Every finding on record at Luther Memorial Home

Based on observation, review of professional reference, and staff interview, the facility failed to ensure food is served in accordance with professional standards for food service sanitation in 1 of 1 kitchen. Failure to ensure proper glove usage when serving food may result in foodborne illness to residents, visitors, and staff. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, pages 61-62, stated, . 3-304.15 Gloves, Use Limitation. (A)If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD . used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Observation of the tray line in the main kitchen on 12/30/25 at 11:15 a.m. showed an unidentified dietary staff member shuffled through several resident menus located on a counter with gloved hands and used the same gloved hands and placed sandwiches onto resident meal plates. The staff member failed to change gloves after touching non-food items and before handling ready-to-eat food. During an interview on 12/31/2025 at 9:55 a.m., the dietary manager (#1) confirmed the dietary staff member failed to change their gloves after touching the menus and before plating the sandwiches.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 17 sampled residents (Resident #10). Failure to accurately complete Section M (Skin Conditions) of the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan, and the care provided to the residents.Findings include:The Long-Term Care Facility RAI 3.0 User's Manual, (Version 1.20.1), revised October 2025, page M-24, stated, M0300F: Unstageable Pressure Ulcers Related to Slough and/or Eschar . M0300F1 Enter the number of pressure ulcers that are unstageable related to slough and/or eschar. Enter 0 if no unstageable pressure ulcers related to slough and/or eschar are present. M0300F2 Enter the number of these unstageable pressure ulcers related to slough and or/eschar that were first noted at the time of admission/entry. Enter 0 if no unstageable pressure ulcers related to slough and/or eschar were first noted at the time of admission/entry or reentry. Review of Resident #10's medical record occurred on all days of survey. The progress notes included the following:*09/23/25 at 12:44 p.m., . Skin assessment completed on admission. No pressure ulcer/injury noted or identified in this progress note.*10/03/25 at 01:51 p.m., . Resident's R) [right] and L) [left] big toes had small purple non-blanchable areas to the tips of the toes. Bed cradle added .*12/19/25 at 12:22 p.m., . WEEKLY SKIN REVIEW: R) great toe had a measurable area on bath day but it has flaked off. Dark pink skin noted that is healed. L) heel measures smaller at 2 x 1.8 cm [centimeter] and skin surrounding is clean, intact, and no dryness noted. Site continues to be closed/unstageable.The quarterly MDS, dated , 12/23/25, showed the facility coded M0300F1 2, indicating two unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar and M0300F2, 2, unstageable pressure ulcers present upon admission. During an interview on 12/31/2025 at 9:56 a.m., an administrative nurse (#2) confirmed facility staff coded Resident #10's MDS incorrectly.

Based on observation, review of professional reference, and staff interview, the facility failed to follow standards of infection control for 1 of 6 sampled residents (Resident #10) observed during cares. Failure to follow infection control practices regarding hand hygiene during cares has the potential for transmission of communicable diseases and infections to residents, staff, and visitors.Findings include:Review of Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 685, stated, . Gloves . The hands are cleansed each time gloves are removed for two primary reasons: (1) The gloves may have imperfections or be damaged during wearing so that they could allow microorganism entry and (2) the hands may become contaminated during glove removal.Information found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, dated, 02/27/24, titled Clinical Safety: Hand Hygiene for Healthcare Workers, stated, . Know when to clean your hands . Immediately after glove removal .Observation on 12/30/25 at 9:02 a.m. showed a certified nurse aide (CNA) (#3) complete colostomy care for Resident #10. The CNA (#3) emptied stool from the colostomy bag into a graduate, wiped the colostomy bag, emptied the graduate into the toilet, rinsed the graduate with water, wiped the colostomy bag, removed his/her gloves, and without completing hand hygiene, opened the door and retrieved a new box of gloves.Observation on 12/30/25 at 9:41 a.m. showed a CNA (#3) performed perineal care for Resident #10. The CNA (#3) washed the perineal area, removed gloves, and without completing hand hygiene, removed the foot cradle from the end of the bed.During an interview on 12/31/2025 at 12:48 p.m. an infection control nurse (#2) stated she would expect a staff member to wash hands after removing gloves prior to touching other objects.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 15 sampled residents (Resident #49). Failure to accurately complete the MDS does not allow the resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the resident. Findings include: Section K: SWALLOWING/NUTRITION STATUS The Long-Term Care Facility RAI Manual, revised October 2023, page K6, stated, . K0300 Weight Loss . Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. Review of Resident #49's medical record occurred on all days of survey. Two quarterly MDSs, dated 06/21/24 and 09/21/24, identified section K0300 coded as 2 for weight loss; however, record review failed to identify Resident #49 experienced a weight loss. Facility staff failed to accurately code the quarterly MDSs as 0 indicating Resident #49 did not have a 5% weight loss in 30 days or a 10% weight loss in 180 days. During an interview on 10/10/24 at 10:21 a.m., a dietary supervisor (#3) confirmed staff failed to code the MDS correctly for Resident #49.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 5 sampled residents (Resident #16) on enhanced barrier precautions (EBP) observed during cares. Failure to practice infection control standards related to EBP has the potential to spread infection throughout the facility. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions occurred on 10/09/24. This policy, revised 04/01/24, stated, . Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and gloves use during high contact resident care activities. 2. Initiation of Enhanced Barrier Precautions: . b. enhanced barrier precautions will be used for residents with any of the following: . i. Wounds (e.g., chronic wounds such as pressure ulcers. diabetic foot ulcers. unhealed surgical wounds, and chronic venous stasis ulcers) . 3. Implementation of enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or upon entry of the resident's room . 4. High-contact resident care activities include: . c. Transferring. d. Providing hygiene . f. assisting with toileting . h. Wound care: any skin opening requiring a dressing . 9. enhanced barrier precautions should be used . until resolution of the wound . Review of Resident #16's medical record occurred on all days of survey and identified the onset of an open stage two pressure ulcer to the right buttocks on 10/05/24. The care plan stated, . Problem start date: 10/05/24 . Impaired skin integrity/Pressure sore to right buttocks-scarred area is now open . Enhanced Barrier Precautions (EBP) initiated . Observation on 10/07/24 at 4:23 p.m. showed no EBP sign or supply cart located outside/inside of Resident #16's room. A certified nurse aide (CNA) (#2) entered Resident #16's room and without donning a gown or gloves transferred the resident from the wheelchair to the toilet and performed perineal cares. During an interview on 10/08/24 at 3:30 p.m., an administrative nurse (#1) stated she expected signage, appropriate PPE available, and staff to follow the policy.

Based on record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 closed record (Resident #1) with diabetes. Failure to ensure residents receive treatment and care according to professional standards of practice related to blood glucose monitoring increases the risk of serious harm, impairment, or death. During the complaint survey, the team determined an Immediate Jeopardy (IJ) situation existed on [DATE] at 5:22 p.m. The IJ resulted from staff failure to recheck a resident's glucose [sugar] or take additional interventions after a test result of 61 mg/dL (milligrams per deciliter) on [DATE]. Staff found Resident #1 unresponsive and could not be revived. * [DATE] at 4:03 p.m., the survey team contacted the State Survey Agency (SSA) to report the findings, discuss, and confirm the presence of IJ. * [DATE] at 5:22 p.m., the survey team notified the administrator and the director of nursing (DON) of the IJ situation, provided them with the IJ template, and requested they develop a plan for removal of the IJ. * [DATE] at 11:33 a.m., the DON emailed the IJ removal plan for the SSA to review. The removal plan contained the following: * For all diabetic residents with orders for blood sugar [BS] checks the facility revised the orders in the electronic medical record [EMR] so if the BS is less than 70 the nurse is prompted to complete required task interventions and complete a BS recheck 15 minutes after the intervention until the BS is greater than 70. The nurse will not be able to sign off the order until all required tasks are completed. The nurses will also be required to enter the BS result in the task before it can be signed off. * The facility updated the blood glucose protocol to incorporate these changes. * All nurses will be educated on this updated facility blood glucose protocol prior to working their next shift. * Added specific education for the blood glucose protocol to the nurse orientation checklist. * [DATE] at 11:35 a.m., the SSA reviewed and accepted the facility's removal plan for the IJ. * [DATE] at 11:43 a.m., the SSA notified CMS (Centers for Medicare & Medicaid Services) location of the presence of IJ and emailed the IJ template to CMS. * [DATE] at 5:05 p.m., the survey team verified the implementation of the facility's IJ removal plan. The deficient practice remained at a G scope and severity following the removal of the IJ. Findings include: Review of the facility policy and procedure titled Blood Glucose - Protocol if Abnormal occurred on [DATE]. This policy, dated [DATE], stated, . Low glucose is considered below 70. For GLC [glucose] ,d+[DATE] - give 15 g [grams] CHO [carbohydrate] * 4 oz juice * 4 oz regular soda * 1 tablespoon sugar (4 packets), honey, jam or jelly * 5 or 6 pieces of hard candy * 6 large Jelly beans, 5 gum drops, 12 [sic] gummi bears, 4 Starburst, 1.S [sic] Skittles. Wait 15 minutes then re-check glucose. If still low repeat this procedure. Once glucose is above 70 a snack containing carbohydrate and fat/protein should be provided, unless the next meal is within 30 minutes. If someone has a glucose above 70 but below 120 at bedtime or several hours before the next meal, they should be given a snack that contains carbohydrate and fat/protein. Review of Resident #1's medical record occurred on [DATE]. Physician orders included: * [DATE], Novolog Flexpen U-100 Insulin [fast-acting insulin] . 100 unit/mL [milliliter] . 30 units; subcutaneous [under the skin] Once A Day 05:00 PM * [DATE], Tresiba FlexTouch U-100 [long-acting insulin] . 30 units; subcutaneous Special Instructions: HOLD FOR BS LESS THAN 150 At Bedtime 08:00 PM Resident #1's Medication Administration Record (MAR) for [DATE] showed the following: * 5:00 p.m., Novolog Insulin, 30 units administered by a nurse (#1) * 8:00 p.m., Blood Sugar Check, a nurse (#1) documented at 10:37 p.m., Administered late Comment: Administering care * 8:00 p.m., Tresiba Insulin, 30 units, a nurse (#1) documented two different entries at 10:37 p.m. Administered late Comment: Administering care and Site: Not Charted: On Hold Comment: bs 61 The medical record documentation showed a delay in completion of 8:00 p.m. orders. The nurses' notes stated the following: * [DATE] at 2:12 p.m. Emesis: Staff report resident had emesis of indigested food. Assisted with cleaning up. Will continue to monitor and have oncoming nurse assess. * [DATE] at 9:15 p.m. (created [DATE] 06:56 a.m.) According to protocol, [resident's name] Tresiba was placed on hold because his Bs [BS] 83, which was less than the 150 the required amount to enable him to have one. In order to help bring his Bs up I gave him some cranberry juice, honey and cookie, which he ate a little, after lots of prompting. I came back after 30mins [sic] to recheck him and see if his Bs had improved, but instead his Bs has decreased further to 61. So I decided to tried [sic] again and gave him a little more juice, cookie and honey with the help of other staff members. After more prompting [resident name] was able to drink some of the juice, take the honey and eat some of cookie and he went to bed. Staff came to his room around 10:30 to changed [sic] and get him ready for bed. According to them he responded well. Around 11 [p.m.] he was heard hitting the wall and talking, which he does usually when he is in his room. When he was checked on the next time around 00: 15 [sic] [a.m.] he was found unresponsive and cold to touch and could not be revived. * [DATE] 12:22 a.m. This writer entered resident's room and round [sic] resident expired. Body cold to touch. Yellow emesis and large amounts of clear phlegm found on bed next to mouth. Apical [specific point on the chest] HR [heart rate] absent for 1 minute, double verified by other charge nurse. During an interview on [DATE] at 3:49 p.m., an administrative staff member (#2) reported she called the certified nurse aide (CNA) (#3) on [DATE] to obtain her recollection of her interaction with Resident #1 on [DATE] after 10:45 p.m. An administrative staff member (#2) reported the CNA (#3) confirmed she worked that night, arriving at 10:45 p.m. The CNA (#3) reported Resident #1 was not banging on the wall, but knocking, as he did all the time. He would play with his light and mess around. The nurse (#1) asked the CNA (#3) to bring the resident four ounces of cranberry juice and a whole packet of honey. The CNA (#3) gave Resident #1 the cranberry juice between 11:00 p.m. and 11:15 p.m. and it did not take the resident long to drink it. The CNA (#3) stated the resident coughed a little bit while drinking the cranberry juice. The CNA (#3) left the resident's head of the bed up because he looked comfortable and had closed his eyes. Resident #1's blood sugars included: [DATE] 5:28 a.m. - 68 mg/dL - Failed to indicate what staff gave to the resident to increase blood sugar and re-check glucose after 15 minutes. [DATE] 8:20 p.m. - 69 mg/dL - Failed to indicate what staff gave to the resident to increase blood sugar and re-check glucose after 15 minutes. [DATE] 8:00 p.m. - 58 mg/dL, 8:20 p.m. - 80 mg/dL - Failed to indicate what staff gave to the resident to increase blood sugar. [DATE] 7:37 p.m. - 78 mg/dL - Failed to indicate if snack was given at bedtime. [DATE] 4:45 p.m. - 146 mg/dL - A nurse's note, dated [DATE] at 9:15 p.m., referenced blood sugars of 83 mg/dL and 61 mg/dL but failed to document the times staff obtained the blood sugars. During an interview on [DATE] at 2:40 p.m., two administrative staff members (#2 and #4) confirmed the following: * Staff are expected to follow the protocol [Blood Glucose - Protocol if Abnormal] unless there are other orders in place by the provider when a blood sugar is low. * Nurse (#1) had been the nurse on the [DATE] evening shift and hadn't charted the events from [DATE] so we requested documentation of a late entry on [DATE]. * It is unknown what time the nurse obtained the blood glucoses of 83 mg/dL and 61 mg/dL. * The nurse should have rechecked the resident's blood sugar after he drank the juice following the BS of 61 mg/dL. * The record lacked documentation of an assessment following the resident's emesis on [DATE] at 2:12 p.m. * Staff were expected to offer Resident #1 a bedtime snack if his BS was less than 120 mg/dL. The record lacked evidence Resident #1 received a bedtime snack on [DATE]. Facility staff failed to: * Re-check blood glucoses after 15 minutes when a blood glucose is below 70 mg/dL. * Document interventions for low blood glucoses or between 70 mg/dL and 120 mg/dL at bedtime. * Complete [DATE] 8:00 p.m. orders in a timely manner. * Document the times the staff obtained blood sugars of 83 mg/dL and 61 mg/dL as referenced in a progress note dated [DATE] at 9:15 p.m. * Assess the resident following an emesis, as indicated in the progress note dated [DATE] at 2:12 p.m. * Create a progress note in a timely manner. The nurse created the [DATE] 9:15 p.m. progress note over 33 hours later. * Provide an HS snack when blood sugars are between 70 mg/dL and 120 mg/dL at bedtime.

Based on observation, record review, and staff interview, the facility failed to ensure an environment free of accidents and hazards for 1 of 1 resident (#25) with a hot liquid spill and 1 of 1 resident (#9) who smoked cigarettes. Failure to ensure appropriate interventions and assessments for residents drinking hot liquids and smoking may result in serious burns/injuries to residents. Findings include: The facility failed to provide a policy regarding hot liquid spills and completing smoking assessments. - Review of Resident #25's medical record occurred on all days of survey and included a diagnosis of dementia. The care plan stated, . At assist table, for supervision/cuing . A progress note, dated 09/18/23, stated, . Resident spilt [sic] hot tea on her stomach. No redness noted. Will monitor for 72 hours. An incident report, dated 09/18/23, identified Resident #25 had spilled hot tea on her abdomen with no injuries. During an interview on 09/26/23 at 3:40 p.m. a dietary manager (#3), stated she was not aware of Resident #25's hot liquid spill and had not put any interventions into place to prevent serious burns and/or injuries. During an interview on 09/27/23 at 8:10 a.m. a licensed nurse (#2) verified the hot liquid spill occurred when Resident #25 was alone in her room with hot tea, which did not have a lid on. During an interview on 09/27/23 at 8:20 a.m. an administrative nurse (#1), confirmed the facility failed to put interventions in place after Resident #25's hot liquid spill. - Review of Resident #9's medical record occurred on all days of survey. An admission assessment, dated 08/14/23, identified the use of tobacco. Diagnoses included reduced mobility, and chronic obstructive pulmonary disease. The care plan stated, I do smoke cigarettes and am aware that my family can assist me off . premises to smoke. Lock box in residents [sic] room for tobacco product storage. COPD - Alteration in respiratory status - uses O2 [oxygen] continuously. is aware that family needs to take her out of facility/off grounds to do this. During an interview on 09/26/23 at 9:00 a.m., Resident #9, stated his/her cigarettes are in a locked box in a drawer of the cupboard and family or staff walk him/her to the front door to leave the facility by him/herself to smoke. During an interview on 09/27/23 at 2:15 p.m., staff member (#2) stated staff could take Resident #9 to the front door to smoke, but were not allowed to go outside with the resident. The staff member (#2) stated residents need to sign in and out when leaving the facility. During an interview on 09/27/23 at 3:10 p.m., an administrative nurse (#1), stated he/she was unaware Resident #9 left the facility to smoke alone and the facility had not assessed the resident's ability to smoke alone. The facility failed to complete a tobacco use assessment for Resident #9 upon admission.

Based on observation, record review, and review of facility policy, the facility failed to ensure staff followed professional standards of practice for 1 of 1 sampled resident (Resident #58) with a feeding tube. Failure to ensure residents received their complete dose of medication during administration may lead to reduced efficacy and adverse health effects. Findings include: Review of the facility policy titled, Medication Administration occurred on 08/31/22. This policy, revised/reviewed July 2018, stated, . Prepare medication for administration, using these rules: Observe the Five Rights of Medication Administration . Right dosage. Review of Resident #58's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order identified [MEDICATION(S)] (anti-[CONDITION(S)]) tablet; 300 mg [milligram]; amt: [amount] 600 mg; gastric tube Twice A Day at 08:00 AM, 08:00 PM. During an observation on 08/30/22 at 9:15 a.m., a facility nurse (#1) administered Resident #58's medication via the feeding tube. The nurse crushed and mixed all medications with water in separate labeled medication cups, and administered them one at a time with a 10 cubic centimeter (cc) water flush between each med. After the nurse finished administering the medication, the cup labeled [MEDICATION(S)] contained a layer of medication that covered the bottom of the cup. The nurse failed to administer the complete dose of the medication.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure acceptable parameters of nutritional status for 1 of 6 sampled residents (Resident #9) with weight loss. Failure to adequately monitor and evaluate weights, complete nutritional assessments, assess the effectiveness of existing interventions, and re-evaluate the need for updated or additional interventions may result in weight loss, inadequate nutrition, and/or delayed wound healing. Findings include: Review of the facility policy titled Weight Loss Protocol occurred on 08/30/22. This policy, dated June 2000, stated, . residents with a 3# [pound] or greater weight change . will be monitored via weights, intakes, etc. to determine if interventions are necessary to prevent further weight loss. Changes to be documented in resident chart. Review of Resident #9's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS), dated [DATE], identified a significant weight loss and not on a physician-prescribed weight loss program. The record lacked a nutritional assessment to address Resident #9's weight loss. Review of Resident #9's weights showed the following. 02/27/22 (122.5 lbs) 08/28/22 (110 lbs) (02/27/22 to 08/28/22 = 10.2% decrease in weight) The current care plan stated, I will maintain weight above 115# thru [sic] next review. Resident would benefit from supplements but has been unwilling to take them. Observations of Resident #9 throughout the survey showed the resident ate independently, without supplements offered at meals. The record lacked evidence that high calorie foods were offered. During an interview on the morning of 08/31/22, an administrative nurse (#6) stated she expected staff to implement supplements and monitor weights. The dietary manager (#7) stated Resident #9 will not take supplements and only wants half portions. Both staff failed to explain the facility's system for identifying weight loss and implemention of interventions. The dietary manager (#7) failed to provide documentation of interventions regarding Resident #9's weight loss.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure proper labeling of multi-dose insulin pens during 1 of 1 medication storage rooms (Unit B) observed. Failure to correctly label insulin pens increases the risk of residents receiving inaccurate doses of medications. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition, 2021, Pearson, Boston, Massachusetts, page 840, states, .The labeling of all medications, medication containers, and other solutions is a risk-reduction activity consistent with safe medication management. Review of the facility policy titled Process for Relabeling Medication Cards occurred on 08/31/22. This policy, revised September 2018 stated, [NAME] Memorial Home [Facility name] will ensure drugs and biologicals used withing the facility are labeled accurately and in accordance with currently accepted professional pharmacy requirements. Review of facility policy titled Medication Administration occurred on 08/31/22. This policy, revised July 2018 stated, . Never administer medication from an unlabeled supply. - Observation during medication storage and labeling on Unit B for Resident #57 on 08/31/22 at 8:20 a.m., with a staff nurse (#8) identified the following: * A [MEDICATION(S)] insulin pen was without a label or original container. * A [MEDICATION(S)] insulin pen was without a label or original container. During an interview on 8/31/22 at 1:03 p.m., an administrative nurse (#6) confirmed the insulin pens lacked labeling and/or original container.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 1 of 9 sampled residents (Resident #23) and 1 supplemental resident (Resident #42) observed during perineal care. Failure to follow infection control practices related to hand hygiene has the potential to transmit infections to other residents, staff, and visitors. Findings include: Review of the facility policy titled Hand Washing and Hand Hygiene occurred on 08/31/22. This undated policy stated, . To provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention or the transmission of infections. When to wash hands with soap and water or alcohol based hand rubs: 1. Hand hygiene should be performed . After contact with a resident's mucous membranes and body fluids or excretions. After removing gloves . If moving from a contaminated body site to a clean body site during resident care. - Observation on 08/29/22 at 3:19 p.m. showed two certified nursing assistants (CNAs) (#4 and #5) transferred Resident #42 from the wheelchair to the bed. The CNAs performed hand hygiene, donned gloves, lowered the front of the resident's brief, performed perineal cares, and rolled the resident onto her left side. One CNA (#4) cleansed the rectal area of bowel movement (BM) with a disposable wipe. Without removing gloves, the CNA (#4) removed the soiled brief, placed a new brief under the resident, obtained a tube of barrier cream from the nightstand, and applied the cream to the resident's buttocks. The CNA (#4) then removed her gloves, adjusted the brief, and placed the the tube of barrier cream back into the resident's nightstand. The CNA (#4) failed to remove her soiled gloves and perform hand hygiene after cleansing the resident's rectal area and before touching other objects and/or applying barrier cream. - Observation on 08/30/22 at 10:38 a.m. showed two CNAs (#2 and #3) transferred Resident #23 from the wheelchair to the bed. The CNA's performed hand hygiene, donned gloves, lowered the front of the resident's brief, performed perineal cares, and rolled the resident onto his left side. One CNA (#2) cleansed the rectal area of BM with a disposable wipe and rolled the soiled brief under the resident. Without removing her gloves, the CNA (#2) obtained a tube of barrier cream from the windowsill and applied the cream to the residents buttocks. The CNA (#2) then placed the tube of cream back onto the windowsill, removed her gloves and held the resident's hand as he rolled onto his right side. The CNA (#2) failed to remove the soiled gloves and perform hand hygiene after cleansing the resident's rectal area and before touching other objects, applying barrier cream and/or holding the resident's hand. During an interview on 08/31/22 at 12:55 p.m., an administrative nurse (#6) confirmed she expects staff to follow the facility's policy regarding hand hygiene.

Based on observation, record review, and staff interview, the facility failed to provide assistance and supervision necessary to prevent accidents for 3 of 9 sampled residents (Resident #14, #31, and #70) identified with falls. Failure to provide supervision and adequate assistance with transfers/ambulation may result in falls and injuries. Findings include: - Review of Resident #14's medical record occurred on all days of survey. Diagnoses included dementia, a history of a right femur fracture, and a history of falls. The current care plan stated, . Problem . IMPAIRED MOBILITY/AMBULATION R/T [related to]: Fractured Right hip/femur . Alzheimer's . Approach . Transfers: Extensive assist of 2 . gait belt- yes . Walking in Corridor: Ext [extensive] assist of 2. Gait belt: Yes . Walking in Room: Extensive assist of 2. Gait belt: Yes . A nurse's note, dated 05/06/21 at 5:51 p.m., stated, . Called to MLL [memory care unit] at 540p [p.m.], when resident was lowered to the floor. CNA [certified nursing assistant] reports she was assisting him and he became resistive and pushed on her, then knees gave out and she lowered him to the floor onto his buttocks. On assessment no injury noted and no complaint of pain. Observation on 05/18/21 at 3:33 p.m. showed a CNA (#1) placed a gait belt around Resident #14's waist, assisted him to stand and ambulated with one assist to the resident's room to use the bathroom. The CNA then ambulated with Resident #14 to the dining area for activities. Upon completion of the activity, the CNA ambulated with Resident #14 down the hallway and back to the TV area. - Review of Resident #31's medical record occurred on all days of survey. Diagnoses included dementia and a history of falls. The current care plan stated, . Problem . IMPAIRED MOBILITY/AMBULATION R/T WEAKNESS, DEMENTIA . Approach . Transfers: Extensive assist of 1 and standing lift . Problem: Resident at risk for falling R/T limited mobility, attempts to self transfer without staff support, weakness. Approach . Do not leave resident alone in bathroom . A nurse's note, dated 03/25/21 at 6:30 p.m., stated, . Fall: Staff alerted this nurse that resident had fallen from his wheelchair in the bathroom. Resident was found sitting between his wheelchair and the toilet with L) [left] foot pedal to his back and R) [right] foot pedal under B) [bilateral] knees. He denies pain. ROM WNL [range of motion] [within normal limits]. Resident hoyered [full body mechanical lift] from floor with assist x3. No noted redness/bruising or injuries noted. Resident reports hitting his head on the wall when leaning back. Neuro assessment completed and WNL. Careplan updated that resident cannot be in bathroom alone. Observation on 05/18/21 at 9:04 a.m. showed a CNA (#3) transferred Resident #31 from his wheelchair to the toilet using a standing lift. The CNA then gave the resident the call light and left the room. At approximately 9:15 a.m., Resident #31 used the call light, and the CNA returned to his room to finish cares. During an interview on 05/19/21 at 4:13 p.m., a supervisory nurse (#2) confirmed two staff should ambulate with Resident #14, and staff should not leave Resident #31 alone in the bathroom. - Review of Resident #70's medical record occurred on all days of survey. Diagnoses included Alzheimer's Disease. The resident's care plan date 03/14/21 stated, . Impaired mobility/ambulation R/T dementia. Approach Transfer: Extensive assist of 2, may use Standing Lift with butt trap 2 assists after nurse assessment if unable to stand. An event report dated 03/14/21 stated, . Called to room by CNA at 440pm [4:40 p.m.] with report that resident was lowered to floor when knees became weak. On assessment sitting bathroom floor [sic] on buttocks with legs extended. Staff report she was lowered to her knees and then positioned to sitting position. Denies pain and no injury noted. Assisted to standing by 4 staff and seated on toilet. Continues to deny pain. The event report identified one CNA caring for the resident at the time of the fall. An event report dated 03/24/21 stated, Called to room for fall. CNA present, states was transferring resident and knees gave out, CNA lowered to floor [sic]. Resident sitting on the floor with back against recliner, gait belt on, shoes on. Denies pain other than to her knees. ROM [range of motion] as prior to fall. Assisted to standing with 3 staff and gait belt, assisted to wheelchair. Vitals WNL. Continues to deny pain other than to knees . The event report identified one CNA caring for the resident at the time of the fall. During an interview on the afternoon of 05/19/21, a supervisory nurse (#6) confirmed at the time of the above falls Resident #70 required assistance of two staff members for transfers and the event report identified one staff member assisting the resident at the time of each fall.

Based on observation, record review, facility policy review, and resident and staff interview, the facility failed to implement policies related to the investigation and reporting of abuse/neglect for 1 of 1 sampled resident (Resident #17) with an injury of unknown origin. Failure to recognize an injury of unknown origin as potential abuse/neglect and implement their investigation/reporting policy placed all residents at risk for abuse/neglect and possible injury. Findings include: Review of the facility policy Abuse and Neglect (including Elder Justice Act) occurred on 05/19/21. This policy, dated 08/25/20, stated, . Identification: 1. Any staff witnessing or possessing knowledge of any act (or suspected act) involving . injuries of unknown origin such as bruising . must IMMEDIATELY notify the charge nurse, who will IMMEDIATELY notify the D.O.N. [Director of Nursing] and ADMINISTRATOR and SOCIAL SERVICES. 2. Injuries of unknown source mean source of injury was not observed by any person OR the source of injury could not be explained by the resident AND the injury is suspicious because of the extent of the injury or the location of the injury . Review of Resident #17's medical record occurred on all days of survey. The current care plan stated, . Cognitive function: . BIMS [Brief Interview for Mental Status] TESTING: 2/19/21 score 7, indicating severe cognition impairment. Cognition is noted to vary. Memory loss: Mental function does vary. [CONDITION(S)], right hemi-plegia - Medication: ASA [Aspirin] - Potential for bruising and bleeding. Approach: Monitor skin for s/s [signs and symptoms] of bruising d/t [due to] ASA use. Be gentle with cares and transfers. Observation on 05/17/21 at 3:13 p.m., showed Resident #17 with two bruises on her right forearm. One bruised measured approximately the size of a quarter and the other one a little smaller. When questioned about the bruises Resident #17 stated some girl squeezed her arm too hard. Observation on 05/18/21 at 5:00 p.m., showed the same two bruises and when questioned Resident #17 stated someone grabbed her arm too tightly. During an interview on 05/19/21 at 11:00 a.m., a licensed nurse (#4) stated she would look at Resident #17's arm. A few minutes later the nurse (#4) reported the resident does have bruises, she will start an event form and notify the Unit Manager. Resident #17's medical record failed to identify the resident's bruises. During an interview on 05/19/21 at 1:10 p.m., a supervisory nurse (#6) stated she assessed Resident #17's bruises and documented the assessment. During an interview on 05/19/21 at 1:35 p.m. the nurse (#4) reported Resident #17 had a bath on Monday and she expected the bath aide to report any bruises. During an interview on 05/19/21 at 1:45 p.m., the bath CNA [Certified Nursing Assistant] (#3) stated she did give Resident #17 a bath on Monday (05/17/21) and she had the bruises. The CNA reported Resident #17 had the bruises last week on her bath. She thought the bruises were old and did not report the bruises. Resident #17's progress notes identified the following: 05/19/21 1:05 p.m. BRUISES: Charge nurse reported that resident has bruises noted to RFA [right forearm]. Writer assessed and mid [middle]-RFA two bruises measuring about 2.5 x 2 cm [centimeters] and 1.5 x 2 cm. One bruise near right elbow measures about 1 x 1 cm. All bruises purple in color. Writer asked resident if she knows how bruises occurred. Res [resident] reported that a girl grabbed her arm a long time ago. Resident unable to tell writer who or which staff member and was not clear as to what shift. Resident stated that she has not seen this girl in a long time and that she use [sic] to know her name but no longer does. Resident did not report this incident at the time of occurrence but stated that she felt the girl was 'too rough.' Writer spoke with daughter [name] and she stated that she has had no concerns with staff or anyone else being too rough with resident. She stated she noticed the bruises about 1-2 weeks ago and that she asked [resident name] about them and [resident name] stated the girl was 'just a little too tight.'. The facility staff failed to report and investigate Resident #17's suspicious bruises on the resident's right forearm.

Based on observation and staff interview, the facility failed to ensure emergency equipment remained in safe operating condition for 1 of 2 suction machines (in the supply room). Failure to ensure the suction machine remained functional in the event of an emergency could delay the availability of suction use for residents and placed residents at risk for choking and aspiration. Findings include: Observation of the suction machine stored in the supply room occurred on the morning of 05/19/21 with a licensed nurse (#4). Observation showed the licensed nurse (#4) attempted multiple times to connect the tubing to the suction machine and the collection canister and the connections did not fit. After approximately five minutes the licensed nurse went to the office of an administrative nurse (#5) and requested assistance. The administrative nurse removed a filter device connected to the machine and stated, I have no idea where this came from. The administrative nurse (#5) connected the tubing to the canister and the machine which then produced suction. During an interview on 05/19/20 at 5:20 p.m., an administrative nurse (#5) stated she still does not know where the filter device came from. The nurse confirmed the filter device caused the connections not to fit and the suction machine would not work.

1. Based on observation, record review, and staff interview, the facility failed to ensure 2 of 3 sampled residents (Resident #65 and #70) received reasonable accommodations of needs regarding the use of a palm protector and a hand splint. Failure to consistently apply a palm protector (Resident #65) and a hand brace (Resident #70) may result in the further contracture of the hand. Findings include: - Review of Resident #65's medical record occurred on all days of survey. The current care plan and the care card stated, . Palm protector to L (left) hand on during the day . Observation on all days of survey showed staff failed to provide Resident #65 with a left hand palm protector. - Review of Resident #70's medical record occurred on all days of survey. The physician progress notes [REDACTED]. The current care plan stated, . Resting Left hand splint . Observation on 09/03/19 at 5:54 p.m. showed Resident #70 in a wheelchair in the dining room. The resident did not have a left hand splint in place. During an interview on 09/05/19 at 11:58 a.m., an administrative staff member (#8 ) confirmed Resident #65 and #70 needed to wear the palm protector and hand splint as per the care plan. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 08/23/18. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide reasonable accommodation of needs regarding call lights for 1 of 19 sampled residents (Resident #6). Failure to place Resident #6's call light within reach may result in an inability to call for help, discomfort, incontinence, and skin breakdown. Findings include: Review of the facility policy titled Accommodation of Needs occurred on 09/05/19. This policy, dated 08/28/18, stated, Policy: The facility . will evaluate and make reasonable accommodations for the individual needs and preferences of a resident . Procedure: 1. The facility will make reasonable accommodations to individualize the resident's physical environment . This includes such things as keeping the call light within reach . Observation on 09/03/19 at 5:11 p.m. showed two certified nursing assistants (CNA) (#6 and #7) entered Resident #6's room to provide cares. The resident verbalized frustration that he could not find the call light. One of the CNAs (#7) found the call light at the end of the bed, which the resident could not reach. This CNA apologized to the resident that the call light was not in reach. Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #6 required extensive assist of two persons with bed mobility and totally dependent on two persons for transfers and toileting. Resident #6's current care plan stated, I have ADL (activities of daily living) self care deficit . Keep call light in reach at all times. Review of nursing progress notes identified the following: 01/31/2019 at 12:30 a.m. Resident alert and orientated to person. Resident . is very worked up about not getting his HS (bedtime) meds and not being able to reach call light. Tylenol will be given to aid in sleep and to help calm him down. 01/31/2019 at 12:43 a.m. Sleep: Resident worked up about not being able to get to his call light, clipped to (Right) side rail, . Pillow was behind his back and he was lying on his left side so he was having a hard time reaching the call light. Repositioned him in bed and clipped call light onto house gown up by his chest. Writer asked him if he would like some Tylenol to help calm him down so he could sleep, he agreed; 650 mg (milligrams) Tylenol given at this time. Writer did sit with him for a bit and listened to him and held his hand. He said thank you. During an interview on the morning of 09/05/19, an administrative nursing staff member (#1) confirmed staff should place call lights in reach for residents to use.

Based on observation, record review, review of facility audit form, and staff interview, the facility staff failed to offer fluids to 2 of 4 sampled residents (Resident #9 and #21) who required staff assistance for fluid intake and are at risk for dehydration. Failure to provide assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: Review of the facility form titled Resident Care Audit occurred on 09/05/19. This undated form stated, . Resident cares: . Fluid offered before leaving room. - Review of Resident #9's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. The current care plan stated, . Nutritional Status . extensive assist of one - vision is poor . Potential for infection R/T (related to) indwelling catheter . encourage fluids . Observation on 09/03/19 at 5:35 p.m. showed two certified nursing assistants (CNAs) (#2 and #3) repositioned Resident #9 in bed. Staff failed to offer fluids before or after cares. Observation on 09/04/19 at 7:51 a.m. showed two CNA's (#4 and #5) transferred Resident #9 from the bed to wheelchair using a full body mechanical lift. Staff failed to offer fluids before or after cares. During an interview on 09/05/19 at 10:22 a.m., an administrative nurse (#1) stated offering fluids with cares is part of the CNA Resident Care audit that is completed annually for all CNAs, and she expected staff to offer fluids with all cares. - Review of Resident #21's medical record occurred on all days of the survey. The current care plan stated, . Encourage fluids . Extensive to total assist of 1 with eating . Observation on 09/03/19 at 3:16 p.m. showed two CNAs (unidentified and #9) provided cares to Resident #21 and failed to offer fluids during or after cares. Observation on 09/03/19 at 5:19 p.m. showed two CNAs (unidentified and #10) provided cares to Resident #21 and failed to offer fluids during or after cares. During an interview on 09/05/19 at 11:20 a.m., an administrative nurse (#1) stated she expected staff to offer fluids to residents with all cares.

Based on observation, review of the facility policy, review of a cleaning log, and staff interview, the facility failed to prepare and serve food in a sanitary manner in 1 of 1 kitchen. Failure to ensure the cleanliness of food preparation and storage areas has the potential to result in foodborne illness to resident, staff, and visitors. Findings include: Review of the facility policy, DIETARY DEPARTMENT EQUIPMENT AND UTENSILS occurred on [DATE]. This policy, revised ,[DATE], stated, To prevent cross contamination . surfaces of equipment must be washed, rinsed, and sanitized . surfaces of all cooking equipment must be kept free of encrusted grease deposits and other accumulated soil . devices to prevent grease . from dripping into food . to be maintained in a clean and sanitary condition . equipment must be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris. A final tour of the kitchen occurred on [DATE] at 9:33 a.m. Observation showed a dusty and encrusted greasy fan blowing air onto food being prepared. During an interview, the dietary supervisor (#2) stated she expected the staff to clean the fans. When asked how often staff clean equipment, the dietary supervisor (#2) stated staff clean daily and weekly and provided a cleaning log for (MONTH) (YEAR) which identified staff inconsistently initialed the log on numerous occasions. Failure to ensure cooking equipment is free from dust/debris increased the risk for contamination and may affect all residents who consume food prepared or served in the kitchen. Continued observation of the kitchen showed three buckets of sanitizer throughout the kitchen/dining area. A dietary supervisor (#2) identified the solution as Oasis 146 Quat and stated staff use Hydrion test strips to test the quat solution. The Hydrion strips available for staff to use to test the solution were outdated with the following dates: [DATE], [DATE], [DATE]. During an interview on [DATE] at 9:38 a.m., two dietary staff members (#2 and #5) confirmed the test strips were outdated. Use of expired quat testing strips may result in a sanitizer concentration that is either too weak to sanitize kitchen surfaces or too strong, which may be unsafe or toxic.

Based on observation, record review, and staff interview, the facility failed to provide reasonable accommodation of needs regarding call lights for 1 of 4 sampled residents (Resident #7) observed requiring toileting assistance. Failure to place Resident #7's call light within reach may result in an inability to call for help, discomfort, incontinence, and skin breakdown. Findings include: Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #7's current care plan stated, . Resident continues to be extensive assist with mobility and transfers . does not ambulate and uses wheelchair for locomotion . requires extensive assist with cares . use of stand/lift for all transfers-use leg strap to keep LE's (lower extremities) stable in lift . keep call light in reach at all times . Observation on 08/22/18 at 5:36 p.m. showed Resident #7 lying in his bed. The call light was located next to the wall and not within reach. During an interview on 08/22/18 at 5:37 p.m. Resident #7 stated he has been unable to reach his call light since he was laid down at approximately 1:30 p.m. The resident stated this happens a few times a week and he ends up having to call out for help. During an interview on 08/22/18 5:39 p.m., an activity staff member (#3) agreed the call light should be within reach. During an interview on 08/22/18 at 5:46 p.m., an administrative nurse (#1) stated caregivers need to make sure the call lights are placed within reach.

Based on observation, record review, review of facility policy and procedure, and staff interview, the facility failed to follow professional standards for 1 of 1 supplemental resident (Resident #83) observed receiving the wrong medication dosage during medication administration. Failure to follow the Five Rights of Medication Administration placed all residents at risk for medication errors. Findings include: Review of the facility's policy and procedure titled Medication Administration occurred on 08/22/18. This policy, revised (MONTH) (YEAR), stated, . 3. Prepare medication for administration, using these rules: a. Observe the Five Rights of Medication Administration . iii. Right dosage. Observation during medication administration on 08/22/18 at 8:05 a.m. showed a nursing staff member (#6) prepare medications for Resident #83. The nurse (#6) prepared [MEDICATION NAME] 8.6-25 milligrams (mg) from a stock medication bottle. Review of the electronic Medication Administration Record [REDACTED]. The nurse reviewed the order and the medication bottle and confirmed [MEDICATION NAME] S (Plus) as the correct medication, and stated she had administered the incorrect dose on previous occasions. Review of Resident #83's medical record occurred on 08/22/18 and identified [MEDICATION NAME] S (8.6-50 mg) ordered daily. During an interview on 08/22/18 at 11:15 a.m., a nurse manager (#1) agreed the nurse failed to ensure the correct dose of [MEDICATION NAME] S was administered to Resident #83.

Based on observation, record review, review of facility policy, operator's instructions, and staff interview, the facility failed to ensure a resident received adequate supervision/assistance to prevent accidents for 1 of 1 sampled resident (Resident #48) observed utilizing a mechanical lift with a seat sling for transfers. Failure to ensure proper use of the stand-lift and seat sling resulted in Resident #48 experiencing discomfort and possible injury/bruising. Findings include: Review of the facility policy titled Mechanical E-Z standing Lift occurred on 08/23/18. This policy, revised (MONTH) 2005, stated, . To provide a safe means of transferring to prevent injury to resident's . Refer to Owner's Manual for specific lift usage. Review of the EZ Way Smart Stand . Operator's Instructions occurred on 08/23/18. These instructions stated, The Seat Strap is used for additional lower body support . Extend the Seat Strap to its fullest length. Attach the loops at the end of the Seat Strap to the same hooks the harness is attached to, located at the top ends of the EZ Way Smart Stand arms. Make sure the Seat Strap is loosely placed on the backside of the patient. NOTE: The Seat Strap is not a lifting accessory and should not be so taut as to lift the patient during the raising or lowering activity. Slide the Seat Strap under the patient's buttocks. An observation on 08/21/18 at 10:25 a.m. showed two certified nurse aides (CNAs) (#7 and #8) transferred Resident #48 to the commode from the recliner chair utilizing the EZ stand (mechanical stand lift) and the seat sling. The CNAs placed the seat sling's strap on the outside of the resident's hands/wrists/forearms where it rubbed during transfer. The CNAs lowered the resident onto the commode while the seat sling remained tight. When the CNAs attempted to loosen the strap the resident verbalized (ow) pain. After toileting, the CNAs transferred the resident back into the recliner with the seat sling still in place. One CNA (#8) pulled the sling from under the resident's buttocks/thighs and stated the sling should have been removed before the resident sat down, because pulling the sling from under the resident might cause injury from friction/shearing. Observation before the transfer showed Resident #48 had a large purple/bluish bruise on her left forearm and a small bruise on the top of her right hand. Resident #48's current care plan stated, . Transfers: ext (extensive) assist and s/l (stand lift) with 2 - use buttock strap for transfers if res (resident) not assisting with it. Review of Resident #48's progress notes identified the following: * 08/18/2018 6:49AM Skin: CNA noticed 3 small scratches to the back of res (resident) rt (right) thigh. * 08/19/2018 3:30AM Bruise: 13cm (centimeters) x (by) 14cm purple bruise noted to (L) (left) forearm. Origin unknown. * 08/22/2018 3:40AM Pain: Resident yelling out at 0315 (3:15 a.m.) c/o (complained of) pain in L) arm . * 08/22/2018 4:15AM Bruises: RFA (right forearm) measuring 5 x 5.6 cm area that is reddish/blue with a 0.8 x 1 cm area that is black/blue. This smaller black/blue bruise is within the larger reddish/blue area. Dorsum of R) hand; measuring 3.4 x 3 cm and is black/blue . CNA noted the bruises while assisting resident during toileting rnds (rounds) during the night; unknown as how resident obtained these bruises. During an interview on the afternoon of 08/22/18, a nurse manager (#1) stated she had just finished the incident investigations for Resident #48's bruises and scratches. The nurse (#1) indicated the incorrect use of the EZ stand with seat sling may have caused the bruises, and the scratches may have been from turning the resident from side to side in bed. She also stated the seat sling belt should have been placed on the inside of the resident's arms, and the seat sling should have been removed before the resident was seated in her recliner. Facility staff failed to properly utilize the EZ stand with seat sling during Resident #48's transfer resulting in discomfort and possible bruising.