Every finding on record at Lourdes Rehabilitation and Healthcare Center

This citation pertains to Complaint 3052364Based on observation, interview and record review, the facility failed to ensure vision services were provided for one (R801) of two residents reviewed for vision services resulting in emergency laser surgery to reduce eye pressure and lost vision in the left eye. Findings include:A complaint was filed with the State Agency [SA] that alleged in part, .[R801] complained of eye pain and asked about seeing an eye doctor, was told. that she is on the eye doctor list. she was diagnosed with glaucoma in 2015. [R801] again requested Tylenol for her eye pain and asked to see an eye doctor 6/15/25. is on the list for their next visit. continued to express eye pain and discomfort, so the family coordinated an off-site eye appointment. eye pressure was alarmingly high, so the optometrist referred her to an ophthalmologist. told time is of the essence to save her eye sight due to the high pressures 1/9/26. performed emergency same-day laser to both eyes . confirmed [R801] is now blind in her left eye.On 6/29/26 at 10:00 AM, R801 was observed lying in bed. R801 was asked if she had any issues with her eyes. R801 explained she had narrow angle glaucoma and had laser surgery in 2015, she was supposed to have seen her eye doctor when she had her stroke in 2024 and had not seen an eye doctor until January 2026 when her eye pressures were very high and she lost vision in her left eye. R801 was asked if she had ever had pain in her eyes while at the facility. R801 explained she sometimes would get headaches due to the pressure in her eyes.Review of the clinical record revealed R801 was admitted into the facility on 5/13/24 and readmitted [DATE] with diagnoses that included: stroke; chronic angle-closure glaucoma, left eye, severe stage; and chronic angle-closure glaucoma, right eye. According to the Minimum Data Set [MDS] assessment dated [DATE] R801 was cognitively intact.On 6/29/26 at 10:56 AM, Social Work [SW] 'C' was interviewed via phone and asked if the eye doctor had ever seen R801. SW 'C' explained R801 had told her she wanted to see the eye doctor because she needed new glasses, and due to unforeseen circumstances, it took a year for her Medicaid to be approved so she had not been seen due to not having Medicaid. When asked why R801 had not been seen by the eye doctor after her Medicaid was approved, SW 'C' had no explanation.Review of a History and Physical readmission exam dated 4/16/25 for R801 read in part, .Pain of both eyes Discussed with social worker, the patient is on the list to be seen by optometry.Review of Orders-Administration Progress Notes revealed R801 requested Tylenol for a headache on: 1/28/26 at 8:49 PM, 1/30/25 at 1:56 PM, 2/7/25 at 7:24 PM, 2/11/25 at 5:49 PM, 2/15/25 at 4:54 PM, 2/25/25 at 5:31 PM, 3/2/25 at 9:46 PM, 3/7/25 at 9:39 PM, 3/11/25 at 6:22 PM, 3/19/25 at 12:22 PM, 4/18/25 at 1:29 PM, 4/26/25 at 8:57 PM, 4/27/25 at 10:56 AM, 4/29/25 at 1:24 PM, 5/1/25 at 1:37 PM, 5/3/25 at 5:01 PM, 5/11/25 at 3:35 PM, 5/16/25 at 3:37 PM, 5/19/25 at 1:29 PM, 5/20/25 at 4:40 PM, 5/24/26 at 3:23 PM, 5/30/25 at 6:35 PM, 5/31/25 at 1:36 PM, 6/7/25 at 1:44 PM, 6/27/25 at 9:30 PM, 7/3/25 at 9:05 PM, 7/5/25 at 4:07 PM, 7/10/25 at 1:29 PM, 7/11/25 at 10:13 PM, 7/14/25 at 5:31 PM, 7/15/25 at 5:32 PM, 7/28/25 at 4:16 PM, 8/2/25 at 2:38 PM, 8/5/25 at 4:03 PM, 8/22/25 at 7:11 PM, 8/23/25 at 5:12 PM, 8/25/25 at 2:59 PM, 9/2/25 at 10:12 PM, 9/5/25 at 8:49 PM, 9/9/25 at 8:46 PM, 9/15/25 at 3:40 PM, 10/6/25 at 10:30 PM, 10/9/25 at 1:24 PM, 10/30/25 at 1:11 PM, 11/8/25 at 1:36 PM, 12/18/25 at 1:38 PM, 1/9/25 at 1:39 PM and 1/7/26 at 4:17 PM.Review of a Health Status Progress Note for R801 revealed a note dated 6/2/25 at 12:29 PM that read in part, MDS review: .Resident was able to read larger size print, and unable to read average size print in books, with glasses in place. Memo to SW for next vision f/u [follow-up].On 6/29/26 at 12:13 PM, the Business Office Manager [BOM] was interviewed and asked about R801's application for Medicaid. The BOM explained usually it takes 30-45 days for a Medicaid application to be approved, but R801's application took a year to be approved. The BOM was asked when R801 was approved for Medicaid. The BOM explained it was approved on 5/5/25.Review of an optometry consult for R801 dated 1/7/26 read in part, .High IOP [intraocular pressure] OD [right eye] 42 [normal range 10-21] OS 47 Dilated pupil OS w/ [with] reduced vision. Immediate referral needed to ophthalmologist for treatment of narrow angles causing dangerously high eye pressure.Review of an ophthalmology consult for R801 dated 1/9/26 read in part, .patient with angle closure glaucoma s/p [status post] YAG Peripheral Iridotomy [laser procedure to improve fluid drainage] today in office. IOP was 42 OD, 57 OS when checked. this morning. Pupils: Right Eye Shape Normal. Minimal Reaction, Left Eye pupil Fixed and Dilated.Review of an ophthalmology consult for R801 dated 3/2/26 read in part, .Chronic Angle Closure Both eyes unknown but likely severe stage. End stage left eye (no light perception).On 6/29/26 at 12:30 PM, the Director of Nursing [DON] was interviewed and asked if she had been aware of R801 having eye concerns. The DON explained she had not known about any eye issues until R801's family took her to the eye doctor and she needed surgery. The DON was asked when the eye doctor had come to the facility in 2025 and 2026. The DON explained she would get the dates.On 6/29/26 at 1:01 PM, information was provided that the eye doctor had visited the facility on 5/9/25, 9/26/25 and 3/12/26.On 6/29/26 at 3:32 PM, the Administrator was interviewed and asked if there was any reason R801 was not seen by the eye doctor on 5/9/25 and/or 9/26/25 at the facility after being approved for Medicaid. The Administrator explained he had not been at the facility during that time, so he had called SW 'C' who told him R801 was on the list to be seen, then he had called the eye doctor who told him R801 was not on the list until 3/12/26. The Administrator was asked about the discrepancy of if R801 was on the list to be seen or not. The Administrator had no explanation. When asked if R801 should have been seen by the eye doctor, the Administrator explained R801 should have been seen.Review of a facility policy titled, Hearing and Vision Services undated read in part, .The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: a. Obtaining history from medical records, the family, and the resident regarding hearing and vision abilities; b. MDS and care area assessments; c. Ongoing monitoring of sensory problems. The Social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources [e.g. Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs.

Based on observation, interview and record review the facility failed to ensure wound treatments/interventions were completed for one resident (R21) of one resident reviewed for pressure ulcers. Findings include:On 8/26/2025 at approximately 8:38 a.m., R21 was observed in their room, laying in their bed. R21 was observed laying in the supine position in the middle of the bed without any wedges or pillows offloading pressure of their sacral area. On 8/27/25 at approximately 10:11 a.m., R21 was observed in their room, laying in their bed. R21 was observed laying in the supine position in the middle of the bed without any positing wedges or pillows offloading pressure of their sacral area. On 8/27/25 the medical record for R21 was reviewed and revealed the following: R21 was initially admitted to the facility on [DATE] and had diagnoses including Pressure Ulcer Sacral Region Stage 4 and Venous insufficiency. A review of R21's careplan revealed the following: A review of R21's careplan revealed the following: [R21] is at risk for pressure ulcer development d/t (due to) Venous insufficiency, declines repositioning at times, weakness, decreased mobility, incont (incontinent) B&B (bowel/bladder), prone to MASD (moisture associated skin damage), dementia, diuretic med use, inadequate PO (by mouth) intake at times, prefers to stay in bed Goals-[R21] will have no complications r/t (related to) pressure ulcer skin impairment to sacrum through the review date. Date Initiated: 07/10/2024 .Target Date: 11/07/2025 .Interventions-Follow physician order for treatment of skin impairment . A review of R21's physician orders revealed the following: Wound Cleanse sacral wound with Saline or soap and water, pat dry. Apply Skin prep to peri-woundmaceration and to the area where dressing will be. Apply FibraCol Plus (cut to fit) INTO wound bed. Cover with a foam dressing. Change daily and PRN (as needed). every day shift related to PRESSURE ULCER OF SACRAL REGION, STAGE 4 (L89.154) after lunch; administer Tylenol 1 hr to treatment A wound evaluation completed by Nurse Practitioner A (NP A) on 7/31/25 revealed the following: Wound #1 Stage 4 Pressure Injury of Sacrum Location(s): SacrumWound Length x Width x Depth: 1cm (centimeters) x 1cm x 0.6cm. Undermining/Tunneling-Yes Undermining 12-2 o'clock - 0.4cm depth Wound Thickness [ ] Partial [x] Full .Wound Type: [x] pressure injury A review of R21's TAR (treatment administration record) for July and August 2025 were reviewed and revealed R21's treatments for their sacral wound were not documented as being completed on 8/3, 8/4 and 8/5. A review of R21's progress notes revealed the following notes pertaining to the days of no treatments: 8/3/25-No notes noted, 8/4/25-unable to complete. night nurse will do tx (treatment), 8/5/25- completed by midnight nurse this am Further review of the August 2025 TAR had no documentation that the night nurse on 8/4/25 or the mid night nurse on 8/5/25 completed the treatment. Further review of R21's progress notes did not reveal any documentation by the indicated night nurse on 8/4/25 or the mid night nurse on 8/5/25 that R21's sacral wound treatments were administered. A skin/wound note dated 8/7/25 completed by the facility Wound Care Nurse revealed the following: RN (Registered Nurse) did wound assessment and treatment to resident's sacral wound with wound NP (Nurse Practitioner) A (NP A). The resident's sacral wound measurements are larger. The wound bed is red. There is minimal serosanguinous drainage. The peri-wound skin is slightly macerated. There is a foul odor that is new. Wound NP changed treatment to NS (normal saline) and pack wound with Dakin's moistened gauze, skin prep on peri-wound and Foam dressing. The resident remains bed bound. She requires maximum assistance for turning in bed. She is incontinent of bowel and bladder On 8/28/2025 at approximately 9:32 a.m., Wound Care Nurse B (WCN B) who coordinates the wound care and does the weekly skin assessments was queried regarding R21's sacral wound. WCN B indicated that when they saw the wound on 8/7 it had increased in size and had developed a new foul order and as a result, NP A changed the order to Daykins. WCB B was queried where the Nursing staff document completion of the treatment and the indicated it was in the TAR. WCN B was informed of the missing treatments on 8/3, 8/4, and 8/5 and they indicated that since R21 was incontinent, the dressing should have been changed and documented by the Nursing staff. On 8/28/2025 at approximately 9:39 a.m., NP A was queried regarding R21's sacral wound and they indicated that they felt it would not heal and that the goal was to prevent worsening/infection. NP A indicated that the wound presentation on 8/7 had foul order and slightly increased in size since they previous time they had seen them.NP A was informed of the missing treatments leading up to their exam on 8/7/25 and they indicated that since R21 had a history of urinating a lot the dressing would need to be changed. On 8/28/2025 at approximately 09:46 a.m., an observation of R21's sacral wound was done with a Nurse from the State Agency, WCN B and NP A which revealed the following: R21 was observed lying in supine position on their back with no offloading device such as pillows or wedges applied. R21's wound measurements were 3 cm (L) x 0.6 cm (W) x 0.5 cm (D) with undermining at 12-2 0.5 cm, deep red base, no peri-wound maceration noted. It was cleaned with NS (normal saline), packed with fiber col, barrier cream to peri-wound and foam dressing applied. After wound care was provided, NP A voiced wanting to turn R21, no offloading wedges were observed in their room. WCN B was observed opening the closet and removed a wedge, NP A applied the wedge to right side of resident offloading pressure to the wound. On 8/28/2025 at approximately 10:51 a.m., The DON was Interviewed pertaining to R21's missing treatments for their sacral wound on 8/3, 8/4 and 8/5 and reported that felt the Nurses did the treatments, but there was no documentation of them completing them in the record. The DON was queried if Nurses could document in progress note or the PRN administration on the TAR that they completed the administration of the treatment and they reported they could have but that was not done. The DON was queried if R21's should have been provided positioning wedges or pillows to offload pressure on the sacral wound and they indicated they should. No documentation that R21's sacral wound treatments were completed as ordered on 8/3, 8/4 and 8/5 by the Nurses that did the treatments, were provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen and failed to ensure dishware was properly sanitized. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/22/24 between 11:00 AM-11:30 AM, during a kitchen tour with Director of Dining E, the following was observed: In the dry storage room, there was a buildup of dust, trash and food debris on the floor under the racks. In addition, there was a box of bananas, with numerous bananas that were completely black, and several that were split open. There were fruit flies observed swarming inside the box. When queried, Director of Dining E stated, We usually freeze them for banana bread when they get ripe, but those need to get tossed. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions. The ventilation cover located above the ice machine was observed to be coated with dust. According to the 2017 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. The flooring in between the ice machine and the wall was observed to be soiled with a black mold-like substance. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. There was water leaking from the pipes underneath the dish machine. There was standing water on the floor, and there was a buildup of a black, slimy substance on the floor. In addition, the holes in the floor drain cover in front of the dish machine, were almost completely clogged with black sludge. According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and(B) Maintained in good repair. On 7/22/24 at 11:50 AM, in the split kitchenette, there was an unlabeled spray bottle of an unknown chemical. Director of Dining E stated she did not know what was in the bottle, but confirmed it should have been labeled. According to the 2017 FDA Food Code section 7-102.11 Common Name, Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material. On 7/22/24 at 11:55 AM, the high temperature dish machine located in the 300 kitchen was tested with Director of Dining E. The dish machine was run approximately 4 times, and after reading the digital display for the wash and rinse temperatures, Director of Dining E stated that the water temperatures were not getting hot enough. When queried as to what temperature the wash and rinse cycles should be, Director of Dining E stated the wash cycle should be 140 (degrees Fahrenheit) and the rinse temperature should be 180. Director of Dining E stated, My staff have been telling me they couldn't get this machine to work right. Now I know what they mean. I've never had a problem with it. This surveyor then tested the temperature of the dish machine with a Thermoworks plate simulating dishwasher tester, the the surface temperature was noted to be 137 degrees Fahrenheit. Review of the 300 kitchen Dish Machine Temperature Log for July, noted documented wash temperatures that ranged from 112 degrees Fahrenheit to 128 degrees Fahrenheit (the log noted wash temperature should be 150 degrees Fahrenheit). In addition, there were several documented rinse temperatures that ranged from 125 degrees Fahrenheit to 135 degrees Fahrenheit (the log noted rinse temperature should be 180 degrees Fahrenheit). Director of Dining E was unable to provide an explanation for why staff continued to use the dish machine when it was not properly sanitizing. According to the 2017 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: .(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator; P.

Based on observation, interview, and record review, the facility failed to properly utilize personal protective equipment (PPE) for three (R20, R53, and R169) of three residents reviewed for transmission based precautions (TBP). Findings include: On 7/22/24 at 9:08 AM, staff were observed in R169's room wearing a gown and gloves. Signage was observed on the door that indicated R169 was on contact precautions (TBP intended to prevent transmission of infectious agents via contact with the person or their environment). The signage indicated a gown and gloves were to be donned when entering R169's room. Coat hooks were observed inside of R169's room labeled CNA (Certified Nursing Assistant) and Nurse. On 7/22/24 at 3:02 PM, R169 was observed sleeping in bed. Reusable gowns were observed hanging on hooks inside of the room. A family member was observed seated in a chair in the room without any PPE on. On 7/22/24 at 3:15 PM, an interview was conducted with Registered Nurse (RN) 'A'. When queried about why R169 was on contact precautions, RN 'A' stated, She is on contact, but isn't really and reported R169 was infected with Clostridium Difficile (C-Diff, a highly contagious infection of the large intestine that causes diarrhea) but did not currently have any symptoms. RN 'A' explained PPE was still required when entering R169's room. When queried about the gowns hung in R169's room, RN 'A' reported gowns were required when in R169's room and the staff reused the same gown unless soiled. RN 'A' reported the only time staff had to change a gown with each contact was for the residents who were on TBP for COVID-19 (Coronavirus Disease 2019). When queried about whether R169's visitor was required to wear PPE when in R169's room and making contact with her environment, RN 'A' stated, Her husband doesn't have any contact with her. RN 'A' further explained she had educated R169's visitor to wear PPE in the room because he wouldn't be able to handle it. A review of R169's clinical record revealed R169 was admitted into the facility on [DATE] with diagnoses that included: C-Diff. A review of R169's Physician's Orders revealed orders for antibiotic treatment that was not yet completed (stop date of 7/31/24) and an active order for TBP (contact precautions) that were started upon admission. On 7/23/24 at 8:38 AM, an interview was conducted with the Director of Nursing (DON) and Infection Control Preventionist (ICP) 'B'. When queried about the protocol for PPE when a residents was on contact precautions, the DON asked ICP 'B' to get the facility's policy. When queried about whether family members were required to follow TBP, the DON reported they needed to follow the plan of care and they were supposed to be educated. However, they could not force the visitors to wear PPE. When queried about whether gowns were to be reused for residents in contact precautions for C-Diff or droplet precautions for COVID-19, the DON reported a new gown should be worn for each contact with the resident and disposed after use, before exiting the room. A review of a facility policy titled, Isolation Precautions, dated January 2024, revealed, in part, the following: .Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microoganisms, which was spread by direct or indirect contact with the resident or the resident's environment .Facility staff will use Transmission-Based Precautions, in addition to standard precautions, for resident who was known or suspected to be infected or colonized with infectious agents which require, as determined by the CDC (Centers for Disease Control), additional controls to effectively prevent transmission .The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: .contact .droplet precautions. The category of transmission-based precautions will determine the type of PPE to be used .Clostridium Difficile .Contact .COVID-19 .Droplet .Full PPE . A review of a facility policy titled, Infection Control Program, revised May 2024, revealed, in part, the following: .Visitors coming to visit a resident who is on transmission-based precautions .will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident . 47283 R20 On 7/22/24 at approximately 11: 45 AM an initial observation was completed. R20's room door was closed. R20's room was a private room. The room door had a yellow PPE bag with supplies that included reusable gown, gloves, N95 masks (a mask designed to achieve a very close facial fit and very efficient filtration of airborne particles), goggles. The door had signage that read droplet precautions. A follow-up observation was completed at approximately 12:30 PM the same day. During this observation RN A, who assigned to care for R20 was standing outside R20's doorway speaking with the family member who was in R20's room. RN A reported to the surveyor that R20 tested positive for Covid-19 and they were started on Paxlovid (prescription treatment for COVID-19) on 7/19/24. During this observation an interview was completed with R20's family member. The Family member reported that R20 tested positive for Covid and they were getting treatment. The entry way to the room had hooks on the right side of the wall labeled as Nurses, CNAs. There were two used reusable gowns hanging on the wall. A 2nd follow-up observation was completed later that day at approximately 3:55 PM. R20's room had 2 used re-usable gowns hanging on the wall hooks. Review of R20's clinical record revealed that R20 was long-term resident of the facility admitted on [DATE]. R20's progress note and care plan revealed that they tested positive for COVID-19 on 7/19/24 and they were placed under droplet precautions. An interview with the RN A was completed on 7/21/24 at approximately at 4:15 PM. RN A was queried about their PPE process for droplet precautions, in reference to R20. They reported that staff were supposed to use clean re-useable gown in addition to other PPE and bag the reusable gown and discard other PPE supplies appropriately after use. RN A was queried on why R20's room had 2 used reusable gowns hanging on the wall hook and they reported that that was probably from three days ago when R20 was enhanced barrier precautions prior to testing positive for Covid. RN A added that staff should have bagged it and they were going to take care of it. R53 On 7/22/24 at approximately 11: 35 AM an initial observation was completed. R53's room door was closed. R53's room was a private room. The room door has a yellow PPE bag with supplies that included reusable gown, gloves, N95 masks (a mask designed to achieve a very close facial fit and very efficient filtration of airborne particles), goggles. The door had signage that read droplet precautions. Upon opening door, the surveyor observed from the doorway two used re-usable gowns hanging on the wall hooks on the right side of the wall that were labeled nurses, CNAs. Later that day at approximately 3:45 PM a follow up observation was completed from the doorway. Upon opening the door R53 was observed sitting up in their wheelchair. There were 2 used re-usable gowns hanging on the wall hook. Review of R53's clinical record revealed that R53 tested positive for COVID-19 on 7/19/24 and they were placed on droplet precautions. Resident were receiving hospice services. An interview was completed with the LPN C on 7/22/24 at approximately 4PM. LPN C was assigned to care for R53 during that shift. LPN C was queried about the facility PPE process for droplet precautions and queried about the used gowns that were hanging on the wall hooks in R53's room. LPN C reported that they were used gowns. They had assigned hooks for the nurses and CNAs. After they used the gown they removed and placed on the wall hook for reuse. If the reusable gown were soiled they had changed to a new gown, if not the used gowns were placed in plastic bags at the end of the shift.

Based on interview and record review, the facility failed to obtain labs in a timely matter for one resident, (R81) of one resident reviewed for labs, resulting in the potential for delayed treatment. Findings include: On 7/23/24 at 11:24 AM, a review of R81's physician's orders was conducted and revealed the following: An order dated 5/2/24 for a urinalysis and urine culture and sensitivity lab with a discontinuation date of 5/15/24. An order dated 5/8/24 for a urinalysis and urine culture and sensitivity lab with a discontinuation date of 5/15/24. An order dated 5/13/24 for a urinalysis and urine culture and sensitivity lab with a completed date of 5/14/24. A review of R81's lab results in the record did not reveal any results for the lab ordered 5/2/24. A review of R81's progress notes was conducted and did not reveal any information regarding the lab ordered on 5/2/24. Continued review of the notes revealed the following: A note dated 5/8/24 at 3:54 PM that read, .Resident complained of burning on urination and urinary frequency . NP (Nurse Practitioner) .notified. Order received to dip urine. Urine specimen collected and noted to be cloudy. Dip was positive .NP ordered it to be sent for microscopic UAand <sic> urine C and S (urinalysis and culture and sensitivity) Specimen awaiting for pick up. A note dated 5/13/24 at 4:38 PM that read, .Order completed for UA &CNS (urinalysis and culture and sensitivity). Pending lab pick up, placed in fridge. A late entry note for 5/17/24 entered into the record on 5/20/24 that read, .Lab stated that prior UA obtained was not able to be tested . New urine obtained via clean catch and sent with lab technician for C&S. NP aware urine still pending . On 7/23/24 at 12:41 PM, an interview was conducted with the facility's Director of Nursing was conducted regarding R81's labs. They were asked about the order dated 5/2/24 and said it appeared it was not done. They were then asked about the lab order dated 5/8/24 but not documented as being done until 5/13/24 and they said they would look into the delay. A review of a facility provided policy titled, Laboratory Process was reviewed but did not address the staff's responsibility for obtaining and sending out urine specimens.

Based on interview and record review the facility failed to ensure non-pharmacological interventions were utilized prior to the use of an as needed anti-anxiety medication for one resident (R23) of five residents reviewed for unnecessary medications, resulting in the potential for inappropriate use of an anti-anxiety medication. Findings include: On 7/22/24 at 10:22 AM, a review of R23's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia, major depressive disorder and adjustment disorder. R23's most recent completed Minimum Data Set assessment dated [DATE] revealed R23 had mild cognitive impairment and was independent with most activities of daily living. A review of R23's orders revealed an order dated 7/2/24 for Xanax (anti-anxiety medication) 0.25 milligrams every 12 hours as needed for 14 days. R23's medication administration record (MAR) revealed a dose of the medication was given on 7/10/24 at 1:05 PM. A Behavior Note dated 7/10/24 at 8:03 PM entered into the record by Nurse 'D' was reviewed and read, . Resident was given a prn (as needed) xanax for increased agitation r/t (related to) room mates <sic> TV volume being too loud .Resident walking out into the hallways pacing. Resident Son arrived a <sic> hour later to transport resident to an appointment, Resident smiling and calm, no further behaviors noted after she returned from appointment . The note did not indicate any non-pharmacological interventions attempted prior to the administration of as needed Xanax. Further review of the MAR, assessments, Kardex, and care plans was conducted and there was no evidence of any resident specific-targeted behaviors or non-pharmacological interventions to attempt prior to administration of the as needed anti-anxiety medication. On 7/23/24 at 10:00 AM, an interview was conducted with Nurse 'D'. They were asked if they recalled administering R23 the medication on 7/10/24. Nurse 'D' reviewed their progress note and said they did. They were asked if they attempted any non-pharmacological interventions prior to the administration of the medication and they said they did. They were asked why it wasn't documented and said they should have put it in their progress note. They were then asked where they could find resident specific targeted behaviors for R23 and said it should be in the care plan. On 7/23/24 at 12:41 PM, an interview with the facility's Director of Nursing was conducted and they reported resident specific targeted behaviors should be documented in the care plan and prior to administering as needed anti-anxiety medications and non-pharmacological interventions should be attempted and documented in a progress note prior to the administration. A review of a facility provided policy titled, Behavior Management was conducted and read, 9. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions .

Based on observation, interview and record review the facility failed to implement adequate, effective resident specific interventions for a resident with a diagnosis of dementia and a history of a fall, failed to communicate effectively from the therapy staff to the nursing staff and document/implement the safest mode of transferring and ambulation for one (R15) of three residents reviewed for falls, resulting in the resident to have been transferred and admitted to the hospital for a higher level of care, identified to have a right parietal scalp hematoma and laceration that required five staples and an acute right-sided subdural hematoma measuring 0.9 cm (centimeters) in thickness and causing mild mass effect on the subjacent right frontal lobe. Findings include: On 8/22/23 at 9:39 AM, R15 was observed sitting in their wheelchair in the community room watching television. During an interview with R15, the resident mentioned they had a fall that required stitches to the back of their head. Review of the medical record revealed R15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia, repeated falls, difficulty walking and the need for assistance with personal care. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status score of 11 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the preadmission hospital medical record that was provided to the facility upon R15's admission documented in part, . History and Physical . July 09, 2023 . Admitting Diagnosis: Fall . Chief Complaint: Head contusion . presented to the emergency room via EMS secondary to a fall. The patient hit her head on a piece of furniture . The patient was recently discharged from the subacute rehab where her son who is with her right now states that she had fallen in the rehabilitation. The day prior she was discharged home. Son also notes of increased confusion. The patient does have a history of sundowners . Review of the progress notes revealed the following in part: A Nursing note dated 7/18/23 at 2:05 AM, document in part . Resident was witnessed by CNA (Certified Nursing Assistant) when she stumbled backwards, and loss balance before she took a fall to the floor. CNA was assisting resident with toileting before she loss balance while using her 4-wheel walker. Resident hit her head when she landed on the floor. Nurse immediately performed first aid when a one-inch gauge was visually seen with blood leaking out. Nurse applied pressure and wrap head with soft kerlix bandage x2. Blood is pooling through bandage quickly . EMS (Emergency Medical Services) called to the facility. Resident sent out to hospital . A Nursing note dated 7/18/23 at 6:04 AM, documented in part . currently in the ED (Emergency Department) at (hospital name). CT scan done on brain, 0.9 subdural hematoma showed on results . awaiting evaluation from ED Physician . Review of the hospital record documented the following: An Emergency Medicine History and Physical dated 7/18/23 at 2:33 AM, documented in part . presents to the ED following a witnessed fall . Patient is reportedly [NAME] (alert not oriented) x1 at baseline per EMS. She has a history of frequent falls, is not supposed to get up without assistance. The fall was reportedly witnessed by staff there, she had got up, and then shortly after getting up lost her balance and fell backwards . Patient has a laceration, approximately 3 cm on her occiput . Abrasion to the left arm . She is disoriented . CT Head wo (without) Contrast . Acute right-sided subdural hematoma measuring 0.9 cm in thickness and causing mild mass effect on the subjacent right frontal lobe . Right parietal scalp hematoma and laceration without an acute skull fracture . patient should be admitted to the ICU (Intensive Care Unit) . Procedures . Laceration Repair . Scalp . Length (cm): 4 . Number of staples: 5 . Diagnosis . Fall, initial encounter, Subdural hematoma . Laceration of scalp, initial encounter . Review of the progress notes documented that R15 returned back to the facility on [DATE]. Review of a care plan titled The resident is at risk for falls r/t (related to) debility, history of falls . documented the following interventions . Call light within reach and encourage resident to use (initiated 7/12/23) . Ensure a safe environment with (specify: even floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, personal items within reach, handrails/positioning rails as ordered (initiated 7/12/23) . Move to room closer to nurses station for increased visual supervision (initiated 7/13/23) . This indicated R15's fall care plan did not have effective or adequate resident specific interventions to prevent falls for a resident with dementia and a history of falls. Review of a facility policy titled Falls Risk Protocol dated September 2017, documented in part . Falls management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the resident's quality of life . The Nursing Admit/Readmit Assessment and care plan will be initiated within 24 hours of admission . Some risk factors or conditions that may predispose a patient to a fall may include, but are not limited to . Musculoskeletal condition that impair strength, History of falls . Urinary or fecal urgency . Unsteady gait, muscle weakness . Age . Cognitive impairment, dementia . Use of assistive devices . Medications . Physical environment . If upon completion of the Admit/Readmit Assessment the resident is found to be at risk for falls or has a history of falls the physician is contacted for orders, as appropriate; an initial plan of care is developed and individualized interventions are initiated . The interdisciplinary team review the resident's most current fall to determine the resident's present condition or status then a narrative summary of the resident's condition and circumstances surround the even are documented in the resident's clinical record. The care plan is revised as clinically indicated to meet the resident's current needs . Further review of the medical record revealed no documentation of the interdisciplinary team to have reviewed and documented a narrative summary and follow up of R15's fall. Further review of the fall care plan revealed no revision, modifications or new interventions implemented upon R15's readmission to the facility on [DATE]. Review of a facility Accident/Incident Report dated 7/18/23, documented in part . Resident states I was slipping away! CNA (certified nursing assistant) assisted resident to the bathroom when she lost balance and fell down to the floor . walker with gait belt was used to toilet resident . The CNA that assisted R15 at the time of the fall was later identified as CNA B. Review of CNA B statement documented in part, . was assisted with sitting upright on bed I put shoes on and gait belt around her, walker in front and we both agree <sic> on the count of 3 she will <sic> stand up. We proceed <sic> to walk to the bathroom and when we got in front of the sink, she started to lose balance and fell backward. Her weight was overpowering me, so I kick <sic> the nightstand against the wall and yell <sic> for help as she hit the floor . she was bleeding from the head, the back of the head . Review of the initial Physical Therapy (PT) evaluation dated 7/13/23, documented the following goals in part . Patient will improve ability to roll from lying on back to left and right side and return to lying on back with Partial/Moderate assistance to get in/out of bed . Patient will improve ability to safely transfer to a standing position from sitting in a chair, wheelchair or on the side of the bed with Supervision or Touching Assistance with recognition of safety hazards and with ability to right self to achieve/maintain balance . Patient will safely ambulate on level surfaces 30 feet using two-wheeled walker with Supervision or Touching Assistance with precision of movement, with normalized gait pattern, with continuous steps and with functional posture to prepare for walk to dine for meals . Patient will increase B/L (bilateral) LE (lower extremity) Muscles Strength to 3+/5 in order to facilitate safe transition to next level of care and safely return home . Patient will improve static and dynamic standing balance from poor to Fair to improve ability to do functional task without any difficulty . The assessment also documented the following assistance levels required in part . Lying to sitting on side of bed = Substantial/maximal assistance . Sit to stand = Partial/moderate assistance . Walk 10 feet = partial/moderate assistance . Patient exhibits antalgic gait, abnormalities in posture, shuffling gait, decreased velocity, decreased stride length, narrow base of support and reciprocal movement deficit associated with forward lean of trunk and inadequate hip extension and underlying causes that might be modifiable include: impaired proprioception, muscle instability and muscle paresis/weakness . This initial PT assessment was completed by Physical Therapist personnel (PTP) C. On 8/23/23 at 11:19 AM, PTP C was interviewed and asked to review their evaluation completed on R15 on 7/13/23. PTP C began to review their evaluation from their laptop. PTP C was then asked their directive given to the nursing staff on the safest way to assist R15 from their bed to the bathroom. PTP C stated after they completed their evaluation the safest way to assist R15 from their bed to the bathroom would have been for staff to utilize a gait belt at the resident's waist level, while staff stood to the posterior lateral side of R15. One hand holding the gait belt and one hand on R15's wheelchair while wheeling it behind the resident as they ambulated due to their unsteadiness with their lower extremities and to prevent a fall if they resident fell backwards. PTP C was then asked to read the statement documented by CNA B (from the fall on 7/18/23). After PTP C read the statement, they were asked what was wrong with the documented incident, PTP C replied the staff did not use the wheelchair behind the resident like they were supposed to. PTP C stated . We recommended to roll the chair behind her anytime she is ambulating . When asked how the nursing staff was informed of their directive to use the wheelchair while the resident is ambulating, PTP C explained they verbally told the nurse on the day of the evaluation, and they also wrote it on the communication form that is provided to the assigned nurse after the evaluation is completed. On 8/23/23 at 11:43 AM, the Director of Nursing (DON) was interviewed and asked if they could provide the therapy communication form that was provided to the nursing staff for R15's initial PT evaluation. Review R15's PT evaluation dated 7/13/23 revealed no documentation for the staff to use the wheelchair behind the resident when ambulating. At this time the DON was informed of the interview with PTP C and informed of the concern of the therapy department and nursing communication on the safest assistance level to have been initially implemented for R15. The DON acknowledged the concern. On 8/23/23 at 12:04 PM, CNA B was interviewed and asked about the fall incident with R15 on 7/18/23, CNA B repeated the scenario documented in their statement. When asked if they utilized R15's wheelchair behind the resident when ambulating, CNA B stated they did not. CNA B stated they did not know about using the wheelchair behind R15 while they were ambulating. CNA B stated R15's ambulation assistance level was communicated to them by the previous aide and their understanding was that it was safe to ambulate with R15 while using the gait belt and the resident's walker. On 8/24/23 at 8:39 AM, a follow up interview was conducted with the DON, when asked why R15, a resident with dementia and a history of falls did not have effective or adequate resident specific interventions implemented to prevent further falls, the DON stated the facility does the least restrictive interventions during the time that they were getting to know R15. The DON stated the facility did move R15's bedroom when they identified the resident was more confused. No further explanation or documentation was provided before the end of the survey.

Based on observation, interview, and record review, the facility failed to appropriately prepare a PICC (peripherally inserted central catheter, used for infusion of intravenous fluids or medications) line prior to intravenous administration of antibiotics for one resident (R26) of one resident reviewed for PICC lines, resulting in the potential for infection. Findings include: On 8/23/23 at 9:34 AM, Nurse 'A' was observed preparing medications for administration to R26. Nurse 'A' prepared multiple medications including an intravenous (IV) antibiotic. Nurse 'A' entered the room, connected the IV tubing to the antibiotic bag and hung the bag on the IV pole. Nurse 'A' was then observed to flush R26's PICC line with 10 milliliters of normal saline. Nurse 'A' was not observed to scrub the PICC line connection port prior to flushing the line. After flushing the line, Nurse 'A' connected the IV tubing and began the infusion of the medication. On 8/23/23 at 9:49 AM, Nurse 'A' was asked about the process for preparing a PICC line for intravenous medication administration and admitted they forgot to clean the PICC line port prior to attaching the IV tubing. On 8/24/23 at 9:50 AM, an interview was conducted with the facility's Director of Nursing regarding the process of preparing a PICC line for use. They indicated the connection port of the PICC line should be wiped with an alcohol swab prior to attaching the line. A facility provided policy for the administration of intravenous medications was provided, however; the policy did not address cleaning the PICC line. A review of The Center for Disease Control website at https://www.cdc.gov/dialysis/pdfs/collaborative/protocol-hub-cleaning-final-3-12.pdf was conducted and read, . Central Venous Catheter Hub Cleaning Prior to Accessing .Connection Steps: .3. Disinfect the hub (connection port) with caps removed using an appropriate antiseptic .

Based on observation, interview and record review, the facility failed to ensure two residents (R26 and R178) of four residents reviewed for medications were assessed for the safe self-administration of medication and to have medication kept at the bedside. Findings include: 08/22/23 at approximately 10:06 a.m., R26 was observed in their room, up in their bed. R26 was observed to have two bottles of eye drops and a cup full of cough drops on their bedside table. R26 was queried if they were using the eye drops and taking the cough drops and they reported that they were and that their eyes get dry in the facility along with their cough. R26 was queried if the facility Nursing staff knew they had the medications at the bedside and they reported that they did and they they have had them for a few weeks. On 8/22/23 at approximately 3:20 p.m., R26 was observed in their room, up in their bed. R26 was still observed to have a cup full of cough drops on their beside table along with the eye drops located in a tissue box. On 8/22/23 the medical record for R26 was reviewed. R26 was initially admitted to the facility on [DATE] and had diagnoses including Chronic Respiratory failure and Osteomyelitis. A review of R26's MDS (minimum data set) with an ARD (assessment reference date) of 727/23 revealed R26 needed extensive assistance with most of their activities of daily living. A review of R26's Physician orders revealed the following: Artificial Tears Ophthalmic Solution 0.5-0.6 % (Polyvinyl Alcohol-Povidone (Ophth) Instill 1 drop in both eyes every 4 hours as needed for dry eyes. Further review of the Physician orders did not reveal any orders for cough drop medication or the self administration of eye drops or cough drops were noted in the orders. A review of R26's comprehensive plan of care did not reveal any focused areas for the self administration of medication. A review of R26's assessments did not reveal any assessment that indicated R26 had been assessed for the safe self-administration of medication. On 8/23/23 at approximately 8:47 AM, Nurse 'A' was observed preparing R26's medication. Nurse 'A' prepared multiple medications including a packet of cholestyramine powder (treatment for high cholesterol) mixed with water. Nurse 'A' entered the room and put the cholestyramine drink on R26's bedside table. They then administered R26's other medications and left the room. Nurse 'A' was not observed to encourage R26 to drink the cholestyramine that was left on the table. Upon exiting the room, Nurse 'A' was asked about leaving the medication on the table and said R26 would drink it on their own and they would check back later to make sure they had taken it. On 8/23/23 at approximately 11:53 a.m., Nurse A was queried regarding the observations of R26's medications on the bedside table. Nurse A indicated that R26 had had them on the bedside table for a long time but was unsure if they had been assessed for safe self-administration. At that time, the medical record for R26 was reviewed with Nurse A and they indicated that R26 had not been assessed yet and they did not see anything in the record that R26 had any orders from the Physician to self-administer medication. Nurse A indicated they would have to let facility management know about the concern. On 8/24/23 at approximately 8:43 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding R26's assessment of self administration of mediation. The DON reported that it has just been completed and they had to educate the Nurse A on how to perform safe self-administration assessments and what steps to do if a resident wishes to self-administer their medications. 34275 Resident #178 On 8/22/23 at approximately 9:57 AM, R178 was observed lying in bed. The resident was alert and able to answer questions asked. R178 reported they had been in the facility for about five days. A half used tube of hydrocortisone cream was observed in a cup on the resident's bed side table. When asked about the cream, R178 reported that they used the cream underneath their breasts. A review of R178's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: liver cancer and Rheumatoid arthritis. A review of the residents MDS indicated the resident had a Brief Interview for Mental Status score of 14/15 (cognitively intact). *There were no orders in the resident's record for any medication to be applied underneath the resident's breasts. On 8/24/23 at approximately 8:41 AM, an interview was conducted with the DON. When asked if R178 was able to self-administer medications, the DON reported that they were not familiar with the resident as they were a new admit and noted that they were not familiar with the resident's orders. On 8/24/23 a facility document titled Self-Administration of Medications was reviewed and revealed the following: Policy-Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents in the facility, and there is a prescriber's order to do so. Procedures: A. Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facility's interdisciplinary team. B. If the resident indicates no desire to self-administer medications, this is documented in the appropriate place in the resident's medical record, and the resident is deemed to have deferred this right. C. If the resident desires to self-administer medications, an assessment by the interdisciplinary team is conducted of the resident's cognitive, physical, and visual ability to carry out this responsibility. D. The resident's ability to self-administer medications is reassessed periodically according to facility policy.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than five percent for one resident, (R26) of four residents reviewed for medication administration, resulting in a medication error rate of 9.09%. findings include: On 8/23/23 8:21 AM, Nurse 'A' was observed preparing R26's morning medications. Nurse 'A' prepared multiple medications including a Flonase (allergy treatment) nasal spray. After preparing the medications, Nurse 'A' entered R26's room and was observed to assist R26 with the nasal spray. Nurse 'A' administered one spray of the Flonase into R26's right nostril and one spray into their left nostril. At the conclusion of the medication administration, Nurse 'A' exited the room. Nurse 'A' was asked to confirm all of R26's medications due during the morning medication pass were given, and they said they were. On 8/23/23 at 10:24 AM, R26's physician's orders were reconciled (compared) with the observation of the medication administration at 8:21 AM. During the reconciliation it was discovered R26's order for Flonase was to administer two sprays of the nasal spray in each nostril, scheduled for 9 AM. Continued review of R26's orders further revealed R26 had an order for Eliquis (blood thinner) 2.5 milligrams scheduled for 9 AM and 9 PM that was not observed as given. During reconciliation it was also discovered R26 had an order for dorzolamide-hydrochloride-timolol maleate ophthalmic solution (eye drop for glaucoma) scheduled for 9 AM and 9 PM that was also not observed as given. On 8/24/23 at 9:50 AM, an interview was conducted with the facility's Director of Nursing. They were asked about the medication administration process and indicated the nurses should practice the five rights of medication administration. A review of a facility provided policy titled, Medication Administration revised 10/2022 was conducted and read, .10. Review MAR (medication administration record) to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .

Based on observation, interview, and record reviews the facility failed to notify the physician of change of a resident's skin condition (R63), ensure a physician order was implemented for a treatment and proper storage of ointments for two (R's 43 & 63) of four residents reviewed for medications stored at the bedside. Findings include: R63 On 8/22/23 at 8:59 AM, R63 was observed sitting in their wheelchair next to their bed. An interview was conducted with the resident at that time. Observed on R63's nightstand was a medication cup filled with a thick ointment, placed behind a greeting card. When asked, R63 stated the staff applies it to their buttock area. At that time the assigned Infection Control Nurse (ICN) D (who was assigned to work the floor on the day of the observation) was asked to verify the medication in comparison with the resident's medication profile. The medication profile was reviewed with ICN D and revealed the resident did not have an order for an ointment to be applied to the resident. ICN D was asked to inform the surveyor of the next assistance to the bathroom for R63 or brief change so that an observation of R63's buttocks can be made to identify where and why the ointment was being applied. At 9:12 AM, an observation of R63's buttocks revealed a pink/light redden area noted to the middle of R63's buttocks where the left and right buttock formed. When asked, the nurse stated the discolored area should be reported to the physician, the ointment should not be applied without a physician's order and the ointment should be stored in the treatment cart. The nurse removed and disposed of the ointment. R43 On 8/22/23 at 9:15 AM, R43 was observed sleeping in their bed. Observed on their bedside table was a medication cup filled with thick ointment. Certified Nursing Assistant (CNA) E was asked to come in the room of R43, once inside, CNA E was asked about the ointment observed on R43's bedside table and asked if they knew what the ointment was. CNA E obtained the medication cup full of the ointment and stated they were unsure but believed it to be a cream that staff use to apply to the resident buttocks. On 8/22/23 at 3:18 PM, an interview was conducted with the Director of Nursing (DON), when informed of the observations of an ointment left at the bedside for R's 43 and 63, the DON stated that is not the facility's practice or standard of care. The DON stated the ointments should not be placed at the bedside. The DON stated they were educating their staff on the concern immediately. When asked the facility's protocol if staff identifies a skin change or impairment with a resident, the DON stated staff should be notifying the physician and putting treatment in place. No further explanation or documentation was provided by the end of the survey.

Based on observation, interview, and record review the facility failed to ensure a competency assessment was completed for one (R27) of five residents reviewed for advance directives, resulting in the facility to have allowed a family member to have signed medical consents and make health care decisions for R27 without the resident to have been deemed incompetent to make decisions regarding their care. Findings include: Review of the medical record revealed a family member of R27 had signed multiple medical consents and was allowed to make health care decisions for R27. Further review of the medical record revealed patient advocate papers on file, however no competency assessment was identified in the medical record. This indicated the patient advocate was signing consents and making decisions for R27 without the resident being deemed as incompetent to make their own decisions. Review of the medical record revealed R27 was readmitted to the facility on [DATE], with diagnoses that included: chronic pain and anemia. A Minimum Data Assessment (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 (which indicated intact cognition) and required assistance for all Activities of Daily Living (ADLs). On 8/23/23 at 9:16 AM, Social Worker (SW) F was interviewed and asked how R27's family member was able to sign medical consents and health decisions for R27, when R27 had not been deemed incompetent. SW F stated they had identified the error and scheduled the psychologist to come and consult with the resident today to remedy the concern.

This citation pertains to intakes: MI 000, MI 149 and MI 248. Based on interview and record review the facility failed to implement interventions as documented by the Interdisciplinary team, review the effectiveness of fall interventions (R24), and provide adequate bathing assistance for (R34) two of four residents reviewed for falls, resulting in R34 being transferred to the hospital and receiving multiple stitches from a large laceration over the forehead and scalp. Findings include: R34 Review of the medical record revealed R34 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses that included: [CONDITION(S)] and collapse, [CONDITION(S)] and [CONDITION(S)] following a cerebral infarction affecting left non-dominant side, muscle weakness, [CONDITION(S)] stage 3 and type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and requiring staff assistance for all Activities of Daily Living (ADLs). Review of a facility Accident/Incident Report dated 2/9/22 at 12:00 AM, documented in part . Location . Resident Room . Type Of A/I (Accident and Incident) . Slid out of chair . Resident Statement . I slid out of chair, knelt down + I sit down. I don't hurt myself. Outline Sequence of events leading up to fall . Watching TV while in chair . Denies pain . Skin (abrasion, reddened or opened area) . none noted . Interventions Implemented at time of incident . Neuro check done, Bed monitored in low position . IDT (Interdisciplinary Team) Review/Comments . Resident was found sitting on the floor next to her bed . Non-skid surface added to w/c (wheelchair) seat. Therapy to eval (evaluate) . On 8/10/22 at 10:28 AM, Rehabilitation Director (RD) B was interviewed and asked to provide the Therapy evaluation completed regarding R34's February 9th fall. RD B stated they would look into it and follow back up. At 12:39 PM, RD B returned and stated the resident was not evaluated by the therapy department as documented on the Interdisciplinary report. Review of an Accident/Incident Report date 6/13/2022 at 8:50 PM, documented in part . Location . Resident Room . Shower . Type of A/I . Fall . Resident Statement . Resident states she passed out and fell out of her shower chair . Outline sequence of events leading up to fall (Blank) . Resident denied pain following her fall . Sent out 911 . Head injury, skin tear L (left) lower forearm . Review of a written statement by Certified Nursing Assistant (CNA) G dated 6/13/22, documented in part . Monday June 13, 22, Shower was being given on an alert and oriented patient as reported by a facility nurse at the start of shift. Pt (Patient) was showering and staff was in the room area. Pt said she was ready, as staff started to entering <sic> bathroom, staff heard a thud. Staff opened shower curtain found pt on the floor forward facing. Pt said she was fine, but blacked out after she said she was ready to get out. Staff pulled called <sic> light for help, and then got help from the rest of staff . On 8/9/22 at 2:15 PM, a telephone interview was conducted with CNA G who identified themselves as an agency CNA and stated the day of R34's fall (June 13, 2022) was the first time they had ever worked in the facility. CNA G stated in part, . I got the report that she (R34) was a standby assist and I was in her room and I just heard her fall . They (the facility) put two agency staff together (themselves and the nurse they were assigned with that day were both agency per CNA G) . It was like the blind leading the blind . We didn't know about the residents . It should have been more information given to us . CNA G confirmed they were not in the shower room assisting R34. CNA G stated they were in R34's room on standby. Review of a care plan titled (R34 name) has an ADL self-care performance deficit r/t (related to) weakness, and history of [CONDITION(S)] ([CONDITION(S)] Accident) with left sided weakness impaired ROM (Range of Motion) LUE (Left Upper Extremity)/LLE (Left Lower Extremity). She prefers to be independent, but needs assist peri-care and transfers. Refuses care at times (Revised 6/16/22) documented the following intervention . BATHING/SHOWERING: The resident requires extensive assistance by one staff member for showering/bathing. Use shower chair with arm rests for additional support in shower . Date Initiated: 05/21/2021 . This intervention was the same intervention that was supposed to be implemented on the date of R34's June 13th, 2022, fall. The facility failed to follow the intervention they implemented for R34 to have extensive assistance by one staff member for showering/bathing. Review of hospital documents dated 6/13/2022 at 9:53 PM, documented in part . Patient presented to ED (Emergency Department) from (facility name) facility 2/2 (secondary to) loss of consciousness and fall . According to the patient she was taking a shower after <sic> facility. Since she cannot stand she sits on a bench underneath the shower. Patient had completed a ho <sic> water shower after which she felt dizzy while sitting on the bench and lost consciousness. She fell forward, headfirst hitting the ground. She woke up a few sec after . She did notice blood coming out of her head. Facility workers came to help her sit onto the bench. And Called EMS (Emergency Medical Services). Upon Arrival of the EMS patient's blood sugars were noted to be in the 50s. She was brought to the ER since she was bleeding from her forehead and for further work-up for the loss of consciousness . Review of a hospital Internal Medicine document dated 6/14/22 at 4:54 AM, documented in part . The patient was evaluated in the ER . She has a large laceration over the forehead and scalp with crusting of blood . Review of an Admission Summary note dated 6/16/22, documented in part . Resident admitted from (hospital name) at 7:57 PM via stretcher accompanied by EMS. Admitting diagnosis of closed head injury . Resident has stitches to forehead . Review of a June 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented in part, . Monitor sutures to forehead. Report changes to MD every shift for skin alteration . Start Date 06/17/2022 . On 8/9/22 at 2:45 PM, the Director of Nursing (DON) was interviewed and asked why R34 was left in the shower room alone to bathe themselves on June 13, 2022, prior to their fall if their care plan documented for the resident to receive extensive assistance by one staff for showering/bathing? The DON stated they know the resident usually request privacy while showering, however facility staff should never leave anyone unattended. The DON stated they would look into it more and follow up. On 8/10/22 at 10:03 AM, the DON presented Unit Manager (UM) D and stated UM D would be able to share more details surrounding the fall with R34 on 6/13/22. When asked if R34 should have had a staff member assisting during the whole duration of their shower, considering the resident's care plan documented extensive assistance by one staff. UM D stated someone should have been assisting for the whole shower. UM D stated she is very familiar with the resident and the resident does not like others present when they shower. When asked about the safety of the resident and the intervention documented in the resident's care plan for extensive assistance by one staff for showering, UM D replied that means someone should be there the whole time when she showers. On 8/10/22 at 1:40 PM, the DON was interviewed and asked why the resident was not evaluated by therapy as documented by the IDT team as an intervention after the residents 2/9/22 fall. The DON stated they would look into it. No further information or documentation was provided by the end of survey. R24 Review of the medical record revealed R24 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses that included: dementia, spinal stenosis, cognitive communication deficit, [CONDITION(S)], heart failure and [CONDITION(S)] stage 3. A MDS assessment dated [DATE] documented a BIMS score of eight indicating moderately impaired cognition and requiring staff assistance for all ADLs. Review of Incident and Accident reports for falls revealed ten documented falls from December 2021 until the date of survey (August 2022), which revealed the following: On 12/23/21 at 7:30 PM, the resident fell in their room. An intervention was documented of educating the resident to use the call light if help is needed and wait for care. A second intervention for therapy to screen for anti-roll back device to wheelchair was documented. The resident has a diagnosis of dementia and moderately impaired cognition, reeducating the resident to use the call light would not be an effective intervention for this resident. On 2/12/22 at 11:50 PM, the resident fell in their room. An intervention was documented to have educated the resident on using the call light for help, to have metabolic workup and to continue working with therapy for strengthening. The education of the call light is a repeated and ineffective intervention. On 2/18/22 at 8 AM, the resident fell in their room. An intervention to remind patient to not transfer by their self and to have shoes and/or gripper socks on was documented. Educating a resident with dementia to not transfer by themselves is not an effective intervention. The intervention to have shoes or gripper socks applied was not documented on the resident's care plan for staff to implement. On 4/13/22 at 4:30 PM, the resident fell in their room. An intervention to encourage to lay down after lunch was documented. This fall required the resident to be transferred to the hospital. Review of a hospital document dated 4/13/22 at 6:14 PM, documented a right orbital floor fracture. On 4/30/22 at 8:15 AM, the resident fell in their room. An intervention for therapy to evaluate the wheelchair for modifications, offer to lay down after dinner and a room change was documented. Review of the census report revealed the resident room was not changed after this fall. On 8/10/22 at 10:30 AM, the Rehabilitation Director (RD) B was interviewed and asked if therapy evaluated and made modifications to the resident's wheelchair, RD B stated they would review their records and follow up. RD B returned and stated therapy did not evaluate the resident's wheelchair and no modifications was made to the wheelchair by the therapy department. On 8/10/22 at 1:42 PM, an interview was conducted with the DON. The DON was asked about the multiple interventions that were documented by the IDT team and never implemented and the repeated ineffective interventions. The DON stated the IDT was supposed to meet this week (week of survey) to discuss more aggressive fall interventions for the resident, however the State Agency walked in to complete the survey and the meeting was postponed. No further explanation or documentation was provided by the end of survey.

Based on observation, interview, record review, the facility failed to ensure the kitchen dry storage room was free from pests, failed to ensure food items were dated, failed to store wiping cloths in chemical sanitizer, and failed to ensure staff performed hand washing. These deficient practices had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/8/22 between 8:30 AM-9:00 AM, during an initial tour of the kitchen, the following items were observed: In the dry storage room, there were numerous large, black ants observed inside and surrounding the sugar bin. In addition, there were 4 bins of bread products that were stored directly on the floor. On 8/8/22 at 9:15 AM, when queried about the ants in the storage room, Dietary Staff K stated, Ever since they started construction, we've been having issues with ants. Dietary Staff K further stated that the bread bins should not be stored directly on the floor. According to the 2013 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .2. (B) Routinely inspecting the PREMISES for evidence of pests;. According to the 2013 FDA Food Code section 3-305.11 Food Storage, 1. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: .(3) At least 15 cm (6 inches) above the floor. In the Victory Dessert 2 reach-in cooler, there was an opened 5-pound container of cottage cheese with a manufacturer's best by date of 8/1/22. In addition, in the Avantco cooler, there were 6 individual bowls of undated soup. On the food preparation counter, there were 2 wet wiping cloths stored on counter, and not in a sanitizer bucket. According to the 2013 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; On 8/8/22 at 12:15 PM, Dietary Staff M was observed serving lunch at the steam table, with visible facial hair, but was not wearing a beard restraint. In addition, Dietary Staff M was observed stepping away from the steam table, wearing disposable gloves, and going to the hand sink to get some paper towels to wipe the sweat from his brow. After disposing of the used paper towels, Dietary Staff M then went to the wall mounted hand sanitizer dispenser and used hand sanitizer on his gloved hands. Dietary Staff M then returned to the tray line to continue serving lunch, without performing any hand washing. On 8/8/22 at 1:00 PM, acting Dietary Manager L was queried about the lack of hand washing by Dietary Staff M, and confirmed that he should have changed gloves and washed his hands, rather than using hand sanitizer on his gloves. According to the 2013 FDA Food Code section 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (I) After engaging in other activities that contaminate the hands. According to the 2013 FDA Food Code section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on observations, interviews, and record reviews the facility failed to ensure proper infection control protocols and practices were consistently followed by the facility staff during the observation of medication administration performed by one Licensed Practical Nurse (LPN) A of two nurses observed for the administration of medication, this had the ability to affect multiple residents (R's 53, 327, 51, 34, 47, 64 and 6). Findings include: On 8/9/22 at 8 AM, LPN A was observed obtaining a blood sugar level via a handheld glucometer from R327. LPN A removed the blood-stained lancet (blood strip which is inserted in the glucometer) and put it in the palm of their glove then removed their gloves and disposed of the dirty lancet and gloves in the resident's bedside garbage can. LPN A then exited the room and wiped the glucometer machine with an alcohol prep wipe. When asked LPN A confirmed they always clean the glucometer with an alcohol prep wipe and stated they have seven residents that require their blood sugar levels to be taken. LPN A stated they already obtained six residents blood sugar levels and had one more blood sugar level to obtain for the morning. Residents 53, 51, 34, 47, 64 and 6 were the residents identified to have their blood sugar level obtained by LPN A on 8/9/22. Review of the glucometer user instruction manual (Assure Prism- multi) documented in part, . The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission blood-borne pathogens. The meter should be cleaned and disinfected after use on each patient. This Blood glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedure are followed . We have validated Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1, and PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the Assure Prism multi meter . the nurse failed to clean and disinfect the glucometer per the manufacturer's instructions, this had the potential to transmit bloodborne pathogens to other residents that required their blood sugar levels to be obtained. Review of a Blood Glucose Monitoring protocol provided by the facility documented in part, . Dispose of test strip, lancet, and gloves in proper receptacles . On 8/9/22 at 9:24 AM, the Director of Nursing (DON) was interviewed and asked what receptacle the nurses are expected to dispose of blood-stained lancets and the DON stated the nurses are to dispose of them in the sharp's container. The DON was then asked the protocol on cleaning the facility glucometers and the DON stated the nurses are to clean them with the disinfectant wipes located on the carts. LPN A failed to dispose of the lancet in the proper receptacles and clean the glucometer per the manufacture's instruction.

Based on observation, interview, and record review, the facility failed to ensure restorative nursing/range of motion services for two residents (R#'s 17, and 25) of five residents reviewed for restorative nursing services, resulting in the potential for physical decline. Findings include: A review of a facility provided document titled, REHABILITATION COMMUNICATION with an effective date of 9/2020 was conducted and read, Policy: It is the policy of this facility to ensure clear communication from Rehabilitation Services to other departments. Procedure: 1. Ongoing communication between rehabilitation regarding patient needs and goals will be completed utilizing the Therapy Communication Care Plan form to Nursing. 2. Therapist is to complete the Therapy Communication form on admission, performance improvement or decline and at discharge. 3. Completed forms are to be given to the clinical manager. The clinical manager will utilize the information to update the plan of care. 4. Functional Maintenance Programs will be outlined using the Therapy Communication form and provided to the clinical manager/designee . R17 On 8/8/22 at 11:04 AM, R17 was observed in their room in bed. At that time, an interview was conducted and they explained they had been in the facility several times in the past for rehabilitation, but now had transitioned to long term care. They were asked if they received any therapy services and said they did not. They were asked about their functional status and said they were able to self-transfer from their bed to the wheelchair. On 8/9/22 at 8:42 AM, a review of R17's clinical record was conducted and revealed they most recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R17's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated they had intact cognition, needed one-person limited assistance for transferring and bed mobility, was coded that ambulation did not occur, and coded for wheelchair mobility having only occurred once or twice during the look-back period. A review of R17's Certified Nursing Aide (CNA) task list was conducted and revealed no tasks for any type of restorative nursing services such as range of motion or ambulation activities. On 8/9/22 at 10:30 AM, an interview was conducted with Rehab Director 'B' regarding R17. They were asked if R17 was supposed to be receiving any type of restorative services since their discharge from skilled rehabilitation services and explained that when R17 discharged from skilled rehabilitation services on 6/17/22 they were able to walk 40 feet with a front wheel walker and they recalled for restorative services R17 was supposed to be assisted with ambulation with the front wheel walker and have active have range of motion exercises performed. They were asked to provide documentation from skilled rehabilitation to restorative nursing that indicated this was the recommended plan with the frequency for each task. Rehab Director 'B' said their process was to fill out a Communication Form that indicated the plan and hand it off to nursing, but they did not keep a record of them once they were given to nursing. At that time, Rehab Director 'B' did provide a Physical Therapy Discharge Summary for services provided form 5/17/22 thru 6/17/22 that read, .FMP (Functional Maintenance Program): to facilitate patient maintaining current level of performance and in order to prevent decline, development, and instruction in the follow RNP's (Restorative Nursing Program) has been completed with the IDT (Interdisciplinary Team) : ambulation, bed Mobility, transfers, and ROM (range of motion) . It was noted the summary did not go into any further details of the restorative services to be provided to R17. On 8/9/22 at 11:30 AM, a follow-up interview was conducted with R17. They were asked about their discharge from skilled services in June 2022 and did indicate they were able to walk with the front wheel walker at that time. They were then asked if they thought they could still walk with the front wheel walker and said, Probably not. An observation of their room did not reveal the presence of a front wheel walker, rather a standard walker was observed at the bedside. They were asked about the standard walker and said they had started using the standard walker for, more stability. They were then asked if staff ever assisted them with walking with the walker and said sometimes they did. They were asked if they ever walked outside of their room and said they did not. On 8/9/22 at 2:05 PM, an interview was conducted with Unit Manger 'D' and they were asked if R17 was able to ambulate with a walker and said they would have to check the care plan. On 8/9/22 at 2:15 PM, a review of R17's care plans was conducted and revealed a care plan focus that read, .(R17) has limited physical mobility .Interventions .AMBULATION: The resident is non-ambulatory Date Initiated: 5/23/22 . It was noted R17's care plan did not include any care planning for any type of restorative nursing services. On 8/9/22 at 2:48 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding restorative nursing and communication between Skilled Rehabilitation and Nursing. The DON explained a Communication Form was filled out by therapy once a resident was discharged and it was given to nursing, then nursing updated the CNA tasks and care plan. They were asked for a copy of R17's Communication Form from therapy with R17's recommendations and said they did not keep them in the record as the CNA task list and care plans should have been updated to reflect the recommendations. They were then asked about R17's CNA task list and whether the ADL (activity of daily living)-Walk in corridor task or ADL-Walk in Room task were considered documentation for R17's restorative recommendation for ambulation, and said they were not. They further explained any restorative nursing task for ambulation would be specifically written out and would include distances and frequency for the task to be performed, and any restorative nursing task for range of motion would be detailed with the type of exercise, number of repetitions, number of sets, and the frequency. On 8/9/22 at 4:00 PM, Rehab Director 'B' followed-up after investigating R17's restorative referral from 6/2022 and said they confirmed no restorative nursing tasks (ambulation with the walker or range of motion exercises) were included with R17's other tasks. They said they believed the Communication Form from Skilled Therapy to Nursing had never been completed, therefore; the tasks and the care plan had not been updated. Resident #25 On 8/8/22 at approximately 9:59 a.m., R25 was observed in their room, up in their bed. R25 was observed to have a limited range of motion with their bilateral hands. R25 was observed to have trouble opening a small container of butter on their breakfast tray. R25 was queried if they were receiving any help with exercising or stretching their hands or legs and they indicated they were not but that the staff would do it sometimes but that it was not done on a regular basis. On 8/9/22 at approximately 9:02 a.m., R25 was observed in their in room, laying in their bed. R25 was observed to be eating their breakfast. R25 was queried again if they have received any range of motion or any exercises and they indicated they had not. On 8/9/22 the medical record for R25 was reviewed and revealed the following: R25 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R25's care plan revealed the following: Focus-[R25] has limited physical mobility r/t (related to) lumbar spinal stenosis, peripheral [CONDITION(S)], OA ([CONDITION(S)]), cervical fusion, Wilson's disease, chronic pain, depression, anxiety, right and left limited ROM (range of motion), spasms, Weakness, non-ambulatory, prolong sitting up in wheelchairs at times as requested .Interventions-ROM (range of motion): BLE(bilateral lower extremities) AROM (active range of motion) exercise to bilateral hips and knees to all planes - 3 sets x 10 reps (repetitions). BUE (bilateral upper extremities) ROM/stretching shoulders and elbows x15 reps to maintain ROM . A review of R25's CNA (Certified Nursing Assistant) task documentation of R25's range of motion exercises for the last 30 days in July/August 2022 revealed R25 did not receive range of motion exercises on 7/13, 7/14, 7/18, 7/19, 7/20, 7/21, 7/23, 7/25, 7/29, 8/3, 8/4, and 8/7. Further review revealed no documentation that R25 was offered range of motion exercises on 7/15, 7/16, 7/22, 7/24, 7/26, 7/27, 7/30, 8/1 and 8/8. On 8/10/22 at approximately 8:28 a.m., The Director of Nursing (DON) was queried regarding the facility staff providing and documenting range of motion exercises to R25. The DON indicated the CNA's (Certified Nursing Assistants) are supposed to assist R25 with the exercises as indicated on the care plan and should be documented in the medical record. On 8/10/22 at approximately:46 p.m., Therapy Director B (TD B) was queried regarding the need for R25's need for range of motion exercises. TD B Indicated that R25 was previously in therapy and they had put the exercises on their care plan for the Nursing staff to complete and that it was the staff's responsibility to assist R25 with their range of motion exercises on a daily basis.

Based on observation, interview, and record review, the facility failed to administer medications per professional nursing standards for two residents (R#'s 25 and 327) of four residents reviewed for medications administered per professional standards, resulting in medications not administered per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a facility provided policy titled, MEDICATION ADMINISTRATION effective 11/2017 was conducted and read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . R25 On 8/8/22 at 10:33 AM, an observation of medication administration was conducted with Licensed Practical Nurse (LPN) 'F' for R25. R25 prepared multiple medications including a [MEDICATION(S)] topical pain patch to be applied to R25's right shoulder. LPN 'F' entered the room and prepared to apply the topical patch. At that time, it was observed R25 had three patches on and around their right shoulder. It appeared one full patch had been placed over the top of their shoulder and a second patch had been cut in half with one half placed on the back of their shoulder and the other half placed on the front of their shoulder. It was observed the patches were dated 8/7/22. At that time, R25 confirmed the appearance, saying one full patch had been placed and another had been cut in half and placed in two other spots on their shoulder. LPN 'F' removed the three patches and placed the new patch on R25's right shoulder. At that time, R25 asked if they could have a second patch applied. LPN 'F' said they would review the order and let them know. On 8/8/22 at 10:56 AM, a review of R25's order for the [MEDICATION(S)] patch was conducted with LPN 'F' and LPN 'F' confirmed the order was for one patch to R25's shoulder. On 8/8/22 at 12:36 PM, a review of R25's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Apply to REMOVE patch topically at bedtime for REMOVE [MEDICATION(S)] patch r. (right) shoulder It was noted the order had been signed off on 8/7/22. On 8/9/22 at 9:26 AM, the facility's Director of Nursing (DON) was asked to clarify R25's [MEDICATION(S)] pain patch order and explained the patch was to be placed at 9 AM and removed at 9 PM. They were informed of the observation of two patches (one cut in half) removed from R25's right shoulder on 8/8/22 during the morning medication pass. They indicated they would clarify the order as they agreed it was confusing, would look into why more than one patch was placed, and why it had been documented as removed on 8/7/22 in the evening, but observed on 8/8/22 in the morning. R327 On 8/9/22 at approximately 8:05 AM, Licensed Practical Nurse (LPN) A was observed to have prepped [MEDICATION(S)] (via an insulin pen) for R327. At 8:10 AM, LPN A was observed to have administered the [MEDICATION(S)] insulin in the right deltoid muscle of R327. Review of the [MEDICATION(S)] manufactures instruction manual documented in part, . Choose your injection site. [MEDICATION(S)] is injected under the skin (subcutaneously) of your stomach area, buttocks, upper legs, or upper arms (with a picture of the human body, highlighting the posterior (outer) aspect of the upper arms) . On 8/9/22 at 9:24 AM, the Director of Nursing (DON) was interviewed and asked about the administration of insulin in the deltoid muscle. The DON replied that insulin should not have been administered in the deltoid muscle and the nurse should have administered the insulin in the outer aspect of the resident's upper arm. The DON stated they would follow up. Shortly after the DON stated LPN A admitted to administering the insulin in the deltoid muscle and the DON stated they have reeducated LPN A on the administration sites for insulin.

Based on interview and record review the facility failed to ensure the physician services correctly reviewed medication treatments/regimen and maintained accuracy in the medical record for one sampled Resident (R50) of one resident reviewed for Physician services, resulting in inaccurate progress notes, and the increased potential for inappropriate plan of care. Findings include: On 8/9/22 the medical record for R50 was reviewed and revealed the following: R50 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R50's MDS (Minimum Data Set) with an ARD (Assessment Reference date) of 6/30/22 revealed R50 needed extensive assistance from facility staff with most of their activities of daily living. R 50's BIMS score (brief interview of mental status) was six indicating they had severely impaired cognition. A Health Status note dated 7/13/2022 revealed the following: Writer observed dark amber and cloudy urine with a moderate amount of sediment when evaluating Foley bag and tubing system. Physician notified, Urinalysis ordered if dipstick tests positive. Writer collected urine specimen and performed dipstick test. Urine was positive for (+++) Leukocytes, (+) nitrates, and High Specific Gravity. Urine collection sent off to lab . A laboratory (lab) Urinalysis report with a collection date of 7/13/22 and a reported date of 7/17/22 was reviewed which revealed the following: .Specific Gravity: 1.010. [MEDICATION(S)]: Positive. Ph: 9.0 .Escherichia coli DETECTED. 20.76/30 [HIGH] .Proteus mirabilis DETECTED 18.17/30 [HIGH] . A review of the Sensitivity report from 7/13/22 revealed the Proteus mirabilis bacteria was resistant to [MEDICATION(S)]. A Health Status note dated 7/17/2022 revealed the following: Per shift report resident on [NAME] (antibiotic) for [CONDITION(S)] (Urinary tract infection); author viewed orders for resident assessment and observed order for [MEDICATION(S)] Tablet 500 MG, completed on 07/14/22. Resident calm and pleasant this HS (evening) with no change in mental status observed or reported. Urine output slightly cloudy and mildly odorous. fluids encouraged with resident receptive, Foley care completed per facility protocol and will continue to monitor. D/C (discontinue) [CONDITION(S)] charting d/t (due to) ABT completed . A Physician Visit note dated 7/22/22 revealed the following: Present illness with assessment and plan: . Patient overall is comfortable patient with status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan to obtain labs and discussed care with her nurse. Patient has a Foley catheter in place. No signs to suggest active systemic infection .Patient is followed with periodic assessment full assessment completed on July 17. Patient with Foley catheter in place history of [CONDITION(S)] (urinary tract infection). She completed recent antibiotic with [MEDICATION(S)] to completed July 14 . Further review of the medical record revealed R50 had not actually completed an antibiotic treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/09/22 at approximately 3:20 p.m., the facility Medical Director J (MD J) was queried regarding Physician I's visit note dated 7/22/22. MD J was queried if the Physician should have reviewed the current medication regimen for R50 as part of their evaluation to see if R50 had actually been provided the [MEDICATION(S)] and accurately document the status of R50 in the medical record and they indicated they should have. MD J was queried regarding the course of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD J indicated that moving forward the facility was going to change out R50's catheter for a new one, implement more frequent changes of their catheter and order a new urinalysis and culture with sensitivity to see if an additional antibiotic would be needed since R50's had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/22 at approximately 11:45 a.m., Physician I was queried regarding their evaluation on 7/22/22 that documented R50 had recently completed a course of [MEDICATION(S)] on July 14. They indicated they thought R50 had just completed the course of [MEDICATION(S)] and since R50 had recently completed the antibiotic course, no additional medication to treat the [CONDITION(S)] was needed. Physician I was queried how they knew that R50 had finished the [MEDICATION(S)] and they reported they did not remember how they were made aware of it, but that they believed they might have been told by a Nurse. Physician I was queried if they had reviewed R50's medical record on 7/22/22 to see if R50 had actually been given the [MEDICATION(S)] treatment and they indicated they did not. Physician I was queried if they had reviewed the Sensitivity report from 7/13/22 which indicated that Proteus mirabilis was resistant to [MEDICATION(S)] and they reported they thought they did, but could not remember. At that time, Physician I was informed that R50 had not been administered any [MEDICATION(S)] since 2019 and they indicated they were unaware of that but since R50 had chronic urinary tract infections, they believed they would not need an additional antibiotic.

Based on observation, interview and record review the facility failed to ensure that one (R327) of four residents reviewed for the observation of medication administration was accurately administered their insulin medication, resulting in the potential for too much or too little insulin to have been administered. Findings include: On 8/9/22 at approximately 8:05 AM, LPN A was observed prepping R327's [MEDICATION(S)] insulin pen. LPN A rubbed the tip of the pen with an alcohol swab, applied a needle and dialed the insulin pen to 8 units. At 8:10 AM, LPN A was observed administering R327's insulin. LPN A failed to prime the [MEDICATION(S)] pen. Review of the [MEDICATION(S)] manufacturer's instructions documented in part, . Prime before each injection . Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly . If you do not prime before each injection, you may get too much or too little insulin . to prime your Pen, turn the Dose Knob to select 2 units . Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top . Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle . If you do not see insulin, repeat priming . On 8/9/22 at 9:24 AM, the Director of Nursing (DON) was interviewed and asked about the priming of insulin pens and acknowledged that the nurse should have primed the insulin pen before the administration of the insulin.

Based on observation, interview and record review the facility failed to timely report an abnormal urinalysis result to the Physician and accurately assess/monitor for changes in condition for one resident (R50) of three residents reviewed for catheters/urinary tract infections. Findings include: On 8/08/22 at approximately 10:05 a.m., R50 was observed in the day room up in wheelchair. R50 was observed to have their catheter tubing touching floor underneath their wheelchair. R50's catheter tubing and drainage bag were observed to be purple in color. (consistent with purple bag syndrome which may indicate a urinary tract infection) On 8/08/22 at approximately 12:43 p.m., R50 was observed in the day room, eating lunch. R50 was still observed to have purple colored urine through their tubing and drainage bag. On 8/09/22 at approximately 11:15 a.m., R50 was observed in their room, lying in bed. R50 was still observed to have purple colored urine through their catheter tubing and drainage bag. On 8/9/22 the medical record for R50 was reviewed and revealed the following: R50 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R50's MDS (Minimum Data Set) with an ARD (Assessment Reference date of 6/30/20 revealed R50 needed extensive assistance from facility staff with most of their activities of daily living. R 50's BIMS score (brief interview of mental status) of six indicating severely impaired cognition. A review of R50's care plan revealed the following: Focus-[R50] was admitted with an Indwelling Catheter; Failed PVR (post void residual) and re-inserted 3/2/19. urinary retention dx; Neuromuscular dysfunction of bladder .Interventions-Keep tubing and catheter bag off the floor, provide dignity bag .Monitor/record/report to MD (Medical Doctor) for s/sx (signs/symptoms) [CONDITION(S)] (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns . A Health Status note dated 7/13/2022 revealed the following: Writer observed dark amber and cloudy urine with a moderate amount of sediment when evaluating Foley bag and tubing system. Physician notified, Urinalysis ordered if dipstick tests positive. Writer collected urine specimen and performed dipstick test. Urine was positive for (+++) Leukocytes, (+) nitrates, and High Specific Gravity. Urine collection sent off to lab . A laboratory (lab) Urinalysis report with a collection date of 7/13/22 and a reported date of 7/17/22 was reviewed which revealed the following: .Specific Gravity: 1.010. [MEDICATION(S)]: Positive. Ph: 9.0 .Escherichia coli DETECTED. 20.76/30 [HIGH] .Proteus mirabilis DETECTED 18.17/30 [HIGH] . A Health Status note dated 7/17/2022 revealed the following: Per shift report resident on [NAME] (antibiotic) for [CONDITION(S)] (Urinary tract infection); author viewed orders for resident assessment and observed order for [MEDICATION(S)] Tablet 500 MG, completed on 07/14/22. Resident calm and pleasant this HS (evening) with no change in mental status observed or reported. Urine output slightly cloudy and mildly odorous. fluids encouraged with resident receptive, Foley care completed per facility protocol and will continue to monitor. D/C (discontinue) [CONDITION(S)] charting d/t (due to) ABT completed . A Physician Visit note dated 7/22/22 revealed the following: Present illness with assessment and plan: . Patient overall is comfortable patient with status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan to obtain labs and discussed care with her nurse. Patient has a Foley catheter in place. No signs to suggest active systemic infection .Patient is followed with periodic assessment full assessment completed on July 17. Patient with Foley catheter in place history of [CONDITION(S)] (urinary tract infection). She completed recent antibiotic with [MEDICATION(S)] to completed July 14 . Further review of the medical record revealed R50 had not actually completed an antibiotic treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/22 at approximately 1:02 p.m., the Infection Prevention Nurse H (IP H) was queried if the Physician was notified regarding R50's abnormal lab results from the urinalysis reported to the facility on [DATE] and they indicated that R50's Physician was not notified of the lab results until they did an evaluation on 7/22. IP H was queried if R50's Physician had been notified of the change in R50's urine appearing purple in the catheter tubing and draining bag and they indicated that no one had informed Physician I of the changes. IP H indicated that the Nurse should have called the Physician regarding the abnormal lab results on 7/17 and the Physician should have been notified of the change in condition regarding R50's urine appearing purple so any new orders could be implemented. On 8/09/22 at approximately 1:42 p.m., the Director of Nursing (DON) was queried regarding R50's urinalysis results on 7/13/22 and they indicated they were unaware that the labs had been drawn which were positive for bacteria. The DON was queried if R50's Physician had been notified of the abnormal lab results and they indicated they were not notified until 7/22/22 when the Physician evaluated them for a fall. The DON indicated that it was their expectation that the facility Nursing staff should be notifying the Physician regarding abnormal lab results so that any new orders need to be implemented. The DON was also queried regarding the need to notify the Physician of R50's urine appearing purple in the catheter tubing and drainage bag and the DON indicated that the Physician should have been notified of the change. On 8/09/22 at approximately 3:20 p.m., the facility Medical Director J (MD J) was queried regarding Physician I's visit note dated 7/22/22. MD J was queried if the Physician should have reviewed the current medication regimen for R50 as part of their evaluation to see if R50 had actually been provided the [MEDICATION(S)] and accurately document the status of R50 in the medical record and they indicated they should have. MD J was queried regarding the course of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD J indicated that moving forward the facility was going to change out R50's catheter for a new one, implement more frequent changes of their catheter and order a new urinalysis and culture with sensitivity to see if an additional antibiotic would be needed since R50's had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/22 a facility document titled Catheter Care was reviewed and revealed the following: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .24. Document care and report any concerns noted to the nurse on duty .

This citation pertains to intake: MI 723 Based on observation, interview, and record review the facility failed to timely notify the physician of skin changes, obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A complaint submitted to the State Agency reported concerns of the facility failing to prevent the development of facility acquired wounds for R702. R702 was admitted into the facility on [DATE] with a readmitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition and requiring staff assistance for all Activity of Daily Living (ADLs). On 8/17/21 at 1:32 PM, an observation was made of R702 lying in bed. When asked about the wound care provided at the facility, R702 replied that staff do not turn and position the resident throughout the day, nor do they apply the inflatable boots everyday as they should. The resident denied ever refusing the application of the inflatable boots. Review of a Braden Scale for Predicting Pressure Sore Risk dated 3/15/21 revealed R702 was at Moderate Risk for the development of a pressure ulcer. On 8/17/21 at 2:29 PM, an observation was made of R702's wounds on the left and right feet, left hip, and left buttock with the assistance of Registered Nurse (RN) A. The right lateral ankle and foot pink discoloration noted with multiple darkened areas observed throughout the lateral aspect of right foot, extending to the fifth digit. Treatment was applied to the area, skin appeared to be intact. The left hip was observed and noted about a two inch in diameter red discoloration with treatment applied, skin appeared to be intact. A left lateral aspect of buttock wound, about the size of a nickel, with depth noted. Bright red blood noted around the left buttock wound edges and on the wound dressing. The hip and lateral aspect of buttock wounds were both noted on the left side. RN A was asked if the resident ever refused to care for their wounds or ever refused wearing their inflatable boots. RN A stated No, not for me. Review of a Health Status Note dated 4/2/21 at 10:11 AM, documented Staff observed resident R (right) ankle and outer aspect of R foot to have redden areas; mediplex <sic> applied and heel protector boot. Further review of the medical chart failed to reveal any documentation of the physician being notified or was there a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse (R) malleolus with NS (normal saline), pat dry. Apply small smear of Triad paste to open wound, skin prep to intact peri wound and cover with 4x4 [MEDICATION(S)], every day shift for pressure relief . Review of the April 2021 MAR (medication administration record) & TAR (treatment administration record) revealed no physician orders prescribed to be applied to the resident's right foot. Review of a Skin/Wound Note dated 4/3/21 at 9:30 AM, documented in part . This writer performed skin care of R. (right) lateral foot. It is noted foot protectors ON bilat. (bilaterally) Removed soiled [MEDICATION(S)] cleansed 3 discolored areas w/nss (normal saline), applied 2 skin prep wipes to each discolored area, allowing each to dry in between and new sterile [MEDICATION(S)] applied to all. Distal area is 2.2 cmL (centimeters length) x 1.8cm W (centimeters width) x deep pink/soft bed, no drainage, medial area is 1.1cm L x 1.2 cm W x deep pink/soft bed, no drainage, proximal area is 1 cm L x 1cm W x deep pink/soft bed, no drainage. Surrounding skin blanches well and bilat boot protectors re applied. Further review of the clinical record revealed no documentation of the physician being notified of the identification of the wound or directive from the physician to implement treatment to the right foot. Review of a Health Status Note dated 4/5/21 at 5:06 PM, documented in part . R ankle 3cm x 2cm with red with dark brown center. lateral area to R foot has 1.2cm x 1cm red with dark brown center and lateral to R foot has another red discoloration 1 cmx 1cm on outer aspect of r foot with no drainage mediplex <sic> dsg (dressing) applied with heel protector. Further review of the clinical record revealed no documentation of a physician notification of the worsening of the resident's right foot wound or physician ordered treatment to the right foot. Review of a wound consultation dated 4/7/21 was reviewed, however revealed no documentation of the facility staff notifying the wound clinic of the right foot wounds. The right foot was not assessed at this wound appointment. Review of the clinical record revealed multiple documentation for April 2021 by the facility nurses applying treatment to the resident's right foot, however, R702's April 2021 MAR and TAR contained no treatment ordered by the physician for the nurses to implement. Review of a wound consultation dated 4/21/21 was reviewed, however revealed no documentation of the facility staff notifying the wound clinic of the right foot wounds. The right foot was not assessed at this wound appointment. Review of a Physician Visit Note dated 4/28/21 at 7:42 PM & 5/2/21 at 8:02 PM, revealed no documentation of the physician being aware of the resident's right foot wounds, no assessment of the right foot wound completed or documentation of prescribed treatment to the right foot wounds. Review of Skin/Wound Note dated 5/5/21 at 1:43 PM, documented in part . Assessed bilateral feet first and treatments completed as ordered. (R) lateral foot noted to have 3 areas present and assessed for any changes. 1) Distal area DTI (Deep Tissue Injury) measuring 0.8cm x 0.7 cm with callous appearance and purple discoloration to site with skin intact. 2) Medial wound is a stage I and measuring 1 cm x 1 cm of pink/blanchable tissue. 3) Proximal wound: DTI measuring 1.0 cm x 0.8 cm with purple discoloration present to center of wound. (R) lateral malleolus noted to have Stage II present with scant amount of serious drainage present- measuring 0.9cm x 0.8cm . 0.1cm. Peri wound intact/blanches and new treatment ordered to cleanse wound with NS (Normal Saline), pat dry. Apply thin smear of Triad paste to open wound, apply skin prep to intact peri wound and cover with 4x4 [MEDICATION(S)] . treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Skin/Wound Note dated 5/6/21 at 9:36 AM, documented the right foot wounds as . Distal area is 1.7 cmL x 1.5cm W x deep pink/soft bed, no drainage, medial area is 1.1 cm L x 1.2cm W x deep pink/soft bed, no drainage, proximal area is 1cm L x 1cm W x deep pink/soft bed, no drainage . Review of a Skin/Wound Note dated 5/10/21 at 9:40 AM, documented the right foot wounds as . Distal area is 1.7 cmL x 1.5cm W x deep pink/soft bed, no drainage, medial area is 1.1 cm L x 1.2cm W x deep pink/soft bed, no drainage, proximal area is 1.4cm L x 1.2cm W x deep pink/soft bed, no drainage . Noting a slight increase to the size of the proximal area. Review of a wound consultation dated 5/12/21 was reviewed, however revealed no documentation of the facility staff notifying the wound clinic of the right foot wounds. The right foot was not assessed at this wound appointment. Review of a Skin/Wound Note dated 5/14/21 at 11:42 AM, documented in part . Assessed unstageable wound to (R) lateral malleolus and noted to measure 0.9cm x 1.0cm x 0.2cm depth with slough observed to wound bed. Peri wound deep pink, raised, and measuring 3.5cm x 3.5cm. Notified (Doctor name redacted) via phone of changes and discontinued current treatment with Triad and new orders received to start Santyl to slough on wound bed daily and PRN (as needed) for disruption. Scant amount of serous drainage present to old dressing when removed, no odor or c/o pain voiced. Review of a Physician Visit Note dated 5/14/21 at 7:22 PM, documented in part . Giving ulcers noted on lower extremities we will obtain an arterial Doppler. Patient is followed by wound care services to coccyx area stage II in addition right heel ulcer lateral malarious . arterial Doppler of lower extremity obtained to evaluate peripheral arterial disease currently with history and positive DVT on anticoagulation . This note revealed that the primary physician believed the resident was being assessed, monitored, and treated by the wound clinic in regard to the resident's right foot wounds, however this did not take place until 6/2/21. Review of a Skin/Wound Note dated 5/15/21 at 9:27 AM, documented in part . Distal area is 1.7 cmL x 1.5 cm W x 0.25cm deep with slough noted, scant serous drainage old [MEDICATION(S)], medial area is 1.1cm L x 1.2 cm W x deep pink/soft bed, no drainage, proximal area is 1.9cm L x 1.5cm W x deep purple today 50% and 50% slough, santyl applied to proximal wound, scant serous drainage old dressing, all covered w/new sterile [MEDICATION(S)] . Further review of the medical record revealed no documentation of notification to a physician regarding the wound changes. Review of a Physician Visit Note dated 5/20/21 at 7:16 PM, documented in part . Arterial Doppler of bilateral lower extremity was done showed no evidence of severe peripheral artery disease otherwise patient with ulcers to coccyx area lower extremity with a history of DVT . Patient to continue on current plan of care medications reviewed arterial Doppler lower extremity finding compatible with mild/moderate peripheral vascular disease on the left and right finding compatible with mild peripheral vascular disease . Review of a Skin/Wound Note at 5/21/21 at 9:52 AM, documented in part . Distal area is 1.7 cmL x 1.5 cm W x 0.25cm deep with slough noted, scant serous drainage old [MEDICATION(S)], medial area is 1.1cm L x 1.2 cm W x deep pink/soft bed, no drainage, proximal area is now 2.1cm L x 1.5 cm W x deep purple slough bed, santyl applied to proximal wound, scant serious drainage old dressing, all covered w/ new sterile [MEDICATION(S)] . Review of a Skin/Wound Note dated 5/25/21 at 12:51 AM, documented in part . Resident noted to have areas on (R) lateral foot- Distal area near lateral aspect of pinky toe noted to be deep pink in color, slow to blanch, (+) slough to wound bed and increased depth from previous week measuring 1.7cm x 1.5cm x 0.2cm depth. Wound bed deep red/purple peri wound raised and non-blanchable. Medial aspect noted to be a stage I with pink blanching tissue at this time, 1.1cm x 1.2cm. (R) Lateral Malleolus noted to have 95% slough present to wound bed, raised irregular border with some redness noted to peri wound. Measuring 2.0cm x 1.6cm x 0.4cm at this time. Cleansed with NS, applied Santyl to slough on wound bed and covered with [MEDICATION(S)]. Notified Dr. [NAME] of minimal improvement since ordering Santyl and new order received to start Calcium Alginate with Silver to (R) malleolus and (R) lateral foot near pinky toe on 5/26/21 . Review of a Skin/Wound Note dated 5/27/21 at 9:22 PM, documented in part . Wound to right lateral malleolus has odor with a small amount of purulent drainage. Area cleaned. (Doctor name redacted) notified, orders for CBC (complete blood count), CMP (comprehensive metabolic panel) in AM . Review of a 6/2/21 wound consultation documented in part, . 3 new pressure ulcers, one on the right foot . Wound #4 Left Metatarsal head fifth is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2cm length x 2cm width x 1cm depth, with an area of 4 sq (square) cm and a volume of 4 cubic cm. Bone and adipose are exposed. There is a moderate amount of serosanguineous drainage noted . Wound bed has Yes slough . peri wound skin exhibited: friable, [CONDITION(S)] . Wound #5 Right Malleolus is a Stage 2 Pressure Injury Pressure Ulcer . encounter measurements are 0.5cm length x 0.5cm width x 0.2cm depth, with an area of 0.25 sq cm and a volume of 0.05 cubic cm . Wound #4 Left Metatarsal head fifth . Cleanse wound with 0.9 Normal Saline . Santyl and [MEDICATION(S)] ad advantage (wound dressing) to be applied in wound center. Triad or santyl and [MEDICATION(S)] ag to be applied in SNF (Skilled Nursing Facility) . Change Dressing : - daily, Cover and secure with: - ABD (Abdominal)/[MEDICATION(S)] Border . Wound #5 Right Malleolus . Cleanse wound with 0.9 Normal Saline . Triad or santyl and aquael ag to be applied in SNF. Change Dressing: - daily, Cover and secure with: - ABD/[MEDICATION(S)] Border . Review of a Skin/Wound Note dated 6/7/21 at 1:31 PM, documented in part . L. (left) hip sheering out to 4cm in diameter, cleansed w/nss, applied skin prep wipes x 2 and thin smear of triad paste . Further review of the clinical record revealed no documentation that the physician was notified of the left hip sheering at that time. Review of a Skin/Wound Note dated 6/8/21 at 9:45 AM, documented in part . (L) hip measuring 4.0cm in diameter and pink/slow to blanch skin noted. (Doctor name redacted) notified and new order received to start [MEDICATION(S)] for protection . The day after the initial identification of the Left hip wound the primary physician was notified for treatment. Review of the wound consultations for 6/22/21 and 7/6/21 were reviewed and revealed no documentation of being informed by the facility of the left hip skin changes or assessment of the left hip area. Review of Physician Visit Note(s) dated 6/9/21, 6/11/21, 6/14/21, 7/5/21, 7/8/21, 7/9/21, and 7/11/21 revealed no documentation of follow up, assessment or examination of the left hip skin changes. On 8/17/21 at 2:57 PM, Clinical Care Manager B was interviewed and asked how often skin assessments are completed at the facility and CCM B stated on shower days and shower days are done once a week. When asked where the abnormal skin changes were being documented CCM B stated in part, . They (nurses) document it on paper, it's a skin assessment shower sheet. At this time the skin assessment shower sheets for R702 was requested from January to August 2021. When asked about the facility's wound program CCM B stated in part, . We do not have a wound doctor or wound nurse in the building. We get orders from the physician and start treatment. Whoever is assigned to that resident will do the treatments. We document in the progress notes and talk about it in the morning with the IDT (Interdisciplinary team). When we can't manage it in the building, we would send them to (outpatient wound clinic name redacted). At 4:23 PM, CCM B stated they could not find any skin assessment shower sheets for R702, with the exception of 7/29/21, 8/5/21 and 8/12/21 shower sheet, which is titled CNA (Certified Nursing Aide) Skin Assessment Record. On 8/18/21 at 10:30 AM, RN I was interviewed on the facility's wound protocol and stated in part, . Let the physician know and get a treatment order in place. It's up to the charge nurses when they are doing the care regarding the worsening or improvement of wounds . When asked how often body assessments are completed, RN I stated in part . Weekly on shower days and the aides are very good here about telling the nurses if they see something and pop up on the treatment sheet. They (aides) have a binder where they mark down on the shower sheet, if you find something we (nurses) will write it in the progress note or skin note . On 8/18/21 at 9:30 AM, Clinical Care Manager (CCM) C (a second nurse manager in the facility) was interviewed regarding the facility wound protocol and stated in part, . There is not a wound nurse and no wound doctor. The CNA will alert the nurse and the nurse will go assess it and notify the doctor to get treatment. The nurse manager tried their best to assess it the next day. The nurse manager logs weekly and update the care plans and keep families updated . When asked where the nurses document abnormal findings found on the weekly skin assessment, CCM C replied in the shower book. At that time CCM C was asked to look into the shower book and provide all of R702's shower sheets from January to August 2021. CCM C looked through the shower book and was unable to provide the requested shower sheets. CCM C stated they would keep looking and follow up. No documentation of weekly skin assessments and/or shower sheets were provided by the end of survey. At 11:47 AM, CCM C was asked how the right foot wounds could be identified by staff on 4/2/21 and not reported to a physician, why staff didn't obtain physician orders for treatment and asked which physician was monitoring the effectiveness of the treatment from April to June (initial wound physician assessment of the right foot). CCM C stated in part. the staff continued the same wound treatment prescribed to the whole right foot area. The primary physician monitored it until we felt like we couldn't handle it in house anymore. The nurses assess to see if it was getting better or not . CCM C was also asked about the left hip skin change identified on 6/8/21 with treatment being implemented on 6/9/21 and asked if any physician to date (8/18/21) had assessed the area. CCM C stated they would look into it and return with any information found. On 8/18/21 at 1:39 PM, Physician K was interviewed and as about their involvement in the wound protocol at the facility and stated in part, . I can't say that I see them (R702's wounds) every time that I saw him . I'm not a wound care specialist . He is clearly identified as a high-risk resident. The communication between the facility and wound clinic is essential. We don't have a wound specialist in the facility . they (nurses) may call me for treatment when they find a problem with the skin, but the expectation is to have the specialist to manage it. You expect that the facility will inform me of all new wounds or any updates of present wounds. They (facility nurses) are capable of calling the wound clinic for a sooner appointment if necessary. It's very irresponsible for me to step in on the wound doctor treatment and interfere with their care . I thought and expected all of his wounds was treated by the specialist, but that wasn't the case, especially with him I feel like that. A facility policy titled Pressure Ulcer Prevention Guidelines dated April 2021 documented in part, . Interventions will be implemented in accordance with physician orders . the licensed nurse will utilize nursing judgement in accordance with pressure ulcer prevention guidelines to provide care and will notify physician to obtain orders . The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include . Development of a new pressure ulcer, lack of progression towards healing or changes in wound characteristics .

This citation pertains to intake #MI 6. Based on observation, interview and record review, the facility failed to: (1) implement and consistently utilize preventative measures to prevent the development of pressure ulcers, (2) ensure consistent, accurate, on-going wound assessments, and (3) ensure treatments were completed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This caused actual harm to R801 who developed a deep tissue injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) that worsened to an unstageable (Full-thickness skin and tissue loss in which the extent of the tissue damage with in the ulcer cannot be confirmed because it is obscured by slough or eschar, or dead tissue typically brown or black found in a full thickness wound), as well as the development of a deep tissue injury that worsened to a stage II pressure ulcer (Partial-thickness loss of skin with exposed dermis for R805. R801 On 4/8/21 a review of R801's closed clinical record was conducted and revealed R801 admitted to the facility on [DATE] and readmitted on [DATE]. R801's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R801's re-admission Braden Score revealed a score of 11.0, indicating R801 was a High Risk for the development of pressure ulcers. R801's significant change MDS assessment dated [DATE] indicated R801 was an extensive 2 person assist for transferring, was non-ambulatory, and had bilateral lower extremity range of motion deficits. The record also indicated that R801 was non-weight bearing on their left leg related to the [CONDITION(S)] and developed a pressure ulcer on their coccyx on 12/6/20. A progress note dated 12/15/20 was reviewed and read, .Resident also has redden <sic> area to R (right) heel with look of blister area and L (left) heel has redden <sic> area tx (treatment) ordered . A review of R801's TAR for December 2020 was reviewed and revealed the first orders for any type of treatment or monitoring to R801's heels began on 12/17/20. It was further noted no interventions to prevent the development of wounds to R801's heels were implemented prior to their discovery on 12/15/20. It was also noted that though there was a treatment order dated 12/18/20 that read, monitor bilateral heels for any skin breakage and s/s (signs/symptoms) infection apply abd (abdominal) pads and [MEDICATION(S)] (bulky) wrap and elevate heels off of mattress in the morning for monitor. Nowhere in the record did it mention the implementation or use of soft heel lift boots. A review of R801's Skin/Wound notes was conducted and revealed the following: A note dated 12/18/20 that documented the physician ordered treatment to R801's bilateral heels, however; the note did not indicate any measurements, description, type of wound, or wound staging if the wound had been determined to be pressure related. A note dated 12/21/20 that read, .both wounds now measure 3cm in diam (diameter) and are dark black with DTI (deep tissue injury) . It is noted that as defined by NPIAP (National Pressure Injury Advisory Panel) a deep tissue injury presents as .persistent non-blanchable deep red, maroon, purple discoloration . and a pressure ulcer is considered unstageable when there is .full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar . A note dated 1/1/21 that made no mention of any wounds to R801's heels. A note dated 1/4/21 that read, .protective dressings to bilateral heels . The note did not document any description of the wounds on R801's heels. A note dated 1/5/21 that read, .Left heel is intact dark tissue appears as absorbed blister? <sic> with measurement on 1.2 x 2 cm. Right lateral heel appears as a dried blister and is fully intact. Measures 3.5 x 4 cm. A note dated 1/10/21 that made no mention of any wounds to R801's heels. A note dated 1/19/21 that read, .Left heel eschar remains intact. Right Lateral heel eschar is lifting at the lateral border AEB (as evidenced by) scant red drainage on dressing . A note dated 1/29/21 that made no mention of any wounds to R801's heels. A note dated 2/2/21 that read, .#4 Left heel 2x2.2cm DTI eschar intact, no drainage. #5 Right heel 2 x 1cm eschar cap intact with no drainage . It was not noted in R801's clinical record that the wounds to their heels had been determined as avoidable or unavoidable pressure ulcers. R801's care plan Focus for skin alteration included interventions that read, .monitor bilateral heels for any skin breakage and s/s infection apply abd pads and [MEDICATION(S)] wrap and elevate heels off of mattress .Weekly skin check by nurse on shower day and PRN (as needed), documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . R805 On 4/8/21 at 10:20 AM, R805 was observed in bed, asleep. R805 was in a high Fowlers position (The upper half of the resident's body was between 60 degrees and 90 degrees in relation to the lower half of their body) and had slid down in the bed. R805's right lateral aspect of their foot was pressed against the bed's footboard and the right heel was in direct contact with the mattress. R805's left heel was also observed to be in direct contact with the bed. A pillow was observed under R805's legs, however the pillow was so flattened it had no function in ensuring R805's heels were elevated off the mattress. A table was observed across from R805's bed and soft heel lift boots (soft boots designed to keep the bony prominence of the heels elevated off surfaces) were observed on the table. A dry erase white board in R805's room was observed and had Please keep heels up written on it. On 4/8/21 at 12:00 PM, R805 was again observed in their bed asleep. R805's legs continued to be elevated on the flattened pillow and their heels were pressed directly into the mattress. The heel boots remained on the table across from R805's bed. A review of R805's clinical record was conducted and revealed an admitted [DATE]. R805's admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the record failed to reveal R805 had pressure induced deep tissue damage of the right and left heel upon admission. R805's admission Minimum Data Set (MDS) assessment dated [DATE] (7 days after admission to the facility) indicated R805 had moderately impaired cognition, was non-ambulatory, and required extensive assistance of one to two staff members for activities of daily living. A review of Section M. (Skin) of the MDS assessment indicated R805 was at risk for the development of pressure ulcers and had two unstageable pressure ulcers with suspected deep tissue injury that were not present upon admission/entry to the facility. A review of R805's admission Braden Score (a score that assesses the risk of the development of pressure ulcers) documented on 12/22/20 also indicated R805 was at risk for the development of pressure ulcers. Continued review of R805's clinical record included a review of their Skin/Wound progress notes, their physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Skin/Wound note dated 12/27/20 at 10:52 AM was reviewed and read, .Assessed heels and (R) (right) heel discolored with DTI (deep tissue injury) noted. Non-blanchable and soft/boggy . A second note dated 12/27/20 at 6:21 PM read, .Approx 1600 (4:00 PM) resident (L) (left) heel also discolored with DTI, non blanchable and boggy . A Skin/Wound Note dated 12/28/20 read, Bil (bilateral) heel skin assessment done the lateral aspect of the L (left) heel has a DTI measuring 2.6 x 2.3 cm (centimeters), the color is dark purple .The R (right) heel has a 2.4 x 3 cm DTI, the color is dark purple . A wound note dated 1/12/21 read, .The right heel is intact .The left heel is a brown flat blood blister measuring 2 x 3.9. The middle part of the blister is open . The It was noted the next assessment of R805's heel wounds was documented on 1/28/21, over two weeks after the last documented assessment. It was further noted there was a documented note of the heel wounds on 2/19/21 that indicated the right heel was .a healing stage 2 (Partial-thickness loss of skin with exposed dermis) wound . and the left heel .is a light brown scab . It was noted the next wound assessment note wasn't documented until 3/10/20, almost a month after the previous note. R805's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was further revealed R805's treatments to their heels were not signed off as completed on 1/1/21, 1/2/21, 1/11/21, 2/15/21, and 2/19/21. R805's care plan Focus for their heel wounds was implemented on 12/30/20 and interventions included: .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress .Bilateral foam boots when in bed .Weekly treatment documentation to include measurement of each are of skin breakdown's width, length, depth, type of tissue and exudate . R806 On 4/8/21 at 10:30 AM, RN 'E' was observed performing wound care for R806. Registered Nurse (RN) 'E' prepared the wound care supplies and entered the room. RN 'E' donned a pair of clean gloves, positioned R806 and removed the foam dressing from R806's coccyx. At that time, it was noted the foam dressing was dated 4/6/21. RN 'E' then cleansed the wound, applied the wound care treatment, and placed a new foam dressing on the wound. RN 'E' was not observed to perform hand hygiene or change their gloves between removing the old dressing, cleaning the wound, and applying the new dressing. It was also observed that at the time of the treatment, RN 'E' did not obtain any measurements of the wound despite a note RN 'E' documented on 4/8/21 at 10:43 AM, 13 minutes after the start of the wound care observation (reviewed on 4/8/21 at 1:50 PM) that read, This writer performed left/sacral wound care as follows .Wound measures 1.0cm L (length) x 0.5cm W (width) x surface shearing . A review of R806's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/8/21 at 1:35 AM, an interview was conducted with RN/Unit Manager 'F' regarding the facility's wound care program. During the interview, RN 'F' indicated the facility did not have a wound care nurse and the wound care program was overseen by the Director of Nursing, Unit Managers, and the interdisciplinary team. RN 'F' further explained that each week staff nurses were to assess the wounds and document a detailed assessment of the wounds. RN 'F' admitted they did not know if this was being done weekly by the nursing staff. RN 'F' was then asked about who would determine the type of wounds and if the nursing staff could stage pressure ulcers. RN 'F' indicated the nurses could stage the pressure ulcers but indicated many were probably uncomfortable with it. RN 'F' agreed that someone should stage the pressure ulcers as it would be helpful to see whether wounds were improving or worsening. When queried if anyone was auditing the wound care documentation, RN 'F' explained that they were trying but also believed it was probably not being done consistently. A review of a facility provided policy titled, Skin Management effective February 2018 was conducted and read, POLICY: Nursing staff will assess and document a resident's risk factors for developing skin issues. The goal is prevention of pressure ulcer development and to promote the healing of pressure ulcers that are present to the extent possible .If a pressure ulcer is identified: 1. A comprehensive evaluation is completed and documented in the resident's clinical record . A review of a second facility policy titled, Pressure Ulcer Prevention Guidelines dated May 2018 was conducted and read, .POLICY: To prevent the formation of avoidable pressure ulcers .3. Interventions will be implemented in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Pressure Relieving Devices:3. Apply heel suspension devices according to the manufacturer's instructions .b. For stage III, IV, or unstageable pressure ulcers: May place foot and leg into a heel suspension boot . A review of a third facility provided policy titled, Nursing Documentation with an effective date of [NAME] 2019 was conducted and read, POLICY: Each Resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation .

This citation had two deficient practice Deficient Practice #1 This citation pertains to Intake #MI 193 Based on observation, interview and record review the Facility failed to remove a safety hazzard (bedside table with wheels) from a resident's room with a known history of poor safety awareness and history of using the tray table as an ambulation device for one for one (R#75) out of four reviewed for falls/accidents, resulting in R#75 sustaining a fracture to the right hip, pain and an extended stay in the Facility. Findings include: The Facility reported to the State Agency that R#75 sustained an unwitnessed fall resulting in a right (R) greater trochanteric (hip) fracture with pain. On 4/15/19 at approximately 10:30 AM resident #75 was observed lying in bed. The resident had some bruising to the left hand. The resident was alert, but not able to answer questions asked pertaining to falls. A review of R#75's paper care plan, attached to the inside of the resident's closet, indicated the resident was a fall risk and included an intervention that indicated R#75's tray table should be placed on the window side of bed. It was observed that a tray table, with wheels, was not located on the window side of bed, but located on the resident's right side closure to the bathroom and door leading to the hallway. A review of R#75's clinical record documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#75's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (MDS) score of 7/15 (severely cognitively impaired) and required extensive two person assist for transfers and bed mobility. The MDS further indicated that R#75 had a fall with major injury. Continued review of R#75 clinical record revealed, in part, the following: 3/9/19 (Health Status Note): .Resident was observed in the bathroom with his bedside table which he used as a walker to toilet himself . 3/11/19 (Physician Visit Note): .Left hip pain with hx (history) of mechanical fall .history of falls . 3/12/19 (Social Services): .R#75 to discharge to home (name redacted) on Friday 3/15/19 . 3/15/19 (Health Status Note): Resident complaining of severe pain on R hip when turning, unable to move R leg. Physician was notified, order received to transfer resident to hospital for further evaluation .Writer called resident's son .EMS (emergency medical services) called and arrived at 8:55 am . 3/15/19 (incident note): .note related to being observed on the floor on 3/14 state I had to take a crap. Was observed by visitor using the tray table as support to ambulate to the bathroom. Tray table found in the bathroom with him, noted to have regular socks on. Walker was on side of bed. Did not verbalize pain initially with good range of motion, skin tear to right elbow; placed in w/c (wheelchair) and positioned near nurses station. Within 20 minutes began to c/o (complain of) right hip pain . 3/15/19 (Note): Received call from (name redacted) ER (emergency room ) .Dr.stated that resident did that same thing to his R hip that he had done to his L hip. He has a greater trochanter fracture that is inoperable . On 3/16/19 a review of the Facility Incident/Accident Report(s) (I/A) and attached investigation documentation for R#75 was conducted and documented, in part, the following: Fall #1 3/15/19 (Summary of Alleged Incident): Resident complained of right hip pain after being found on the floor on 3/14/19. Initial X-ray at facility completed 8:00 pm with no acute fracture noted. Resident continued to complain of pain and on 3/15/19 sent to Emergency Department, a CT (cat-scan) was performed and identified a Right Greater Trochanteric Fracture .Summary of Critical Information Obtained During Investigation: .admitted .on 2/20/19 for left [MEDICAL CONDITION] .for rehab services .he is dependent for showers and bathing .On 3/14/19 resident was last observed by a visitor across the hall ambulating in room and using the bedside table for support. Shortly after observation (3:00 PM) a noise was heard and staff found Resident on floor of bathroom with bedside table in bathroom with him .initially denied any pain and a skin tear was noted on right elbow. Resident was placed in a wheelchair and initially did not complain of pain but within 20 minutes began to c/o of right hip pain .hip x-ray ordered. The x-ray results came back at 8:10 pm and the results were Mild [MEDICAL CONDITION] of the right hip. No definite acute fx (fracture), consider more sensitive imaging evaluation with CT as clinically directed. Resident slept through the night but upon rising was complaining of continued pain to his hip area .Resident transferred to Emergency Department .Resident returned to facility at 1:00 PM at 3/15/19 with CT results of right hip showing Right Greater Trochanteric Fracture .Resident remains at facility and is ambulating with 1 person assist and walker with weight bearing as tolerated . Quality Assessment: Statement: Name and Position: Registered Nurse C . Date of Incident: 3/14/19 .Date and Time of interview: 3/20/19: Statement: Resident makes loud noises when moving around in bed which <ques>sic. staff to check on resident. On this afternoon I was sitting at the desk and I heard a call out and then a noise of something falling. I ran to residents room and noted resident sitting on bathroom in front of toilet with back against wall. His bedside table was in the bathroom with him. When I asked what happened resident stated, I needed to take a sh-- and I did a dumb thing. Call light was not used. Resident was assessed and c/o pain in RT upper hip/leg area . ( Signed 3/20/19). Quality Assessment Statement: Name and Position: CNA G .Date and place of interview: 3/20/19 via phone. Date of Incident: 3/14/19 . I was assigned to him on the day shift .The nurse found him in the bathroom. I did not see him in the bathroom. I did not see him or help with getting him off the floor .Signature 3/22/19. Fall #2 Accident/Incident Report (3/20/19): Resident Name: R#75 .Date 3/20/19 . Time: 2:45 PM .Location: BR (bathroom) .Type of A/I: Fall: Resident Statement: Patient stated he attempted to get up from the toilet and lost his balance and fell to the floor Fall was witnessed: Blank Interventions: Reinforce the need to call .IDT (inter disciplinary team) review/comments: Room change for better visual supervision, bowl and bladder diary . No additional investigation documents, including statements, were provided by the end of the survey. On 4/16/19 at approximately 11:30 AM, R#75 was observed in his room in a wheelchair. R#75's bedside table was observed on the resident's right side and not near the window as indicated in the care plan. At approximately 11:40 AM an interview and record review was conducted with Nurse C. When queried as to the incident that occurred on 3/14/19, Nurse C reported that R#75 resided in a room that was not visible from the nurses station and indicated that on 3/14/19 she heard a loud noise and entered the resident's room and observed R#75 in the bathroom on the floor. When further queried as to how the resident ambulated to the bathroom, Nurse C reported that he used his bedside table and stated that R#75 liked to use the bedside table as a walker and that she had observed him using it on a few occasions prior to the fall. When asked if using a bedside table was a safe device to us for ambulation, Nurse C stated, No. When further queried if the R#75's careplan addressed the use of the bedside table, Nurse C reported that after the 3/14/19 incident the careplan was updated to ensure that the bedside table was placed between the window and the bed, along with an indication that the resident should wear non-skid socks. Nurse C was also queried as to the fall incident that occurred on 3/20/19 and the Nurse reported she was aware of the incident, but was not aware of the circumstances surrounding the fall and noted that the resident did receive a room change to be closer to the nurses station. When queried as to the current location of the bedside table, Nurse C stated, It should be placed on the resident's left side between the bed and the window, not on the side near the bathroom. On 4/16/19 at approximately 11:50 AM an interview was conducted with CNA (certified nursing assistant) G. When queried as to the incident that occurred on 3/14/19 and 3/20/19, CNA G reported that she had been assigned to work with R#75, and indicated that she did not observe either incident. When queried as to R#75's transfer status, CNA G reported that the resident was initially a two person assist for transfers when he entered the Facility with a left [MEDICAL CONDITION] and stated, He was getting better and was supposed to go home. He would sometimes transfer on his own and sometimes use his tray table, but now the tray table should be placed near the window. On 4/17/19 at approximately 9:30 AM an interview and record review was conducted with the Administrator and Director of Nursing (DON). When queried as to R#75's initial fall risk assessment, the Administrator reported that the initial nursing assessment indicated that the resident was a fall risk and entered the Facility following a fall with a fracture to the L hip. When asked what initial interventions were put in place upon admission for a resident who was a fall risk, the Administrator reviewed the initial care plan that documented, in part, the following: 3/4/19: Follow fall protocol .Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers as to causes .The resident needs a safe environment . The Administrator and DON where then queried as to the incident that occurred on 3/14/19. The DON indicated that the R#75 used the bedside table to ambulate to the bathroom and when he was getting up from the toilet he fell . When queried as to whether the use of bedside table was a safe device to use for ambulation, the DON stated, It is not a good way to ambulate. When queried as to whether they were aware that the resident was using the table at the facility prior to 3/14/19 as a means to ambulate, the DON and Administrator reported that they were not aware that R#75 had been using prior to the incident. The DON and Administrator reported that following the incident that resulted in a fracture to the R hip, fall interventions were put into place that included placing the tray table on the window side of the residents bed and the walker and ensure non-skid socks were used. The DON and Administrator were interviewed as to the incident that occurred on 3/20/19 that indicated the resident was found on the floor in the bathroom. When queried as to how the resident ambulated to the bathroom, both the Administrator and DON were not able to provide any information that indicated how the Resident ambulated to the toilet. The DON indicated that she believed he ambulated on his own. When further queried as to means by which he ambulated to the toilet, the DON indicated that she would need to look for additional documentation. No additional investigation documentation for the 3/20/19 incident was provided by the end of the survey. On 4/17/19 at approximately 10:00 AM, R#75 was observed lying in bed. The resident's bedside table was located on the right side of the resident. CNA N entered the room to assist the resident and moved the resident's rolling bedside table to the window side of the bed. CNA N reported that the resident was a fall risk and his careplan indicated that the tray table should be placed between the bed and the window to prevent the resident from using it as an ambulation device. On 4/17/19 at approximately 3:00 PM a review of the Facility Policy titled, Fall Risk Protocol (effective (MONTH) (YEAR)) documented, in part, the following: Policy: Falls management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the resident's quality of life . Procedure .2. Some risk factors or conditions that may predispose a patient to a fall may include, but are not limited to: History of falls, unsteady gait, muscle weakness, .age .cognitive impairment, use of assistance devices .physical environment .3. If upon completion of the Nursing Admission Screening/History the resident is found to be at risk for falls or has a history of falls .an initial plan of care is developed and individualized interventions are initiated . Deficient Practice #2: Based on observation, interview, and record review the facility failed to ensure the resident was free from preventable accidents for one (R#22) of four residents reviewed for accidents, resulting in the resident being hit in the face with a tray lid. Findings include: On 4/15/19 at 8:38 AM R#22 was observed in their room. R#22 was observed to have purple bruising present around the resident's left eye. R#22 was queried as to the bruise, and responded that yesterday at breakfast or lunch they were hurrying and had brought up the lid for plate too fast, and hit her in the left eye. On 4/17/19 at 9:34 AM review of the resident's clinical record revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's minimum data set (MDS) assessment dated [DATE] the resident scored 15 of of 15 on a brief interview for mental status exam, which indicated the resident was cognitively intact. Review of an incident and accident report for R#22 dated 4/13/19 documented the type of incident as the following: hit head on side of food cover. Per the Resident Statement section of the form it was documented, This was an accident Talk to (CNA 'K') (Resident unable to verbalize exact incident. CNA 'K' stated that while removing tray lid he bumped resident side of face.) Review of a statement dated 4/15/19 taken by the DON for CNA 'K' documented the following information (dated 4/16/19): Passing breakfast tray & she was sitting up in the chair. I was standing over her I lifted lid & was removing the tops off the liquids when the lid slipped (& I was holding near my stomach) I tried to catch it but it hit her face. I immediately told the nurse. On 4/17/19 at 11:05 AM a voicemail message was left for Certified Nursing Assistant (CNA) 'K'. On 4/17/19 at 11:45AM CNA 'K' returned the call and was queried about what had occurred with R#22. Per CNA 'K', he was in the middle of passing breakfast trays. CNA 'K' explained that R#22 had been in their wheelchair, he had set the resident's tray on the stand and then uncovered the lids. Per CNA 'K' the lid had been in one of his hands around his stomach area, and with his other hand CNA 'K' was taking the lids off of the resident's beverages. CNA 'K' explained the lid cover had slipped out of his hand, he had tried to catch it before it fell , and the lid cover had hit the side of the resident's face. On 4/17/19 at 11:57 AM the facility's Director of Nursing (DON) was queried about the situation involving R#22. The DON explained, in part, that when CNA 'K' worked again he was going to receive education related to being careful when holding such objects and to be aware of where the person was situated. A request for a Facilty Policy pertaining to accidents was made. The Facility indicated that they did not have a specific policy detailing accidents.

This citation pertains to intake #MI 792. Based on observation, interview and record review, the facility failed to ensure adequate supervision and implement appropriate safety interventions for one (#703) of five sampled residents reviewed for accidents, resulting in multiple falls with injuries that included an acute subdural/subaraccnoid hemorrhage (a collection of blood outside the brain and the thin tissues that cover the brain), lacerations, bruising, skin tears, and two emergency hospital encounters since (MONTH) (YEAR). Findings include: On 2/26/19, review of a facility reported incident reported to the State Agency included, .On (MONTH) 22 resident (R#703) was found lying on the floor outside of a resident room, resident observed with a 3cm (centimeter) laceration to the back of his head and transferred to acute care for further follow up .On (MONTH) 23 at or around 1745 (5:45 PM) received a referral for identified resident to return to facility. Review of medical information identified a small subdural hematoma post fall . On 2/26/19 at 10:16 AM, R#703 was observed seated in a scoot chair (a high backed recliner chair with wheels that sits lower to the ground) in the lounge area between the nursing station and chapel. At that time, the resident was observed asleep, his arms were folded in his lap, and his head was bent down towards his lap. The Director of Nursing (DON) entered the area from behind closed doors and upon observation of R#703 stated, They may need to lay him down. There were no other staff present in the immediate area. The doors leading to the adjacent nursing hallway were observed closed (not in view of direct care staff). On 2/26/19 at 2:10 PM, R#703 was observed seated in the same manner as earlier. There were two other residents nearby. Staff were observed down the hallway, not in direct view of the residents. The doors leading to the adjacent nursing hallway remained closed. On 2/27/19 at 8:57 AM and 9:05 AM, R#703 was observed seated in a scoot chair in the lounge area between the nursing station and chapel (same as day before). The resident was observed asleep, his arms were folded in his lap, and his head was bent down towards his lap. There were six other residents seated nearby. There were no staff present. A Nurse was observed at the medication cart near the end of the hallway (furthest point away from the nursing station) without the ability to maintain visual contact of the residents seated in the lounge, including R#703. Review of R#703's facility investigation documentation from 11/22/18 identified the incident/accident report had been completed by Licensed Practical Nurse (LPN I). The Certified Nursing Assistant (CNA) assigned to R#703 was CNA G. A written statement signed by LPN I and the DON included, .When I pass my 9:00 medications I place my med cart by the lounge so I can keep visual supervision of (R#703). I was in room (number redacted) giving that resident her medication when I heard a loud bang. I could not leave the room immediately but when it was safe to do so I observed (R#703) in <sic> the hall outside of room (number redacted). He was laying on his back on the floor. He was unresponsive upon approach. I did a sternal rub and he responded to it. I touched the back of his head and felt a wetness and realized he had a laceration to the back of his head. He slowly came back to a level of his normal alertness (took about 3 minutes) .ordered to send him out to the hospital for further evaluation .No other residents were in the lounge at the time of his fall. I believe I was the last person to see him before the fall and the first person to see him after. There were no additional interviews included with other staff. Review of the staffing schedule included in the provided documentation identified CNA H, CNA G and LPN I were assigned to work on 11/22/18 from 3:00 PM - 11:30 PM for the hallway R#703 resided on. Review of the hospital documentation available for review which was included in the facility's investigation documentation indicated 14 pages, however pages 2, 4, 6, 7, 10, 12, and 14 were not included. Review of the radiology reports available documented, .INTERPRETATION: [MEDICAL CONDITION]: There is a small focus of hyperdensity in the anterior left para falcine region, likely representing subdural/subarachnoid hemorrhage .IMPRESSION: 1. There is likely a small focus of hyperdensity in the anterior left para falcine region likely representing acute subdural/subaraccnoid hemorrhage . On 2/26/19 at 11:00 AM, a phone interview was conducted with CNA G. At that time, when asked to recall the events of R#703's fall on 11/22/18, CNA G reported, I wasn't assigned to him. I was one of the aides on the floor. When asked about R#703's behaviors and the level of supervision required, CNA G described R#703 as having an increase in behaviors on the afternoon and evenings such as being very restless, impulsive, attempting to get up unassisted, spitting, hitting. When asked about the possibility of requiring more increased supervision such as one to one, CNA G stated, Oh yeah, he needs that. CNA G identified two other CNAs (H and P) as possible staff that might have been assigned to R#703. On 2/26/19 at 11:05 AM, CNA H was contacted by phone and a message was left to return the call. There was no return call by the end of the survey. On 2/26/19 at 11:07 AM, LPN I was contacted by phone and a message was left to return the call. There was no return call by the end of the survey. On 2/26/19 at approximately 4:15 PM, the DON reported she had also attempted to contact LPN I but was unable to do so. Review of the clinical record revealed R#703 had an initial admission of 12/2/15, and readmission on 1/3/19 with [DIAGNOSES REDACTED]. According to the significant change Minimum Data Set (MDS) assessment dated [DATE], R#703 had severely impaired cognition, was not steady and only able to stabilize with human assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfers, and had two falls without injury and one fall with injury since prior assessment. Review of the interdisciplinary progress notes from (MONTH) (YEAR) - (MONTH) 2019 revealed R#703 had 12 falls, 2 of which required hospitalization for treatment of [REDACTED]. The progress notes included: On 9/29/18 at 4:15 AM, .his gait began to be unsteady and writer as well as assigned cena and staff from another unit continually trying to assist resident in sitting or laying down he will not sit more than a minute, resident was observed and heard falling in the door of the solarium .res (resident) has skin tear .had minimal bleeding .was difficult to re-direct, requiring a 1:1; otherwise he will not sit or lay down . On 10/12/18 at 5:52 PM, .Resident changed and repositioned in bed at 5:45 this evening .just minutes before 6:05 writer walked past room and observed resident resting in bed. At 6:05 Resident observed on floor with a <sic> left side-lying position with left arm underneath him, parallel to bed. He did complain of left arm discomfort .abrasion/bruise to left lower back .Resident assisted to reclining chair and brought to common area for close supervision for safety. Multiple attempts to climb out of chair after all needs met .1:1 staff provided to maintain safety . On 10/22/18 at 2:48 PM, .Resident up in wc (wheelchair) and in hallway for supervision by staff. Resident observed sitting in wc with eyes closed. 2 minutes later observed him standing up and took 1 step and fell on right side .In wc with staff doing 1:1 at this time . On 11/19/18 at 8:29 PM, .Resident observed laying on floor, left side in doorway of St. Jude Solarium . On 11/21/18 at 6:54 PM, .Became restless, propelling wc in halls, standing up unassisted .Staff has been doing 1:1 as continues to stand up by self . On 11/22/18 at 6:43 AM, .Received resident attempting to get out of his chair as well as cussing, punching, spitting at staff . On 11/22/18 at 7:51 AM, .Received resident calling out for help, standing up out of bed, staff toileted him at 7 a.m. and he laid <sic> back down and was back up urinating in <sic> floor, clothes wet .Resident constantly attempting to get up out of scoot chair. Breakfast came and resident needed 1:1 to keep focus on eating and to redirect him from trying to standing <sic> up from scoot chair .Resident restless, cursing . On 11/23/18 at 12:11 AM, .Rec'd (received) resident this evening sitting in chair in common area accompanied by a cena at this time .Resident appeared to be asleep. Writer was passing meds down hall when she heard a very loud noise, res was observed lying on the floor outside of a resident room, his eyes were closed and he was unresponsive for about a minute .it was observed he was bleeding from the back of his head, res observed with a 3cm, laceration on his occipital region of his head, he had a moderate amount of bleeding . On 11/24/18 at 6:34 PM, Nursing Admission/Screening Note .UTI (urinary tract infection), Acute subdural hematoma with hemorrhage, laceration with 5 staples . On 11/25/18 at 6:58 PM, .At 3:30 pm resident started to become more restless and anxious. Standing up unassisted multiple times .Resident cursing frequently at staff, swinging out at staff at times .Resident has had constant attention of a staff member since 5:15 pm . On 11/26/18 at 7:45 PM, .Resident alert, up and sitting in scoot chair, attempting to get up unassisted several times within the last hour. He isn't easily redirected .attempted to walk resident but he is too unsteady. On 12/1/18 at 2:35 AM, .Res. did require 1:1 monitoring through evening hours. Behaviors were reaching out and grabbing staff, attempting to ambulate unsupervised, cursing and spitting . On 12/2/18 at 3:40 AM, .res assisted to bed but attempted to get up constantly had to be re-directed . On 12/3/18 at 7:42 AM, .res constantly has to be re-directed, attempted to self x-fer (transfer) . On 12/4/18 at 4:26 AM, .Res. was received at 7 p.m. on unit propelling in a scoot chair and yelling out .grabbing at staff and cursing. Res. required constant re-directing and 1:1 monitoring by staff present .Staples removed from back of head on day shift .Res. remained in scoot chair through evening. Periodically resident attempted to ambulate from chair through evening . On 12/5/18 at 3:05 AM, .Resident required 1:1 rotating staff monitoring until 11pm. resident was laid <sic> in bed after appearing tired and calm .then observed at 12:15 a.m. sitting on his buttocks next to his bed .Res. has continued to require 1:1 rotating staff at his side due to repeatedly yelling out and being disruptive . On 12/7/18 at 6:31 PM, Transfer to Hospital Summary .Resident restless during and after dinner, attempting to get up out of scoot chair and propelling himself down hallway, staff at 6 pm resident fell at nurses station and staff observed residents fall-resistant to laying on floor next to nurses station across from 1st window and blood noted on desk, and floor, staff yelled for writer to come down and RN (Registered Nurse) saw blood .noted < (less than) 1 inch laceration posterior skull, and edges open about 0.3-0.04 cm open area .gave order to send in ER (emergency room ) . On 12/8/18 at 6:46 PM, .Resident readmitted at 6:30 pm .Has 2 staplew <sic> on posterior head. Multiple bruising on hands, arms, right lower back, right hip, right buttock, scattered on legs . On 12/8/18 at 6:50 PM, Up in scoot chair .By nurses desk for supervision. On 12/9/18 at 5:30 AM, .readmit to facility .2 staples were placed after recent 12/7/18 fall with [MEDICAL CONDITION] sustained .Residents behaviors continue .Res. did required 1:1 rotating staff on hand from 7p until 11pm . On 12/10/18 at 3:47 PM, .Two staples intact to mid back cephalic. Below this area resident continues to heal form a previous, recent fall which had 5 staples, now removed .Res. did not require 1:1 supervision this past evening. Res. able to propel unit without difficulty . On 12/10/18 at 8:54 AM, .stated yes when asked if he had a headache . On 12/12/18 at 6:42 AM, .he is attempting to self x-fer, and his is swinging out at staff and cursing, resident is very difficult to re-direct, and can not be left alone for a second . On 12/14/18 at 10:35 PM, .Resident agitated and difficult to redirect. Observed swearing at staff and visitors .Resident under close supervision. Multiple attempts to stand and ambulate without assistance . On 12/14/18 at 11:46 PM, .He made several attempts to climb out of bed unassisted, poor balance and poor safety awareness .Resident assisted back in scoot chair and brought back to common area at 11:10. Multiple attempts to stand from chair and resident spitting on floor around him while swearing at staff. At 11:25 this evening resident stood up from scoot chair and lost balance and fell on buttocks .Resident provided with 1:1 sitter . On 12/16/18 at 8:16 PM, .at 545pn <sic> he attempted to stand up constantly, resistive to staff .attempting to stand up and required one on one. On 12/19/18 at 3:51 AM, .Resident was observed restless, anxious and combative with staff and care .Res. required 1:1 staff at this time after standing up and ambulating to adjoining unit and resisting care .Resident's yelling and cursing behavior began to increase and was close by writer, during med pass and resident observed quickly standing up from his scoot chair on St Jude Hall and falling into the wall and sliding down on to his buttocks .did sustain two skin tears to his right elbow . On 12/24/18 at 5:17 AM, .At 3:30 a.m. writer heard a loud thump, staff responded immediately and resident observed sitting on the floor at doorway exit of his bedroom, leaning against doorway. Both legs of resident extended in front of the resident . On 12/28/18 at 2:10 AM, .Res. has been yelling and swearing since resident was received last night 7p .Staff has provided 1:1 rotating staff for company, redirection and monitoring .Res. noted ambulating in room and safely transferred to scoot chair and again brought to common area for rotating monitoring . On 12/29/18 at 3:20 AM, .Res. observed walking in random and unsafe directions .A CENA from rehab was assigned to resident for 1:1 care and was present for 1 ½ hrs (hours) . On 1/4/19 at 7:24 AM, .res requires 1:1 assistance in afternoon shift, as he was attempting to get out of chair . On 1/7/19 at 5:27 PM, .Resident attempted x 3-4 to get up out of scoot chair but isn't strong enough to do so on his own . On 1/12/19 at 11:45 AM, .Resident attempting for short periods to get up out of scoot chair, then realizes he isn't able to and rests his head down and is calm . On 1/12/19 at 8:00 PM, .Staff was notified by another residents visitor that resident was laying in the floor in the puzzle room. Staff went to room, resident laying on his back, head at area by the closet doors, feet under small tables .Resident prior to fall was self propelling by nursing station, and then was going down the hallway towards the solarium . On 1/13/19 at 6:43 AM, .Resident continually had to be re-directed through the night . On 1/14/19 at 6:48 AM, .Res sitting up in common area at nurses station attempting to self transfer, his is spitting and cursing, has to be constantly re-directed . On 1/20/19 at 1:29 AM, Writer outside of residents room at 10p and noted resident in a brief only ambulating away from his bed towards doorway. Writer immediately approached resident whom lost his balance and fell backwards landing on his buttocks .brought in his scoot chair to the common area .Res. noted quiet within 30 minutes and again place in bed at 12:15 a.m . On 2/26/19 at 1:30 PM, an interview was conducted with the DON. The DON reported R#703 as having many falls due to dementia and behaviors of attempting to get up from the chair unassisted. At that time, when asked about the facility's investigation into the fall that occurred on 11/22/18 and the lack of interviews with all staff including the CNA assigned to R#703, the DON reported, I looked at the schedule and thought (CNA G) had been his assigned aide. When asked about the facility's identified interventions to prevent continued accidents, the DON reported, Periodic one to one because of behaviors. His dementia is pretty advanced. He had been able to ambulate stand by assist. At times, provided one to ones. When asked how it was determined if a resident required increased supervision such as a one to one due to poor safety awareness and risk of injury, the DON reported, If looks like harm to self or gets up to ambulate, agitated with others. When asked about the facility's decision to place intermittent one to one supervision, the DON reported, The determination to place a one to one was intermittent, or following accident incidents, why the intervention for a one to one for identified need for increased supervision had not been continued, the DON reported, The one to ones usually are not more than three days. When asked what was being done to anticipate the fall occurrences given R#703's known behaviors of impulsivity, instead of reacting post incidents as documented for R#703, the DON was unable to offer any further information. The DON was requested to provide additional incident/accident reports for R#703 since (MONTH) (YEAR). On 2/27/19 at 3:00 PM, the DON was asked to clarify the information regarding the decision to place increased supervision following an incident and reported, If the nurse feels it's not safe on the floor, we can send out who wants to come in and be a sitter. Have done it for (R#703) usually on the midnight shift. Also have done one to one if waiting for someone to come in. If felt he needed a sitter one to one all the time, we can't provide that. We do have a dementia facility (on campus) but he doesn't qualify (due to lack of finances). We can still offer visual supervision. Tried room change, and did testing for appropriate medications. When asked about how the staff are able to provide visual supervision while providing care to other residents such as bathing, dressing, toileting, medication administration, and the DON reported, There is usually one person around. At that time, the DON was asked about the fall occurrence reported to the State Agency and the documentation that reflected the Nurse was not in view of the resident and whether the other fall incidents could have been prevented with increased supervision, the DON offered no further explanation. Review of the facility's Falls Risk Protocol dated (MONTH) (YEAR) documented, .Falls management focuses on minimizing fall risks factors and fall related injuries while continuing to promote the resident's quality of life .Some risk factors or conditions that may predispose a patient to a fall may include .Cognitive impairment, dementia .

This citation pertains to intake #s: MI 083 and MI 157. Based on interview and record review, the facility failed to consistently provide adequate supervision per the resident's assessed needs, and implement and revise fall interventions for one (#703) of three residents reviewed for falls, resulting in the resident having multiple falls and the resident sustaining an acute right [MEDICAL CONDITION] which required hospitalization and surgical intervention. Findings include: On 8/27/18 at 10:10 am, a phone interview was conducted with R#703's daughter. At that time, the daughter reported the resident had been hosptalized on [DATE] for a [MEDICAL CONDITION] which required surgical intervention. When asked to provide further details regarding R#703's fall, the daughter reported R#703 had four falls during her stay at the facility from 6/19/18 - 8/1/18. The daughter further reported, Prior to her stroke on (MONTH) 4th, (R#703) was fully functioning, independent but getting forgetful. Following the stroke, she was in (name of local hospital) two weeks for acute rehab. Due to dementia and the stroke she had no use of her right arm and leg. She was starting to talk, short phrases and they recommended subacute rehab and she was sent to (name of facility) .She had a fall risk bracelet and asked what they could do to keep her from falling. They (Administration) told me they couldn't do alarms and said they would monitor her. Within three days of admission, she (R#703) had two falls. One of the falls, they said the CNA (Certified Nursing Assistant) couldn't get to her .The second time she fell , I called the DON (Director of Nursing). The DON said she'd investigate, that she understood my concerns and will put (R#703) by the nursing station to keep close .They switched her chair after talking with the DON to a scoot chair (adaptive wheelchair which can recline back and is low to the ground) since it was harder to get up from. I said ok and the DON said implement. (R#703) was working with speech therapy and PT (physical therapy) worked hard and her mobility was improving and walking a little bit. Therapy then changed the scoot chair back to a regular wheelchair since they didn't want her movement to be restricted, so I said ok .The third fall was in her room with no witness. So that evening I went to see if she was ok. I went to the nurse who said she'd keep her out at the tv (in lounge area near the nursing station). That nurse said she was leaving and the other (oncoming) nurse said she'd monitor her .Two days later, got another call saying she fell again. The last two falls she was found on the floor on her bottom. That last fall was in the evening of the night before she went out to the hospital (7/31/18). I got a call around seven or something (in the evening) and asked them to let me know if she needs to go to the hospital. I called the facility in the morning and asked for her to move. I didn't get a call back until noon, it was a nurse saying she's complaining of pain and going to get x-rays. Told her I didn't hear back from anyone until now. I got a call a little while later saying she fractured her hip and was being sent to the hospital .her hip was impacted and needed surgery .had surgery after three days and now she's very weak, not eating and now I'm considering taking her home with hospice .I don't feel the facility did enough to monitor her given her high risk for falls. On 8/28/18 at 9:00 AM, review of documentation provided by the facility included an investigation of an injury of unknown origin identified on 8/1/18, which included four incident reports of R#703's falls during her stay at the facility. Review of these incident reports involving falls included: Fall #1 - On 6/20/18 at 2:20 PM, .Fall .Hallway .No injury noted .Interventions Implemented .Remind patient to remain in chair and not get up without help .IDT (Interdisciplinary Review/comments) Evaluate seating, possible scoot chair or high back w/c (wheelchair) or positioning cushion . Fall #2 - On 6/22/18 at 3:35 PM, .Fall .Rehab East Lounge .No injury .Witnessed fall Resident attempting to stand up and fell on left hip .w/c wheels locked, non-slip socks on feet .Interventions Implemented .Resident close to nurses station due to fall risk. To be observed directly .IDT Review/comments Agree with above, encourage resident to remain in common area when up in chair care plan reviewed and updated . Fall #3 - On 7/27/18 at 12:00 PM, .Slid out of chair (fall) .Resident Room .No injury .Patient found on her buttock by foot of bed. Patient was in wheelchair prior to incident .Interventions Implemented .Patient moved to nurses station so staff can see her .IDT Review/comments Encourage to be in common area for closer supervision . Fall #4 - On 7/31/18 at 7:10 PM, .Slid out of chair (fall) .Resident Room .small dime sized skin tear to right knee .pt (patient) found sitting on floor in front of w/c legs feet extended toward bathroom door .Interventions Implemented .will update care plan when residents returns from hospital .IDT Review/comments 8-1-18 reported to state agency at 3:07 PM resident unable to describe circumstances regarding incident . Review of the facility's undated investigation report following the fall on 7/31/18 included: Radiology Results Report dated 08/01/2018 which read, .Results: There is a right femoral neck fracture with mild displacement .Conclusion: Acute right [MEDICAL CONDITION] . Summary of Alleged Incident On 8/1/18, therapist reported patient was complaining of pain in her right knee and hip Daughter was made aware her mother was complaining of pain that x-rays were ordered and completed. At approximately 2:00 pm the facility was made aware of x-ray results showing a right femoral neck fracture with mild displaced. X-ray results called to physician and orders received to send patient to the hospital .Daughter aware of x-ray results and transfer to hospital . Summary of Critical Information Obtained During the Investigation .Her BIMs (brief interview for mental status exam) score was 3 out of 15 showing a significant cognitive deficit which required staff to anticipate her needs. She was identified, and care planned as a high risk for falls upon admission. She experienced three falls prior to her discharge to the hospital on [DATE] (incorrect as there were four fall incidents provided for review) .Each fall was reviewed by the interdisciplinary team and interventions were put into place. The interventions included, evaluation of a scoot chair or high-back wheelchair for positioning, encouraging the patient to remain in a common area when out of bed, and utilizing diversional tasks and activities as suggested by the patient's daughter .After initiation of the scoot chair, the therapy team felt the scoot chair became a hinderance in the patient's progress toward her therapy goals .On the afternoon of 7/31/18, at approximately 6:00pm, the patient was in the dining room for dinner. Following dinner at approximately 6:30pm, the patient was taken out of the dining room for safety as the staff members were transporting other patients back to their rooms. It was also noted the resident liked to lay down after meals. Following the patient's wishes, she was taken back to her room. The C.N.A. entered the room shortly thereafter and observed the patient on the floor. The patient was sitting on the floor in front of the sink with the wheelchair a few feet behind her. It appeared the patient had taken a couple of steps toward the sink. The C.N.A. alerted the nurse and the patient was assessed for injuries .The C.N.A. caring for the patient on the 3pm to 11pm shift was interviewed. The interview revealed that at approximately 9:30 pm, the C.N.A. stated she was providing incontinence care and the patient stated the word ouch .The nurse assigned to care for the patient stated that after the C.N.A. reported the patient's statement during incontinence care Tylenol was administered as ordered and noted to be effective .At approximately 10:00 am in the am (morning) of 8/1/18, the therapist alerted the nurse the patient was complaining of pain in her right knee and hip area. The physician was notified, and an x-ray was ordered .At approximately 2:00 pm the nurse received the results of the x-ray which showed a mildly displaced femoral neck fracture .The patient was given something for pain prior to leaving for the hospital and left the facility at 2:40 pm .Conclusion The patient was admitted to the facility following a stroke. The patient was care planned as a high risk for falls. The patient had poor safety awareness because of the stroke . Facility documented interviews with staff included: On 7/31/18, CNA C reported, After dinner yesterday, I helped (R#703) went to her room last night. Told her not to get up someone will help her to go to bed . On 8/1/18, first interview with CNA J reported, I walked into her room to get her ready for bed. I observed her in front of the sink sitting on the floor with her legs bent to the right side. She did not c/o (complain of) any pain at that time .It was after any dinner and it was around 6:30 -7:00. Prior to getting her ready for bed I observed her in the dining room around 6:00 pm. I went back in to give (R#703) care around 9:30 and when I turned her she was saying ouch. I changed her and notified the nurse . On 8/1/18, second interview with CNA J reported, Was her leg bend when you saw her on the floor? 'Yes like she was sitting on a blanket on the ground.' Were her legs sticking straight out?'No'. Do you know who put her in her room? 'No.' On 8/1/18, first interview with Licensed Practical Nurse (LPN G) reported, At 710pm CNA come and got me. I told the resident was on the floor. I checked on the resident, she was sitting on the floor about 2 feet away from her w/c. Her legs were extended out, her left leg was on the right leg and both legs were towards the bathroom. I uncrossed her legs I touched her hip .she denied pain anywhere . On 8/3/18, second interview with LPN G reported, I remember her legs crossed and in front of her. I uncrossed her legs and I recall her bending her legs in what appeared to be an effort to get herself up. She (R#703) was in front of the sink and her w/c was about 2 feet behind her as if she walked for several steps Further review of the clinical record revealed R#703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/26/18, R#703 had a BIMs score of 3/15 (which indicated severe cognitive impairment), exhibited no behavior concerns (such as refusal of care), and required extensive assistance of one person for bed mobility, transfers, dressing, hygiene and toilet use, had upper and lower extremity limitations, had falls prior to admit and had two falls with no injury during this assessment period. Review of the the discharge return anticipated MDS assessment with an ARD of 8/1/18 documented R#703 had short term memory loss with moderately impaired decision making skills, required extensive assistance with bed mobility, transfers, dressing, hygiene and toilet use, and had a fall with major injury. Review of R#703's fall care plan Date initiated: 06/21/2018 and Revision on: 07/30/2018 documented: The resident is High risk for falls r/t (related to) Confusion, Gait/balance problems, Incontinence, Poor communication/comprehension, Unaware of safety needs P[NAME] (plan of care) reviewed 06/21/18 .06/25/2018 .and updated 7/30/18 . Interventions included: Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 06/21/2018 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 06/21/2018 Encourage to be in common areas while awake. Date Initiated: 07/30/2018 (Per the fall incident report this was implemented on 6/22/18 after the second fall.) will evaluate seating and possible introduction of scoot chair. Date Initiated: 06/21/2018 (Per the therapy note dated 7/12/18, this intervention was discontinued on 7/12/18 and the care plan had not been updated to reflect this change.) Review of the progress notes included: On 6/20/2017 at 2:53 PM, Patient was observed lunging from wheelchair, landing on both knees . On 6/21/18 at 10:02 AM, IDT note related to being observed bending forward and propelled to both knees on the floor in hallway. Resident is a [MEDICAL CONDITION] with significant impairment and poor safety awareness with impulsivity .Will look at seating .Possible introduction of scoot chair, high back wheelchair and or positioning cushion. On 6/21/18 at 11:33 AM, .Patient is up in wheel cahir (sp) at this time and has tried to get out of wheelchair several times. Patient needs redirection and frequent reminders to remain in chair . On 6/22/18 at 3:43 PM, .Patient is up to scoot chair and in common area across from nursing station for monitoring. Patient was noted to attempt to stand and slipped to the floor on her left hip. Staff rushed to her but were unable to prevent her from falling .wheelchair was locked .Daughter called and was informed of the fall, she requests a return call from Management, DON (Director of Nursing) aware . On 6/22/18 at 5:04 PM, Received call from daughter regarding residents witnessed fall in the common area by the nurses station. Concerned that this might not be the right place for her. Discussed poor safety awareness and the scoot chair being in place. Also stressed the importance of therapy; we cannot provide 1;1 supervision but looking to anticipate her needs and why she is moving. States resident was very busy at home and likes to do household chores. Will slant scoot chair back more and provide items for the resident to fold . On 7/27/18 at 12:15 PM, Patient found on her buttock at foot of bed . On 7/30/18 at 9:57 AM, IDT note related to resident found at the foot of her bed on her buttocks with wheelchair in front of her. Could not state what she was doing, but she was in the process of brushing her teeth .Will encourage to be in common areas to increase visual supervision. On 7/31/18 at 7:21 PM, Patient was noted sitting on the floor on her bottom with her legs extended toward the bathroom . On 8/1/18 at 7:39 AM, .Resident had a fall before shift change yesterday evening, has a small skin tear noted to right knee and c/o some soreness .Reminded and educated on call light and not getting up without assistance . On 8/1/18 at 9:56 AM, Writer notified by therapy department resident c/o pain in right knee and hip MD (Medical Doctor) on call notified new order fro (sp) right hip, right knee stat x-ray to rule out dislocation/fx (fracture) . On 8/1/18 at 11:53 AM, (Daughter) notified of pt increased pain and xray orders . On 8/1/18 at 1:52 PM, Writer notified on call physician regarding result of R (right) hip x-ray which showed mildly displaced femoral neck fracture; physician ordered for resident to be transferred to the hospital . On 8/28/18 at 1:10 PM, an interview and record review was completed with the DON. At that time, upon review of the incident and accident reports, the DON reported the facility had additional documentation regarding the multiple falls which gave additional information about events and care provided just before and after the falls and reported only being aware of three falls, not four. When asked why this information was not provided with the fall investigation, the DON reported, You didn't ask for that. I gave you what you asked for, the reports. At that time, upon review of each of the falls, when asked about any conversation about the daughter's concerns for falls and adequate supervision, the DON reported, Yes, she (daughter) was asking for one to one supervision to prevent falls but we don't do that unless there is a high risk of injury. That was not clinically indicated, that was the family' request. At that time, we did a scoot chair. On 7/12/18, she went to a regular wheelchair with leg rest. When asked about what interventions were identified, the DON reviewed the incident/accident reports and reported, At that time we did a scoot chair. On 7/12/18, she went to a regular wheelchair with leg rest since therapy was concerned with flexion. She (R#703) needed increased visual supervision to her tolerance. If she didn't want to be there (in the lounge area across from the nurse's desk) of course we'd take her to her room. When asked if an intervention to remind the resident to ask for help was appropriate given R#703's significant cognitive impairment, and poor safety awareness, the DON confirmed the documentation this was done on multiple occasions and reported, No. When asked about the documented interview with CNA C about being left in her room and reminded to not get up, as well as whether it was normal protocol to lock the wheelchair were appropriate interventions, the DON reported, No don't expect wheelchairs to be locked. The DON denied being aware of R#703 having any behaviors such as refusal of care. When asked about the discrepancy with documentation following the falls, including the care planned interventions not reflecting the actual status of the residents, the DON acknowledged the discrepancies and was unable to offer any further explanation. On 8/28/18 at 2:15 PM, CNA I was interviewed regarding R#703's fall on 7/27/18 and reported, I had just given her a shower and was assisting her with brushing her teeth .I said I'll be right back I have to answer her light across the hall and said I'll be back. I went across the hall and went back to (R#703's) room and showed she was like this (CNA positioned herself seated on the floor with her legs extended out in front). She slid down, she was turned away from the sink. I turned the light on and the DON helped. It was only a matter of a few minutes! When asked if she was aware of the interventions in place to provide increased supervision due to poor safety awareness as identified in the care plan and incident reports, CNA I denied and stated, I set her up, gave her two washcloths .and said I was right back. The toothbrush looked like she had used it. I'm not aware she was needing increased supervision. She was getting better. On 8/28/18 at 2:23 PM, Certified Occupational Therapy Assistant (COTA H) was interviewed about R#703's change in status during treatment as documented on 8/1/18. At that time, COTA H reported, She was dressed by laying in bed. I think she had a pillow under her knee and that's when she grabbed it she was in pain. When asked about whether there had been any changes in condition identified the day prior (7/31/18) during therapy, COTA H reported, No, we finished around 4:00 PM. Not until I saw her that next morning. When asked about R#703's comprehension and communication just prior to the change in condition, COTA H reported, Her communication was very limited. 50/50 chance she'd respond at all or respond appropriately. On 8/28/18 at 2:30 PM, LPN G was interviewed about R#703's fall on 7/31/18. At that time, LPN G reported, When she first got here, she was less cognizant of her abilities. When you spoke with her not sure she was understanding towards the end she responded more one word responses. When asked about the fall in which it was documented about R#703 being taken to her room after dinner and staff locking the wheelchair, LPN G stated, It's better to not be locked cause if stationary, may try to get up and if it's not locked, then they have optimal ability to go where they choose to. When asked about whether she had done a skin assessment following the fall, LPN G stated, I was at the nurse's station wrapping up paperwork. An aide came to the desk area and said I needed to come with her (R#703) was on the floor. Then got up, went to the room with the aide - she's someone that doesn't typically work in my section .Her legs were out in front of her. One was crossed over a little bit down the ankles .I gathered she was trying to get walker to go to the bathroom .I gave the oncoming nurse the report . When asked if she had been aware of R#703's need for increased supervision due to fall risk and poor safety awareness, LPN G reported, I didn't see her as needing to be having increased supervision. She wasn't someone that still needed to be in the common area. When asked how care plan interventions were reviewed, or updated to reflect changes with the resident's status (either improvement or decline) LPN G reported, I'd think it would be physical therapy. When asked if she had been aware of any concerns from the resident's family regarding falls, LPN G reported, To be perfectly honest when I called the daughter, I don't recall what she said but she did yell at me. Review of the facility's Falls Risk Protocol dated (MONTH) (YEAR) documented, in part: .An evaluation of the resident is completed timely following a fall or change in patient condition The interdisciplinary team review the resident's most current falls in to determine if the resident's present condition or status then a narrative summary of the resident's condition and circumstances surround the event are documented in the resident's clinical record. The care plan is revised as clinically indicated to meet the resident's current needs .

This citation has two deficient practices. Deficient practice #1: Based on observation, interview and record review, the facility failed to provide adequate supervision and/or implement safety devices for two sampled resident's (#'s 907 and 908) out of 13 residents reviewed for safety out of a total sample of 19, resulting in skin tears and a hip fracture. Findings include: On 4/22/15 at 6:20 a.m., observation was made of resident #907 laying in a low bed pushed up against the wall on the resident's left side and a body pillow on the right side. Purplish bruising was noted on the right side of the resident's face, forehead, and cheek bone. Upon further examination, bruising was also noted on the resident's right hand and hip area. Midnight shift Nurse S, who was outside the resident's room passing medications, was asked about bruising noted on resident #907. Nurse S stated, The resident fell out of her wheelchair (w/c) the other afternoon and broke her hip. The family didn't want any surgery done to repair the fracture. I guess it would have been too hard on her. So, she is receiving Hospice services and is comfort measures. On 4/22/15 at 9:30 a.m., resident #907's roommate (who was alert and oriented to person place and time) was interviewed. The roommate said she remembered the day that resident #907 fell . The roommate said that (resident #907) was always trying to get up from her wheelchair. I know because I stopped her several times before. This day, she got up and I heard her fall. I felt really guilty about it. She (resident #907) use to have an alarm, but they took it away. It was the type that hooks on you and also to the wheelchair. It had a string attached to it. After the fall I put my call light on and yelled for the nurse. On 4/22/15 at 11:40 a.m., record review revealed that resident #907 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident's cognition was severely impaired, exhibited delusional behavior (physical and verbal) and required one person, limited assistance with wheelchair mobility. The MDS also documented that the resident was not steady, only able to stabilize with staff assistance when moving from seated to standing position. On 4/22/15 at 1:00 p.m., review of the Accident/Incident Reports (I/A's) for resident #907 revealed the following falls: #1. 7/3/14-Observed sitting on floor in front of (w/c) wheelchair. Alarm sounding. Was in room. #2. 12/23/14-Resident observed sitting on floor in front of w/c. Alarm attached and sounding. Periods of anxiety, as needed Xanax (antianxiety medication) given and effective. #3. 2/4/15-Resident observed on her knees next to her bed on the floor mat, no injuries. W/C mobile on unit per usual activity and cognition. Awake at night. Up in w/c for monitoring. #4. 3/14/15-Certified Nurse Assistant (CENA) observed resident on her knees on the floor mat facing her bed. Periods of anxiety, crawling out of bed. #5. 3/29/15-Resident was observed sitting up on the floor mat beside her bed. Alarm was attached and sounding. Periods of yelling, crying, then rested quietly. Awake at night, restless. At nursing station for observation. #6. 4/13/15-Observed kneeling on fall mat next to bed. Body pillow on bed. No injuries. #7. 4/14/15 @ 3:15 p.m. Resident noted out of wheelchair on floor on right side. Hematoma (bruise), abrasion right forehead. Complains of right hip pain, neck discomfort. Immobilized until ambulance arrived. CNA had been in resident's room approximately 5 minutes prior (passing water) resident seated quietly in wheelchair at bedside Resident observed lying on floor in her room by massage therapist. 7-3 p.m. CNA's were in hallway, heard roommate call out for NURSE-responded to room at same time massage therapist was passing by. Resident sent out to hospital for evaluation. The physician's orders [REDACTED].#907 had the pull tab alarm discontinued on 4/10/15 (four days prior to the fall with fracture). A nurses note dated 4/17/15 documented, Resident returned from the hospital today.Resident had stood up from her w/c and fell on the floor in her room.Resident's hip was broken and the hospital consulted with the family regarding choices for care. Surgery was considered but no guarantee resident would survive this according to family.Following the meeting at the hospital with the staff there, the family decided not to put resident through a hip replacement surgery because she might not make it and wouldn't be able to do therapy.family decided to have Hospice meet them at the facility to sign up for Hospice services. The physician's orders [REDACTED]. On 4/23/15 at 8:45 a.m., the I/A's, fall risk assessment (dated 3/25/15) and the Fall Risk Care Plans (dated 3/26/15) for resident #907 were reviewed with the Director of Nursing (DON) and the Safety Nurse (Nurse B). Nurse B was asked if resident #907 was a high risk for falls and responded, Yes, she is a high risk for falls. She is a very high risk for falls. Nurse B was asked what criteria was used in determining the discontinuing of the tab alarm for resident #907 and stated, The resident was assessed to be a candidate for the alarm removal because most of her falls were from the bed. She was exhibiting a lot of psychotic behaviors and the physician was adjusting her medications, but she was always anxious. The DON and Nurse B were asked how a resident that was exhibiting psychotic behaviors, continually attempted to self transfer, continually kept falling, and was experiencing antipsychotic medication adjustments would be a good candidate for an alarm reduction, they both responded by saying the resident remained on close supervision (the Falling Star Program) and had been assessed for three (3) days prior to the discontinuation of the alarm. Nurse B stated, I interviewed staff after the three day alarm reduction evaluation period, they indicated that she was not exhibiting any behaviors or attempting any self transfers during the reduction period. Nurse B was unable to provide documentation of the evaluation of the restraint reduction or the interviews from the staff she questioned. Nurse B was unable to provide documentation as to how many times the alarm sounded to which staff responded promptly to prevent an incident from occurring. On 4/24/15 at 9:40 a.m., staff nurse A was queried regarding the fall for resident #907. Nurse A stated that she was familiar with the resident and was her assigned nurse the day of the fall. The nurse said that a few days prior to the fall, the facility staff had removed the residents tab alarm (due to an alarm reduction effort). She went on to state, I was very surprised when I came back from my days off and they had removed the alarms. If they would have asked me I would have told them 'not to remove' the alarms. She was the type of resident that would attempt to stand up on her own. We would have to run to her room when her alarm would be sounding and redirect her back to her wheelchair. She preferred to be in her room by herself. At the time of the fall it was shift change. Maybe if the alarm would have been sounding we could have responded quicker. I don't believe she was a good candidate to have the alarms removed, especially from the wheelchair, because that left her with no safety devices on when she was up in it. On 4/24/15 at 11:30 a.m., review of the facility's policy titled Falls-Falling Star Program Policy, revised 2/2014 documented, #3. Residents that have a history of frequent falls and that are oblivious to safety will use bed and chair alarms as deemed necessary and appropriate. #4. Residents that are high fall risk will be in the falling star program. There will be a star placed by their name outside their door to alert staff. These residents will also be using the bed and chair alarm system as deemed necessary and appropriate, unless they are up ad-lib in their room and ambulate independently around the nursing home. Resident #908 On 4/21/14 at 6:30 A.M., Resident #908 was observed sitting in a wheelchair with a tab alarm (personal safety device) and a full tray table restraint. Resident #908 was alert with confusion. Resident #908 had a cast on her left wrist, and was not wearing any protective sleeves (geri-sleeves) on her arms or legs and was not wearing thrombo-embolytic deterrent stockings (TED hose). On 4/21/15 at 10:00 A.M., 12:30 P.M., and 1:00 P.M., Resident #908 was observed, and was not wearing geri-sleeves on her arms or legs, or TED hose. On 4/22/15 at 9:05 A.M., Resident #908 was observed with her assigned nurse, Licensed Practical Nurse (LPN) D and was observed to not be wearing either geri sleeves or TED hose. The resident had a solid mat on her right forearm, made up of multiple steri strips (external sutures) overlapping each other in parallel strips, to form a four centimeter (cm) by five cm cover over a blue and brown area on the resident 's arm. When asked what this was, LPN D stated, (Resident #908) has a skin tear there. Steri strips hold the skin edges together and cover the wound to form a dressing. She has very fragile skin and gets skin tears easily because she gets agitated and bangs on things and bumps into things as she moves her wheelchair around the unit. On 4/22/15 at 11:00 A.M., an observation of Resident #908 's skin was performed with the facility Treatment Nurse E. Nurse E stated, (Resident #908) ' s has a treatment order for steri-strips to a right forearm skin tear, and a right ankle skin tear. She has a history of fragile skin. She's supposed to have geri-sleeves on her arms and her legs. A dime sized dry brown scab was noted on Resident #908 ' s right ankle. Treatment Nurse E stated, That ' s almost healed. A healing skin tear with pale center and nearly approximated edges was observed on Resident #908 ' s right forearm. Treatment Nurse E stated, That ' s healed. I ' ll just put a transparent dressing over it to protect it. On 4/22/15 at 11:10 A.M., Treatment Nurse E was observed as she interviewed Resident #908 ' s assigned Certified Nursing Assistant (CNA) F . Treatment Nurse E queried, Why isn ' t (Resident #908) wearing geri-sleeves? CNA F answered, I didn ' t know she was supposed to have them. It ' s not on her care guide. In response to query, CNA F reported, I didn ' t get (Resident #908) up this morning. Midnights (11: 00 P.M. to 7:30 A.M.staff) gets her up. She didn ' t have the geri-sleeves on this morning when I got here. CNA F then left the room, and reentered two minutes later with geri sleeves, which she then applied to Resident #908 ' s arms and legs. Resident #908 was cooperative with applying the geri sleeves, and allowed CNA F to put them on without objecting. On 4/22/15 at 11:25 A.M., Review of Resident #908 ' s clinical record with Treatment Nurse E revealed the following: A face Sheet documented that Resident #908 was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #908 had severely impaired cognition, behaviors that effected self or others, needed extensive staff assistance for transfers to the wheelchair, was mobile around the unit in a wheelchair with limited assistance, needed staff assistance for dressing and hygiene, and had skin tears. A Nursing Care Plan for Skin for Resident #908, dated 9/8/14 contained the following intervention, geri-sleeves arms and legs to resident tolerance. Treatment Nurse E was queried about this, and stated, sometimes (Resident #908) gets agitated and resists care. When asked what the staff are supposed to do if Resident #908 refuses to allow staff to apply the geri-sleeves, Treatment Nurse E stated, It ' s all about the approach and timing. She could refuse at first, then agree five minutes later. physician's orders [REDACTED]. Dated 4/7/15, Cleanse skin tear to left wrist area with normal saline (NS), approximate edges and apply steri strips. Dated 3/28/15, Cleanse with NS, apply steri strips for right ankle skin tear. Dated 3/18/15, Skin tear right forearm, cleanse with NS and apply steri strips. Dated 3/10/15, Left posterior forearm skin tear. Cleanse with NS and apply steri strips as needed. physician's order [REDACTED]. Geri-sleeves to bilateral legs to resident tolerance. Take off for showers. An additional order noted, Thigh high TED hose to bilateral lower extremities (legs); on at 7:00 A.M., off at 5:00 P.M. On 4/22/15 at 11:30 A.M., Treatment Nurse E was asked how CNA's caring for Resident #908 were informed that Resident #908 needed to wear geri-sleeves on arms and legs, and responded, It ' s supposed to be on the CNA care guide in the resident ' s closet. Review of the Closet Plan of Care for Resident #908 at this time with Treatment Nurse E revealed no documentation to indicate that Resident #908 required either geri-sleeves or TED hose. Treatment Nurse E stated, I ' ll add it right now. I only work two days a week, and I was off work for three weeks. Normally I review the orders and care plans for skin, and make sure everythings in place. On 4/23/15 at 12:00 P.M., The DON stated that Resident #908 was prescribed to wear geri-sleeves on both arms and legs to protect her skin. When asked how staff would know that Resident #908 needed to wear geri-sleeves on arms and legs, the Safety Nurse B stated, I ' m supposed to get a copy of the doctor ' s order and then add it to the CNA closet care guide. If it wasn ' t done (on the care guide), it was my fault. A facility policy on preventative skin care for skin tears and on application of geri-sleeves was requested but not received by survey exit. ( / ) Deficient Practice #2. Based on observation, interview and record review the facility failed to secure sharp objects (needles)resulting in the potential for accidental puncture injuries. Findings include: On 4/23/15 at 12:20 p.m., during general observations of the St. Jude Hall nursing unit, two needles for blood extraction were noted on the top of the nurses medication cart located in the hall. The needles and blood extraction paraphernalia were out of site of the staff nurse. There were residents, staff and visitors noted near or walking past the cart. At 12:30 p.m., staff nurse C returned to her medication cart and was asked about the unsupervised needles and stated, I should have secured them before I walked away. I was distracted by a family member. On 4/24/15 at 3:00 p.m., during an interview with Clinical Care Specialist, Nurse G she was asked about the facility's policy on the securing of sharp objects and needles and said that sharp objects should be secured when out of site of the nursing staff and disposed of properly in a sharps container after use. On 4/24/15 at 3:30 p.m., review of the facility's policy titled Sharps Collection/Disposal dated 4/2015 documented, Place used sharps (syringes, razors, lancets, ect.) in sharps container provided in or on: Medications carts, medication rooms, soiled utility rooms, tub rooms, laundry or dentist office. The policy did not address the securing of clean sharp objects or needles. ( )