resident #50. 2. NA D failed to properly transfer Resident #63 on 01/14/2025. These deficient practices could place residents at risk of falls and injuries during transfers. The findings included: 1.Record review of a facility face sheet dated 01/14/2025 indicated Resident #50 was an [AGE] year-old male that admitted to the facility on [DATE] with cerebral infarction (brain damage due to death of tissue), muscle weakness, and hemiplegia affecting left side (paralysis of the left side). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #50 had a BIMS score of 14 indicating intact cognition, impairment of left extremities, and dependent for all transfers. Record review of a comprehensive care plan revised 11/08/2024 indicated Resident #50 required two staff members for transfers. During an observation on 01/13/2025 at 12:15 p.m. Resident #50 was sitting in sitting in a Geri-chair with a lift sling underneath his buttocks, the sling was frayed on the edges with edging splitting from the body, straps were faded in color, the care tags were illegible, torn, crinkled, and [NAME]. During an observation and interview on 01/14/2025 at 8:15 a.m., a mechanical lift sling hanging in linen closet 300 hallway was faded and the care tag is illegible. Nurse Aide A said he worked at the facility since November 2024 and was training to become a certified nurse aide. Nurse Aide A was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. Nurse Aide A said that if a sling was not available on the hallway, he would go to the linen storage closet and retrieve one for use. Nurse Aide A said the resident could suffer an injury or could be scared to get up with a lift if they were dropped. Nurse Aide A said he had received training to remove lift slings if they are coming unsewn or had tears. During an observation and interview on 01/14/2025 at 8:30 a.m., of the laundry area revealed Hoyer slings were being actively washed in the laundry room. Laundry staff B said she has worked at the facility for one year and been trained on how to wash the mechanical lift slings. Laundry staff D said she washes them when soiled without bleach and hangs to dry. Laundry staff D was not aware the manufacturer recommended for the Hoyer slings to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. During an interview on 01/14/2025 at 8:30 a.m., CNA C said mechanical lift slings should be taken out of service of service if they have tears, holes signs of coming unsewed. CNA C said she had worked at the facility three years and received training of Hoyer lift safety and when to take Hoyer slings out of service. She said the risk to the resident of a damaged sling was used to transfer a resident could be an injury if dropped from the sling. During an Interview on 01/14/2025 1:00 p.m., the DON said that the staff had received education on when to remove Hoyer. The DON said she had removed two Hoyer slings from service before the survey started and she would find the Hoyer sling that was used for Resident #50 and take it out of service. The DON said the risk to the resident was injury if the Hoyer sling failed during a transfer. During an interview on 01/14/2025 at 3:30 p.m., the Administrator said that lift slings are discarded according to the facility policy and manufacturer's suggested guidelines which is that the slings are discarded when the slings show signs of wear or any tears. The administrator said that the CNAs are to inspect the slings for any signs of rips or tears prior to using the sling. She said that the DON also inspects the slings and replaces any slings with signs of wear and tear with new slings. She said that moving forward staff will be inspecting for rips, tears, and fading. She said that residents are at risk for injury if a sling does not function properly. A record review of Full Body Slings- Medline, Instructions for use www.medline.com accessed 01/14/2025 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use Sling maintenance best practices .Check condition before each use. If there is any fraying or visible wear and tear, do not use . Reusable slings should be replaced every six months. Follow care instructions on wash tag. If illegible, do not use. Keep at least two reusable slings per patient on hand-one available and one in the laundry. A record review of a facility policy for Lifting Machine, using a Mechanical dated July 2001 indicated .Sling Care: 8. Make that all necessary equipment (slings, hooks, chains, straps, and supports) is on hand and in good condition. A record review of a facility assessment dated [DATE] indicated . Physical Equipment is checked as needed by maintenance department. Nursing department checks medical equipment before use. 2. Record review of Resident #63's face sheet dated 01/14/2025 revealed she was [AGE] year-old female and admitted on [DATE] with diagnoses hypertensive heart disease (heart condition caused by high blood pressure) and Parkinson's (age-related degenerative brain condition). Record review of Resident #63's Quarterly MDS assessment dated [DATE] revealed she scored a 99 on her BIMS and a staff assessment for mental status was completed and indicated moderately impaired cognitive skills for daily decision-making. Record review of Resident #63's comprehensive care plan dated 11/15/2024 revealed she had an ADL Self Care Performance Deficit and required assistance of 2 staff for transfers. During an observation on 01/14/2025 at 8:20 AM, NA D was observed in Resident # 63's room preparing for a transfer. NA D positioned Resident #63 on the side of the bed. NA D then placed her arms under Resident #63's arms and manually lifted her into her wheelchair. During the transfer Resident #63 did not bear weight or pivot and was full weight bearing on NA D. NA D placed Resident #63 in her wheelchair and then placed her arms back under Resident #63's arms and lift again to position in wheelchair. During an interview on 01/14/2025 at 8:36 AM, NA D said she started at the facility in December 2024 and had completed her training for transfers by the therapy department. She said she thought Resident #63 was a 1 person transfer and she could transfer manually or by a gait belt. She said a residents needed care level was on the care plan Kardex and she should have checked her ADLs at the start of her shift. She said if a resident could not bear weight, she should use a gait belt or two people and should have used a gait belt for Resident #63. She said most days the resident could bear weight and not sure why she did not today but had told the nurse. She said by transferring incorrectly it could cause falls or injuries. During an interview on 01/14/2025 at 3:51 pm, LVN E said she was the charge nurse for Resident #63 and responsible for oversight of the nurse aides on the hall. She said Resident #63 required assistance with all ADL's. She said in the past Resident #63 was a one person assist with transfers, but the nurse aides had reported at times that Resident #63 did not stand and bear weight and that her care plan had changed to a two person assist. She said the MDS coordinator updated the care plans and would notify the charge nurses of the changes, but it was the nurses and nurse aides' responsibility to check the care plan every day for any changes. She said if a resident was transferred incorrectly, it could cause falls or injuries. During an interview on 01/14/2025 at 4:00 pm, the MDS Coordinator said she was responsible for updating care plans. She said when Resident #63 had her care plan revised in November 2024 her transfer status had changed from one person to two person. She said the charge nurses and nurse aides should check the care plan Kardex daily as resident care changes could occur daily. She said that residents that are transferred incorrectly could have falls or injuries. During an interview on 01/14/2025 at 4:05 pm, the DON said all nurse aides were trained on hire how to check the care plan Kardex and properly transfer residents. She said the facility utilizes the therapy department to determine the transfer ability of the resident and if a resident requires a two-person transfer than that was how the resident should be transferred. She said the charge nurses were responsible for oversight of the nurse aides and she and the ADON evaluate their performance through competency checks. She said NA D had completed a transfer training in the last 2 weeks. She said a resident could be injured or fall if incorrectly transferred. During an interview on 01/14/2025 at 4:10 pm, the Administrator said the DON was responsible for oversight of the nursing department. She said the DON and ADON complete competency checks on the nurse aides on hire, as needed and annually. She said the nurses and nurse aides should be following the care plan for ADL's daily and expected each resident receive the care they need and require ensuring safety. She said if a resident was transferred incorrectly a fall or other injury could occur. Record review of a nurse aide proficiency check dated 12/20/24 revealed NA D had demonstrated competency on transfers and ADL care. Record review of an in-service training reported dated 01/03/2025 revealed NA D had received training on transfer technique from therapy department. Record review of a facility policy titled Safe Lifting and Movement of Residents dated July 2017 indicated, .in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . 46436

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 staff (CNA G, CNA Q, CNA N) and for 2 of 5 residents reviewed for infection control (Resident #9 and Resident #45). 1. The facility failed to ensure MA P wore gloves when administering eye drops to Resident #45. 2. The facility failed to ensure the Treatment nurse used a clean gauze pad to dry a wound for Resident #9. 3. The facility failed to ensure CNA G, CNA Q, and CNA N washed or sanitized their hands when passing out meal trays to residents on Hall 200 and Hall 300. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1.Record review of a facility face sheet for Resident #9 dated 12/20/2023 indicated that she admitted to the facility on [DATE] with diagnosis of complication of nephrostomy catheter (tube draining fluid from kidneys). Record review of a Comprehensive MDS dated [DATE] for Resident #9 indicated that she had no cognitive impairment with a BIMS score of 15. Bowel and Bladder section of MDS was answered yes for indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of a physician order report dated 12/20/2023 for Resident #9 indicated that she had a physician's order stating: Clean around Nephrostomy catheters to lower back with SNS,(sterile normal saline), pat dry then leave open to air. May apply a dry dressing qd (every day) if sites have any drainage with order start date of 1/13/2023. Record review of a Care Plan for Resident #9 dated 10/12/2023 indicated that Resident #9 had a surgical site to both right and left flank where Nephrostomy tubes exit, with interventions to monitor sites for signs and symptoms of infection and report to MD. During an observation and interview on 12/19/2023 at 3:55 pm, the Treatment Nurse was observed performing wound care to Resident #9's nephrostomy tubes. She washed her hands before beginning treatment. She placed a plastic trash bag on the bed next to resident to discard supplies in while performing care. When she was finishing wound care, she dropped a clean 4x4 gauze pad into the trash bag. She reached to grab it back out of the bag, hesitated, then continued to pick it up and patted the wound dry with it. During an interview on 12/19/2023 at 4:15 pm, the Treatment Nurse said that she should not have picked the gauze up out of the trash to pat the clean wound dry with. She said that this could be an infection risk to the resident. 2.Record review of a facility face sheet dated 12/19/2023 for Resident #45 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atrioventricular block (when the electrical signal that controls your heartbeat is partially or completely blocked) and hypertension (high blood pressure). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #45 indicated she had moderate impairment in thinking with a BIMS score of 11. During an observation on 12/19/2023 at 8:20 am MA P was observed administering eye drops to Resident #45. She did not wear gloves during administration. During observation of meal service on 12/18/2023 at 11:45 AM, CNA Q took meal tray into room [ROOM NUMBER] and repositioned resident to sitting position on side of bed and moved bedside table in position with tray on top of table. CNA M did not wash or sanitize hands prior to exiting room or handling meal tray for next room, 306. CNA did not sanitize hands prior to passing tray to room [ROOM NUMBER] or after setting up tray on bedside table. During observation of meal service on 12/19/2023 at 12:30 PM, CNA G and CNA N were passing trays on hall 200. CNA G entered rooms [ROOM NUMBER] and was touching bedside tables while setting up meals. CNA G did not wash or sanitize hands upon exiting rooms or prior to serving trays from the cart in the hallway. CNA N was passing a tray to room [ROOM NUMBER] and did not wash or sanitize hands before or after serving and setting up tray. During an interview on 12/18/2023 at 12:23 PM with CNA Q said the staff were to use hand sanitizer before getting the tray and after serving. She stated she had hand sanitizer in her pocket but just did not use it. CNA A stated that germs could be passed to other residents if their hands were not sanitized during meal service. During an interview on 12/20/2023 at 10:30 am MA P said that she did not wear gloves when administering the eye drops. She said that she had been nervous, but that she should have worn gloves to prevent infection. During an interview on 12/20/23 at 01:40 PM, the Administrator said the staff were expected to wash or sanitize their hands if an object that was touched by the resident was touched by the staff while passing trays, and they should be sanitizing or washing their hands when they exited the room or were picking up the next tray. Administrator stated that the expectation for the staff ws to follow the policy and to sanitize their hands after any contact with the residents or anything touched by the resident. During an interview on 12/20/2023 at 01:54 PM, the DON stated that staff were expected to sanitize their hands between each tray and if their hands were visibly soiled. The DON stated they were expected to wash their hands with soap and water. DON stated that she expected the staff to follow hand washing and hand sanitizing policy while performing all duties. DON stated that she would be doing additional training and observations with staff. During an interview on 12/20/2023 at 2:30 pm Administrator said that the facility would be implementing education regarding proper procedures. She said that there was a new treatment nurse, and she would also be receiving more education regarding proper procedures. She said that they may shadow her for a while to ensure proper technique was followed. She said that residents were at risk of developing infection if proper wound care techniques are not followed. During an interview on 12/20/2023 at 2:50 pm DON said that she expected her staff to follow policy when passing medications, which included wearing gloves when administering eye drops. She said that residents could be at risk of developing an eye infection if staff did not wear gloves. Record review of a facility policy titled Nephrostomy tube, long term care of dated 1/12/2023 read .After cleaning, dry each area with a fresh 4 x 4 gauze . Record review of facility policy titled Instillation of Eye Drops dated January 2014 read .Steps in the Procedure .2. Wash and dry your hands thoroughly, 3. Put on gloves . Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2019 indicated .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; l. After contact with objects (e.g., medical equipment) in immediate vicinity of the resident; p. Before and after assisting a resident with meals. Record Review of nurse aide proficiency indicated that Handwashing procedural guideline demonstration was completed correctly for CNA G on 7/7/2023, CNA N on 2/9/2023 and CNA Q on 2/9/2023. 49017

46273 46436 Based on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 4 of 6 Residents (Resident #49, Resident #56, Resident #67, and Resident #76) reviewed for PASSAR (Preadmission Screening and Resident Review Services) in that: 1. The facility failed to ensure Resident #49 had a PASSAR level II evaluation completed with a diagnosis of psychotic disorder (abnormal thinking and perceptions). 2. The facility failed to ensure Resident #56 had a new level 1 PASSAR completed with a new diagnosis of schizoaffective disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). 3. The facility failed to ensure Resident #67 had a new level 1 PASSAR completed with a new diagnosis of Post-Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). 4. The facility failed to ensure Resident #76 had a new level 1 PASSAR completed with new diagnosis of psychotic disorder with hallucinations. These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life. Findings: 1. Record review of an Admission Record for Resident #49 dated 12/20/23 indicated she admitted to the facility on [DATE] and was [AGE] years old with a primary diagnosis of multiple fractures of pelvis, and other diagnoses included psychotic disorder, GERD (acid reflux) and dementia (a progressive or persistent loss of thinking). Record review of a Significant Change MDS assessment dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 8. She had diagnoses of non-Alzheimer's dementia, anxiety disorder, and psychotic disorder. A referral was not made to the local contact agency. Record review of a care plan for Resident #49 dated 7/28/2022 indicated she had impaired cognitive function/dementia or impaired thought processes. Record review of a physician order for Resident #49 dated 7/24/2023 indicated a new diagnosis of psychotic disorder with delusions was added. Record review of a PL1 (PASSAR Level I) for Resident #49 dated 6/13/2022 indicated she was not positive for MI, ID, or DD. Record review of a Form 1012 for Resident #49 dated 12/20/2023 indicated that she had a primary diagnosis of dementia and the PL1 remained negative and no new PL1 needed to be completed. The form did not have the required physician signature. 2. Record review of a facility face sheet dated 12/20/203 for Resident #56 indicated that she was admitted to the facility on [DATE] with diagnoses of disorder of bone density (weakened bones). Record review of a Comprehensive MDS dated [DATE] for Resident #56 indicated that she had no cognitive impairment with a BIMS score of 15. Record review of a psychiatric note dated 07/05/2023 for Resident #56 indicated that new diagnosis of schizoaffective disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) was added. Record review of a PASSR Level 1 screening dated 6/13/22 for Resident #56 indicated that she was negative. No new evaluation was done after new diagnoses were added on 7/5/2023. 3. Record review of a facility face sheet dated 12/20/2023 for Resident #67 indicated that she was admitted to the facility on [DATE] with diagnoses of myocardial infarction (heart attack). Record review of a Comprehensive MDS dated [DATE] for Resident #67 indicated that she had no cognitive impairment with a BIMS score of 15. Record review of a psychiatric note dated 4/26/2023 for Resident #67 indicated that new diagnoses of Major Depressive Disorder and Post-traumatic Stress Disorder. Record review of a PASSR Level 1 screening dated 1/6/23 for Resident #67 indicated that she was negative. No new evaluation was done after new diagnoses were added on 4/26/2023. 4. Record review of facility face sheet dated 12/19/2023 revealed Resident #76 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of Parkinson (chronic and progressive movement disorder). Record review of significant change MDS dated [DATE] revealed had an anxiety disorder and hallucination diagnosis, and no referral to local contact agency. Record review of medical diagnosis list revealed Resident #76 was diagnosed with psychotic disorder with hallucinations and delusions on 07/24/2023 by a psychiatrist. The facility did complete a new PASSAR level 1 with new qualifying diagnosis until 12/18/2023. Record review of Resident #76's PASSAR level 1 completed prior to admission on 07/03/2023 was negative. During an interview on 12/19/23 at 03:30 pm, the ADON stated she had been completing PASSAR since July 2021. She stated she was trained on completing PASSAR, but she was not aware that a new level 1 PASSAR had to be completed with new identified qualifying diagnosis. She stated the psychiatrist gave the residents the new diagnosis and she added the new diagnosis but missed the need to for a new level 1 PASSAR and PASSAR evaluation. She stated by not completing PASSAR correctly with new identifying diagnosis could affect resident receiving needed services. During an interview on 12/19/23 at 4:03 pm, the DON stated that she had trained the ADON on PASSAR submission. She stated when a new qualifying diagnosis was received from a physician, then form 1012 had to be completed and a new level 1 had to be submitted if dementia was not the primary diagnosis. She stated there had not been any formal training and she did not have a system for monitoring that PASSAR was completed accurately. She stated if residents identified with a qualifying diagnosis were not accurately assessed for PASSAR, it could affect residents receiving services. During an interview on 12/20/2023 at 8:45 AM, the DON and MDS Coordinator both said the MDS nurses were responsible for coordinating with PASSR services. They said that the MDS nurses and DON were responsible for entering new diagnosis given by the physicians or from hospital stays. They both said the care plans should be updated to reflect the new diagnosis, submit the form 1012, and follow the steps if a new PL1 was needed. The DON said going forward she would in-service staff, pay more attention to diagnoses, and update the PL1 per protocol. The DON said residents could be at risk of not being able to receive appropriate services for mental illness. During an interview on 12/20/23 at 9:11 am, the Administrator stated the ADON was responsible for making sure residents with new qualifying diagnosis get a new PASSAR completed. She stated the ADON was trained by the DON, and she should have known to complete the paperwork for the residents with new qualifying diagnosis. She stated the risk could be missed services under PASSAR and (he/she) expected that all residents were appropriately assessed for PASSAR prior to and during admission at the facility. She stated they did not have a facility policy for PASSAR and used the guidelines from Health and Human services for completing PASSAR level 1 and referring entities. Record review of document titled Detailed item by item guide for referring entities to complete the PASRR Level 1 screening form dated June 2023. The document did not include information regarding the facility completing a new PASRR level 1 for residents that receive a new qualifying diagnosis.

46436 Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Resident #1 and Resident # 24) reviewed for quality of care. The facility failed to ensure Residents #1 and 24's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings: 1. Record review of facility face sheet dated 12/21/2023 revealed Resident #1 was a [AGE] year-old female that admitted on [DATE] with diagnosis of chronic kidney disease and urinary tract infection (UTI). Record review of annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12 indicating moderate impairment in thinking. Indwelling catheter was new and was not present at time of MDS. Record review of comprehensive care plan dated 11/20/2023 revealed Resident #1 did not have indwelling catheter at time care plan was updated. Record review of the physician order dated 12/17/2023 revealed Resident #1 may have an indwelling catheter and to record output every shift. There was no order to check for catheter securement device. Record review of nurses note dated 12/17/2023 revealed Resident # 1 returned from the hospital on 12/17/23 with an indwelling catheter due to a UTI. During an observation and interview on 12/18/23 at 2:00 pm, Resident #1 had an indwelling catheter present in a privacy bag and tubing was not secured with a securement device. Resident # 1 stated she was at the hospital over the weekend, and they put the catheter in because she had an infection. During on observation on 12/19/2023 at 10:48 am, Resident # 1 received catheter care by CNA C and CNA D. Resident # 1 did not have a catheter tubing securement device in place. During an interview on 12/19/2023 at 10:55 am, CNA C stated she was not sure about the securement device, the nurses put those on, but she would find out. During an interview on 12/19/2023 at 10:57 am, Resident #1 stated the catheter was heavy and pulling and was causing discomfort. During an interview on 12/19/23 at 11:02 am, LVN A stated Resident # 1 came back from the hospital with an indwelling catheter and the nurse was responsible for checking the catheter every shift to ensure it was patent (unobstructed) and a securement device should have been in place to prevent discomfort from pulling and irritation. She stated she would reassess Resident #1 to ensure a securement device was in place. During an interview on 12/20/23 at 09:16 am LVN B stated she was responsible for catheter assessments, and she assessed Resident #1 the morning of 12/18/2023 and there was a securement device in place. She stated Resident #24 did not have a securement device and she missed that she did not have one. She stated there was no specific order for checking for the securement device, she just checked the catheter for patency. She stated by not having a securement device for the catheter tubing it could cause pulling, irritation, discomfort, infections, and dislodgement. 2. Record review of an Admission Record dated 12/20/2023 for Resident #24 indicated he admitted to the facility on [DATE] and was [AGE] years old with a diagnosis of hypothyroidism (thyroid gland does not produce enough thyroid hormone), type 2 diabetes, dementia (a progressive or persistent loss of thinking) and hypertension (high blood pressure). Record review of a Significant Change MDS assessment for Resident #24 dated 10/27/2023 indicated he was unable to complete the interview with a BIMS score of 99 and he had an indwelling catheter. Record review of a care plan undated for Resident #24 indicated he had an indwelling catheter with foley care to be provided every shift and prn. Interventions to ensure tubing was anchored to the resident's leg or linens so that tubing is not pulling on the urethra. Record review of active physician orders for Resident #24 indicated an order to change foley catheter stabilization device in place every 7 days with a start date of 12/20/2023. Record review of a Treatment Administration Record (TAR) for Resident #24 for 12/1/2023 to 12/31/2023 indicated a treatment order for foley catheter care every shift and as prn was completed daily as indicated by checkmarks and staff member's initials from December 1, 2023 to December 20, 2023. During an observation on 12/19/2023 at 9:52 AM, CNA J and CNA E were in the room of Resident #24 to provide incontinent and foley catheter care. Resident #24 had an indwelling catheter in place that was not anchored to his thigh using a tubing securement device. During an observation and interview on 12/19/2023 at 3:55 PM, CNA E was in the room of Resident #24. The Surveyor questioned CNA E if Resident #24 had a tubing securement device for his indwelling catheter and she pulled down the linens to look at his foley catheter. Resident #24's indwelling catheter was not secured and was positioned on the left side of bed with privacy bag noted. CNA E said the nurses were responsible for ensuring the foley catheters were anchored. During an interview on 12/19/2023 at 4:05 PM, LVN F said she had been employed at the facility for 2 years on the 6a-6p shift. She said the nursing staff alternated halls daily and today 12/19/2023 she was assigned to the hall for Resident #24. She said Resident #24 was the only resident on hall 100 that had a foley catheter. She said normally residents with foley catheters should have them anchored to the resident's thigh. She said it was not listed on the TAR for the foley catheters to be anchored and it only indicated for foley catheter once per shift. She said they normally placed anchors for the catheters but did not know if they were out of them at the facility. She said residents could get a tear especially for men if the catheters were not anchored. During an interview on 12/20/23 at 09:05 am, the DON stated LVN B was responsible for assessing residents with indwelling catheters to ensure there was a securement device in place. She stated the charge nurse should also assessed the securement device on each shift to ensure the resident was not having any discomfort or pulling of the tubing. She stated she expected every resident with an indwelling catheter to have a securement device. During an interview on 12/20/23 at 09:09 am, the Administrator stated the nursing staff were responsible for ensuring catheters were secured and in place. She stated by not having a device it could cause discomfort, infections, and dislodgement. She stated she expected each resident with a catheter to have a securement device. Record review of facility policy titled Catheter Care, Urinary dated August 2022 indicated, .ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site .

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team had determined that self-administration of medications by a resident was clinically appropriate for 1 of 4 (Resident #34) residents reviewed for resident rights, in that: The facility failed to assess, obtain physician orders, and interdisciplinary team approval for Resident #34 to self-administer his Ventolin inhaler. This failure placed the resident at risk of not receiving the proper medication or the therapeutic benefits of medications. Findings: Record review of facility face sheet dated 12/19/2023 revealed Resident #34 was a [AGE] year-old male that admitted to the facility on [DATE] for diagnosis of chronic obstructive pulmonary disease (COPD) (lung disease affecting breathing). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #34 had a BIMS score of 15 indicating intact cognition. Record review of physician order dated 11/04/2019 revealed an order for Ventolin aerosol solution 90 mcg 2 puffs inhale orally every 8 hours as needed for COPD. The order did not indicate Resident #34 could self-administer. Record review of Resident #34's comprehensive care plan dated 11/20/2023 did not reveal a care plan was developed for Resident #34 to self-administer medications. During an observation and interview on 12/18/23 at 09:28 am. Resident #34 had a Ventolin inhaler at his bedside and stated he was safe to use his inhaler when he needed it and had an order to keep it on him. He stated the staff told him to keep it on him for safety and let them know when he needed a new one. During an interview on 12/19/23 at 10:29 am, LVN A stated Resident #34 was able to self-administer his inhaler and was deemed competent to do so. She stated if a resident was assessed to be able to safely self-administer medications, there should be an order and it should be put on their care plan. She stated she was not aware Resident #34 did not have an order or that it was not on his care plan. She stated if residents were self-administering medications without properly being assessed it could affect their wellbeing and receiving proper medication dose. During an interview on 12/19/2023 at 2:03 pm, the ADON stated she was responsible for completing the assessment and care plan for a resident to self-administer medications if they wished to do so. She stated Resident #34 should have had an order for self-administration of medications and it should have been on his care plan because he has expressed desire to use his inhaler when he needed it. She stated by not properly determining that resident could self-administer their meds could affect their overall health and medication effects. During an interview on 12/20/23 at 08:50 am, the DON stated the ADON was to complete the resident assessments on admission, quarterly and as needed for safe self-administration of medication. She stated if the resident was deemed safe, an order was obtained for self-administration of medication and the care plan was updated. She stated the charge nurse was responsible for monitoring the medication left at the bedside. She stated if residents were not accurately assessed, and the resident was self-administering medications it could cause adverse effects to medications. She stated she expected all residents to be accurately assessed for safe self-administration of medications before meds are left at the bedside. During an interview on 12/20/23 at 09:13 am, the Administrator stated nursing staff were responsible for assessing residents for self-administering medications. She stated the ADON assessed residents that wished to self-administer medications and if safe administration was determined there should be an order and IDT (interdisciplinary team) should do a care plan. She stated if a resident was not accurately assessed before self-administering medications, it could cause inappropriate medication administration and drug interactions. She stated she expected each resident to be accurately assessed and documented appropriately before allowing resident to self-administer medications. Record review of facility's policy titled Self-Administration of Medications dated February 2021 indicated, .if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan . Record review of facility's policy titled Resident Self Determination and Participation dated August 2022 indicated, .self-administer medications if the IDT care planning team determines it to be safe .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 2 of 7 resident's (Resident #21 and 38) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure the refrigerator for Resident #21 did not contain strawberry and chocolate boostdated [DATE] and [DATE] and a plastic container with something orange that was undated. The facility failed to ensure the refrigerator for Resident #38 did not contain chocolate boost and a bowl of pot pie that was undated. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a facility policy titled Personal Property undated indicated, .Residents are permitted to bring personal property and use personal possession to create a home-like environment. 3b. Personal refrigerators. v. Staff must discard food from refrigerators that show obvious signs of potential foodborne danger, and/or is beyond expiration date . Record review of a facility policy titled Foods Brought by Family/Visitors with a revised dated [DATE] indicated, .Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. 6. The nursing staff will discard perishable foods on or before the use by date . 1. Record review of an Admission Record dated [DATE] for Resident #21 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (progressive or persistent loss of thinking), parkinsonism (characterized by tremor, slow movements and stiffness), anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues), and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of a Quarterly MDS Assessment for Resident #21 dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 9. She required supervision with eating and the assistance of setup help only. Record review of a care plan for Resident #21 dated [DATE] indicated she had a personal refrigerator in room. Interventions included for housekeeping to check it weekly for outdated food and discard. Record review of an active physician order for Resident #21 dated [DATE] indicated an order for a personal refrigerator. During an observation on [DATE] at 9:52 AM, Resident #21's personal refrigerator had two bottles of strawberry boost dated [DATE] and two bottles of chocolate boost dated [DATE] and a plastic container with something orange that was undated. 2. Record review of an Admission Record for Resident #38 dated [DATE] indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of postherpetic polyneuropathy (pain that persists after having shingles), Alzheimer's disease (a progressive disease that destroys memory), dementia, and age-related osteoporosis (brittle, bone disease). Record review of a Quarterly MDS assessment dated [DATE] for Resident #21 indicated she did not have any impairment in thinking with a BIMS score of 13. She required set up or clean up assistance with eating. Record review of a care plan for Resident #38 dated [DATE] indicated she had a personal refrigerator in room. Interventions included for housekeeping will check weekly for outdated foods and discard. Record review of an active physician order for Resident #38 dated [DATE] indicated an order for a refrigerator in room. During an observation on [DATE] at 9:52 AM in Resident #38's personal refrigerator had two bottles of strawberry boost dated [DATE] strawberry boost, two bottles of chocolate boost dated [DATE], and plastic container with something orange that was undated. During an observation and interview on [DATE] at 2:45 PM, HSK K was on hall 100 and said she had only been employed at the facility for 6 days. She said the housekeeping staff were assigned a hall each day. She said housekeeping was responsible for checking the personal refrigerators on Fridays. She said they checked the personal refrigerators for temperatures, ice buildup in the freezers, and for any expired foods or drinks. She said today was her first day to work on hall 100. During an observation on [DATE] at 2:48, Resident #21's personal refrigerator was cleaned and did not have any expired items or undated food items. During an observation on [DATE] at 2:49 PM, Resident #38's personal refrigerator was cleaned and did not have any expired items and undated food items. During an interview on [DATE] at 3:00 PM, HSK L said the housekeeping staff were responsible for checking the personal refrigerators once a week on Fridays. She said housekeeping staff could check more often if they needed to. She said they were supposed to check the personal refrigerators every other day for items like milk with expiration dates. She said they kept a log on their cleaning carts with the temperature readings and cleaning of the refrigerators on Fridays. She said she last worked on hall 100 on Sunday [DATE]. She said residents could get sick if they ate foods that were expired. She said she did not know that Residents #21 and #38 had expired items in their personal refrigerators. Record review of a facility refrigerator log for hall 100 undated indicated room [ROOM NUMBER] for Resident #21 was not initialed to indicate it was checked. room [ROOM NUMBER] for Resident #38 was blank with no initials. During an interview on [DATE] at 2:19 PM, the Administrator said the housekeepers were responsible for checking the personal refrigerators. She said the housekeepers had a log and they checked the refrigerators every Friday for temperatures and if a resident allowed them to discard any food items that were not safe. She said if a resident refused to allow the housekeepers to discard items, then it should be care planned. She said residents could get sick if they ate or drank items that were expired. She said going forward, she would change the cleaning dates and educate the housekeeping supervisor and would oversee to ensure it was done or designate someone.

Based on observations, interviews, and record reviews, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside; and toilet and bathing facilities for 1 of 7 residents (Resident #51) reviewed for call lights. The facility failed to ensure Residents #51's emergency call light located in the bathroom would reach the floor. This failure could affect residents who used their call light or desired to use the call light and place them at risk of not being able to notify staff of their needs. Findings: Record review of facility face sheet dated 12/19/2023 indicated Resident #51 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of arthropathy (arthritis). Record review of comprehensive MDS assessment dated [DATE] indicated Resident #51 had a BIMS score of 06 indicating severely impaired cognition. Resident #51 required substantial/maximal assistance with toileting. Record review of Resident #51's comprehensive care plan dated 10/10/2023 indicated Resident #51 was at risk for falls related to history of falls, decreased balance, and increased weakness. Interventions included: .The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light . During an observation on 12/18/23 at 09:20 am, the string on Resident #51's bathroom call light was observed to be too short, was approximately four inches long and would not have been reachable from the floor in the event of a fall. During an interview and observation on 12/19/2023 at 10:20 am, Resident #51 was observed sitting in her room in wheelchair with family in the room getting ready to go out for lunch. She said that she used the restroom by herself, but she did not remember ever needing to use the call light in the restroom. A family member, in room at the time, said that Resident #51 did use the restroom alone even though they encouraged her to call for help. During an interview on 12/19/2023 at 11:00 am, the Administrator said that they would be making rounds to ensure no other call lights were inaccessible. She said that Resident #51's light had been fixed and she was unsure how it had gotten missed. She said that all residents should be able to reach the call light in case of a fall in the bathroom. During an interview on 12/20/2023 at 2:30 pm, the DON said that residents could be at risk of not being able to reach the call light if they were to fall in the bathroom and the call light was too short. Review of a facility's policy titled Call System, Residents dated September 2022 read .Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor Review of a facility's policy titled Answering the Call Light dated September 2022 read .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 8 residents (Resident #45) reviewed for pharmacy services. The facility failed to ensure MA P held Resident #45's Losartan Potassium 25mg (for high blood pressure) for a blood pressure reading that was lower than ordered parameters. This failure could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life. Findings included: Record review of a facility face sheet dated 12/19/2023 for Resident #45 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atrioventricular block (when the electrical signal that controls your heartbeat is partially or completely blocked) and hypertension (high blood pressure). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #45 indicated she had moderate cognitive impairment with a BIMS score of 11. Record review of a care plan for Resident #45 dated 10/18/2023 indicated she had hypertension with interventions to administer medications as ordered, and monitor/document for side effects and effectiveness. Record review of an active physician order summary report dated 10/17/2023 for Resident #45 indicated she had the following medication orders with a start date of 01/06/2023: Losartan Potassium Tablet 25 MG Give 1 tablet by mouth one time a day related to Essential (primary) hypertension; hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60; and Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day related to essential (primary) hypertension; hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60. Record review of the Medication Administration Records for Resident #45 for the months of October and November 2023 indicated that resident had received: Losartan 25 mg by mouth on 10/26/2023 when her blood pressure reading was 109/60 Losartan 25 mg by mouth on 11/17/2023 when her blood pressure reading was 106/72 Carvedilol 6.25 mg by mouth on 10/26/2023 when her blood pressure reading was 109/60, and Carvedilol 6.25 mg by mouth on 10/26/2023 when her blood pressure reading was 108/62. During an observation on 12/19/2023 at 8:20 AM, MA P administered medications to Resident #45. Prior to administering medications to Resident #45, she checked her blood pressure which was outside parameters at 107/61. She continued and administered Losartan 25 mg by mouth. During an interview on 12/19/2023 at 3:25 PM, MA P said she had been a medication aide for approximately [AGE] years. She said the parameters for Resident #45's Losartan were to hold if less than 110/60. She then looked at Resident #45's blood pressure reading from earlier that morning and said It was 107/71, I should have held it. She said residents' blood pressure could bottom out if they get a blood pressure medication when they are below parameters. During an interview on 12/19/23 at 3:30 pm, the DON said that the risks to residents that get blood pressure medications when they are below parameters include blood pressure plummeting. She said that parameters for almost all other residents are 100/60, but she would be clarifying to ensure if there was a reason for Resident #45's to be higher. She said that she expected her staff to pay better attention because parameters may be personalized to residents. During an interview on 12/20/2023 at 2:30 pm, Administrator said that going forward, she would have the nurse clarifying the orders for Resident #45. She said that her parameters were 110/60 and everyone else in the building was 100/60. She was unsure at this time whether there was a reason for hers being higher, but they would be clarifying it. She said that a resident that gets a blood pressure medication when their blood pressure is below parameters could be at risk of their blood pressure bottoming out. During an interview on 12/20/2023 at 2:45 pm, MD said that he could not think of any harm unless they had been significantly below parameters. He said that he would consult with his nurse practitioner to see if there was a reason for the higher parameters and change them if needed. Record review of the facility's policy titled Administering Medications dated 2001, with revision date of April 2019 read .Medication are administered in accordance with prescriber orders .

46273 Based on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 22 residents (Resident #20) and 1 of 10 staff (CNA N) reviewed for resident rights. The facility failed to treat Resident #20 with respect and dignity when she did not receive her lunch meal tray while the other residents seated with her in the dining room were already eating. The facility failed to ensure staff referred to residents in a dignified manner when CNA N referred to residents requiring assistance with meals as feeders where residents could hear her. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings: 1.Record review of an Admission Record for Resident #20 dated 12/19/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of major depressive disorder (persistent depressed mood or loss of interest in activities), H. pylori (a bacteria that infects the stomach), bipolar disorder (mental health condition that causes extreme mood swings), and GERD (acid reflux disease). Record review of an Annual MDS assessment for Resident #20 dated 11/2/2023 indicated she did not have any impairment in thinking with a BIMS score of 15. During an observation on 12/18/2023 at 11:40 AM, two residents were seated at the table in the dining room with Resident #20 for lunch. The other two residents were served their meal while Resident #20 was not. During an interview on 12/18/2023 at 11:54 AM, the ADON stated she was responsible for the dining room today 12/18/2023 and was not aware that Resident #20 had not received her tray. She stated the nursing staff were responsible for making sure all residents received their meal tray and each resident at a table should be served at the same time. She stated she would see that Resident #20 received her tray. During an observation on 12/18/2023 at 12:00 PM, Resident #20 was served her lunch meal tray. During an interview on 12/18/2023 at 12:00 PM, CNA G said she had been employed at the facility for 1 1/2 years. She said when the CNAs helped in the dining room with serving meal trays, they had to go into the kitchen before the mealtime and pull the tray cards for the residents who were eating in the dining room for that meal. She said staff from each hall were responsible for pulling their own tray cards. She said Resident #20's staff was CNA H who was assigned to that hall. During an interview on 12/18/2023 at 12:15 PM, CNA H said that staff were to go into the kitchen before meals and pull the tray cards for the residents that were eating in the dining room. She said CNA J pulled the tray cards for hall 100 today. During an interview 12/18/2023 on 12:18 PM, CNA J said she pulled the tray cards to hall 100 today in the kitchen for the residents from the hall that were eating in the dining room. She said today 12/18/2023, most of the people that normally ate in the dining room from hall 100 were in the dining room at lunch. She said she pulled the tray cards for the residents on hall 100 that were eating in the dining room and placed them face down in the kitchen so the kitchen staff would know the residents were in the dining room. She said Resident #20 ate in the dining room daily and she did not know why she received her tray after everyone else in the dining room. During an observation and interview on 12/19/2023 at 8:37 AM, Resident #20 was in her room alert to person, place, and time. She said sometimes the staff forget to turn her meal tickets in. She said she ate all meals in the dining room except for breakfast. She said she believed the aides were responsible for turning her ticket in to the kitchen staff. She said she should not have been the last person to get her meal at lunch on 12/18/2023 and everyone else was eating and had already said their grace. She said sometimes they forget. During an interview on 12/19/2023 at 10:45 AM, the DM said the dietary helper would pull the tray cards and get the resident's drinks, silverware, and dessert, and pass it down the assembly line to the cook who would plate the food. She said the tray cards were assigned to the aides to pull so the kitchen staff would know which residents would be coming to the dining room for mealtime. She said Resident #20's tray card was not pulled and they did not know she was in the dining room for lunch yesterday. She said if staff let them know when they noticed someone had not received their meal tray or the tray cards were not pulled, then the kitchen staff would stop and prepare the meal tray for that resident. She said she would be angry if everyone was served their meal before her. She said the aides were responsible for pulling the tray cards so the kitchen staff would know who was eating in the dining room. During an interview on 12/20/2023 at 2:19 PM, the Administrator said that the CNAs and nursing staff were responsible for passing trays to the residents in the dining room. She said CNAs went into the dining room ahead of mealtimes and pulled the tray cards for the residents who would be eating in the dining room that day. She said the dining room staff relied on the tray cards that were pulled and prepared the meal trays for those residents in the dining room. She said Resident #20 had been sick and eating in her room prior to 12/18/2023 and the nurse aide for her hall forgot to pull her tray card that day. When asked how she would feel if that happened to her, she stated that she would want to eat when everyone had their food. She said going forward, the nurses were responsible for overseeing each meal and would ensure no one was left behind with getting their meal trays. 2.During an observation and interview on 12/18/23 at 12:10 pm CNA N was observed on 200 hall with resident doors open. CNA N said, we have a lot of feeders down this hall, she then repeated We have about 9-10 feeders down here. During a joint interview on 12/19/23 at 12:10 pm, the Administrator and DON both said that the staff should know better than to refer to residents as feeders. The Administrator said that they would be doing in-services and she expected staff to not refer to residents as feeders in the future. She said that this was a dignity issue for the residents. During an interview on 12/19/23 at 12:15 pm, CNA N said that she did refer to the residents as feeders and she said that she knew she should not have done that because it could make the residents feel bad about themselves. Record review of a facility's policy titled Dignity with a revision date of February 2021 read .Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and ot labeling or referring to the resident by his or her room number, diagnosis, or care needs Record review of facility's policy titled Assistance with Meals dated March 2022 read .Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example .avoiding the use of labels when referring to residents (e.g., feeders) . Record review of a facility's policy titled Dignity with a revised date of February 2021 indicated, .Each resident shall be cared for in a manner that promotes and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 2 medication carts (nurse cart for halls 100/200 and 300/400). The facility did not dispose of expired insulins for Resident #76 and glucose control solutions from the nurse medication carts for halls 100/200 and 300/400. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization . Findings included: 1.During an observation, and interview on 10/31/22 at 10:15 am with LVN C the medication cart for 100/200 hall contained Assure Prism Glucose Control Solution High and Low with a discard date of 10/20/22, (no opened date) LVN C said I will take that out and dispose of it. LVN C said she did not know the solution had expired and the night staff perform glucometer checks nightly and provided the logbook. LVN C said the Glucose solution should be replaced because they are only good for 28 days dates depending on manufacturer. Record Review of the Glucometer High/Low solution log indicated control Lot #CSTU28BN was opened in July 15,2022 and logged in use for the months of August 2022, September 2022 and logged as being used from 10/01/22 until 10/31/22. 2. During an observation and interview on 10/31/22 at 10:30 am with LVN D for medication storage and labeling on the 300/400 Hall LVN cart, the cart had an opened Insulin vial dated 09/21/22, indicating the insulin expired 28 days later on 10/19/22. LVN D said, Resident #76's Insulin should have been discarded. LVN D said if the vials of insulin were not labeled with the date it was opened and discarded after 28 days it could affect to efficiency or potency of the insulin and the insulin should be discarded 28 days from removing the cap. LVN D said Resident #76 gets a FSBS after meals and every HS with sliding scale insulin to cover the value of glucose. Review of MAR for October 1 to October 30, 2022, there had been no glucose value requiring coverage since 10/07/22. LVN D said Resident #76 remains at risk due to the existing order for sliding scale coverage and that the insulin should be discarded and reordered. Record Review of Monthly order summary dated 10/01/22 indicated Resident #76 with an initial admitted [DATE], readmitted [DATE] with a date of birth 07/20/1957 age 65. Dx. [CONDITION(S)], Depression and Diabetes. Order for [MEDICATION(S)] Solution 100 Unit per ml inject as per sliding scale before meals and at bedtime related to Type Two Diabetes ( High Blood Sugar) with other specific complications: If glucose per finger stick blood sugar is 200-250=give 2 units; 251-300= give 4 units; 301-350= give 6units; 351-400=give 8units;401-451=give 10units; if over 400 give 10 units and notify MD. During an Interview on 10/31/22 at 10:45 am the DON said she would provide the policy for glucose monitoring and checks, multi-dose vials and insulin. The DON said that the expired controls in the 100/200 cart should have been discarded on 10/15/22, 90 days after they were opened and logged for use on July 15, 2022. The DON said the Insulin vials should be discarded after 28 days after opening since the efficiency could be affected. The DON said she is responsible for ensuring medications carts did not contain expired medications and the night staff perform the cart checks and she monitors them also. During an interview on 11/02/22 at 11:20 am with the Administrator, she said the DON was responsible for oversight of the medication storage and labeling. A review of L. [MEDICATION(S)] Insulin Solution 100 Unit/ML had a use by date of 28 days from opening www. Lilly.com accessed on 10/31/22. and Assure Prism Glucose Control Solutions and Test strips 90 days after opening at www. assureglucometers.com accessed on 10/31/22. A review of Insulin Administration Policy Revised 2014 Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the procedure (Insulin injections via syringe) 4. Check Vial of for expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer's recommendations for expiration after opening).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 CNAs (CNA E, CNA G and CNA I) reviewed for infection control. CNA E did not change gloves and perform hand hygiene when providing incontinent care for Resident #14. CNA G did not wash or sanitize her hands when changing gloves while performing incontinent care for Resident #37. CNA I did not wash or sanitize her hands when changing glove while performing incontinent care to Resident #66. These failures could place residents at risk for infections from improper incontinent care. Findings include: 1. Record review of face sheet dated 11/2/2022 indicated Resident # 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident # 14 had a BIMS score of 06 indicating severely impaired cognition and required extensive assistance of one person for toileting. Record review of care plan dated 09/09/2022 indicated Resident # 14 has an ADL self-care performance deficit and required extensive assistance of 1 person for toileting. During and observation on 11/02/22 at 9:34 am Resident # 14 received incontinent care provide by CNA E and CNA F. Prior to incontinent care both CNAs gathered the needed supplies, sanitized their hands, and donned (applied) gloves. Resident # 14 was positioned by CNA E and soiled brief removed. Incontinent care provided to front peri-area using 6 wipes and wiping front to back by CNA E. Resident # 14 was then positioned on her left side by CNA F and CNA E cleaned the buttocks. CNA E then removed soiled brief, placed a clean brief and clean incontinent pad without changing gloves or hand hygiene. CNA E then adjusted resident bed and linen with same soiled gloves. CNA E and CNA F then removed gloves and sanitized hands before leaving room. During an interview on 11/02/22 10:00 AM CNA E stated she should have changed her gloves and performed hand hygiene when going from soiled brief to clean brief and before handling resident linen. Stated she had been trained and just had a training with a check off a month ago. CNA E stated the risk to the resident would be infections. During an interview on 11/02/22 at 10:14 AM DON stated that she had a training on 9/30/2022 regarding incontinent care, infections, hand hygiene and urinary tract infections with a return demonstration from all CNA's. DON stated CNA E received the training and successfully demonstrated competency. DON stated the risk would be infection control. Record review of in-service training dated 9/30/2022 indicated CNA E received training regarding incontinent care, urinary tract infections, hand hygiene and infection prevention. 2. Record review of an Admission Record dated 11/2/2022 for Resident #37 indicated she was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Significant Change MDS assessment dated [DATE] for Resident #37 indicated she had moderate impairment in thinking with a BIMS score of 9. She required extensive with bed mobility, transfers, dressing, toilet use and personal hygiene with 1-2 person assist. She was always incontinent of bowel/bladder. Record review of a Care Plan for Resident #37 with a last care plan review completed on 8/5/2022 indicated she had bladder incontinence with an intervention for incontinent care at least every 2 hours and apply moisture barrier after each episode. Record review of an in-service dated 9/30/2022 on Infection Control, Peri Care, UTI's, and Foley Cath Care by the DON indicated that CNA was in attendance with her signature noted on sign in sheet. During an observation on 11/01/2022 at 9:12 AM, CNA G and NA H were in Resident #37's room. Both washed their hands in the bathroom and gloves were applied to their hands. Resident #37's brief was opened and pulled down between her legs. CNA G removed a wipe from the plastic bag and wiped Resident #37's vaginal area from front to back on left side of her thigh. She placed the wipe in the trash. CNA G took another wipe and wiped Resident #37 on the right side of her vaginal area. CNA G placed the wipe in the trash and took another wipe and wiped down the middle of Resident #37's vagina from top to bottom. Resident #37 was rolled to her left side assisted by NA H and CNA G took a wipe and wiped her rectal area from front to back 4 times using 4 wipes. CNA G rolled the brief underneath Resident #37's buttocks and removed it. CNA G removed her gloves and placed them in the trash. CNA G placed gloves on her hands without washing or sanitizing them and placed a new brief underneath Resident #37's buttocks. Resident #37 was rolled to her right side being assisted by NA H. CNA G secured Resident #37's brief. CNA G removed her gloves and placed them in the trash. Resident #37 was covered back up with linens, repositioned back in bed in the lowest position. NA H removed her gloves and placed them in the trash. Both CNA G and NA H went into the bathroom and washed their hands. During an interview on 11/01/2022 at 9:29 AM, CNA G said she had been employed at the facility since June 2022. When asked if she would have done anything differently with the incontinent care performed on Resident #37, she said she was supposed to wash or sanitize her hands after she changed her gloves. She said she did receive training on handwashing at the facility upon hire and has had training since then. She said there was a risk for cross contamination if someone does not wash or sanitize their hands between glove changes. During an interview on 11/2/2022 at 10:10 AM, DON said CNA G had an in-service on 9/30/2022 at the facility on infection control, peri care, UTI's, and incontinent care that was conducted by her. She said the risk of staff not washing or sanitizing their hands between glove changes would be infections. 3. Record review of an Admission Record for Resident #66 dated 11/2/2022 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Significant Change MDS dated [DATE] for Resident #66 indicated she was unable to complete the interview with a BIMS score of 99. She was always incontinent of bladder and bowel. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene with one-to-two-person physical assist. Record review of a Care Plan for Resident #66 with last care plan review date of 10/26/2022 indicated she had bowel/bladder incontinence with interventions of incontinent care at least every 2 hours and apply moisture barrier after each episode. During an observation on 11/2/2022 at 9:16 AM CNA I was outside in the hallway of Resident #66's room gathering supplies to perform incontinent care. CNA I entered the room of Resident #66 and told Resident #66 that she would be providing incontinent care. CNA I pulled the linens back, applied gloves to both hands and pulled Resident #66's brief down between her legs. CNA I removed a wipe from the plastic bag and wiped both sides of vagina with a wipe and then took another wipe and wiped down the middle of Resident #66's vagina. CNA I then rolled Resident #66 to her left side and removed a wipe from the plastic bag and wiped from front to back a total of 6 times with 6 wipes. CNA I removed the brief and placed it in the trash. CNA I removed the glove from her left hand and placed it in the trash. CNA I then applied a glove to her left hand without washing or sanitizing her left hand. CNA I applied skin protectant ointment to Resident #66's buttocks with her left hand. Resident #66 was rolled back onto her back, and CNA I applied skin protectant ointment to both inner thighs and perineal area with her left hand. Brief was applied and secured. Resident #66 was positioned in bed. CNA I removed her gloves and placed them in the trash. CNA I then placed the linens back on Resident #66. CNA I exited the room and sanitized her hands. During an interview on 11/2/2022 at 9:25 AM, CNA I said she had been employed at the facility since December 2021. She said she should have sanitized or washed her hands between glove changes when asked if she would have done anything differently with the incontinent care provided to Resident #66. She said she had received in-services on hand washing and hygiene at the facility recently. During an interview on 11/2/2022 at 10:10 AM, DON said CNA I had an in-service on 9/30/2022 at the facility on infection control, peri care, UTI's, and incontinent care that was conducted by her. She said the risk of staff not washing or sanitizing their hands between glove changes would be infections. Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2019 indicated, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; m. after removing gloves . Record review of a facility policy titled Perineal Care with a revised date of February 2018 indicated, .The purpose of this procedure and to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly .

Based on observation, interview and record review the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen. The DM used the wrong test strips, (QT40 Strips) instead of chlorine test strips to test the sanitizer level (ppm) in the low temperature dish machine. The dish machine would only reach 118 degrees F after three cycles, and not the manufacturer's recommendation temperature of 120 degrees F. The [DATE], Dish Machine Temperature & Chemical Logs, were pre-filled for lunch and dinner before the meals occurred. There were chicken strips, biscuits, and French fries in the freezer in clear bags with no label. These clear bags were removed from the original manufacture's box and had no labels on the bag indicating what was in the bag, date received, use by date, or expiration date. The beef broth in the refrigerator was expired with an expiration date of [DATE]. The dietary aide licked her fingers to separate the tray cards, while setting up trays on the serving line. She then picked up the tea glass, the silverware and straw and placed these items on the resident's tray. These failures could place residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings Include: During an observation on [DATE] at 9:20 a.m., the DM tested the low temperature dish machine's chlorine level (ppm) with Quaternary Sanitizers (QT40) test strips. These test strips were indicated for testing the concentration of Quaternary Sanitizers, particularly multi-quat broad range quaternary ammonium sanitizer solutions and not the (PPM) of sanitizing solutions required for their low temperature machine. The dish machine only reached 118 degrees F after three cycles, instead of required manufacture's recommended water temperature of 120 degrees F. The Dish Machine Temperature & Chemical Log had been prefilled for lunch, and dinner at 9:20 a.m During an observation on [DATE] at 9:30 a.m., the following was observed in the freezer: There were frozen chicken strips, biscuits, and French fries in clear plastic bags with no label indicating the date received, or use by date. There were slices of cheese with a received date of [DATE], there is no use by date on the bag. There was beef broth in the refrigerator that had expired of [DATE]. During an interview on [DATE] at 9:45 a.m., with the DM she said she had only been working as the DM for a month. She said she texted the service man to find out what test strips she needed. (Chlorine test strips) During an interview on [DATE] at 10:00 AM with the ADM she said they had not had an onsite registered dietician in 3 months, she said the company they were using only provided an off-site dietician. She said she had been trying to find someone to come to the facility and help the new DM. She said they had not been able to find anyone in this area. She said the DM has only been in the position for one month and has not completed the DM certification course. She said she thought there was a waiver for the dietary manager course because no one wants to take the course. During an interview on [DATE] at 10:11 a.m., with the ADM, she said her expectations for the kitchen was for all items in the kitchen to be labeled with date received, use by date, and proper manufactures expiration dates. She said that not discarding foods by the expiration date, could cause the residents to get sick. She said she expects the DM to make sure the dietary staff are labeling food items per policy and checking expiration dates on foods in the refrigerator and freezer. During an interview on [DATE] at 11:38 a.m., with the DM she said she had not completed the Texas Certified Food Manager course. She said the staff in the kitchen were supposed to label and date the items in the refrigerators and freezers, that includes the date received and use by date. The DM said she did not realize that when the staff removed the bags from the boxes they are received in, there were no label or expiration dates on the packages. She said she had talked to the ADM and the kitchen staff are to check the refrigerators/freezers for expiration date on all foods every morning. During an interview on [DATE] at 12:15 p.m., the ADM she said she would get someone out to check the dish machine temperature today and make sure they had the proper test strips and dietary staff were trained to use them. During an observation on [DATE] at 11:45 a.m., of the serving line dietary aide H was observed licking her fingers to separate the tray cards. She then picked up the drink glass, dessert, silverware, and condiments, and placed them on the resident's tray after licking her fingers. During an observation on [DATE] at 11:46 a.m., of the serving line dietary aide H licked her fingers again to pick up a tray card, then picked up drinks, dessert, silverware, and condiments to place on the resident's tray. During an observation on [DATE] at 11:55 a.m. dietary aide H, was observed with a resident's tray card in her mouth while retrieving items from the fridge, and then placed tray card on a resident's tray, and continued to load trays. During an interview on [DATE] at 11:36 a.m. with dietary aide H she said she was stressed out and nervous so she made a mistake when she licked her fingers. She said she realizes that licking her fingers and touching the items on the trays, could make the residents sick. During an interview on [DATE] at 11:41 a.m., with the DM, she said she is still learning. She said the ADM., is trying to find a RD who will come to the facility. During a record review on [DATE] at 11:45 a.m., of a policy titled Food Receiving and Storage, revised ,d+[DATE], indicated all food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Such food will be rotated using a first in-first out system. During a record review on [DATE] at 12:00 p.m., of a policy titled Refrigerators and Freezers revised [DATE] indicated: 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is open. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators and freezers are not expired or past parish dates. Supervisors should contact vendors or manufacturers when expiration dates are within question or to decipher codes. During a record review on [DATE] at 12:15 p.m., of a policy titled Dishwashing Preparation and Dishwashing indicates: 2. Automatic dishwasher; Low temperature machine c. The was cycle shall be at least 40 seconds with a temperature of 120 degrees F in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimal water temperature of 120 degrees F. d. Prior to washing the soiled dishes after a meal the dish machine shall be tested for proper temperature and PPM of sanitizing solution. The dish machine may need to be ran empty for a couple of cycles to ensure the proper temperature is attained, and no dishes will be washed prior to achieving this standard. h. Facilities shall use the appropriate test kit to measure the parts per million (ppm) of the chemical solution in the dish machine on a daily basis. Any abnormal test result shall be reported to the Dietary Manager. A ppm of 50 will be attained prior to dishes being washed.

Based on observation, interview, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 1 of 3 resident personal refrigerators reviewed for food safety (Residents #12). The facility did not implement the personal food policy related to personal refrigerators for Resident #12. The refrigerator for Resident #12 contained food items that were expired. This failure could place the residents at risk for food borne illnesses. The findings included: Record review of an Admission Record for Resident #12 dated [DATE] indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, [CONDITION(S)] [CONDITION(S)] (low iron in the blood) major depressive disorder (persistent feeling of sadness and loss of interest), atherosclerosis (hardening of the arteries) and PVD (narrowed blood vessels in the legs). Record review of a Quarterly MDS Assessment for Resident #12 dated [DATE] indicated he did not have any impairment in thinking with a BIMS score of 15. He required supervision with eating, toilet use and personal hygiene with set up help only. Record review of the most current Care Plan for Resident #12 completed on [DATE]indicated he had an ADL self-care performance deficit. He had a personal refrigerator in room. Intervention included was that housekeeping would check his refrigerator weekly for outdated foods and discard. During an observation on [DATE] at 10:39 AM of Resident #12's personal refrigerator in his room revealed 1 bottle of Miracle Whip with an expiration date of [DATE], 1 bottle of Parkay butter with an expiration date of [DATE], a container of Country Crock butter with an expiration date of [DATE], 1 strawberry yogurt with an expiration date of [DATE], 1 can of tomato juice with an expiration date of [DATE], 2 fruit cups with an expiration date of [DATE], and 1 jar of horseradish with an expiration date of [DATE]. During an observation and interview on [DATE] at 11:45 AM, Resident #12 was present in his room eating lunch, said he had been at the facility for quite some time. He said the housekeepers were responsible for checking the temperatures and removing expired food items from his refrigerator. He said he did not know he had expired items in his refrigerator. During an interview on [DATE] at 9:01 AM, HSK J said she had been employed at the facility since [DATE] but has been in housekeeping since [DATE]. She said she was responsible for checking the personal refrigerators every Friday along with cleaning them out, defrosting and recording temperatures in a logbook on the housekeeping cart. She said Resident #12 would refuse most times and not allow staff to clean out his refrigerator. She said she did not know he had multiple foods that were expired. She said the housekeepers were also responsible for throwing away stuff that was out of date. She said if a resident ate food that were expired it could make them sick. During an interview on [DATE] at 2:20 PM, the Administrator said she was not aware that Resident #12 had multiple expired food items in his personal refrigerator. She said she had a talk with him earlier and told him if he did not allow the staff to clean out his personal refrigerator, then he would be told to do it himself. She said he agreed to allow the housekeeping staff to do it and check every Friday. A Facility Policy Titled Personal Property undated indicated, .Resident are permitted to bring personal property and use personal possessions to create a home-like environment. 3. Small appliances are allowed by: B. Personal refrigerators 4. Housekeeping staff will clean and temp each refrigerator once a week if resident does not agree to housekeeping cleaning refrigerator they or family must agree to check and clean weekly. 5. Staff must discard food from refrigerators that show obvious signs of potential foodborne danger, and/or is beyond expiration date .

Based on observations, interviews and record reviews, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 18 residents (Resident #39) reviewed for respiratory care and services. Resident #39 was receiving oxygen therapy with humidification. The prefilled humidifier bottle was dated 09/25/2022. This deficient practice could place residents who receive respiratory care and services at risk of developing respiratory infections and complications. Findings: Record Review of face sheet dated 11/2/2022 indicated Resident # 39 was admitted to facility on 03/02/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident # 39 had a BIMS of 15 indicating intact cognition. At the time of MDS, Resident # 39 was not receiving oxygen therapy. Record review of care plan dated 09/21/2022 indicated Resident # 39 required oxygen therapy. Record review of order summary report dated 11/01/2022 indicated Resident # 39 had oxygen ordered on 09/25/2022 at 2 to 4 liters per nasal cannula as needed and to change and date oxygen tubing and humidifier water every Sunday night. During an observation on 10/31/2022 at 10:34 am Resident # 39 was receiving oxygen therapy at 2 liters per nasal cannula and oxygen tubing was dated 10/30/2022 and connected to prefilled humidifier bottle that was empty and dated 9/25/2022. During an observation on 11/01/22 at 08:35 AM Resident # 39 was receiving oxygen that was connected to a prefilled humidifier bottle dated 9/25/2022 and empty. During an interview on 11/02/22 at 08:15 AM LVN A stated the night nurse is responsible for changing the oxygen tubing and humidifier weekly and as needed. Both the tubing and humidifier are dated when they are changed. LVN A did not know why the prefilled humidified water was not changed when the oxygen tubing was changed. There is an order placed on the nurse treatment record for the weekly change. The risk could be infection to the resident. During an interview on 11/02/22 at 08:19 AM LVN B stated prefilled humidifier should be changed weekly. It is done on night shift on Sunday. LVN B stated she did not realize Resident # 39 prefilled humidifier had not been changed on the days she worked. The risk to the resident could be infections and discomfort. During an interview on 11/02/22 at 08:32 AM DON stated the night nurses are responsible for changing the prefilled humidifier bottles. DON and ADON are responsible for overseeing that the night nurses are following the policy. DON did not know why the prefilled humidifier water was not changed with the oxygen tubing. The risk to the resident could be infection control and discomfort if the humidifier is out of water. Record review of undated policy titled, [facility name] Nursing Departmental (Respiratory Therapy) Prevention of Infection Policy stated, .infection control consideration related to oxygen administration #3 prefilled sterile humidification water bottle will be marked with date and initials upon opening and changed and discarded every 7 days and prn .

Based on observation, interview and record review, the facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards and practices for 1 of 12 residents reviewed for medical records. (Resident #s 4) *Resident #4's nutritional supplement (Glucerna) for protein malnutrition was not given and was documented as given. This failure could place residents at risk for not receiving the appropriate care and services to maintain their highest practicable well-being. Findings included: 1. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #4 was to receive 1 can of Glucerna with each meal with start date of 9/3/20. The most recent MDS dated [DATE] indicated Resident #4's cognitive ability was intact, and he required supervision and set-up for eating. A comprehensive care plan dated 2/21/21 indicated Resident #4 is at Potential Risk for Malnutrition with approaches of offer diet as ordered by physician A MAR dated 9/1/21 - 9/22/21 indicated Resident #4 was prescribed Glucerna 1 can with meals and had received Glucerna on 9/19/21 and 9/20/21. During an interview and observation on 9/19/21 at 9:00 a.m., Resident #4 said he does not always get Glucerna with his meals, as this surveyor looked at his breakfast tray. The breakfast meal did not have Glucerna can or bottle on the breakfast tray at bedside. During observation and interview on 9/20/21 at 8:30 a.m., Resident #4 said no Glucerna was on his breakfast tray as we observed his tray. He said he would drink it if it was on the breakfast tray for him. During an interview on 9/20/21 at 10:20 a.m., LVN A said she had not given the Glucerna to Resident #4 at breakfast on 9/20/21 and 9/21/21. She said I initialed the MAR and documented a check mark however she said the Glucerna was not given. She said she had been trained to mark the MAR correctly and to indicate not given if it was not given. LVN A said it was important to correctly document, so physician and dietician are aware if the orders were effective. During an interview on 9/21/21 at 10:30 a.m., the DON said her expectations was for the nurses to document correctly and if not given indicate why the Glucerna was not given as ordered. During the exit on 9/21/21 at 4:45 p.m., the administrator was asked for any additional information and no additional information was provided.

Based on interview and record review, the facility failed to ensure a resident was served a therapeutic diet as ordered nutritional supplement (Glucerna) for 1 of 12 residents reviewed for dietary services. (Resident #s 4) *The facility did not follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] This failure could place residents at risk for not receiving the appropriate care and services to maintain their highest practicable well-being. Findings included: 1. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #4 was to receive 1 can of Glucerna with each meal with start date of 9/3/20. The most recent MDS dated [DATE] indicated Resident #4's cognitive ability was intact, and he required supervision and set-up for eating. A comprehensive care plan dated 2/21/21 indicated Resident #4 is at Potential Risk for Malnutrition with approaches of offer diet as ordered by physician A MAR dated 9/1/21 - 9/22/21 indicated Resident #4 was prescribed Glucerna 1 can with meals and had received Glucerna on 9/19/21 and 9/20/21. During an interview and observation on 9/19/21 at 9:00 a.m., Resident #4 said he does not always get Glucerna with his meals, as this surveyor looked at his breakfast tray. The breakfast meal did not have Glucerna can or bottle on the breakfast tray at bedside. During observation and interview on 9/20/21 at 8:30 a.m., Resident #4 said no Glucerna was on his breakfast tray as we observed his tray. He said he would drink it if it was on the breakfast tray for him. During an interview on 9/20/21 at 10:20 a.m., LVN A said she had not given the Glucerna to Resident #4 at breakfast on 9/20/21 and 9/21/21. She said I initialed the MAR and documented a check mark however she said the Glucerna was not given. She said she had been trained to mark the MAR correctly and to indicate not given if it was not given. LVN A said it was important to correctly document, so physician and dietician are aware if the orders were effective. During an interview on 9/21/21 at 10:30 a.m., the DON said her expectations was for the nurses to document correctly and if not given indicate why the Glucerna was not given as ordered. The undated Comprehensive Care Planning policy indicated The facility will develop and implement a comprehensive person-centered care plan for each resident. During the exit on 9/21/21 at 4:45 p.m., the administrator was asked for any additional information and no additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure an accurate PASRR was completed for 1 of 4 residents reviewed for PASRR screenings. (Resident #28) The facility did not conduct an accurate PASRR level 1 screening for Resident #28. The PASRR level 1 screening indicated Resident #28 did not have a mental illness. Resident #28 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents who have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR level 1 screening completed by the transferring hospital dated 4/2/21 indicated Resident #28 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. A Quarterly MDS dated [DATE] indicated Resident #28 had a BIMS score of 14 indicating she was cognitively intact and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of #28 medical record revealed a quarterly MDS dated [DATE] indicated Resident #28 had a BIMS score of 15 indicating she was cognitively intact and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan revision dated 6/28/21 indicated Resident #28's Focus: Resident #28 has mood problem r/t bi-polar depression. Intervention: Behavioral health consults as needed. During an interview and observation on 9/19/21 at 11:00 a.m., Resident #28 was in her room in the bed. She was watching TV and answered interview questions appropriately, with cognitively organized thinking during interview. During an interview on 09/21/21 at 2:35 p.m., the MDS Nurse said she is the person responsible for completing the PASRRs. She stated that for Resident #28 she had reviewed the admitting facility's PASRR but don't know how she overlooked the area about mental illness. She stated that she looks at the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she did not realize Resident #28 had [CONDITION(S)] disorder, bi-polar type. The MDS Nurse acknowledged Resident #28's PASRR was inaccurate and another PASRR screen would be uploaded to the portal. MDS Nurse said Resident #28 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an Interview on 9/21/2021 at 3:00 p.m., the DON she said she expected MDS Nurse to complete PASRR screening according to regulatory guidelines and that Resident #28's Level 1 PASRR was coded wrong because she does have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated that not having an accurate Level 1 puts the resident at risk of not getting psych services and/or not getting the treatment they need. DON said she monitors the accuracy of PASRRs in the morning meetings for new admits and readmits but that she did not know how Resident #28 PASRR got over looked. The facility policy and procedure revised dated 3/6/19, titled PASRR Level 1 Screen Policy and Procedure revealed in part . . The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to lie as independently as possible . Procedure: . 3. The facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. The type of admission is reviewed for correctness . and review each item on the PL1 to ensure accuracy and prevent a regulatory problem . 7. The facility will maintain PL1 Best Practices as follows . Review the PL1 form for completion and correctness before admission . During the exit on 9/21/21 at 4:45 p.m., the administrator was asked for any additional information related to PASARR. No additional information was provided.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 of 4 residents reviewed for pressure ulcers (Resident #44). The facility did not provide treatments for Resident #44's denuded skin on her buttocks as ordered on [DATE] and [DATE]. The resident's buttocks worsened to an unstageable pressure ulcer with eschar on [DATE]; however, the treatment was not changed. The resident was not provided treatment to the worsened pressure ulcer on [DATE] and the wound developed slough and worsened in size. This failure placed 35 residents who were either bedbound or in a chair all or most of the time at risk of avoidable pressure ulcers and inadequate treatment for [REDACTED]. Findings included: Physician orders [REDACTED].#44 was admitted [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. The (MONTH) Weekly Skin Assessment sheet dated [DATE] indicated Resident #44 had no areas of skin impairment. A skin assessment flow sheet dated [DATE] indicated Resident #44 was found to have denuded skin (loss of the top layer of skin, caused by exposure to urine, feces, body fluids, wound exudate or friction) on her gluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum). A nursing note dated [DATE] indicated Resident #44 received treatment to the denuded skin on her buttocks. The skin grid dated [DATE] indicated Resident #44 had denuded skin on her buttocks. The (MONTH) Treatment Sheet dated [DATE] and [DATE] for Resident #44 indicated the day shift nursing signature was initialed and circled. The ordered treatment was [MEDICATION NAME] (barrier cream) to be applied to the resident's denuded skin on her buttocks. There was no documentation to indicate why the resident did not receive the treatment. A nursing note dated [DATE] (no time noted) indicated Resident #44 had an open area with eschar on her left buttock measuring 5.0 centimeters (cm) x 4.0 cm, with redness around the area measuring 7.0 cm x 9.0 cm. The (MONTH) Treatment Sheet dated [DATE] for Resident #44 indicated the nursing signature for the day shift was initialed and circled. The ordered treatment was [MEDICATION NAME] (barrier cream) to be applied to the resident's denuded skin on her buttocks. There was no documentation to indicate why the resident did not receive the treatment or of the worsened appearance of the wound. A nursing note dated [DATE] at 1:00 p.m. indicated a follow-up skin assessment for Resident #44 was done. The resident had an unstageable pressure ulcer on her left buttock. The wound bed had a black with eschar center surrounded by yellow/tan slough, moderate serosanguineous drainage (thin, watery slightly yellow in color), and no odor. A physician order [REDACTED].#44's pressure ulcer with normal saline and apply Santyl (topical debridement) to eschar area only, and to cover with a foam protective dressing every day. The (MONTH) Skin Assessment Sheet indicated on [DATE], Resident #44 had an unstageable pressure ulcer on her left buttock measuring 7.6 cm x 7.1 cm. During an interview on [DATE] at 1:53 p.m. and 2:01 p.m., LVN D (male) said he was one of the staff who assessed Resident #44 when the skin breakdown was found on [DATE]. He said the breakdown was on the resident's left buttock and was covered in eschar. He said days prior to this, the area had started out as denuded skin, and they were treating it as per orders. He said a lot of times the resident would refuse for the skin area to be treated because the resident did not like for a man to provide her with care. LVN D said when Resident #44 would refuse her skin treatments, he did not ask a co-worker to attempt to administer the treatment, nor did he report this to anyone. He said when the resident refused the treatment, he would circle it on the treatment sheet. He said he did not remember documenting the circumstances about the resident refusing, but normally that would be documented in the nursing notes. The staff records for ,[DATE] indicated LVN D worked on ,[DATE], ,[DATE], and [DATE]. The MDS dated [DATE] indicated Resident #44 was severely cognitively impaired, and required extensive assistance with bed mobility, transferring, and toileting. The MDS indicated the resident was at risk of developing pressure ulcers. The resident had one unstageable pressure ulcer, measuring 5.5 cm x 7.0 cm, with eschar at the time of this assessment. The (MONTH) Treatment Sheet for Resident #44 indicated the resident did not receive the skin treatment on [DATE] (this date was blank). The ordered treatment was to cleanse the unstageable pressure ulcer on the resident's left buttock with normal saline and apply Santyl to the eschar/slough area only and apply foam protein dressing every day. There was no documentation to indicate why the resident did not receive the treatment. The (MONTH) Weekly Skin Assessment sheet dated [DATE] for Resident #44 indicated to see skin grid. The Skin grid sheets for Resident #44 did not include an assessment for [DATE]. The Care Plan dated [DATE] indicated Resident #44 had an unstageable pressure ulcer on her left buttock that started on [DATE]. This document also indicated that the resident had denuded skin to her buttocks that started on [DATE]. Interventions included: Encourage resident to not stay in same position in bed, and to not stay in wheelchair for long periods of time. A Skin Assessment flow sheet dated [DATE] indicated Resident #44 had a stage 4 pressure ulcer measuring 6.5 cm x 7.7 cm x 2.8 cm. The assessment noted a tendon was exposed at the base of the wound with pink tissue in the wound bed. There was moderate serosanguinous drainage noted without odor. The wound had tunneling noted at 11 o'clock of 2.3 cm and at 12 o'clock of 2.8 cm and the surrounding skin was pink and blanching. Pain was noted to touch of the wound bed. The weekly skin assessment sheet shows an assessment on [DATE] and refer to skin grid. The Skin grid sheets for Resident #44 did not include an assessment for [DATE]. A nursing note dated [DATE] indicated Resident #44 died at approximately 3:30 a.m. on the morning of [DATE]. During an interview on [DATE] at 1:52 p.m., CNA C said she was the person who discovered the skin breakdown on [DATE] when working with Resident #44. She said she reported it LVN D. She said the resident was particular, and did not want/like for males to provide care to her. During an interview on [DATE] at 2:20 p.m., the DON said LVN D should have asked someone else to do the skin treatment for [REDACTED]. She said the resident had a pressure ulcer on her buttocks which required daily treatments. During an interview on [DATE] at 4:21 p.m., the administrator said since male nurse LVN D knew Resident #44 was refusing treatments for skin due to him being a male, he should have asked his female co-worker to do the treatment. The Skin/Pressure Injury Prevention and Management Policy dated ,[DATE], indicated prevention interventions will be identified and implemented to prevent the development of pressure injuries. The National Pressure Ulcer Advisory Panel website accessed [DATE] indicated the following: * Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). * Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The CMS 672 Resident Census and Conditions dated [DATE], indicated there were 35 residents who are either bedbound or in a chair all or most of the time.

Based on observation, interview, and record review, the facility failed to assess, evaluate, and revise pain relief interventions ensure adequate pain relief in accordance with the comprehensive assessment and plan of care for 1 of 6 residents reviewed for pain. (Resident # 4) The facility did not evaluate and assess Resident #4's pain interventions to ensure pain control. Resident #4 complained of excruciating pain immediately following an unwitnessed fall that resulted in a [MEDICAL CONDITION] and surgery. Resident #4 experienced excruciating pain for seven hours before being sent to the emergency room . This failure could place 9 residents who are at risk for falls at risk for unrelieved pain and delayed. Findings included: Computerized physician orders [REDACTED]. Resident #4 was to receive [MEDICATION NAME] one tablet of 10-325 milligrams (mg) every four hours routinely for pain; [MEDICATION NAME] one tablet, 10 mg every 12 hours for pain routinely; [MEDICATION NAME] capsule 100 mg three times a day routinely for nerve pain; [MEDICATION NAME] tablet 5 mg every two hours for pain as needed; and [MEDICATION NAME] over the counter 650 mg rectal suppository every four hours as needed for pain. The most recent MDS dated [DATE] indicated Resident #4 was cognitively intact without impairment, had clear speech, had the ability to understand others, and was able to make herself understand. The assessment indicated Resident #4 suffered repeated falls. This MDS indicated Resident #4 received a regimen of scheduled pain medication and had not experienced pain or hurting in the last 5 days. A care plan revised 04/06/17 for Resident #4 by the Administrator addressed the following: ADLs/Rehabilitation - This care plan noted Resident #4 was limited in the ability to balance herself while standing and would be free of injury/fall. Interventions listed included .encourage the resident to sit/dangle before attempting to stand, instruct resident in proper balancing techniques to raise slowly and mase sure she was steady, monitor fo rpresence of orthostatic [MEDICAL CONDITION] (dizziness, light-headedness, [MEDICAL CONDITION]) when resident moves from sitting/lying position to a standing position and to remind the resident not to stand without assistance and use the call light . Falls - This care plan noted the resident had impaired balance during transfers, ambulation, sitting and standing and would safely transfer self with using cueing transfer technique. Interventions listed included .adapt enviorngment to maximize independence grab bars in restroom, positioning rails on bed, etc., keep call light within reach and remind resident not to transfer without assistance as needed, use call light, non-skid socks in place and/or shoes . Pain - This care plan noted the resident had complaints of chronic pain related to [DIAGNOSES REDACTED]. Interventions listed included . acknowledge to the resident that her pain is unique and believable, assess effects of pain on the resident (disturbances in sleep, activity, self care, etc.), assess past effective and ineffective pain relief measures, clarify misconceptions about addiction to pain medications, evaluate effectiveness of pain management interventions and adjust if ineffective or adverse side effects emerge . During an observation and interview on 05/31/17 at 10:00 a.m., Resident #4 was in bed, fall mat in place, call light was not within in reach, and there were no positioning rails. The bedside commode was across the room not near Resident #4's bed. Resident #4 said she was looking in her closet and fell . She said she just lost her balance. Resident #4 said she yelled for help but no one came. She said when she fell , her left leg immediately hurt and she could not get it to straighten out. She said she had to pull her body across the room in order to use her call light. Resident #4 said she was in excruciating pain. She said after she finally got to the bed and pressed the call light button for help, she layed on the floor waiting for staff to come. Resident #4 said it was an hour before anyone came to check on her after she pressed the call light button. She said the night staff are always slow about responding to the call lights. Resident #4 said her leg had swollen by the time it was x-rayed. Resident #4 said it took the facility seven hours to send her to the emergency room . She said she told the nurses, the administrator, the DON, and CNAs she was in pain, but they did not do anything about it. Resident #4 said she was given her routine pain medications but they didn't help at all. I thought I was going to pass out it hurt so much. She said she does not know why it took so long to send her out but she told the hospital staff about her delayed transfer. Resident #4 said the facility staff said she had to be discharged from hospice before they could send her to the hospital. Resident #4 said she asked several times to be sent to the emergency room and was not. Resident #4 said she was in pain the entire time she was waiting to be sent to the hospital. Resident #4 said she had to have surgery and was now participating in therapy. Resident #4 said she used to do everything for herself but now she had to depend on staff for all of her ADL care and assistance. A nursing note dated 05/17/17 at 2:45 a.m., for Resident #4 indicated the resident was lying on her right side on the floor at her bedside complaining of left hip pain. This same note indicated the doctor was notified and instructed not to send to the emergency room because the resident received hospice services and to contact hospice for orders. This note further indicated hospice gave orders for a stat portable x-ray to hip and pelvis for fall and pain. An undated physician's telephone order for Resident #4 at 3:00 a.m. indicated a stat order for x-ray to the left hip for [DIAGNOSES REDACTED]. The order was for a portable x-ray because the resident was too weak to tolerate transport. X-ray results for Resident #4 dated 05/17/17 at 5:33 a.m. indicated there was an acute mildly deformed intertrochanteric [MEDICAL CONDITION] femur without dislocation. A nursing note dated 05/17/17 at 7:00 a.m. for Resident #4 indicated the x-ray report was called to the doctor and hospice. According to this nursing note the doctor gave a new order for a foley catheter to be inserted and awaiting a return call from hospice. There was no documentation to indicate hospice was attempted to called again or notified of persistent complaints of pain. The MAR indicated [REDACTED] [MEDICATION NAME] one tablet 10-325 mg every for hours for pain at 2:00 a.m., 6:00 a.m, 10:00 a.m., and 2:00 p.m. There was no documentation to indicate effectiveness of the medication. [MEDICATION NAME] one tablet, 10 mg every 12 hours for pain routinely at 6:00 a.m. There was no documentation to indicate effectiveness of the medication. [MEDICATION NAME] capsule 100 mg three times a day routinley for nerve pain at 8:00 a.m and 1:00 p.m There was no documentation to indicate effectiveness of the medication. [MEDICATION NAME] tablet 5 mg every two hours for pain as needed. This medication was not administered on 05/17/17. [MEDICATION NAME] over the counter 650 mg rectal suppository every four hours as needed for pain. This medication was not administered on 05/17/17. During an interview on 05/31/17 at 1:00 p.m., LVN X said Resident #4 fractured her hip when she fell on the night shift. She said the portable x-ray staff were leaving as she arrived to work at 6:00 a.m. on 05/17/17. LVN X said she got the x-ray results, which showed the fracture. LVN X said the resident told her that, following the fall, she had been unable to sleep all night due to the severe pain from her fall. LVN X said she notified Resident #4's doctor at 7:00 a.m. and was told to notify hospice for the orders to send out. LVN X said she immediately called hospice who told her Resident #4 was not on services for falls and for LVN X to send Resident #4 wherever the doctor wanted her to go. LVN X said she faxed the results to the doctor at 9:00 a.m. on 05/17/17 and the doctor told LVN X to see where the resident wanted to go. LVN X said Resident #4 was undecided. LVN X said Resident #4's pain medication was administered routinely as ordered, but she was not administered the as needed pain medication. LVN X said Resident #4 complained of pain after the routine pain medications were administered. LVN X said critical lab results were received after lunch and the decision was made to send Resident #4 to the emergency room at that time. LVN X said it took the ambulance about an hour to arrive because it had to come from out of town. LVN X said Resident #4 told her it was about 20-30 minutes before anyone came to her room to check on her after she put on her call light. A physician's telephone order dated 05/17/17 at 2:00 p.m. indicated Resident #4 was to be sent to the emergency room to evaluate and treat due to left [MEDICAL CONDITION] and critical lab levels. A nursing note dated 05/17/17 at 2:00 p.m. for Resident #4, indicated new orders to send to the emergency room related to the [MEDICAL CONDITION] and the ambulance was transporting Resident #4 at this time. The hospital radiology report dated 05/17/17 at 4:48 p.m. indicated Resident #4 suffered an intertrochanteric [MEDICAL CONDITION] femur with displacement of the distal fracture fragment. Resident #4 was admitted with orthopedic surgery consulted and saline lock, intravenous [MEDICATION NAME] (pain medication) around the clock on top of [MEDICATION NAME] to continue. A nurses note dated 05/18/17 at 6:15 a.m. indicated Resident #4 remained in the hospital due to [MEDICAL CONDITION]. A hospital discharge summary dated 05/21/17 at 9:51 a.m. indicated Resident #4 fell at 2:00 a.m. on the day of hospitalization (05/17/17). This summary indicated Resident #4 crawled to her bed to press the call button for assistance and was in excruciating pain while awaiting assistance that did not come until 5:00 a.m. but not transported to the hospital until later in the day. This summary noted the pain was a 10 out of 10 constant. Resident #4 underwent intramedullary nailing of the left femure. During an interview on 05/31/17 at 12:02 p.m., CNA E said she came on duty and Resident #4 was still in the facility. CNA E said Resident #4 said she had fallen and was in pain. She said Resident #4 walked without assistance and was independent prior to this fall but now needed staff assistance with all areas of her care. She said it was a long time before Resident #4 was sent to the hospital. During an interview on 05/31/17 at 2:15 p.m., the DON said Resident #4 got up during the night and fell . She said the resident sustained [REDACTED]. The DON said Resident #4 was not sent to the emergency because the doctor did not give the order. The DON then said Resident #4 was not sent to the emergency room because hospice had to give an order to discontinue hospice services before Resident #4 could be transported out for evaluation and treatment. The DON said there was only one attempt made to call the doctor and a message was left. The DON said it was seven hours after the facility knew Resident #4 sustained a [MEDICAL CONDITION] before she was transferred to the emergency room . The DON said Resident #4 had surgery. The DON said it took too long to get Resident #4 the care she needed. She said the resident complained of pain to her when she visited Resident #4 in her room at the facility about 9:30 a.m. on 05/17/17. The DON said the facility should have just sent Resident #4 out to the hospital. During an interview on 05/31/17 at 3:15 p.m., with the administrator/abuse coordinator said Resident #4 was not sent to the emergency room after the results showed a [MEDICAL CONDITION] because she had to be discharged from hospice services first. The administrator said she had not spoken with hospice but assumed that's what they would want, to discharge Resident #4 before she was sent out for surgery. The Administrator said she talked to Resident #4 between 9:30 a.m. and 10:00 a.m. on 05/17/17 to be sure we were doing what she wanted to do. Told her she could discharge from hospice and go to the emergency room if she wanted to, whatever she wanted to do, it was her choice. The Administrator said Resident #4 wanted to go to the hospital. The Abuse/Neglect Prohibition Management policy revised November, 2016 indicated .Neglect: The failure of the facility, its employees or service providers to provide goods and services necessary to a resident that are necessary to avoid physical pain, harm, mental anguish, or emotional distress. The facility CMS 802 dated 05/31/17 indicated there were 9 residents at risk for falls.

Based on observation, interview, and record review, the facility failed to implement interventions based on a comprehensive assessment to prevent development and worsening of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. (Resident #1) Resident #1 developed a facility-acquired pressure ulcer that was not identified or addressed by the nursing facility until it was present at stage III. The facility did not: *ensure dietary recommendations were followed to improve wound healing; *ensure antibiotics were given to prevent infection; *ensure all physician ordered treatments were followed; *notify Resident #1's physician when the pressure ulcer worsened. This failure could place 3 residents with pressure ulcers at risk for development of new pressure ulcers and decline in existing pressure ulcers. Findings included: physician's orders [REDACTED].#1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. She was on hospice since 03/20/15 for [MEDICAL CONDITION]. Weekly skin assessments for Resident #1, dated 12/07/15, 12/14/15, and 12/21/15 indicated there were no areas of skin impairment. Skin assessment flow sheets for Resident #1 dated 12/29/15 indicated Resident #1 had a stage III pressure ulcer measuring 2 cm x 1 x 0.5 with slough to the coccyx area. The most recent MDS assessment dated [DATE] indicated Resident #1 was cognitively impaired, totally dependent for ADLs including bed mobility, always incontinent of bowel and bladder, and had a stage III pressure ulcer measuring 2.0 cm x 1.0 cm x 1.0 cm. A Braden scale, used to predict pressure ulcer risk, dated 01/26/16, indicated Resident #1 was at high risk for pressure ulcer development. physician's orders [REDACTED].#1's care was to include the following: *float heels every day *low air loss mattress to reduce pressure to boney prominences was recommended *skin barrier cream applied to coccyx every shift (start date of 09/02/15) *cleanse the wound, dry, apply dressing, and cover *change dressing every day and as needed, (start date of 12/29/15) A progress nursing note dated 01/21/16 at 3:40 p.m. indicated 30 ml of Pro-Stat (a liquid protein nutritional supplement) twice daily for wound healing. Resident #1's MAR indicated [REDACTED]. Resident #1's MAR indicated [REDACTED]. Resident #1's MAR indicated [REDACTED]. A nutrition assessment note dated 03/24/16 indicated Resident #1 had an unstageable pressure ulcer. The note indicated Pro-Stat, 30 ml, twice daily, was ordered on [DATE], but had not been followed in February or March. Resident #1's MAR indicated [REDACTED] During an interview on 03/25/16 at 1:41 p.m., the CMA said Resident #1's Pro-Stat started on 03/25/16. During an interview on 03/25/16 at 10:00 a.m., the ADON said the facility realized that Resident #1 was not given the ordered Pro-Stat since January, and the facility started the Pro-Stat again on 03/25/16. She said the order failed to be carried over for the months of February and March 2016. The ADON did not know if the Resident #1's physician had been notified about Resident #1 missing the Pro-Stat. During an interview on 03/26/16 at 10:21 a.m., the RNC said the Pro-Stat was not given since 01/31/16. She said the order had not been entered in the computer and did not appear on the MAR. The RNC said Resident #1 should have received Pro-Stat in February and March. A progress nursing note dated 03/10/16 at 10:00 a.m. indicated Resident #1's wound had a strong odor. Hospice was notified about the odor, and the note indicated hospice would obtain antibiotics for Resident #1's wound. A nursing note dated 03/10/16 at 1 p.m. indicated an order for [REDACTED]. Resident #1's MAR for March 2016 indicated the following doses of [MEDICATION NAME] were missed: *2 a.m. dose on 03/11/16 *2 a.m. dose on 03/12/16 *2 a.m. dose on 03/17/16 *2 p.m. dose on 03/17/16 *2 p.m. dose on 03/18/16. The final dose of [MEDICATION NAME] was given on 03/20/16. A hospice note dated 03/21/16 at 2:30 p.m. indicated Resident #1's wound had slough and eschar remaining, with redness to the surrounding tissue, and the foul odor had returned. The note indicated the case manager was notified to obtain a new order of antibiotics. Review of Resident #1's MAR indicated [REDACTED]. During an interview on 03/26/16 at 9:40 a.m., the ADON said she had discussed additional antibiotics with the hospice case manager. She said she did not consult with Resident #1's physician. During a telephone interview with Resident #1's hospice case manager on 03/28/16 at 2:30 p.m., she said 03/25/16 was her first day to see Resident #1 because she had just been added to her caseload that day. She said she had not looked at the pressure ulcer and she had not discussed antibiotics with anyone in the facility. During an interview on 03/29/16 at 11:25 a.m., the hospice LVN said she had spoken with her nurse manager on 03/21/16 about the deterioration of Resident #1's wound, and was told the facility ADON said the physician would be notified about additional antibiotics for Resident #1. She said it was the facility's responsibility to notify the physician of changes in Resident #1's condition not related to her [MEDICAL CONDITION]. During a telephone interview on 03/28/16 3:09 p.m , the NP said she had not been notified about Resident #1's wound deterioration. She said she was in the facility on 03/23/16 and the facility did not inform her of any changes in Resident #1's wound. She said she expected the facility to notify her of changes in Resident #1's condition. A wound treatment flow sheet dated 02/01/16 through 02/29/16 indicated an order to cleanse the stage III pressure ulcer to Resident #1's coccyx, dry, apply dressing, and cover, with a start date of 12/29/16. An order dated 02/10/16 indicated to cleanse Resident #1's stage III pressure ulcer, dry, and apply Puracol (a collagen dressing), and cover with dry dressing. The wound treatment flow sheet for February indicated no treatment was done for 02/14/16 through 02/22/16, 02/22/16, 02/24/16, 02/25/16, 02/28/16, and 02/29/16. The wound treatment flow sheet dated 02/01/16 through 02/29/16, indicated barrier cream should be applied to the coccyx on every shift and as needed, twice daily. The flow sheet indicated no barrier cream was applied on the day shift from 02/12/16, 02/13/16, 02/14/16, 02/17/16, 02/18/16, 02/24/16, 02/25/16, 02/27/16, 02/28/16 and 02/29/16. The flow sheet also indicated no barrier cream was applied on the evening shift 02/25/16 through 02/29/16. During an interview with LVN D at 11:18 a.m., LVN D said that she would put skin barrier on Resident #1. She said the CNA's usually did it and the nurses signed. She said she would do Resident #1 wound care for her shift but she was unsure if the other shifts did wound care as ordered by the physician. A wound treatment sheet dated 03/01/16 through 03/31/16 indicated the treatment plan to continue the 02/09/16 order for treating Resident #1's stage III pressure ulcer, (wound cleanser, dry, apply a collagen cover with dressing) was not done on 03/04/16 through 03/05/16, and the treatment was discontinued on 03/05/16. A telephone order dated 03/05/16 indicated an order clarification to discontinue the Puracol treatment. The wound treatment sheet dated 03/01/16 through 03/31/16 indicated to cleanse Resident #1's stage III pressure ulcer, apply skin prep to Resident #1's per wound, apply hydrogel or equivalent to the wound bed, and cover with foam dressing, twice daily and as needed. The wound treatment sheet indicated treatments were completed on 03/01/16 through 03/13/16 at 8 a.m., and 03/01/16 through 03/16/16 at 8 p.m. A telephone order dated 03/10/16 indicated to cleanse Resident #1's wound with normal saline, dry, apply calcium alginate with silver, and cover with foam twice daily, and as needed until healed. The wound treatment sheet indicated the treatment following the 03/10/16 order for Resident #1 was only completed on the 6 a.m. to 2 p.m. shift, 03/10/16 through 03/16/16. The treatment sheet indicated no treatments were done by the 2 p.m. to 10 p.m. shift on 03/10/16 through 03/16/16. The wound treatment sheet indicated the wound treatment was increased to every shift and as needed on 03/14/16. The treatment sheet indicated no treatments were done by the 6 a.m. to 2 p.m. shift on 03/19/16 and on 03/24/16. The sheet also indicated that the wound treatment was not completed by the 2 p.m. to 10 p.m. shift 03/22/16 and on 03/24/16. The sheet also indicated that no treatment was done by the 10 p.m. to 6 a.m. shift on 03/19/16. During an interview and observation on 03/25/16 at 11:23 a.m., LVN D was treating Resident #1's wound. The old dressing indicated a date of 03/24/16, initialed by LVN D. LVN D said she had only changed the dressing one time on 03/24/16 at 11:00 a.m. The wound had not been changed on any other shift as required by physician orders. The wound had a foul odor, and there was brownish slough to the wound bed with brown necrotic tissue. There was a moderate amount of drainage noted on the old dressing. LVN D said the wound had worsened over the past few weeks. She said she had not notified the physician concerning the wound. She measured the wound, 13 cm x 12 cm, but was unable to get the depth due to tunneling in the wound. LVN D said the wound had increased in size since the last measurement. During an interview with CNA E on 03/29/16 at 1:50 p.m., CNA E said she felt Resident #1's wound had worsened because the nurses were not doing the treatments like they were supposed to. A wound care evaluation dated 03/11/16 indicated wound on the coccyx was a pressure ulcer- unstageable 4 cm x 2.10 cm depth unable to determine, no tunneling, no undermining with [MEDICAL CONDITION] (consisting of a mixture of blood serum and pus) drainage and was facility acquired with onset date of 03/20/15. The note indicated the wound was infected. The policy indicated: a code key for pressure ulcers. This key indicated stage II was a Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without sloughing or bruising. A stage III as Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle us not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. A stage IV as Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some portion of the wound bed. Often includes undermining and tunneling. An unstageable pressure ulcer as Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The policy indicated: assessment of pressure ulcer is documented using the (skin assessment flow sheet -pressure ulcers) A printed note on form page 2 under completion of skin evaluation flow sheet for pressure ulcers indicated: the treatment should be evaluated every 14 days or more often as indicated. The physician is to be contacted for additional treatment orders. The resident and interested party is also to be notified and the care plan updated appropriately. The policy indicated all notifications to physician, interested party of the resident and the resident are to be completed and documented. The CMS 672 dated 03/25/16 indicated there were 3 Residents with pressure ulcers.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices. 1. One of 5 residents (Resident #20) reviewed for falls fell 6 times in 2 months and sustained a fractured arm with the sixth fall. The facility did not implement fall preventions or provide interventions to prevent injuries after each fall. 2. There were cigarette butts on the ground by the front entrance, behind the laundry, and at the Hall 300 and Hall 400 exit doors. 3. Two of 3 dryers had a large amount of lint hanging from the filters. These failures could place the census of 37 residents at risk for injuries. Findings included: 1. Physician orders [REDACTED]. A care plan dated 06/04/15 indicated Resident #20 was at risk for falls. Interventions included to give verbal reminders not to ambulate/transfer without assistance. The most recent MDS dated [DATE] indicated Resident #20 had severely impaired cognition, required extensive assistance of one staff for bed mobility, and total assistance of one staff for transfers. The MDS indicated her mode of mobility was by wheelchair. The MDS also indicated that the resident had falls, but was not experiencing any pain. Fall risk assessments dated 08/10, 08/11, 08/13, 08/19, 10/03, and 10/25 indicated Resident #20 was at high risk for falls. Incident/Accident reports for Resident #20 noted the following: *08/10/15: While in the TV room (adjacent to the nursing station), Resident #20 stood up from her wheelchair and tripped over her wheelchair tire and fell . Interventions noted, Due to current dementia diagnosis, resident forgetful to wait or ask for assistance with transferring and mobility. Frequent reminders given on safety and need for assisted transfers. *08/11/15: While in the TV room, Resident #20 was found lying on the floor in front of her wheelchair against the entertainment center. Interventions included to obtain a urinalysis (negative) and for staff to monitor and re-direct resident. *08/13/15: While in the TV room Resident #20 was found on the floor by another resident. The measures put into place or systematic changes made indicated the urinalysis completed with the last fall was negative for infection. There were no other meaures or changes listed. A care plan dated 08/13/15 indicated Resident #20 had falls and an intervention indicated to keep within sight and reach if possible. Incident/Accident reports for Resident #20 indicated the following: *08/19/15: While in the dining room (adjacent to the TV room and visible from the nursing station), Resident #20 slid out of her wheelchair onto her left knee and side. The intervention was May use geri chair as needed, but beneath it was noted, Geri chair dc'd (discontinued. 10/03/15: While in the TV room, Resident #20 stood from her wheelchair, fell back on her buttocks, and hit her head on another resident's wheelchair wheel. Interventions were to place her within staff eye sight at all times when out of bed and a drop seat for her wheelchair. A therapy screen dated 10/05/15 indicated Resident #20 .could benefit from skilled OT (occupational therapy) to address deficits with strength, range of motion, increase independence with ADLs (activities of daily living) . An Incident/Accident report dated 10/25/15 indicated Resident #20 was sitting at the nursing station when she leaned forward in her wheelchair and fell out on her right side and arm. She complained of right arm pain. She was sent to the emergency room and an x-ray noted a right humerus fracture. A sling was applied and the resident returned to the facility. Interventions indicated, No systemic change needed. Continue to monitor close and re-direct. A care plan dated 10/25/15 indicated Resident #20 had a recent fall and was at risk for further and/or increased falls and fractures. Interventions included to ask staff for assistance and to anticipate needs and provide prompt assistance. During an observation on 11/08/15 at 8:30 a.m., Resident #20 was lying on her bed. Her right arm was on a rolled blanket and had edema from the shoulder to fingertips and was discolored purple, green, and yellow. Resident #20 was moaning and grimacing. She said she fell and broke her arm. She did not remember when. The resident's bed was not in the lowest position. There were no alarms. During an observation on 11/08/15 at 12:10 p.m., Resident #20 was in her wheelchair in the dining room. There was a slight backward tilt noted to the wheelchair seat. During an interview on 11/08/15 at 10:50 a.m., LVN E said on 10/25/15 at about 3:10 p.m., she was away from the nursing station and was the only nurse on duty that day. LVN E said as she came back up Hall 200, she saw Resident #20 stand, but could not get to her before she fell . She said CNAs F and G assisted her to make the resident comfortable while awaiting the ambulance. She said Resident #20 complained of arm pain and held her right elbow. LVN E said the emergency department called report before returning the resident and indicated she had three broken bones in her right upper arm. She said the resident returned to the facility 10/25/15 at about 6:30 p.m. and had a sling on her arm. She said the resident went to an orthopedic physician a couple of days later and he removed the sling because of risk of contractures. She said the primary means of fall prevention for Resident #20 was to keep her at the nursing station or TV room and monitor her. During an interview on 11/08/15 at 11:12 a.m., CNA F said on 10/25/15 she did not see Resident #20 fall. She said she was assisting residents to the dining room and heard LVN E say Resident #20 had fallen and she went to assist She said Resident #20 often tried to stand without assistance, but staff could usually get to her in time to catch her. She said the main thing they did to prevent falls for Resident #20 was to place her at the nursing station. She said there was usually staff at the nursing station. During an interview on 11/08/15 at 12:13 p.m., CNA G said on 10/25/15 she did not see Resident #20 fall. She said she was assisting residents to the dining room and heard LVN E say Resident #20 had fallen and she went to assist. She said Resident #20 was kept at the nursing station so staff could watch her. She said Resident #20 tried to stand and could not remember to call for assistance. During an interview on 11/10/15 at 3:50 p.m., the DON said the main intervention for fall prevention for Resident #20 was to monitor her closely by keeping her at the nursing station or TV room by the nursing station. Resident #20 could not remember re-direction or to call for assistance with transfers. The DON said a geri chair was tried for a day, but discontinued because she thought it might be considered a restraint. They considered a pommel cushion, but she thought it might increase the likelihood of a fall. She said a pommel cushion was not tried. The back of the wheelchair seat was dropped following the fall on 10/03/15. Following the therapy screen on 10/05/15, she discussed Resident #20 with the occupational therapist and it was decided the resident did not have the cognition necessary to participate in therapy. The DON re-iterated their primary intervention for fall prevention for Resident #20 was to keep her at the nursing station and monitor her. The DON was asked for the most recent fall risk assessment for Resident #20 prior to the fall on 08/10/15. The fall risk assessment was not provided. A Fall Evaluation and Prevention policy and procedure dated 09/2014 indicated the following: It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention. 2. During observation on 11/09/15, the following was noted: 12:03 p.m.: 9 cigarette butts were by the side walk on the driveway at the Hall 400 exit and 1 cigarette butt was in the grass by the side walk; 12:07 p.m.: 3 cigarette butts were by the Hall 300 exit door; 12:10 p.m.; 9 cigarette butts wee on the ground behind the laundry building and 1 cigarette butt was on the sidewalk beside the laundry building; 12:17 p.m.: 23 cigarette butts were on the ground to the right of the front entrance, 44 cigarette butts were on the ground to the left of the front entrance, and 31 cigarette butts were in the planted area by the front drive and breezeway. During an interview on 11/09/15 at 1:40 p.m., the administrator said this was a non-smoking facility for residents, therefore, there were no designated smoking areas and no smoking receptacles. She said there was no set policy for staff smoking. A Smoking policy and procedure dated 02/2013 indicated, Smoking will be permitted in designated safe area(s) only . A Fire Safety plan dated July 2015 indicated, .3. All personnel must be alert for .d. Smoking in unauthorized areas . 3. During an observation and interview on 11/11/15 at 7:50 a.m., the maintenance supervisor opened the three dryer lint filters. Two of the three dryers had a heavy build-up of lint. The lint on the middle dryer was falling from the filter into the dryer filter bin. The maintenance supervisor said he thought the lint filters were cleaned at least once a week, but usually on Monday and Thursday. During an interview on 11/11/15 at 8:55 a.m., the administrator said she was surprised at the build-up of lint in the dryers because that was something she had stressed the laundry staff keep cleaned. She said she had not given laundry staff specific guidance on how often the filters should be cleaned. A Laundry Dryers guideline dated 01/2005 indicated, .2. Brush and clean these lint screens at least every two to three loads .one spark on lint can cause a fire.