Every finding on record at Litchfield Health & Rehab Center

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 61 residents who reside in the facility. Findings include: On 3/20/25 at 10:40 AM, V21, Assistant Director/Infection Preventionist (ADON/IP) stated she was not aware of any registered nurse (RN) staffing issues. She stated that we have RNs who works days and RNs who work nights, so she is not aware that has ever happened. On 3/20/25 at 10:45 AM, V5, Certified Nursing Assistant (CNA) stated that she is not aware that an RN has ever not been present for an eight-hour period out of twenty-four hours. On 3/20/25 at 10:50 AM, V2, Director of Nursing (DON) stated that if she was aware that an RN was not available for an eight-hour period she would call an RN in. V2 added that she is on call 24/7 and would come in or V21 would come in. If a resident needed care that only an RN could provide and one was not available, she herself would come in. On 3/17/25 at 9:04 AM, V1, Administrator, provided copies of nursing staff schedules for dates January 1 to March 19, 2025. On 1/12/25, 1/25/25, 1/26/25, 2/8/25, 2/9/25, 2/17/25, 2/18/25, 2/21/25, 2/26/25, 3/4/25, 3/7/25, 3/8/25, 3/11/25, 3/17/25 and 3/18/25 there was no RN coverage for 8 consecutive hours in a 24-hour period. On 3/20/25 at 10:55 AM, V1 stated they have no specific RN policy. V1 stated they follow the guidelines and refer to the staffing policy. The facility's Long-term Care facility Application for Medicare and Medicaid, dated 3/17/25, documents there are 61 residents residing in the facility.

Based on observation, interview, and record review the facility failed to perform proper and safe transfers for 4 of 5 residents (R1, R31, R36, R46) reviewed for supervision to prevent accidents in the sample of 46. Findings include: 1. R46's Care Plan, dated 4/30/2024, documents that (R46) has a self-Care Deficit As Evidenced by: Needs assistance with ADLs (activity of daily living) and Transfer: One-person physical assistance required with wheeled walker. R46's Minimum Data Set (MDS), dated [DATE], documents that R46 is moderately cognitively impaired and requires supervision/touching assistance with transfers. On 3/17/2024 at 10:24 AM, V18, Certified Nurse's Aide, CNA, transfer R46. R46 was sitting on toilet andV18 was standing bathroom door. R46 then stood up from toilet. V18 grabbed a hold of R46's arm and guided R46 to the wheelchair. V18 encouraged R46 to wash her hands. R46 agreed and rolled towards the sink. V18 grabbed R46 under her left arm assisted R46 into a standing position from the unlocked wheelchair. V18 holding onto R46s arm assisted R46 into her unlocked wheelchair allowing the wheelchair to roll back away from the sink. On 3/20/2025 at 11:29 AM V18 stated R46 had taken herself to the restroom. V18 stated that she responded to R46 transferring and did not have the gait belt. V18 stated that she should have applied the gait belt when transferring R46. V18 stated that she left the gait belt on a different resident. On 3/20/2025 at 11:17 AM V5, CNA, stated that if she responds to a resident that requires assist with transfers, she uses a gait belt. When asked if she does not have one, V5 stated V5 pulls call light in bathroom and she calls for one On 3/20/2025 at 11:21 AM V34, CNA, stated when transferring a resident that requires assist a gait belt is used. V34 stated that if they enter a room and the resident has transferred themselves and she doesn't have one (gait belt) she calls to get one. 50628 2. R1's undated face sheet documented that she was admitted to the facility on [DATE] with diagnoses of dementia, chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. R1's MDS dated [DATE] documented she has severe cognitive impairment. She has no upper or lower extremity impairment but requires the use of a wheelchair for mobility. She is always incontinent of stool and frequently incontinent of bladder. R1's Care Plan dated 2/12/25 documented she has a low air mattress on bed with 1/4 rails for safety with mattress and is at risk for falls and injuries with a goal to decrease fall risk. The interventions include assessing toileting needs, bed in lowest position always, full mechanical lift for all transfers, mat at bedside when in bed and pressure alarm under the mattress. On 03/18/25 at 2:09 PM R1 transferred to R1's bed from the reclining high back wheelchair via mechanical lift by V23, certified nursing assistant (CNA) and V9 CNA. V23 and V9 did not check the straps of the mechanical lift sling when attached to the sling to check the stability of attachments. No gentle support was provided during transfer. 40650 3. R36's Physicians orders, dated 3/20/2025, documented diagnoses of Rheumatoid Arthritis with Rheumatoid factor of right hand without organ or systems involvement, Alzheimer's disease, unspecified, and age-related osteoporosis without current pathological fracture. R36's Care Plan, dated 12/2/2024, documented, Transfer: Full mechanical lift for all transfers. R36's MDS, dated [DATE], documented, that her cognition was severely impaired and that she was dependent upon staff for chair/bed to chair transfers. On 3/17/2025 at 12:15 PM, R36 was lying in bed and there was a full mechanical lift pad underneath R36 prior to being transferred. V6, CNA, hooked up the pad to the lift. V5, CNA, operated the mechanical lift, V5 lifted R36 up, over her bed, but V6 did not check the lift pad straps prior to V5 moving R36 from bed to wheelchair. 4. On 03/18/25 at 04:00 PM, R31 was lying in bed. The full mechanical lift pad was underneath R31, and it was hooked up to the full mechanical lift, V7, Licensed Practical Nurse and V11, CNA entered the room. No staff member checked to see if the full mechanical lift pad straps were secured to the full mechanical lift prior to moving resident away from the bed, V11 operated the full mechanical lift, and V7 held the wheelchair. No one was supporting and guiding the resident during the transfer, and R31 was swaying back and forth during the full mechanical lift transfer. Care Plan dated 3/10/2025 documented, Transfer: Full mechanical lift with assist x 2 for transfers. MDS dated [DATE] documented, that his cognition was moderately impaired, frequently incontinent of bowel and bladder. and required substantial to maximum assist for chair/bed to chair transfers. It also documented that he uses a wheelchair. R31's Physicians order sheet, dated 3/20/2025, documented diagnoses of Unspecified Sequelae of Cerebral Infarction and Dementia in other disease classified elsewhere unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 03/19/2025 at 01:05 PM, V6, Certified Nurse Assistant (CNA), stated that she checks the straps of the full mechanical lift pad before moving the resident away from the bed or the chair. She also stated that 1 person drives the full mechanical lift and the other person guides and supports the resident. On 03/19/2025 at 01:10 PM, V13, CNA, stated that she checks the straps of the full mechanical lift pad before moving the resident away from the bed or the chair. She also stated that 1 person drives the full mechanical lift and the other person guides and supports the resident. On 03/19/2025 at 01:10 PM, V14, CNA, stated that she checks the straps of the full mechanical lift pad before moving the resident away from the bed or the chair. She also stated that 1 person drives the full mechanical lift and the other person guides and supports the resident. On 03/19/2025 at 01:15 PM, V9, CNA, stated that she checks the straps of the full mechanical lift pad before moving the resident away from the bed or the chair. She also stated that 1 person drives the full mechanical lift and the other person guides and supports the resident. On 03/19/2025 at 02:05 PM, V19, Registered Nurse, stated that 1 person operates the full mechanical lift and the other person guides and supports the resident. On 03/19/2025 at 02:09 PM, V8, Licensed Practical Nurse, stated that 1 person operates the full mechanical lift and the other person guides and supports the resident. The facility's policy, Using a Mechanical Level II, dated 11/01/2023, documented, 1. At least two (2) nursing assistants are needed to safely move a resident with a full mechanical lift. It continues, E. Check the stability of the straps. It continues, 13. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. It continues, 16. Gently support the resident as he or she is moved, but do not support any weight. The facility's policy, Transfer Policy, dated 7/01/2023, documented, 5. When using a gait belt, apply the belt around the resident's waist over clothing. Never apply gait belt over bare skin.

Based on observation, interview, and record review the facility failed to perform complete incontinence care with an authorized cleansing agent for 4 of 6 residents, (R58, R27, R49, R12) reviewed for Bowel/Bladder Incontinence/ Catheter Care in a sample of 46. Findings include: 1.R58's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, facture of the sacrum, acute respiratory failure with hypoxia and moderate protein-calorie malnutrition. R58's Minimum Data Set (MDS) dated [DATE], documented she was severely cognitively impaired and dependent on the assistance for toileting hygiene. R58's Care Plan dated 2/17/25, documented she required assistance with ADLs (activities of daily living) with interventions of, in part, for staff to provide personal hygiene (one-person physical assist required). On 3/18/25 at 12:35 PM, R58 stated she needed to be cleaned up as she pointed to her groin region. At 12:44 PM V9, certified nursing assistant (CNA) and V10 CNA provided incontinent care to R58. V10 took a wet washcloth with a cleansing agent on it then wiped R58's left groin, took the same section with the same cloth and wiped her right groin, then proceeded to use the same washcloth and section to wipe her midline vaginal area. V9 then handed V10 a new wet washcloth with just water and V10 used it to rinse R58's groin regions and midline vaginal crease and did not dry off the area. V10 then washed R58's buttock region while she was rolled onto her left side and rinsed it without drying it off. 2.R12's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, hemiplegia and hemiparesis following cerebral infarction, polyneuropathy and hypertensive heart and chronic kidney disease with heart failure. R12's MDS dated [DATE], documented he was moderately cognitively impaired and is dependent on assistance with toileting hygiene. R12's Care Plan dated 3/4/25, documented he has a self-care deficit as evidenced by needing assistance with ADLs such as personal hygiene (one-person physical assist required) and he is at high risk for urinary tract infection due to indwelling catheter care and on enhanced barrier precautions as long as catheter is in place. On 3/19/25 at 10:35 AM, V21, Assistant Director/infection preventionist (ADON/IP), provided peri and indwelling catheter care to R12 with the assistance of V10 CNA, while V22, Registered Nurse (RN), V19 RN, and V31 MDS coordinator provided help as needed. V21 used washcloths in warm water with antibacterial hand soap pumped directly from the bottle onto the cloth by V10 for R12's peri and indwelling catheter care. V21 stated we typically use this hand soap for peri-care. The bottle of hand soap used for R12's incontinence care had warnings on the label stating, for external use only: hands only with directions stating, wet hands, apply palmful to hands, scrub thoroughly, rinse thoroughly. On 3/20/25 at 11:24 AM, V17, CNA stated she uses the total body skin and hair cleanser with vitamin E moisturizing lotion while performing incontinence care and has never used anything else. On 3/20/25 at 11:32 AM, V18, CNA stated she uses the total body skin and hair cleanser with vitamin E moisturizing lotion while performing incontinence care. On 3/20/25 at 11:50 AM, V5, CNA stated she uses the total body skin and hair cleanser with vitamin E moisturizing lotion while performing incontinence care. On 3/19/25 at 4:05 PM, V1, Administrator, stated she approved the hand soap to be used for incontinence care despite the bottle warning stating for hands only. V1 stated she expects staff to be folding the washcloths using a different section of it for each wipe and to be drying of the skin after rinsing during incontinence care. 42108 3. R27's Care Plan, dated 3/25/2024, documents that R27 has a self-Care Deficit As Evidenced by: Needs assistance with ADLs (Activity of Daily Living). It also documents Toileting needs - One-to-two-person physical assist required. R27's MDS, dated [DATE], documents that R27 is cognitively impaired and dependent on staff for toileting. On 3/18/2025 at 9:40 AM R27 was sitting in shower chair with gown on. There was wheelchair with a clean incontinent brief observed open on wheelchair. R27 was transferred into wheelchair on, top of the incontinent brief, using mechanical lift. R27 was then transported to her room and transferred into bed using mechanical lift. Upon lifting R27 into bed observed a moderate amount of black stool was observed on the incontinent brief. R27 was then laid on her right side revealing a moderate amount of black stool to buttocks. V12, CNA, using the wet wipes cleansed, V12 wiped R27's left buttock and partial right buttock. V12 then applied the incontinent brief. V12 did not cleanse the peri area, groin, labia, and entire right buttock. 4. R49's Care Plan, dated 12/20/2024, documents that (R49) has a self-care deficit as evidenced by need for assistance with ADL's. It continues Toilet Use - One-person physical assist required. R49's MDS, dated [DATE], documents that R49 is cognitively intact and dependent on staff for toileting. On 3/18/2025 at 10:10 AM V12, CNA, provide incontinent care to R49. R49 was incontinent of urine. R49 stated that she was wet and had urinated on the sheet in the wheelchair. V12 removed the urine-soaked sheet and placed in container. V12 was transferred to the bed using a mechanical lift. Upon rising from wheelchair resident stated that she was urinating at that time. Once in bed V12, using a wet washcloth cleansed both side of the groin. V12 then applied the clean incontinent brief. V12 did not cleanse the inner thighs or buttocks. On 3/20/205 at 11:13 AM V20, CNA, stated that when cleansing an incontinent resident, they clean the resident's peri area and buttocks. V20 stated that when incontinent both areas area cleansed. On 3/20/2025 at 11:29 AM V18, CNA, stated that she when cleansing a resident that is incontinent of urine, she cleanses both the front and back of the resident because of gravity and the urine goes backwards. V18 stated that she cleanses both the buttocks and the front when the resident is incontinent of stool. Cleanses the legs as well. On 3/20/2025 at 11:17 AM V5, CNA, stated that she cleanses the peri area, inner thighs and buttocks when performing peri care for a resident incontinent of bowel and bladder. On 3/20/2025 at 11:21 AM V34, CNA, stated that when performing incontinent care for a resident incontinent of bowel or bladder the front peri area and back buttocks are cleansed. The facility's Peri Care policy, not dated, documents that Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Equipment and Supplies: 4. Cleanser (or other authorized cleansing agent) Steps in the Procedure Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. Perform hand hygiene. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. Fold the bedspread or blanket toward the foot the bed. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. Put on gloves. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. For a female resident: Wet washcloth and apply soap or skin cleansing agent. Wash perineal area, wiping from front to back. Separate labia and wash area downward from front to back. (Note: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. Gently dry perineum. Ask the resident to turn on her side with her top leg slightly bent, if able. Rinse wash cloth and apply soap or skin cleansing agent. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Rinse and dry thoroughly.

Based on observation, interview, and record review, the facility failed perform proper hand hygiene and glove changes when performing incontinence care and providing meal service. The facility also failed to don personal protective equipment appropriately when providing care for a resident on enhanced barrier precautions for 5 of 7 residents ( R12, R15, R17, R27, R49) reviewed for infection control in a sample of 46. Findings include: 1. R27's Admission Record, not dated, documents that following diagnoses: Frontal Lobe and Executive Function Deficit Following Cerebral Infarction, Heart Failure, Unspecified, Cardiovascular and Coagulations, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Overactive Bladder. R27's Care Plan, dated 3/25/2024, documents that (R27) has a self-Care Deficit As Evidenced by: Needs assistance with ADLs (Activity of Daily Living). It also documents Toileting needs - One-to-two-person physical assist required. R27's Minimum Data Set (MDS), dated [DATE], documents that R27 is cognitively impaired and dependent on staff for toileting. On 3/18/2025 at 9:40 AM V12, Certified Nursing Aide, CNA, perform incontinence care for R27. R27 was incontinent of stool. V12 performed hand hygiene and applied gloves. R27 was transferred to the bed. When lifting R27 from the wheelchair revealed a stool soiled incontinent brief. V12 then removed the incontinent brief, rolled it, and discarded it. V12 then assisted R27 with rolling on side revealing a moderate amount of dark stool on R27's rectum. V12 then cleaned R27's buttocks. With the same soiled gloves V12 then open closet door and obtained incontinent brief. With the same soiled gloves V12 then applied incontinent brief and manipulated R27's covers. 2. R49's Care Plan, dated 12/20/2024, documents that (R49) has a self-care deficit as evidenced by need for assistance with ADL's. It continues Toilet Use - One-person physical assist required. R49's MDS, dated [DATE], documents that R49 is cognitively intact and dependent on staff for toileting. On 3/18/2025 at 10:10 AM observed V12, CNA, perform incontinent care. R49 was incontinent of urine. V12 performed hand hygiene and applied gloves. R49 stated that she was wet and had urinated on the sheet in the wheelchair. V12 removed the urine-soaked sheet and placed in container. V12 then using the same soiled gloves assisted R49 into the bed, touching the lift, sling, and bed. Upon rising from the wheelchair resident stated that she was urinating at that time and V12 removed the urine soiled incontinent brief and placed in the trash. V12 then obtained a new brief from the closet. V12, using a wet washcloth cleansed both side of the groin. Using the same urine soiled gloves, V12 then applied the clean incontinent brief and touching the clean linen and R49 clothing. On 3/20/2025 at 11:13 AM V20, CNA, stated when entering a room with a resident on enhanced barrier the Personal Protective Equipment (PPE) is applied. The gown is applied, and the straps are secured. When asked how she makes sure the gown does not fall during care. V20 stated that she ties the straps. V20 stated that hand hygiene and glove change are performed during care. V20 stated that the gloves are removed, hand hygiene performed and then items in room can be touched. On 3/20/2025 at 11:29 AM V18, CNA, stated that when entering a room with enhanced barrier she applies PPE. The gown is applied and secured. V18 stated that she ties the strap in the back of the gown to assure that the gown stays secure. On 3/20/2025 at 11:17 AM V5, CNA, stated that hand hygiene is performed and residents clothing, briefs are not to be touched by the soiled gloves. V5 stated that the gloves would be removed, wash hands then touch other items. V5 stated that she applied PPE when entering rooms of enhanced barriers posted. V5 stated that she applies the PPE and ties the ties on the back to assure that the gown remains secure during care. On 3/20/2025 at 11:21 AM V34, CNA, stated that hand hygiene is performed during this process (incontinence care) with glove changes. V34 stated that hands are cleaned before touching items in room. V34 stated that she applies PPE when entering enhanced barrier. V34 stated that the Gown is applied, and the straps are secured. When asked how are they secured? V34 stated that they are tied to make sure the gown doesn't fall. 50908 3.R12's face sheet documented he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, polyneuropathy and hypertensive heart and chronic kidney disease with heart failure. R12's MDS dated [DATE], documented he was moderately cognitively impaired and is dependent on assistance with toileting hygiene. R12's Care Plan dated 3/4/25, documented he has a self-care deficit as evidenced by needing assistance with ADLs such as personal hygiene (one-person physical assist required) and he is at high risk for urinary tract infection due to indwelling catheter care and on enhanced barrier precautions as long as catheter is in place. On 3/19/25 at 10:35 AM, V21, Infection Preventionist, closed the window curtain then provided peri and indwelling catheter care to R12 with the assistance of V10, Certified Nursing Assistance (CNA), while V22, Registered Nurse (RN), V19, RN and V31 MDS Coordinator, provided as needed help. R12 is on Enhanced Barrier Precautions requiring staff to don gowns and gloves while providing resident care. V10 did not tie her gown completely and had to readjust her gown after it kept sliding off during care. 40650 4. On 3/18/2025 at 12:58 PM, V5, CNA, pushed the hall meal cart down to R17's room. V5 took R17's lunch tray into him, she donned gloves without performing hand hygiene, rolled R17's head up and set R17's meal tray up, buttered R17's bread and removed the foil off his baked potato. She then doffed her gloves and performed hand hygiene. V5 the pushed the hall cart across from R15's room. V5 then took R2's, tray to her room and handed it to the staff member in there. V5 then returned to the food cart, and at 1:02 pm took R15's lunch tray into her. V5, donned gloves without performing hand hygiene, rolled R15's head of her bed up, and raised R15's bed to place overbed table in place. She then removed R15's baked potato out of the foil and cut it up and added butter. She then removed R15's bread out of the bag, opened the small container of butter and buttered her bread. She then exited R15's room and used ABHR (alcohol based hand rub) for hand hygiene. On 03/19/2025 at 01:05 PM, V6, Certified Nurse Assistant (CNA), stated that she will wash her hands prior to putting on gloves and after she takes them off. On 03/19/2025 at 01:10 PM, V13, CNA, stated that she washes her hands or uses alcohol-based hand rub, before putting on gloves and after taking them off. On 03/19/2025 at 01:10 PM, V14, CNA stated that she washes her hands or uses alcohol-based hand rub, before putting on gloves and after taking them off. On 03/19/2025 at 01:15 PM, V9, CNA stated that she does wash her hands before putting gloves on and after she takes it off. The Facility's policy, Quick Resource Tool: Serving Specific Glove Usage, dated 09/01/2024, documented, 3. If resident needs assistance with food that would require staff to directly touch food items, gloves need to be worn. It continues, 5. Staff must wash their hands prior to putting gloves on and sanitize hands after removing gloves. The Facility's policy and procedure, Handwashing/Hand Hygiene, undated, documented, This facility considers hand hygiene the primary means to prevent the spread of infections. It continues, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. It continues, 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. It continues, B. Before and after direct contact with residents. It continues, D. Before performing any non-surgical invasive procedures. It continues, H. Before moving from a contaminated body site to a clean body site during resident care. It continues, J. After handling used dressings, contaminated equipment. It continues, L. After removing gloves. M. Before and after entering isolation precaution settings; N. Before and after eating or handling food. It continues, P. After personal use of the toilet or conducting your personal hygiene. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. It continues, Applying and Removing Gloves. 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching on the top of the cuff.

Based on observation, interview, and record review, the facility failed to provide privacy during wound care for 1 of 15 residents (R12) reviewed for privacy in a sample of 46. Findings include: R12's Face Sheet documented he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, polyneuropathy and hypertensive heart and chronic kidney disease with heart failure. R12's Minimum Data Set (MDS) dated [DATE], documents R12 as moderately cognitively impaired. R12's Care Plan dated 3/4/25, documents R12 has a pressure ulcer to rear right flank and requires assist with turning and repositioning. On 3/19/25 at 10:20 AM, R12 was provided wound care by V21, Assistant Director of Nursing/Infection Preventionist, with V22, Registered Nurse (RN), V19 RN, and V31 Minimum Data Set (MDS) Coordinator all present. R12's pants and brief were pulled down while he was rolled on his right side to expose his wound while V21 provided wound care while his curtain and window shade were wide open. At 10:35 AM, V21 stated, I can't believe I forgot to close the curtain. On 3/20/25 at 12:05 PM, V17, Certified Nurse's Aide (CNA) stated during resident care she closes the curtains and window shades to provide the resident privacy. On 3/20/25 at 12:06 PM, V32 Licensed Practical Nurse (LPN) stated she absolutely closes the curtains and window shades during resident care to provide privacy. On 3/20/25 at 12:07 PM, V33, CNA stated she closes the closes the curtains and window shades during resident care to provide privacy. On 3/19/25 at 4:05 PM, V1, Administrator, stated she expects staff to close room curtains and window shades while the resident's body is exposed during care. The facility's Contract Between Resident and Facility; Attachment E: Statement of Resident Rights, undated, documented the resident has, the right to respect for bodily privacy and dignity at all times, especially during care and treatment.

Based on observation, interview and record review, the facility failed to check placement of a gastrostomy tube prior to administering water flushes for 1 of 2 (R42) residents reviewed for enteral feeding tubes in a sample of 46. Findings include: R42's Physicians Orders, dated3/20/2025, documented diagnosis of Hemiplegia and Hemiparesis following unspecified Cerebrovascular disease affecting left dominant side and Dysphagia, Unspecified. On 03/17/2025 at 10:37 AM, A tube feeding was hanging, dated 3/17/25 but not infusing. It was not opened or spiked. R42's Physicians Order Sheet, dated 3/20/2025, documented, Enteral Feed every 6 hours Flush with 125 (milliliters). It continues, Enteral Feed every shift Enteral - Check Residuals before beginning OF feeding and before medication administration. If Greater than 100 cc, HOLD Feedings and Recheck in 1 HR. If not resolved, call (Medical Doctor). R42's Care Plan, dated 7/3/2024, documented, Check for tube placement and gastric contents/residual volume per facility protocol and record. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. On 03/18/2025 at 10:45 AM, V8, Licensed Practical Nurse, performed hand hygiene and donned gloves, obtained tap water in a graduated cylinder, opened a new syringe, filled it with 60ml of tap water, opened R42's gastrostomy feeding tube and pushed flushed R42 enteral feeding tube. She then filled the syringe with another 60ml and pushed flushed into R42's gastrostomy tube and then filled it with another 5 ml of tap water and pushed it into R42 gastrostomy tube. V8 did not check residual or placement of the gastrostomy tube prior to water flushes. R42's Minimum Data Set, dated dated [DATE], documented that her cognition was moderately impaired and that she had a feeding tube. On 03/19/2025 at 02:05 PM, V19, Registered Nurse, stated that she wouldn't check placement every time, but she would auscultate for placement of the feeding tube. V19 also stated that she was a new employee so it would depend upon the facilities policy. On 03/19/2025 at 02:09 PM, V8, Licensed Practical Nurse, stated that yes, she should have checked for placement before flushing R42. Facility's Policy, Enteral Tube Flushing, undated, documented, 5. Pause active feeding if applicable, clamp enteral tube. Remove the plug and cover end of tubing. 6. Verify placement of tube. 7. If anything suggests improper tube positioning, do not administer water flush, feeding or medication. Notify the physician. 8. When correct tube placement has been verified, flush tubing with at least 30ml water (or prescribed amount).

Based on interview and record review, the facility failed to obtain a timely x-ray for 1 of 4 residents (R3) reviewed for diagnostic services in the sample of 4. Findings include: R3's Minimum Data Set, MDS, dated [DATE] documents R3 has a BIMS (Brief Interview for Mental Status) of 10, which is moderate cognitive impairment. R3's Progress Note, dated 4/8/24 at 7:30 AM, documents the following: Writer called to resident room, noted right knee deformity and resident complained of inability to move leg. No redness or swelling noted. Resident denies bumping or twisting leg at any time. CNA (Certified Nursing Assistant) reports resident ambulated to bathroom approximately 5 AM with gait belt and 1 assist with walker. No difficulty noted by caregiver or complaints of pain voiced by resident. Spoke with son who stated resident has had both knees replaced in the past. Further stated, 'she doesn't even move around that much.' Informed son we would be requesting X-ray and would update when results received. R3's Progress Note, dated 4/8/24 at 8:30 AM, documents MD (medical doctor) notified of resident c/o (complaining of) right knee pain with deformity noted. New order received for x-ray of right knee stat. POA (Power of Attorney) aware. R3's Progress Note, dated 4/8/24 at 8:44 AM, documents Upon current assessment, resident resting in bed with eyes closed. Noted discoloration evolving to right lower thigh above knee. Awaiting x-ray at this time. Resident in no apparent distress. R3's Progress Note, dated 4/8/24 at 7:45 PM, documents the following: x-Ray company in facility at this time to complete x-ray to right knee. R3's Progress Note, dated 4/8/24 at 8:08 PM, documents the following: On call physician returned call to facility at this time. He was updated on resident increased pain. New order received to send resident to emergency room for evaluation. R3's Progress Note, dated 4/9/224 01:08 AM, documents the following: Resident admitted to hospital. R3's x-ray Report with a date of service 4/8/24, no time, documents the following: right knee x-ray, impression - knee arthroplasty, proximal to which is an acute fracture. R3's Hospital Records, SNF (Skilled Nursing Report) dated, 4/9/24 documents R3 was admitted with a right femur fracture. R3's POS (Physician Order Sheet, documents an order dated 4/8/24 at 8:30 AM, for a portable x-ray of the right knee due to pain and deformity. Portable due to resident limited mobility. On 4/11/24 at 9:08 AM, V3, LPN (Licensed Practical Nurse), stated when she came into work on 4/8/24, R3 was waiting for an x-ray. V3 stated she received the results, which showed a fracture, she notified the on-call physician and V14, R3's Son and then sent R3 to the local hospital for further evaluation. On 4/11/24 at 12:51 PM, V14, R3's Son, stated he was notified by the facility sometime early in the day that R3 was complaining of pain in her knee, and they were ordering an x-ray. V14 stated he came to the facility around 5:00 PM and stayed until around 7:30 PM and no one came to do the x-ray. V14 stated he asked the staff what was going on and he was told they (x-ray company) would be at the facility in about an hour. V14 stated he stayed until 7:30 PM and they hadn't shown up. V14 stated around 45 minutes after he left the facility, he received a call stating that R3 had a fracture, and they were sending her to the local emergency. On 4/11/24 at 1:35 PM, V15, Registered Nurse (RN)/ Assistant Director of Nurses (ADON), stated she had requested an x-ray for R3, and it was ordered just as a regular x-ray, the doctor didn't say stat or routine. V15 stated it was quite a while, close to 12 hours before the x-ray was completed. On 4/11/24 at 1:35 PM, V2, Director of Nurses, DON, stated V15 had come and gotten her, and they went and assessed R3's leg. V2 stated there was a deformity and the physician was notified for an x-ray. V2 stated the order was placed at 8:30 AM and wasn't obtained until around 7:30 PM that night, around 11 hours later. The Mobile Imaging Services Agreement, dated 11/8/19, documents the following: provider shall provide the following services to facility's patients: Provider, an independent contractor using their equipment and qualified staff, will provide portable diagnostic x-ray and doppler, ultrasound and EKG (electrocardiogram) services where available that have been ordered by a qualified MD (Medical Doctor), DO (Doctor of Osteopathy) or NPP Non-Physician Provider). Provider will respond within a reasonable time frame to requests for services, usually within a few hours. A duly licensed radiologist radiologic exams and cardiologist will interpret cardiology exams. Provider will notify facility by phone of positive exam findings as soon as possible and will provide a full written report to facility within twenty-four hours of the exam. Images and reports are also available on-line for review 24/7.

Based on interview, and record review, the facility failed to provide supervision during toileting to prevent falls for 1 of 4 residents (R2) reviewed for supervision. This failure resulted in R2 falling and sustaining a hip fracture. Findings include: R2's Admission Record, print date of 7/12/23 documented R2 has diagnoses of weakness, muscle weakness, and unspecified dementia. R2's Care Plan, dated 2/3/23 initiated, documented R2 had a self-care performance deficit due to weakness, history of falls and dementia and needs mostly limited assistance with all care needs. The Care Plan documented *Restorative* will continue safe transfers with assist will minimize risk factors for falls thru next review. Care Plan Interventions documented Assist of one with wheeled walker, ambulate to/from all destination and wheelchair to follow outside of room distance as tolerated. R2's Fall Risk Assessment, dated 2/8/23, 4/19/23 and 6/26/23 documented R2 as a moderate risk for falls. R2's, Physical Therapy discharge summary for date of service: 2/3/23-4/21/23, documents, Patient will increase static standing balance was Fair+ spontaneously righting self when needed in order to decrease LOB (level of balance) during functional mobility. The Summary documented Standing prior to onset was Fair+. A baseline dated 2/3/23, documented fair (requires minimum assistance or upper extremity support to stand without loss of balance. R2's Final Discharge Therapy Note, dated 4/21/23, documented Fair (stands unsupported without upper extremity support or loss of balance for 1-2 minutes, referred recommendation to RNP, (Restorative Nursing Program). R2's Restorative Program Evaluation, dated 6/27/23, documents, is safe with assistance and walker, sometimes unable to ambulate due to knee pain. R2's Minimum Data Set, MDS, dated [DATE], documented R2 had Brief Interview of Mental Status (BIMS) score of 12, indicating R2 had moderately impaired cognition. R2's MDS documents R2 required limited (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight-bearing assistance) of one staff person physical assistance for transfers and toileting. R2's MDS documents R2 is not steady, only able to stabilize with staff assistance when moving on and off the toilet and walking. R2's MDS documents R2 was frequently incontinent of bowel and bladder. R2's Nurse's Note, dated 7/8/23 at 7:18AM, documented, Writer called residents room and observed (R2) lying on the bathroom floor on his left side with his head resting against door frame. The commode riser twisted on toilet, water on floor around toilet when asked (R2), what happened, (R2) states, 'I was trying to get up off the toilet so I could get ready for the day and fell .' R2's, Facility Reported Occurrence Report, documented on 7/8/23 at 7:18 AM, R2 was found on floor in bathroom. The Report documented R2 had attempted to transfer self from toilet, did not use call light for assistance. The Report documented areas of injury, scalp, hematoma to head and left hip pain during range of motion assessment. The Report documented there was a wet floor, and alarm not activated at time off fall along with Care Plan interventions to be completed upon resident return to facility after assessment of current status completed. R2's entitled, Fall Details Report, dated 7/8/23 at 7:18 AM, documented visually observed on floor by V6, Certified Nurse's Aide (CNA), call light off, care prior to fall was 7/8/23 at 6:15AM, last documentation. Residents state of motion at time of fall was transferring with no staff assistance. R2's Hospital Imaging Services report, dated 7/8/23 at 8:36 AM, documented R2's final result report study of anterior (front) and posterior (back) of left hip with two radiology views taken, Exam is positive for mildly displaced left intertrochanteric fracture. On 7/12/23 at 2:30 PM, V2, Director of Nursing, DON, stated it was reported that a fluid substance was found on the floor around the toilet base at the time of R2's fall; however, when V2 went to address R2's incident, there were towels wrapped around the toilet basin. V2 stated that R2 is a one nursing assist with walker to the bathroom. V2 stated V5, CNA from night shift, had gotten R2 up and transferred him to the toilet at 5:45 AM and at 6:00 AM, V5 went to re-check on R2, where he continued to remain on the toilet and that R2 had stated he was not ready to get off the toilet. V2 stated that V5 left her work shift at 6:00 AM and gave report to the on-coming CNA, V6, that R2 remained on the toilet. V2 stated that at 6:15 AM, V6 went to check on R2 and R2 stated I still need more time. V2 stated V6 continued to care for her residents as she was assigned too. V2 stated I returned to check on R2 at 7:15AM and found him on the bathroom floor lying on his left side. V2 stated prior to this incident, R2 had complained of left knee pain and was recently ordered for a cortisone (steroid) injection) to his left knee. V2 stated R2 has always used his call light, but R2's call light was not activated on 7/8/23 when R2 fell . On 7/17/23 at 9:02 AM, V2 stated that V3, Licensed Practical Nurse (LPN) went to R2's room around 6:27 AM on 7/8/23 to get R2's oxygen saturation and R2 was still on the toilet. V2 stated V3 had observed towels around the toilet basin and based on V6 fall incident interview that a liquid was observed around the toilet basin V2 stated she notified maintenance. V2 stated maintenance observed no water coming out around the toilet basin, but V2 stated the maintenance man stated, if a person is to sit too far back on the toilet seat it can cause the toilet base to separate from the toilet tank and could cause water to come out around either the tank, the maintenance man found no evidence the toilet seals were broken to cause a leak but ordered for a new toilet parts replacement anyway. V2 continues to state, she feels the facility did no wrong for R2's fall incident, he is known to use his call light. On 7/17/23 at 9:30 AM, V3 stated on 7/8/23 at 6:29 AM she went into R2's room to get his oxygen saturation monitored while R2 was on the toilet and observed no liquid substance on the floor around the toilet. V3 stated she remained on the same hall across from R2's room attending to resident medication needs and heard no call light activated from R2's room at 7:18A M, V6 found R2 lying on the bathroom floor, performed an assessment on R2 and found towels wrapped around the toilet basin. V3 states, I feel he (R2) should not have been left alone, his legs are weak and especially, after receiving a cortisone injection in his left knee, due to his complaint of pain. On 7/17/23 at 3:40 PM, V7, CNA stated R2 was a tall guy at least 6 feet and then some and V7 took care of him a lot. V7 states, (R2) was quick to get up on his own but knew he needed assistance, and when he was taken to the toilet, he was told to use the call light and he would, when he wanted, but would be quick to the draw to get up on his own, so since (R2) got up off the toilet without listening, I (V7) started staying right at his bathroom door, until he was finished, because no one is going to fall on my shift. The Facility's CNA Report for Falls, dated 7/8/23 and written by V6, documents, the last time V6 repositioned R2 was 6:15 AM, and the last time fluids were offered was 6:00 AM. The report documented there was water on the floor. R2's CNA Statement of Care Provided During Shift, written by V6, dated 7/8/23, documents Offered fluids at 6:00 AM. Came on shift and at 6:15 AM and at 6:15 AM checked on resident. He stated he was not ready, and he needed more time, so when I came back, and he was on the floor 7:18 AM. Resident did not use his call light R2 usually rings light when done, he has gotten up by (V5). Facility's, untitled sheet, dated 7/14/23, documents, Per interview with (V3) regarding (R2) 7/8/23, documented, during this interview form, V3 was asked was R2 prior to the fall did you remind him to use the call light when he was finished, answer from V3, Yes, I always tell the residents to use their call light if they need anything before, I leave the room. Interviewer asked, what was his response.? V3 documented I don't remember. On 7/18/23 at 9:30 AM, V1, Administrator with V2 present, states, Yes, I see that (R2's) fall resulted in a fracture would be considered harm. But I can't see in the future if the fracture was due to his fall or a weakness in his hip already. V1 stated she reached out to a physician, unknown name, that informed V1 of the possible causes of R2's fracture. The Facility's policy and procedure, entitled, Accidents & Incidents, date initiated: 7/1/23, documents, An accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident.

Based on observation, interview and record review, the facility failed to provide services to prevent the worsening of contractures for 1 of 3 residents (R15) reviewed for contractures in a sample of 26. Findings include: On 01/23/23 at 9:35 AM, R15 was observed in her wheelchair with a carrot (an aid to prevent fingers from going into the palm) in left hand. On 1/23/23 at 9:37 AM, V5, Certified Nurse's Aide (CNA), was questioned if R15 receives any range of motion exercises (ROM) on her hand. V5 stated that they do ROM exercises with R15's left hand. V5 was asked to perform the exercises on R15. V5 then performed finger stretches in and out of the left hand and bending of the first knuckle of the fingers on the left hand. V5 failed to do repeated flexion and extension of the finger at all joints. On 1/23/23 at 9:40 AM, V13, Registered Nurse/ Restorative Nurse, was questioned about where the resident's restorative plan of care could be located and who was in charge of making up the restorative plans. V13 stated that she oversees the restorative nursing program, and she makes up the resident's programs if they need one and the program can be found in the residents Care Plan. On 01/24/23 at 8:45 AM, V13 was questioned as to why R15 did not have a Range of Motion plan of care in place for her left hand due to contractures. V13 stated that the staff do work with R15's hand but there is not a plan made up for it and she is going to get an order from the doctor for range of motion today. V13 further stated that she was not aware that R15 did not have an order or a plan of care for range of motion. On 1/24/23 at 2:30 PM, V1, Administrator, stated, I do expect everyone with a contracture to have a program put in place, so they do not get further contracted and then the staff know what exactly the resident's program is. (V13) and I talked of this last night, and she knows everyone with a contracture needs to have a plan that address it in their care plan. On 1/25/23 at 10:30 AM, V2, Director of Nurses, stated, Range of Motion should be done on all planes. R15's Admission Record, print date of 1/24/23, documents that R15 was admitted on [DATE] and has diagnoses of Dementia and personal history of a stroke. R15's Minimum Data Set, dated dated [DATE], documents R15 is moderately cognitively impaired and has limited range of motion impairment on one side. R15's January Physician Orders fail to document an order for range of motion. R15's Care Plan, dated 6/24/20, documents, I have an ADL (Activities of Daily Living) Self Care Performance deficit r/t (related to) HTN (hypertension), GERD (gastric reflux disease), hx (history of) CVA (stroke) and weakness. I need extensive to total assist with ADLs. Interventions: Date Initiated: 7/17/2020 I am to have therapy carrot in left hand at all times, except when giving skin checks and washing of hand. I will take it out / put independently. R15's Care Plan fails to document any other intervention for R15's left hand. The facility Range of Motion Competency Checklist undated, documents, Fingers: Flexion - make a fist. Extension - straighten fingers out. Abduction - spread fingers apart. Adduction - bring fingers together. Thumb: Rotation - move thumb in a circular motion. Opposition - touch thumb to each finger of the same hand.

Based on observation, interview and record review, the facility failed to prevent the potential spread of infection by failing to perform hand hygiene during incontinent care and medication administration and failing to disinfect blood glucose monitors between residents for 4 of 6 residents (R7, R23, R36 and R143) reviewed for infection control in the sample of 31. Findings include: 1. On 02/23/2022 at 7:42 AM, V20, Licensed Practical Nurse (LPN), was observed during a medication pass. V20 retrieved medications for R7, donned gloves without benefit of hand hygiene and took blood glucose monitor into R7's room. V20 performed blood glucose test and administered medications to R7 and exited R7's room. V20, placed the blood glucose test machine on top of the medication cart and doffed her gloves. V20 did not clean the blood glucose test machine. V20 then retrieved R23's medication, without benefit of hand hygiene, and administered medication to R23. V20 then exited R23's room, documented on the computer that was on top of the medication cart. V20 then pushed the medication cart down hallway to R143's room. V20 retrieved medications for R143 and donned gloves, without benefit of hand hygiene. V20 used the same blood glucose test machine that was used on R7, that was not cleansed afterwards, to perform blood glucose test on R143. V20 then administered medications to R143. V20 doffed gloves and did not perform hand hygiene afterwards. On 02/24/2022 at 1:04 PM, V1, Administrator, stated that the nurse should have cleaned the blood glucose monitor with dispatch wipes in between resident use. On 2/28/22 at 2:20 PM, V1 stated I would expect the nurses to perform hand hygiene in between residents while passing medications. The facility's policy, Subject: Blood Glucose Testing and Monitoring, dated 02/2016, documents, Clean blood glucose meter with Dispatch product if meter is shared between residents. The facility's policy, Hand Hygiene Protocol, dated 07/26/2021, documents, Use an Alcohol Based Hand Sanitizer: Before resident contact. It continues, After contact with blood body fluids or contaminated surfaces. Immediately after glove change. 2. On 2/24/22 at 8:36 AM, R36 was resting in her wheelchair, had just finished with breakfast, and had requested to get back to bed. V4, CNA, and V5, LPN, entered with a mechanical lift to get R36 to bed and provide incontinent care. R36 was placed into her bed using the mechanical lift. No gloves or hand hygiene were used before or during the transfer. V4 put gloves on without first performing hand hygiene. V4 turned R36 in order to partially remove her incontinence brief and pants. V4 changed her gloves with no hand hygiene done between the glove change. V5 went out of the room for more washcloths as there was only a couple brought into the room. V4 wet the washcloths and applied perineal wash to them. V4 wiped R36's left buttock once and placed the soiled washcloth on the bed. V4 doffed soiled gloves and applied new gloves with no hand hygiene done between glove change. V4 wet some washcloths again and wiped R36's left groin once. V4 then doffed her gloves and washed her hands. V4 donned clean gloves and then patted/dried R36's groin. R36 then rolled to the left and soiled brief removed from under her. V4 changed gloves with no hand hygiene between, wet some washcloths again and wiped R36's right buttock, then changed gloves again without hand hygiene performed before donning clean gloves. The pad was rolled up with the soiled washcloths on it and placed inside the trash can in the room. V4 changed gloves again, without hand hygiene performed, and a clean incontinent brief applied. Both staff members failed to perform hand hygiene before care and in between glove changes. On 2/28/22 at 2:10 PM, V2, Interim Director of Nursing (DON), stated We have gone over this with the staff, and we even had the local hospital donate a mannequin to us for perineal and incontinence care training. We have trained the staff. They should know this stuff. On 2/28/22 at 2:15 PM, V1, Administrator, stated I would expect staff to perform hand hygiene before care, after care and in between glove changes while performing care to our residents. The facility's Hand Hygiene Protocol dated 7/26/21, documents Perform Hand Hygiene During routine resident care: before resident contact, before moving from work on a soiled body site to a clean body site on the same resident, after touching a resident or the resident's immediate environment (e.g., belongings or equipment), after contact with blood, body fluids or contaminated surfaces, immediately after glove removal, before donning sterile gloves, after handling soiled linen or trash, before applying Personal Protective Equipment (PPE), after removing PPE, prior to leaving resident's room.

Based on observation, interview and record review the facility failed to perform complete incontinent care for 4 of 5 (R11, R26, R27, R36) residents reviewed for toileting, in the sample of 31. Findings includes: 1. R11's Care Plan, dated 1/27/2021, documents I need extensive to total assist with ADLs (activities of daily living). I have been incontinent of bladder and bowel in ARD (assessment review date) I do not make my needs known. Dx (diagnosis) Dementia and has difficulty communicating. R11's Minimum Data Set (MDS), dated [DATE], documents R11 is severely cognitively impaired, always incontinent of bowel and bladder and dependent on 2 staff for toileting. On 2/22/2022 at 9:50 AM V15, CNA (Certified Nursing Assistant), and V16, CNA, assisted R11 into the bed and performed incontinent care. R11 was heavily soiled with urine and stool. V15 and V16 washed their hands and applied gloves. V15 and V16 opened R11's undergarment revealing a heavily soiled undergarment with a large amount of stool and urine. V16 cleansed and dried R11's peri area. V15 then assisted R11 onto her right side. V16 then cleansed R11's left buttock. V15 assisted R11 onto her left side and removed the soiled undergarment. V15 and V16 then assisted R11 onto her back and pulled covers over her. V15 and V16 removed gloves, washed their hands and left the room. V16 did not cleanse R11's right buttock and inner thighs. 2. R27's Care Plan, revision date 1/10/2022, documents I have an ADL Self Care Performance Deficit r/t left ankle fx (fracture), OA (osteo arthritis), obesity, polyneuropathy and anxiety. I am able to make some needs known and feed myself. I need extensive to total assist with ADLs. I am incontinent of bladder and bowel. R27's MDS, dated [DATE], documents R27 is always incontinent of bowel and bladder. It also documents that R27 is totally dependent on 2 staff for toileting. On 2/23/2022 at 10:50 AM V17, CNA, and V18, CNA, assisted R27 with incontinent care. V17 and V18 pulled back the covers from R27 revealing a urine soiled incontinent pad. V18 cleansed, rinsed and dried R27's peri area. V17 assisted R27 over onto her left side and cleansed R27's peri rectal area. V17 then assisted R27 over onto her right side and V18 applied the undergarment. V18 then assisted R27 onto her back. V17 and V18 applied R27's pants and transferred R27 into the wheelchair. V17 did not cleanse R27's gluteal folds, inner and outer thighs. On 2/28/2022 at 1:45 PM V18 stated that when cleaning a resident, you clean the peri area and buttocks all the way down to the knees. V18 stated that this includes the inner thighs. On 2/28/2022 at 2:11 PM V26, Licensed Practical Nurse (LPN) stated that when cleaning an incontinent resident, she expects the staff to cleanse all areas of incontinence including inner and outer thighs and both buttocks. 3. On 2/22/22 at 12:55 PM, V7, CNA, and V8, CNA, entered to transfer R26 from his bed to a wheelchair. V9, Registered Nurse/Team Care Coordinator (RN/TCC) was also in the room to watch. V8 put a pair of clean pants on R26's lower legs. V7 turned R26 and V8 wiped his left buttock only and did not clean R26's anal area. R26 was stating his butt is really sore. R26 was not rolled far enough (due to his obesity) to reveal his anal area to perform proper cleaning. This surveyor requested to see R26's buttocks and anal area further due to R26 complaining of his butt hurting. V9 then told V7 and V8 to roll R26 over even further in order to assess. Once turned completely to his side, R26's anal area was noted to be reddened and covered with an excessive amount of barrier cream and a small amount of bowel movement. V8 began wiping R26's anal area when R26 began complaining of pain. V8 stopped wiping, changed her gloves, and applied more barrier cream to R26's anal and buttock area without cleaning all the soiled cream off. There was no cleaning of R26's penis or scrotum area during this incontinent care. A clean incontinence brief was put on and R26's pants then pulled up. R26's Care Plan dated 1/12/22, documents (R26) has an ADL Self Care Performance Deficit related to history of falls at home, weakness, [CONDITION(S)] ([CONDITION(S)]) with [CONDITION(S)], Diabetes Mellitus (DM) and [CONDITION(S)]. (R26) needs extensive to total assist with ADL's. The Care Plan documents (R26) has been incontinent of bowel during Assessment Review Date (ARD). History of pressure ulcers to his buttock. The Care Plan documents Staff to provide any needed skin cleansing with incontinency. May apply barrier cream as needed (PRN) as preventative. Notify charge nurse of any red or open areas. R26's MDS dated [DATE], documents R26 is cognitively intact and required total dependence from two staff members for toileting, and bathing. R26 is occasionally incontinent of bladder and frequently incontinent of bowel. 4. On 2/24/22 at 8:36 AM, R36 was resting in her wheelchair, had just finished with breakfast, and had requested to get back to bed. V4, CNA, and V5, LPN, entered with a mechanical lift to get R36 to bed and provide incontinent care. V4 turned R36 in order to partially remove her incontinence brief and pants. V5 went out of the room for more washcloths as there was only a couple brought into the room. V4 wet the washcloths and applied perineal wash to them. V4 wiped R36's left buttock once in a circular motion and placed the soiled washcloth on the bed. V4 wet some washcloths again and wiped R36's left groin once in a downward motion. V4 then patted/dried R36's left groin. R36 then rolled to the left and soiled brief removed from under her. V4 wet some washcloths again and wiped R36's right buttock in a circular motion. There was no cleaning of R36's vaginal area or the right groin. The pad was rolled up with the soiled washcloths on it and placed inside the trash can in the room. V4 applied a clean incontinent brief. R36 was covered and bed lowered. Staff failed to perform complete incontinent care to R36. R36's Care Plan, dated 2/2/22, documents (R36) requires extensive to total assist with ADLs. (R36) is always incontinent of bowel and bladder. Interventions: Staff do cleansing of skin when incontinent and apply barrier cream as preventive measure. Skin checks with care. Report any changes to charge nurse. It continues (R36) has an ADL Self Care Performance Deficit related to dementia, [CONDITION(S)] (OA) and Restless Leg Syndrome (RLS). R36's MDS dated [DATE], documents R36 is severely cognitively impaired and is totally dependent from two staff members for transfers, toileting, and bathing. The MDS documents R36 is always incontinent of both bowel and bladder. On 2/28/22 at 2:07 PM, V1, Administrator, stated I would expect the staff to perform complete incontinent care for our residents. On 2/28/22 at 2:10 PM, V2, Director of Nurses (DON), stated We have gone over this with the staff, and we even had the local hospital donate a mannequin to us for perineal and incontinence care training. We have trained the staff. They should know this stuff. The facility's Incontinent Care-Male & Female Policy dated 2/22/10, documents the procedure: 2. Obtain equipment and bring to bedside. It continues 5. Wash hands thoroughly and apply gloves PRN. It continues 6. Expose perineal area and drape the resident, avoiding any unnecessary exposure. (It is important that staff is able to see the area well so appropriate cleansing can be done). 7. Cleanse area well with soap and water (or perineal cleanser) on wash cloth. (For male residents, retract the foreskin if the resident is uncircumcised and after cleansing return the foreskin to its normal position.) A) Use clean part of wash cloth, cleanse downward from top to bottom. B) Use a clean wash cloth for each swipe down. 8. Rinse area well. NOTE: Some perineal cleansers do not require rinsing. A) Using a clean wash cloth, rinse downward from top to bottom. B) Use a clean wash cloth for each swipe down. 9. Pat dry area with a towel. Take gloves off wash hands put new gloves on. 10. Repeat above procedure 7, 8, and 9 when cleansing rectal area. It continues 12. Wash hands thoroughly. It continues *Front to back or top to bottom motion is to keep stool or rectal contamination away from urinary meatus. This will decrease the chance of a urinary tract infection.

Based on observation, interview, and record review, the facility failed to provide a safe transfer techniques for 2 of 5 residents (R11, R36) reviewed for safe transfers in the sample of 31. Findings include: 1. On 2/24/22 at 8:36 AM, R36 was resting in her wheelchair, had just finished with breakfast, and had requested to get back to bed. V4, Certified Nursing Assistant (CNA), and V5, Licensed Practical Nurse (LPN), entered with a full body mechanical lift to get R36 to bed. The sling was already under R36 while she sat in the wheelchair a few feet away from her bed. V4 attached the 4 straps of the sling to the lift machine. V5 was holding the wheelchair as V4 lifted R36 from her wheelchair without checking to see if the straps were secure. V5 pulled the wheelchair out from under R36. V4 pushed R36, while R36 was swinging freely in the air, to her bed. V4 then lowered R36 to her bed and released the sling. R36 was rolled side to side to remove the sling from under her. On 2/28/22 at 10:53 AM, V20, LPN, stated When we use the mechanical lift, we always make sure we have two people. Once the resident is on the sling, I will always make sure the sling is not pinching the resident anywhere. One person will hold the wheelchair while the other is operating the lift. Once the resident is lifted up, one person will remove the wheelchair while the other is moving the resident over to the bed. The resident is then lowered to the bed. On 2/28/22 at 2:18 PM, V1, Administrator, stated I would expect staff to maintain constant contact with the resident while performing a transfer using a mechanical lift device. R36's Transfer Assessment Tool, completed on 6/25/19, documents that (R36) can be delegated as a full-size mechanical lift transfer. R36's Care Plan, dated 2/2/22, documents (R36) is at risk for falls related to diagnosis of seizures, Restless Leg Syndrome and Weakness. (R36) has a history of falls. (R36) transfers with a full mechanical lift. Interventions: Full mechanical lift for transfers. It continues (R36) requires extensive to total assist with Activities of Daily Living (ADLs). R36's Minimum Data Set (MDS) dated [DATE], documents R36 is severely cognitively impaired and required extensive assistance from one staff member for bed mobility and dressing. R36 required total dependent from two staff members for transfers, toileting, and bathing. R36 is always incontinent of both bowel and bladder. The facility's Safe Resident Handling Program Policy dated 3/18/18, documents Initial screening will be performed on all residents to assess transfer and ambulating status. Resident transfer status will be reviewed via care plan time frame and on an as needed basis. It continues Resident transfer status will be listed on the resident plan of care (POC). The Mechanical Lift Company's User Instruction Manual, documents The intended use of this lifting device is for the safe lifting and transfer of an individual from one resting surface to another (such as a bed to a wheelchair). (This company) recommends that the transfer of a patient is fully assessed and conducted safely over a short distance only. (This Mechanical Lift) is suitable for patients in the sitting, sitting/recumbent and recumbent positions. 2. R11's Care Plan, dated 11/3/2020, documents Hx (history) of falls while self transferring or ambulating. It also documents Full mechanical lift for all transfers. R11's MDS, dated [DATE], documents R11 is totally dependent on 2 staff for transfers. On 2/22/2022 at 9:50 AM V15, CNA, and V16, CNA, assisted R11 into bed with a full body mechanical lift. V15 and V16 attached the sling straps to the lift. V15 operating the controls lifted R11 up out of the chair. V15 and V16 assisted R11 into the bed. V15 and V16 did not perform a safety check on the sling traps before moving R11 to the bed. On 2/28/2022 at 1:45 PM V18, CNA, stated that when transferring a resident with the full body lift it takes two people. V18 stated that the second person is there to guide the resident. V18 stated that the second person holds on to the resident and sling make sure that resident doesn't bump into anything during the transfer. On 2/28/2022 at 2:11 PM V26, LPN, stated that she expects that the staff to utilize 2 staff during transfer and the second staff to stay in contact with the resident during the entire transfer.

Based on observation, interview and record review, the facility failed to discard expired medications for three of three residents (R7, R27 and R39) reviewed for medication storage in the sample of 31. Findings include: 1. On 02/23/2022 at 7:42 AM, V20, Licensed Practical Nurse (LPN), administered 25 units of [MEDICATION(S)] [MEDICATION(S)] insulin to R7. The [MEDICATION(S)] [MEDICATION(S)] insulin injection pen was dated 12/18/2021. The facility's policy, Medication Storage and Labeling, dated 02/2017, documents, Multi-dose vials, which have been opened or accessed (e.g., needled-punctured), should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) dated for that opened vial. It continues, Insulin pens containing multiple doses of insulin are meant for single-resident use only, and must never be used for more than one person, even when the needle is changed; insulin pens must be clearly labeled with the resident's name and other identifier(s) to verify that the correct pen is used on the correct resident; insulin pens should be stored in a sanitary manner to prevent cross- contamination. The manufacturers guidelines for the [MEDICATION(S)] insulin [MEDICATION(S)] injection 100 units (per milliliter), undated, documents, Once opened, the [MEDICATION(S)] vials, prefilled pens, and cartridges, should be thrown away after 28 days. 2. On 2/22/2022 at 12:32 PM the Rosemont Medication Cart was inspected. The medication cart contained the following expired medication: a. R37's Artificial Tears Solution 1-0.3 % with open date 12/16/21 written on bottle. b. R39's Natural Balance Tears Solution 0.4 % with open date 12/16/2021. 3. On 2/22/22 at 3:10 PM, V13, LPN stated they don't use a med cart in this area. Resident's medications are kept in a container that are in the locked room behind the nurses desk. All resident medications were checked for expiration, including as needed (PRN) medications that were kept in a cabinet. There was a bottle od [MEDICATION(S)] 5 (milligrams) mg, 100/bottle with an expiration date of 1/2022.

Based on observation, interview and record review the facility failed to safely transfer 2 of 9 residents (R4, R12) reviewed for transfers in the sample of 34. Findings include: 1. On 02/26/19 at 9:20 AM, V13 Certified Nurse Aide (CNA), was transferring R4 using a partial mechanical lift. V13 placed the sling on R4 and connected it to the lift; V13 then raised R4 up off of the wheelchair, without locking the wheelchair and transferred R4 over to the toilet. When R4 was finished toileting, V13 raised her up using the lift and pulled up R4's pants and transferred her back to the wheelchair, lowered her down to the wheelchair seat without locking the wheelchair brakes. On 02/26/19 at 9:35 AM, V3 Licensed Practical Nurse (LPN) stated, she would expect staff to lock the wheelchair prior to transferring residents. 2. On 02/26/19 at 12:51 PM, V11, CNA, V13, CNA, and V17 Registered Nurse, (RN) entered R12's room. R12 was sitting in her wheelchair with the mechanical lift sling positioned under her. V11 and V13 attached the mechanical lift sling to the mechanical lift. V17 was present in the room as an observer. V11 and V13 did not lock the wheelchair brakes and R12 was raised up from her wheelchair with the mechanical lift. The wheelchair brakes were not locked when R12 was raised up from her wheelchair. The facility Lift Operation Manual for MEDICARE PRODUCTS dated 2010 documents in part Care Stand Operations, CAUTION: When lifting from a wheelchair, always engage the wheelchair lock before proceeding. Care Lift Operations, CAUTION: When lifting and lowering from a wheelchair, do not lock the wheels of the Care lift. Always lock the wheels of the wheelchair.

Based on observation, interview and record review the facility failed to provide oxygen and failed to date oxygen tubing for 2 of 2 residents (R27, R45) reviewed for oxygen therapy in the sample of 34. Findings include: 1. On 02/25/19 at 9:05 AM, R45 is sitting in the wheelchair in the hallway and has oxygen (O2) on at 2 liters. R45's oxygen tubing was not dated. In R45's room his nebulizer machine is on the bedside table the nebulizer tubing is not dated. 02/25/19 3:44 PM, V2 Director of Nurses (DON) stated, The O2 tubing is changed weekly and the nurse signs the Treatment Administration Record (TAR). V2 then looked on R45's TAR and change O2 tubing weekly was not on it. No documentation available as to when R45's, O2 tubing was changed. The facility Policy and Procedure for Nasal Cannula documents in part, POLICY: #3. Nasal cannulas are to be changed once a week and PRN (as needed) by nursing. 5. PR[NAME]EDURE: The respiratory therapist/nurse shall complete the following when setting up a nasal cannula: F. Open cannula package. Date cannula. 2. on 02/20/19 at 1:44 PM, observed R27 sitting in her chair in her room. R27 was wearing a nasal cannula which was attached to a portable oxygen container. The control knob on the oxygen container was set on zero. When R27 was made aware the control knob was set on zero, R27 reached down and turned the control knob to the right and then to the left and set the knob on 1.5. V18, Certified Nurse's Aide, (CNA) entered the room followed by V17 Registered Nurse, (RN). V17 turned the control knob to 2. V17 stated, It's full as she picked up the oxygen container. R27 stated, It's full because it wasn't turned on. I was without oxygen since before breakfast, head feels a little funny. I went to coffee at 10:00 AM, and then to lunch. Physician order [REDACTED]. Electronic Medical Record, (EMR), dated February, 2019, documents R27's diagnosis, [MEDICAL CONDITION], Shortness of Breath, and Heart Failure. Minimum Data Set, (MDS), dated [DATE], documents R27's Brief Interview for Mental Status, (BIMS) score as 13, cognition intact. Facility policy documents, Oxygen Policy & Procedure (dated 3/2008) Procedure: 4. Turn the flow control knob clockwise until the prescribed flow rate (numeral) is visible in the knob window and positive detent is felt.

Based on observation, interview and record review, the facility failed to follow safe food handling practices during meal service to prevent the spread of infection for 6 residents (R7, R15, R30, R32, R33, R65) outside the sample. Findings include: On 01/17/18 at 12:35 PM, the lunch meal service was observed at the Ivy Dining Room. V5, Activity Director, washed hands, gloved, and took out a slice of white bread from its bag, placed it on top of the bag, buttered it and left it on top of the plastic bag next to R32's plate. V5 proceeded to butter R15's and R65's slice of bread wearing the same pair of gloves and putting the buttered bread on top of its bag next to R15's and R65's plate. V5 rearranged R65's beverages closer to R65's reach. V5 walked to R7's table and took out the slice of bread inside its plastic bag and put it on top of the bag, buttered it and left it on top of the bag next to R7's plate, wearing the same gloves. On 01/29/18 12:41 PM, V5 passed trays on the Ivy Dining Room including sliced bread individually placed in plastic bags. V5 washed hands and gloved. V5 buttered bread for R15, R32, R30 and put it on top of its bag next to each resident's plate. V5 moved R30's cup and water tumbler closer to R30 with the same gloved hand. V5 then proceeded to butter bread for R65 and R7. V5 used the same pair of gloves during this observation period. On 1/29/18 at 1:04 PM, V4, Registered Nurse (RN), washed hands, put on gloves and buttered bread for R33 and put the buttered bread atop its bag next to R33's plate. V4's gloved left hand was braced on the edge of the table while V4 was talking to R30. V4 served a cup of coffee to R30 and served a small plate of cheese sandwich to R15. V4's gloved fingers touched the sandwich as V4 placed it in front of R15. V4 used the same pair of gloves during the meal service. On 01/30/18 12:20 PM, V1, Administrator, stated the facility does not have a policy that addresses buttering of bread. V1 stated staff should not touch food with their bare hands. V1 stated the facility follows their policy on hand hygiene technique. On 1/31/18 at 2:05 PM, V2, Director of Nursing (DON), stated gloves should be changed when working from dirty to clean surface, after handling contaminated items, between different areas, and staff should wash their hands before putting on gloves. The Facility's Policy on Hand Hygiene, revised 3/1/10, documents, Purpose: To prevent the spread of infection. To decrease the risk of transmission of infection from person to person or from object to person. The Facility's undated Policy on Glove Use documents, Gloves will be worn to maintain safe and sanitary food preparation and service. The Policy further documents, 3. Proper Use of Gloves: d. Change gloves whenever you change an activity, the type of food being worked with, or whenever you leave the work station.

Based on observation, record review, and interview the facility failed to keep a call lights within reach for 1 of 16 residents (R6) reviewed for accommodation of needs in the sample of 16. Findings include: On 1/17/18 at 3:50 PM, R6 was in R6's room, resting in bed, R6's call light was not within reach. It was wrapped around the wall mount on R6's wall. On 1/18/18 at 10:00 AM, R6 was resting in bed, call light was not in reach. It was wrapped around the wall mount on the wall. On 1/29/18 at 10:05 AM, R6 was sitting in R6's chair in R6's room, R6's call light was wrapped up hanging on the wall, not within R6's reach. On 1/30/18 at 11:35 AM, R6 was sitting on R6's bed visiting with a visitor, R6's call light was wrapped up and hanging on the wall. On 1/29/18 at 10:05 AM, R6 stated, If I need anything, I guess I would yell or turn that light on that is up on the wall, pointing to the call light on the wall. On 1/30/18 11:40 AM, V2, Director of Nursing (DON), stated, I expect call lights to be within reach of the residents. The facility's Policy and Procedure for Call Lights, dated 1/8/05, documents, Objective: 1. To respond to resident's requests and needs. Policy: It is the policy of this facility to maintain the highest quality of care for its residents. It continues under Procedure: 7. Make certain the call light is within resident's reach before leaving the room.

Based on interview, observation and record review, the facility failed to develop an effective falls prevention plan and failed to provide adequate supervision/safety devices to prevent falls for 1 of 3 residents (R3) reviewed for falls in a sample of 15. This resulted in R3 having multiple falls, sustaining a fractured hip on 6/1/16, and significant decline in mobility since the fall. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], documents R3 as having severe cognitive impairment (Brief Interview for Mental Status score 3) and requires one assist for transfers/bed mobility and ambulation on and off the hall/room. An Occurrence Report, dated 1/19/16 at 12:15 PM, documents R3's alarm was sounding and the Certified Nurses Aide (CNA) found her sitting on the floor in front of her wheelchair (w/c), leaning back. The Conclusion documents R3 attempted to ambulate on her own and fell . Interventions added included educating resident to call for assistance with transfers and ambulation. The Care Plan, dated 10/27/16, documents other interventions in place as ensuring call light is within reach and reminding resident to use it and waiting for assistance along with a sensor alarm in place. An Occurrence Report, dated 3/1/16 at 12:15 PM, documents R3 was again observed on the floor in the doorway of her room. The report documents R3 stated I wanted to go go bed. The report documents she sustained two skin tears on left upper arm measuring 3.5 centimeter (cm) x 3.2 cm and on her right wrist measuring 2 cm x 2 cm. Immediate interventions documented as applying an alarm although she had a sensor alarm already in place. The fall detail report documents that the alarm was sounding at the time of R3's fall. Interventions added on the Care plan, dated 3/1/16, include offer to lay resident down after breakfast and lunch. Recommendations from the falls follow-up report document staff to remind resident to call for assistance with transfers and ambulation. The conclusion was documented that R3 attempted to ambulate independently, lost her balance and fell on to the floor. There is no evidence the facility assessed R3 for additional safety devices or additional supervision given her tendency to get up and ambulate on her own without assistance. An Occurrence Report on 4/2/16 at 11:15 AM documents R3 was again found on the floor. The report documents R3's alarm was sounding. The report documents R3 complained of pain on hips, ribs and back on left side and was sent to the emergency room for evaluation and treatment. The recommendation was shortened the tab alarm string to alert staff sooner. The conclusion was documented that R3 attempted to ambulate independently, lost her balance and fell on to the floor. The interventions added following this fall include alarm in place at all times (sensor alarm bed/chair.) An Occurrence report, dated 6/1/16, documents R3 was observed on the floor lying on right side with head at the bathroom door at 3:33 AM. The report documents R3's alarm was not sounding. R3 was transferred to the emergency room where she was diagnosed with [REDACTED]. The conclusion documents R3 attempted to ambulate independently to the bathroom and lost her balance, but fails to identify that she removes her alarm. Interviews done at the time of the occurrence with E18 and E19, CNAs present on night shift when she fell , indicated that at 1:30 AM, they both saw the alarm tabs attached to R3. The MDS completed prior to R3's fall on 6/1/16, dated 4/12/16, documents R3 was limited assist of one for bed mobility and minimal assist of one for all transfers and all ambulation. The MDS, dated [DATE], documents R3 to require extensive assist of one staff for bed mobility and dependency of two staff for transfers and ambulation/mobility on/off the unit. On 12/14/16 at 10:35 AM, E4, Registered Nurse, stated R3 never removed her alarm at the time of the fall in June 2016, but would try to get up all the time on her own until she fractured her hip and hasn't really walked since. On 12/14/16 at 10:40 AM, E8, CNA, stated R3 walked about the facility for a long time after admission and then fell fracturing her hip - hasn't walked since. E8 stated R3 never tried to remove her tabs clip. On 12/14/15 at 12:55 PM, E11, CNA, stated she had cared for R3 a long time. E11 also stated R3 never tried to remove the tabs, adding she would just get up and go. E11 stated R3 now has a noodle on the edge of her bed, alarm clip, low bed, and a mat beside the bed. On 12/15/16 at 2:15 PM, E11 stated R3 hasn't used the call light and doesn't know to ask for assistance. On 12/15/16 at 12:45 PM, E17, Care Plan Coordinator/Licensed Practical Nurse (LPN), stated R3 was originally admitted in May 2015 and had an alarm ordered at the time because she had fallen and fractured her humerus and hip prior to admission. E17 confirmed R3 was ambulatory about the facility and in her room with staff assistance and did attempt to get up on her own frequently. E17 stated R3 had two discharges with readmissions since her original admission including one in January 2016. E17 stated her alarms orders would be discontinued and reordered on admission. E17 was asked about the focus area or concerns for falls prevention on R3's Care Plan from admission documenting her risk was due to cognitive deficit, impaired balance and history of falls, but failed to include her getting up spontaneously without assistance and attempting to walk, her inability to use a call light and/or to ask for assistance prior to getting up, and her removing the clip and walking unassisted which was identified as the causative factor in her 6/1/16 fall which resulted in the hip fracture. E17 stated R3 has had a great decline since her June fall in all activities of daily living and doesn't attempt to get up anymore. On 12/15/16 in the late afternoon, E2, Director of Nurses (DON), stated the sensor alarm and tabs alarm in the wheelchair was added in April following that fall and when she fell in June 2016, they changed the type of alarm to a sensor from a tab. E2 stated that R3 had the right to get up and fall and that she did remove the tabs clip on 6/1/16. E2 stated she did not identify inadequate supervision as a contributing factor in R3's falls because they responded as soon as they heard the alarm sound. E3 also stated the alarm string was shortened following the 4/2/16 fall to give staff more of an alert when she was getting up, but when asked why the string length wasn't individualized prior to that, responded that she had a tendency to lean over and pick things up off the floor. When asked about assessing R3 for individual risk factors, E2 stated the facility meets weekly for falls evaluations. The facility Fall Assessment, Risk Identification and Management Policy, dated 3/20/12, documents its the policy of the facility to assess each resident's fall risk on admission to facilitate an interdisciplinary approach for care planning to appropriately monitor, assess, and ultimately reduce injury risk, and factors related to risk will be addressed and care planned. The fall assessment will include general state of health, age, sensory deficits related to hearing and vision, mobility, medication which causes drowsiness, mental status, wandering tendencies and previous falls. The policy documents under Care Planning after a fall, licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regards to future interventions, and resident specific risk factors. The policy documents interventions will be based on the resident assessment and circumstances surrounding the risk for injury or actual injury or fall - examples may include: gait/balance deficit, confusion, positioning problems, toileting needs, syncopal episodes, environmental hazards, sensory/perceptual problems and falls related to poor judgment or knowledge deficit.

Based on observation, interview and record review, the facility failed to store food in a manner to prevent potential contamination and foodborne illness. This has the potential to affect all 70 residents living in the facility. Findings include: 1. On 12/15/2016 at 8:43 AM, the metal stem thermometer was calibrated using an ice water slurry to 32 degrees Fahrenheit (F). On 12/15/2016 at 8:56 AM, the temperatures were taken of food stored in the reach-in refrigerator near the stove, with the calibrated metal stem thermometer, the temperature of leftover Beef Stew was 52 degrees F, the temperature of the leftover Chicken Broccoli Rice 50 degrees F, the temperature of left over carrots was 50 degrees F. On 12/15/2016 at 8:57 AM, E12, Certified Dietary Manager, stated The leftovers are used as a substitute choice for the next day's meal. The Beef Stew, Chicken Broccoli Rice and Carrots were left over from supper last night. They recorded 34 degrees F on the cooling log last night. On 12/15/2016 at 12:20 PM, the temperature was taken of food stored in the reach in refrigerator near the stove, with the calibrated metal stem thermometer, the temperature of cottage cheese was 58 degrees F. On 12/15/2016 at 12:21 PM, E12 stated I have told the Administrator. They are calling a repairman out to fix the reach in. On 12/16/2016 at 9:57 AM, E14, Cook, stated On 12/14/2016 about 6:00 PM, I took the left overs off the steam table and put into plastic storage containers, all three were tall green containers. I then took them to the freezer until about 8:00 PM when I left for the day. They had been in the freezer for about 2 hours. About 8:00 PM, I moved them from the freezer to the reach in refrigerator by the stove. I took temperatures when they came out of the steam table and again about 8:00 PM when I took them out of the freezer. No one was here to take the temperatures at 4 and 6 hours after taking it out of the steam table. Although E14 said no one was here to take temperatures at 4 and 6 hours, the facility's Cooling Hot Foods Temperature Control Log, dated 12/14/2016, documents 4 hr temperature of 38 degrees F for Carrots, Chicken Broccoli Rice, Beef Stew, and 6 hr temperature of 34 degrees F for Carrots, Chicken Broccoli Rice, Beef Stew. The facility's Refrigerator and Freezer Storage Chart policy, dated 7/2015, documents in part, Food will be properly stored so that it decreases the risk of foodborne illness and nutritional quality is maintained. Refrigerator (temperatures are expected to be) 36-40 degrees F. The facility's Asset Maintenance History, dated 12/16/2016, documents, in part, Reach In Cooler, Location: Main Kitchen, Serial #: 1- 32 Due Date - 7/31/2016, Task Description - Inspect condenser coil, clean as required, Task Completion - (Marked done on time by E13, Maintenance Director). The facility's Asset Maintenance Record, dated 12/16/2016, documents in part, Reach In Cooler, Location: Main Kitchen, Serial #: 1- 32. Inspect condenser coils, clean as required. Date Due - Was Due by: July 31, 2016 Completed: (Marked done on time by E13) on August 4, 2016. Category: Refrigerators and Freezers. Steps: 1. Shut off condensing unit, 2. Use brush to remove lint and dirt buildup on condenser coil. 3. Use air compressor to blow residual dirt/dust buildup, 4. Vacuum condenser area to remove all dirt/dust. 5. Inspect the condition of the door gasket and replace if needed. 6. Ensure the light(s) are functioning. 7. Ensure that the units are plugged into the correct power source, 8. Defrost as needed, 9. Inspect the interior shelves for cleanliness and clean as needed, 10. Inspect Door Seals. The facility's Cooling Hot Foods policy, dated 4/2015, documents in part, Purpose: To ensure proper cooling of food to reduce the potential for food borne illness. Procedure: 1. Food will be divided into small batches for cooling with the depth of food 1-4 inches in containers. Roasts will be cut in half or fourths depending on the size of the roast. Food will be lightly covered during the cooling process to allow heat to escape. 3. Cool food from 135 degrees to 70 degrees F in two hours. Check the temperature of the food after two hours and record the temperature on the temperature log. If the food does not reach a temperature of less than or equal to 70 degrees in two hours, you must reheat item to 165 degrees F and start cool down process again. 4. Cool food from 70 degrees F to 40 degrees F in four more hours (this is a total of six hours). Check the temperature of the food after six hours and record the temperature on the temperature log. 5. If the food has not cooled to the appropriate temperatures in the time allotted, DISCARD THE FOOD. 2. On 12/15/2016 at 9:05 AM, the ice machine drain goes through the wall. On 12/15/2016 at 9:05 AM, E12 stated We use the ice in the ice machine for all the residents drinks and they use this ice for all the drinks in the resident rooms too. This is the only ice machine we have. I don't know where the drain goes from the wall. (E13) would know On 12/15/2016 at 11:05 AM, the ice machine drains into a black hose which extends into conduit into wall passes through the wall into the kitchen. The drain pipe extends under the counter to the drain and submerges into the drain 3/8 inches below floor level. On 12/15/2016 at 11:05 AM, E13 stated This ice machine is the only one in the facility. On 12/15/2016 at 11:15 AM, E13 stated The ice machine drain pipe goes into the wall, then into the kitchen, then into the floor drain. On 12/15/2016 at 11:16 AM, when identifying the ice machine drain pipe, E1, Administrator, stated I see water dripping from the drain line submerged into the floor drain. 3. On 12/15/2016 at 8:56 AM, in the reach in refrigerator near the stove, 9 of 9 shelves had peeling plastic coating on the wire racks. On 12/15/2016 at 8:56 AM, E12 stated We cover the food to try to keep it (the peeled plastic from the shelving) from falling into the food below it. The facility's Asset Maintenance Record, dated 12/16/2016, for the Reach In Cooler in the Main Kitchen, documents in part, 9. Inspect the interior shelves for cleanliness and clean as needed. No mention of replacing shelving was made on the facility's Asset Maintenance Record, dated 12/16/2016. 4. The Resident Census and Conditions of Residents, CMS 672, dated 12/13/16, documents there are 70 residents living in the facility.

Based on observation, interview, and record review, the facility failed to assess for dehydration risk and failed to offer/encourage and ensure sufficient fluids during care, at meals and in between meals for 3 of 6 residents (R3, R6, R10) reviewed for hydration in a sample of 15 and one resident (R16) in the supplemental sample. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], identifies R3 as severely cognitively impaired and requires extensive assist of one staff for eating. The Care Plan, dated 11/30/16, identifies R3 has a history of Urinary tract infections with interventions for staff under Nutrition to document intake of food and fluids daily. The Care Plan does not address R3's hydration needs. The Registered Dietician Note, dated 6/30/15, identifies R3's minimal daily fluid requirement as 1325 cubic centimeters (cc)-1590 cc/day. The December 2016 physician's orders [REDACTED]. On 12/13/16 at 11:53 AM, E8 and E9, Certified Nurses Aides (CNAs), provided care for R3. R3's urine had a strong odor as incontinent care was given. R3 was left at the bedside awaiting her lunch tray. Her water pitcher had approximately 400 cc of warm water in it. At this time, E8 stated R3 lies down between meals. No fluids were offered before E8 and E9 left the room. At 12:25 PM, R3 was transferred her wheelchair by E6, CNA. R3 had a 1/2 glass of supplement setting on her bedside stand. No fluids were offered. R3 was served lunch and fed at 12:45 PM by E9. R3 drank 100% of her red drink and sips of milk and water according to observations and interview with E9 at the time. On 12/13/16 at 2:20 PM, R3 was transferred to bed by E5, CNA. No fluids were offered after care before E5 left the room. R3's Nutritional Intake Flowsheet for December 2016 documents R3 took no fluids at noon on 12/13/16, 120 cc for breakfast and 180 cc for supper. On 12/14/16 at 9:05 AM, R3 was up in the wheelchair at her bedside. At 9:45 AM, E6, CNA, passed out fresh ice water down the hall, but passed by and did not enter R3's room. At 9:50 AM, R3 was transferred to bed by E11, CNA. R3's water pitcher setting on her over bed table had 300 cc of warm water in it. No fluids were offered with care. At 10:45 AM, E10, CNA, passed by and did not enter R3's room as she passed snacks/fluids. R3's water pitcher remained with 300 cc of warm water in it when she was transferred to her wheelchair for lunch at 12:10 PM. R3 drank her Red drink and took sips of her milk and none of her water as she was assisted in eating by E9. R3's intake flowsheet has no fluids documented for 12/14/16. The Nutritional Intake Flowsheet for December 2016 documents at most, R3 takes in 960 cc and the least amount documented from mealtime is 60 cc/day. R3's Care Plan fails to include a plan to ensure adequate hydration since her intake at mealtimes is low and observations show fluids are not encouraged and/or cued during care. The facility's Hydration Policy, dated 1/2016, documents adequate hydration will be promoted with the provision of fluids in amounts to meet the needs of each resident. The procedure documents additional fluid will be provided from bedside water pitchers, medication pass, activities and snacks in addition to fluids of meal trays. The policy documents the resident's preferences for fluids will be honored. 2. The MDS, dated [DATE], documents R10 has severe cognitive impairment and requires extensive assist of one for eating. The RD (Registered Dietician) assessment, dated 12/13/16, documents R10's minimum daily fluid requirement as 1325 cc/day. R10's Care Plan, dated 12/1/16, documents under nutrition to monitor food and fluid intake and under Potential for Urinary Tract Infection, staff are to encourage fluids. On 12/13/16 at 11:15 AM, R10 was in bed. Her water pitcher was full and on the side of her bed out of her reach. At 11:53 AM, E9 provided incontinent care and offered no fluids following care in her room. At 3:00 PM, R10 was in bed and her water pitcher remained the same amount and positioned out of reach. On 12/14/16 at 9:05 AM, R10 was in bed with her water full and out of reach. R10 slept the entire morning with no fresh water passed at 9:45 AM when E6 passed the water on the unit at 9:45 AM. No snacks/fluids were offered as E10, CNA, went down the hall with the snack cart at 10:45 AM. At 11:15 AM, R10 was turned in bed by E11, CNA, with no fluids offered during care. E11 stated R10 lies down between meals. At 11:57 AM, R10 was transferred to her wheelchair and taken to the dining room. R10 ate at a table with no assistance. R10 drank less than 25% of her milk, water and lemonade before being taken back to her room by E6 who offered no cues/encouragement to drink more fluids. The Nutritional Intake Flowsheet for December 2016 documents R10's fluids at noon on 12/13/16 was 90 cc and on 12/14/16 was 90 cc. The most fluid recorded from mealtime for any day is on 12/9/16 at 1120 cc with the average ranging between 500-600 cc and the least amount recorded from meals was on 12/10/16 at 260 cc. On 12/14/16 at 10:30 AM, E2, Director of Nurses (DON), stated the staff on the hallway have been inserviced on fresh water for everyone, snacks, water offered from the bedside during care and cueing/encouragement during mealtimes. 3. The MDS, dated [DATE], documents R6 has moderate cognitive impairment and requires minimal assist of one staff for eating. The RD assessment, dated 11/15/16, documents R6's minimum daily fluid requirements is 1525 cc/day. The RD assessment also documents R10 has documented urinary tract infections (8/12/16.) The POS documents R6 receives [MEDICATION NAME] Sodium 100 mg BID for constipation. The Care Plan, dated 11/2/16, does not address fluid needs regarding constipation. Under ADL (activities of daily living) assist, the Care Plan documents staff are to encourage good food/fluid intake and under dietary, staff are to document intake of food and fluids daily. On 12/13/16 at 11:15 AM, R6 was out of his room wandering around the hallways. His water pitcher at his bedside had 750 cc of iced water in it. R6 remained out of his room until lunch time. At lunch, R6 drank his red drink and nothing else. At 3:05 PM, R6 was sitting at his bedside after wandering around the facility. He was asleep and his water pitcher still had 750 cc in it. On 12/14/16 at 9:05 AM, R6 was sitting in his wheelchair at the Nurses Station. At 9:30 AM, he propelled himself toward his room and at 9:45 AM, he was propelling himself back toward the Nurses Station. At 10:07 AM, he propelled himself down to Activities, but didn't stay. From 10:30-10:55 AM, R6 sat outside his room asleep in his chair. At 10:55 AM, E11, CNA, coaxed him to stand up for a few minutes and after he refused to walk, E11 left his side. No fluids were offered and none were observed to be taken from his bedside pitcher. At the noon meal, R6 drank some of his water and sips of milk. The Nutritional Intake Flowsheet for December 2016 documents the most fluids consumed by R6 during mealtime is 1380 cc with the least documented at 390 cc. R6's average intake is approximately 600-700 cc per day during mealtimes. 4. The MDS, dated [DATE], documents R16 has moderate cognitive impairment and requires set up/supervision for eating. The RD assessment, dated 8/10/16, documents R16's minimum daily fluid requirement is 1225 cc/day. The Care Plan, dated 11/9/16, documents under nutrition, staff are to document food/fluid daily and under ADL assist, staff are to encourage good food and fluid intake. R16's 12/2016 POS documents she receives [MEDICATION NAME] (Diuretic) 20 mg daily. On 12/14/16 at 9:05 AM, R16 was sitting in her wheelchair in her door way. At 10:07 AM, R16 went to coffee hour and drank 50% of her coffee. At 10:45 AM, R16 was back in her doorway. R16's water pitcher had 800 cc of iced water in it which was out of reach and on the other side of the bed. At 11:55 AM, R16 was assisted to the dining room table. R16 drank 50% of her coffee, 75% of her tea and none of her water. No staff assist and/or cueing/encouragement was provided during the mealtime to drink more. The Nutritional Intake Flowsheet, dated December 2016, documents the most intake R16 has had on any one day is on 12/9/16 of 1020 cc and the least recorded during mealtime was 580 cc/day. On 12/15/16 at 11:17 AM, E17, Care Plan Coordinator/Licensed Practical Nurse, stated the facility does not assess for dehydration risk and only addresses fluids under ADL with the encourage good food and fluid intake. When asked about the risk level being elevated due to UTIs, diuretic use or medications for constipation, E17 stated she covers the fluids under ADLs and added that staff give fluids during snack time and activities.