Every finding on record at Lutheran Home, The

Based on interview and record review, the facility failed to maintain a system to safeguard resident trust petty cash by commingling money from other sources with resident trust petty cash and by failing to reconcile the resident trust petty cash account. This had the potential to affect all residents whose funds were maintained by the facility. The facility census was 181.The facility did not provide a policy regarding the management, reconciliation, and safeguarding of resident trust petty cash. Observation of the resident petty cash box count and review of the petty cash log on 07/10/26 at 11:15 A.M., showed:- Administrative Assistant E counted $474.50 in resident trust petty cash. The petty cash log showed receipts totaling $435.38. The available cash and receipts did not reconcile to the expected petty cash balance of $600, resulting in a $309.88 discrepancy;- Because resident trust petty cash was commingled with nonresident funds and the account did not reconcile, staff could not accurately account for resident funds maintained by the facility. During an interview on 07/10/26 at 11:15 A.M., Administrative Assistant E said sometimes families gave money to the front desk for the family meal tickets instead of going through the business office, so it caused a discrepancy with the resident trust petty cash. The facility had a couple of events in the last month where they had more visitors which likely caused the cash box balance to be off. He/She would have to go through the receipts and find where the discrepancy was. The facility did have a system in place to keep track of the money, but the family and staff didn't all know it and just knew the visitor meal ticket money needed to be brought up to the front, which resulted in the money being put in with the resident petty cash. The facility kept $600 on hand in the resident trust petty cash. He/She filled out a paper log sheet and collected the receipts from the residents to track who received money. The business office reconciled the account periodically and replenished the petty cash box. He/She gave some cash from the box to the front desk to have on hand to give change to residents when needed. He/She would expect the cash box to contain the expected balance of $600.During an interview on 07/10/26 at 1:00 P.M., the Administrator, Director of Nursing and Assistant Director of Nursing said they would expect the resident petty cash to be balanced and the resident cash to not be comingled with other sources of money.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments accurately reflected residents' clinical status for two (Residents #12 and #18) out of 35 sampled residents. The facility inaccurately coded Resident #12 as receiving hospice services when the resident was not enrolled in hospice and inaccurately coded Resident #18 as receiving insulin during the MDS look-back period when no insulin was administered. These inaccurate assessments had the potential to affect resident care planning, quality measures, and the accuracy of federally required resident assessment data. The facility census was 181. The facility did not provide a policy for MDS accuracy. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed: - The MDS must accurately reflect the resident's status; - An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable; - Information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period). 1. Review of Resident #12's medical record showed: - admission date of 08/18/24; - Diagnoses of unspecified cirrhosis of liver (permanent scarring that damages the liver and interferes with functioning) and unspecified, chronic respiratory failure with hypoxia (lungs are not able to get enough oxygen into the blood); - The medical record contained no physician orders, hospice election statement, hospice admission agreement, or other documentation indicating Resident #12 was enrolled in hospice services. Review of the quarterly MDS dated [DATE] showed: - The resident received hospice services. Review of the resident's physician order sheet (POS), dated 06/30/26, showed: - No order for hospice services. Review of the resident's care plan, dated 07/08/26, showed: - The resident's care plan did not identify hospice services. During an interview on 07/09/26 2:07 P.M., Licensed Practical Nurse (LPN) C said Resident #12 was not receiving hospice services because the family had declined hospice. During an interview on 07/10/2026 at 11:10 A.M., MDS LPN D said hospice coding on the MDS should be determined by reviewing physician orders or confirming the resident's hospice status with nursing staff. 2. Review of Resident #18's medical record showed: - admission date of 04/12/26; - A diagnosis of type 2 diabetes mellitus (DM – metabolic disease) without complications. Review of the resident's June 2026 POS showed: - An order for metformin extended release (treats type 2 DM) 500 milligrams (mg) two tablets by mouth two times a day for DM, dated of 04/12/26; - An order for Ozempic pen-injector (treats type 2 DM) 2 mg/3 milliliters (ml) inject 0.25 mg subcutaneously (under the skin) in the morning every Tuesday for DM, dated 04/14/26; - No order for insulin. Review of the resident's MDS, dated [DATE], showed: - Received one insulin injection during the seven days look back period. Review of the resident's medication administration record (MAR), dated April 2026, showed: - The MAR documented administration of Ozempic on 04/14/26 and 04/21/26. No insulin administration was documented during the seven-day MDS look-back period; - During the MDS seven-day look-back period, the MAR documented administration of Ozempic and no insulin administration. During an interview on 07/10/26 at 12:19 P.M., MDS Registered Nurse (RN) F said Ozempic was not insulin and the MAR should be reviewed to determine medications administered during the MDS look-back period. During an interview on 07/10/26 at 1:15 P.M., the Administrator and the Director of Nursing said they would expect the MDS to accurately reflect the resident's medical record current condition.

Based on interview and record review, the facility failed to follow physician orders by failing to administer a physician-ordered as needed (PRN) antihypertensive medication when the systolic blood pressure (SBP - top number. Normal range: 90-120) exceeded the ordered treatment parameter of greater than 160 millimeters of mercury (mmHg) for one resident (Resident #173) out of 35 sampled residents. The facility census was 181.Review of the facility policy titled, Medication Transcription, undated, showed:- PRN ordered medications are administered only as needed according to a designated time frame identified in the order;- The licensed nurse assesses the resident and makes the decision when to administer the PRN medication. 1. Review of Resident #173's physician order sheet (POS) showed:- admitted on [DATE];- Diagnoses of hypertension (high blood pressure) and falls;- A physician order for hydralazine 10 milligram (mg) by mouth every eight hours PRN for SBP greater than 160 mmHg, dated 04/16/26;- A physician order to check the blood pressure every eight hours with a PRN medication available for SBP greater than 160 mmHg, dated 04/18/26. Review of the resident's medication administration record (MAR) and treatment administration record (TAR) from May 2026 - July 9, 2026 showed:- Staff failed to administer the ordered PRN hydralazine 22 out of 68 opportunities when the resident's SBP exceeded the physician-ordered parameter of greater than 160 mmHg;- For May 2026, the resident did not receive the PRN hydralazine dose for a SBP above 160 mmHg on 05/19 at 5:09 P.M., 05/21 at 5:08 P.M., 05/24 at 5:07 P.M., 05/27 at 6:21 A.M., 05/27 at 4:55 P.M., and on 05/28 at 5:06 P.M., with a total of six out of 28 opportunities missed;- For June 2026, the resident did not receive the PRN hydralazine dose for a SBP above 160 mmHg on 06/05 at 4:35 P.M., 06/06 at 5:19 P.M., 06/07 at 5:34 P.M., 06/10 at 5:00 P.M., 06/11 at 6:07 A.M., 06/15 at 4:22 P.M., 06/16 at 5:07 P.M., 06/18 at 6:12 A.M., 06/21/26 at 5:10 P.M., 06/27 at 4:53 P.M., 06/29/26 at 5:05 P.M., and on 06/30 at 5:01 P.M., with a total of 12 out of 32 opportunities missed;- For July 2026, the resident did not receive the PRN hydralazine dose for a SBP above 160 mmHg on 07/02 at 4:49 P.M., 07/03 at 5:22 P.M., 07/05 at 5:04 P.M., and on 07/07 at 5:37 A.M., with a total of four out of eight opportunities missed. Review of the resident's medical record showed:- No documentation supporting a clinical reason for withholding the physician-ordered PRN hydralazine during any of the 22 missed opportunities;- No documentation staff assessed the resident when the SBP exceeded 160mmHg;- No documentation why the hydralazine PRN dose was withheld when the SPB exceeded 160 mmHg;- No documentation why the PRN hydralazine was withheld'- No documentation the physician was notified each time the blood pressure exceeded the ordered parameter, and the hydralazine was not given;- No documentation the nurse assessed the resident and determined the hydralazine PRN dose was clinically inappropriate;- Resident with severely impaired cognition (the ability to think, remember, understand, and make decisions) that limited the resident's ability to recognize elevated blood pressure symptoms or request the ordered medication. During an interview on 07/09/26 at 1:40 P.M., LPN A said Resident #173's blood pressure often ran high and had an order to check the blood pressure three times a day. The blood pressure order was for two times on night shift and once on day shift. The resident had a PRN order if the BP got high enough and the resident did get the PRN medication several times. He/She administered the PRN hydralazine whenever the resident's SBP exceeded the ordered parameter unless a physician provided other directions. After the PRN medication was administered, he/she would recheck the blood pressure in about two hours to see if it was effective. During an interview on 07/10/26 at 10:25 A.M., LPN B said Resident #173 had an order to check his/her BP every eight hours. The resident had a PRN order if the BP got high enough. The resident did get the PRN medication often, but not every day. LPN B gave the medication as ordered and did not know why staff would not give it. Once administering the PRN medication, he/she would recheck the blood pressure in about two hours to see if it was effective. He/She would document the blood pressures in the resident's medical record. During an interview on 07/10/26 at 1:15 P.M., the Director of Nursing (DON) said she would expect a PRN order for a BP medication to be given if it was needed. She would expect the medication to be given as ordered and for there to be a follow up on the PRN medication to see if it was effective and charted somewhere in the resident's medical record where anyone could find it. Certified Nurse Assistants (CNAs) checked the vital signs which included the blood pressure. The CNAs gave the results to the nurse for the nurse to document, but the nurse could check the vital signs as well. The nurse was ultimately responsible for documenting the blood pressure results.

Based on interview and record review, the facility failed to develop and implement an individualized, person-centered care plan to address post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event) triggers and interventions for one (Resident #7) of three sampled residents reviewed for behavioral health. Although the resident had a diagnosis of PTSD, documented trauma history, and identified individualized triggers and care preferences, the facility failed to identify those triggers or interventions on the resident's care plan. As a result, staff lacked guidance to consistently provide trauma-informed care and reduce the risk of triggering the resident's PTSD symptoms. The facility census was 181.Review of facility policy titled, Care Planning - Interdisciplinary Team, undated, showed:- The planning process is to maximize and maintain each resident's optimal physical, psychosocial, and functional status;- The individualized comprehensive care plan shall include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs;- The care planning/interdisciplinary team is responsible for the periodic review and updating of care plans at least quarterly. 1. Review of Resident #7's medical record showed:- admitted on [DATE];- Diagnoses of anxiety (persistent worry and fear about everyday situations), personality disorder (long-term patterns of behavior and inner experiences that differ significantly from what is expected), disorganized schizophrenia (a subtype of schizophrenia where a person struggles primarily with disorganized thinking, speech, and emotion regulation), major depressive disorder (a serious mental health condition characterized by persistent sadness, hopelessness, and a loss of interest in activities), and PTSD. Review of the resident's Level II Screening Pre-admission Screening and Resident Review (PASRR - an in-depth person-centered assessment required for nursing facility applicants suspected of having a serious mental illness, intellectual disability, or related condition), dated 02/16/24, showed:- Diagnosis of PTSD. Review of the resident's Trauma Informed Care Screening, dated 07/15/24, showed:- Experienced physical and emotional abuse and the loss of a loved one;- No individualized PTSD triggers were identified despite the resident's diagnosis of PTSD. Review of the resident's care plan, revised 05/21/26, showed:- The care plan did not identify the resident's individualized PTSD triggers, preference for female caregivers, or individualized interventions to prevent exposure to known psychological triggers and minimize emotional distress;- Because the resident's individualized PTSD triggers and preferred interventions were not included in the care plan, staff responsible for providing daily care were not given direction to consistently avoid known triggers or implement trauma-informed interventions. During an interview on 07/09/26 at 9:13 A.M., Resident #7 said exposure to certain men's cologne, men's body odor, and visible hair on men's arms or hands triggered PTSD symptoms. Resident #7 said he/she preferred receiving care from female staff members because those triggers caused emotional distress.Review of the resident's individualized trauma-informed care screening, dated 07/15/24, documented a history of physical and emotional abuse and the loss of a loved one. However, the screening did not identify the resident's individualized PTSD triggers or preference for female caregivers. Despite the resident identifying those specific triggers during interview, the individualized triggers were not reflected on the trauma-informed screening or incorporated into the resident's care plan.During an interview on 07/14/26 at 1:57 P.M., Social Worker (SW) G said the trauma informed care screening was completed on admission or if he/she were made aware of any changes for a resident. During an interview on 07/14/26 at 2:09 P.M., Registered Nurse (RN) H said he/she was involved in the care planning process. The information for residents with PTSD was collected from the resident or the resident's family. He/She said PTSD triggers and interventions should be listed on the care plan. During an interview on 07/10/26 at 1:15 P.M., the Administrator and the Director of Nursing said residents diagnosed with PTSD should have individualized triggers and interventions identified and incorporated into the care plan.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #76) out of 32 sampled residents and one resident (Resident #170) outside the sample. The facility's census was 163. The facility did not provide a policy. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section O0110K1, Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions; - Section J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services; - Section A2105: Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. 1. Review of Resident #76's medical record showed: - An admitted [DATE]; - Diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), and chronic kidney disease, stage two (the kidneys are damaged and can't filter blood the way they should); - admitted to hospice on 01/12/24; - A quarterly MDS assessment, dated 10/16/24, with Section J1400 Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? marked no; - A quarterly MDS assessment, dated 01/30/25, with Section O0110K1 marked no for hospice care. 2. Review of Resident #170's medical record showed: - An admitted [DATE]; - Diagnoses of syncope (fainting or sudden temporary loss of consciousness) and collapse (to fall down), orthostatic hypotension (low blood pressure that happens when standing up from a sitting or lying down position) and pulmonary embolism (a blood clot in the lungs causing sudden shortness of breath and chest pain); - Resident was discharged to an assisted living facility/community on 01/29/25; - A discharge MDS assessment, dated 01/29/25, with Section A2105 marked discharge to hospital. During an interview on 03/28/25 at 2:37 P.M., the MDS Coordinator said she would expect the MDS assessments to accurately reflect the condition of the resident and/or the correct discharge/transfer status. If a resident is transferred to an assisted living, the MDS should show discharged to community. During an interview on 03/28/25 at 3:29 P.M., the Administrator and Director of Nursing said they would expect the MDS assessments to accurately reflect the condition and the discharge/transfer location of residents. 46460

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices when staff failed to perform hand hygiene during perineal care (peri care - cleaning the genital and anal area) and catheter (a tube that is inserted into the bladder, allowing urine to drain freely) care for one resident (Resident #67) out of 32 sampled residents and one resident (Resident #15) outside the sample. The facility also failed to wear proper Personal Protective Equipment (PPE) for Enhanced Barrier Precaution (EBP) during care for two residents (Resident #100 and #131) out of 32 sampled residents. The facility's census was 163. Review of the facility's policy, Handwashing/Hand Hygiene, undated, showed: - The facility recognizes that handwashing is the most effective measure for the prevention of infection and cross-contamination. All staff is to understand the importance of handwashing, knows when handwashing is indicated and knows how their hands can be washed when limited resources are available; - The purpose of this procedure is to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections; - Good handwashing behavior improves the quality of services. It reduces the chance of infection to staff and residents; - The use of gloves does not replace handwashing; - When to wash hands: When hands are visibly soiled, Before and after entering isolation precaution setting, Before and after assisting a resident with personal care, After handling soiled or used linens, dressings, bedpans, catheters, and urinals, Before and after assisting a resident with toileting, After removing gloves; - Staff may use hand sanitizer or antiseptic towelettes in between washing when not coming in contact with bodily fluids and or between glove changing, then as soon as possible, rewash hands with soap and running water. Review of the facility's policy, Using Gloves, undated, showed: - All employees are to protect the residents and themselves from contamination. Gloves should be worn when it can be reasonably anticipated that the employee may have contact with blood and other body fluids, excretions, secretions, tissues, mucous membranes, and non-intact skin. Gloves do not replace handwashing. Hands must be washed with soap and running water before and after any resident care; - Non-sterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment or services to the resident and when cleaning contaminated surfaces; - Wash hands after removing gloves (Note: Gloves do not replace handwashing); - Change gloves as often as necessary when grossly contaminated with excretions or when torn; - Gloves should be worn when handling blood specimens, blood soiled items, body fluids, excretions and secretions as well as surfaces, materials and objects exposed to them. Example: Cleansing excrement from residents and when handling or touching contaminated items or surfaces. Review of the facility's policy, Perineal Care, undated, showed: - Perineal care is very important in maintaining the residents' comfort. More frequent care is required for residents who are incontinent or those who have an indwelling catheter. Make every effort to respect the modesty of residents and be gentle when cleansing this sensitive area; - The purpose of peri care is to cleanse the peri area for the resident who is unable to or has difficulty with adequately cleaning self; prevents skin breakdown of peri area; prevents itching, burning, and odor; and prevents infection; - For a female resident: wet washcloth and apply soap or use cleansing wipes; wash perineal area, wiping from front to back; separate labia (folds on either side of the vagina) and wash area downward from front to back; continue to wash the perineum moving from the inside outward to and including thighs, alternating from side to side, and using downward strokes; (Note: if the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter); allow the area to dry; instruct or assist the resident to turn on her side with her top leg slightly bent, if able; wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttock; dry area thoroughly; expose peri area. Gently wash the inner legs and outer peri area along the outside of the labia. Note: Wash from front to back to prevent spreading fecal matter from anal area to vagina or urethra (opening to bladder). Always be very gentle when washing the area; - For a male resident: Wet washcloth and apply soap or use cleansing wipes; wash perineal area starting with urethra and working outward. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area); wash and rinse urethral area using a circular motion; continue to wash the perineal area including the penis, scrotum (a pouch of skin containing the testicles) and inner thighs; thoroughly rinse perineal area in same order, using fresh water and clean washcloth. (Note: if the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter); gently dry perineum following same sequence; instruct or assist the resident to turn on his side with his upper leg slightly bent, if able; wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks; and dry area thoroughly; - Discard disposable items into designated containers; - Remove gloves and discard into designated container. Wash and dry your hands thoroughly; - Reposition the bed covers. Make the resident comfortable; - Place the call light within easy reach of the resident; - Clean the bedside stand; - Wash and dry your hands thoroughly. Review of the facility's policy, Transmission-Based Precautions, undated, showed: - Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. They are based on the principle that that all blood, body fluids, secretions and excretions may contain transmissible infectious agents; - Enhanced Barrier Precautions (EBP) expand the use of gown and gloves beyond standard precautions and was implemented with the goal of reducing the transfer of multi-drug resistant organisms in the long-term care setting; - Transmission based precautions should only be in place for a duration of time, while EBP can remain in place indefinitely if criteria for use is met; - Proper hand hygiene remains the key preventive measure, regardless of type of transmission-based precautions employed; - The proper use of PPE as a barrier to prevent exposure to any body fluids (whether known to be infected or not); - [NAME] gloves (clean, non-sterile) as outlined: Prior to any contact with body secretions/excretions, performing treatments, personal care; change gloves after providing care and when transitioning from soiled to clean; Remove gloves before leaving the room and perform hand hygiene; After removing gloves and performing hand hygiene, do not touch potentially contaminated environmental surfaces or items in the resident's room. If so, repeat hand hygiene prior to exiting; - It is essential to communicate precautions to all health care personnel, and for personnel to comply with requirements to help minimize the transmission of infections within the facility; - A sign will be used to alert staff and visitors of precautions; - Enhanced Barrier Precautions involve the application of gown and gloves prior to performing high-contact resident care activities for residents known to be colonized or infected with a Multidrug Resistant Organism (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with chronic wounds defined as three months or longer or indwelling medical devices); - High-contact resident care activities include dressing, bathing/showering, transferring, personal hygiene, changing linens, device care or use (central lines, urinary catheters, feeding tubes, and wound care); - Residents will be not isolated in their rooms. Signage will be placed on the door alerting staff that EBP precautions are in place. PPE will be placed outside of the room or in closet within the unit with hand sanitizer available for staff use. Soiled linen/biohazards bins will be implemented for residents with an active MDRO infection/colonization in an area that involves secretions or excretions. 1. Observation of peri care for Resident #15 on 03/28/25 at 1:00 P.M. showed: - The resident lay in bed. Without performing hand hygiene, Certified Nurse Aide (CNA) F and CNA G donned gloves and pulled the resident's pants down; - CNA F held and positioned the resident while CNA G wiped fecal matter from the resident's peri area and buttocks, using a new wipe each time; - Without changing gloves or performing hand hygiene, CNA F and CNA G put a clean brief on and pulled the resident's pants up; - CNA G moved the mechanical lift and the resident's wheelchair with the same soiled gloves; - CNA G handed the remote for the mechanical lift to CNA F, who had removed gloves and did not perform hand hygiene; - CNA F then used the remote to lower the resident while CNA G removed gloves and, without performing hand hygiene, held the mechanical lift sling to position the resident as the resident was lowered into the wheelchair and CNA G put his/her right hand on the resident's forehead for protection from the lift; - CNA F obtained a hairbrush and brushed the resident's hair, smoothing the resident's hair with his/her hand, then touched the privacy curtain to get the resident's call light, and clipped the call light to the resident's shirt. During an interview on 03/28/25 at 1:12 P.M., CNA F said he/she should do hand hygiene before and after care. He/She carries sanitizer in his/her pocket all the time. During an interview on 03/28/25 at 1:24 P.M., CNA G said he/she does hand hygiene before and after care. He/She doesn't really do hand hygiene at any other time during care. 2. Observation of peri care and catheter care for Resident #67 on 03/28/25 at 1:20 P.M. showed: - CNA H and CNA I sanitized hands and donned gowns and gloves in the hall; - CNA H rolled the resident onto his/her left side. CNA I wiped fecal matter from the resident's buttocks using multiple disposable wipes. CNA I wiped visible fecal matter off of his/her right glove with a wipe, then finished cleaning the resident's buttocks; - With the same soiled gloves, CNA I rolled up a new bed pad to put under the resident, rolled the resident, then CNA H pulled the soiled pad out from under resident and unrolled the clean pad under the resident and CNA I positioned the resident on his/her back; - CNA H wiped around the resident's catheter insertion site with a disposable wipe, using a new wipe each time; - CNA H reached into the wipes container and the remaining wipes all came out; - CNA H then laid the wipes he/she had taken out of the container on the resident's bedside table with no barrier, then wiped with them, and folded the last wipe before he/she wiped the resident's catheter insertion site; - CNA H and CNA I removed gloves and washed hands. CNA I rolled the resident to the left to place a clean brief underneath the resident, then rolled the resident back and secured the brief; - CNA H and CNA I washed hands and both left the room with the trash. During an interview on 03/28/25 at 1:40 P.M., CNA H said he/she should wash or sanitize before and after care and when going from dirty to clean. During an interview on 03/28/25 at 1:43 P.M., CNA I said he/she messed up today. He/She should have removed gloves after wiping the resident's bowel movement and washed hands. He/She should wash or sanitize before and after care. 3. Review of Resident #100's medical record showed: - admitted [DATE]; - Diagnoses of Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills), congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly, leading to a buildup of waste and fluid in the body), generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things), and seizures (sudden, temporary, bursts of electrical activity in the brain that change or disrupt the way messages are sent between brain cells). Review of the resident's Physician's Order Sheet showed: - An order for wound care to coccyx (tailbone), cleanse with stock wound cleaner, apply collagen pad (encourages the body to heal wounds quickly and effectively) to wound bed, apply skin prep (used to apply a protective film over skin that helps to prepare it for adhesives) to wound area and cover with foam dressing (a dressing that helps maintain a warm, moist wound environment that encourages proper healing) every other day, dated 02/24/25; - An order for wound care to the left heel, cleanse with stock wound cleaner, apply calcium alginate (dressing that promotes healing by preserving moisture in the wound area) cut to fit wound bed, apply skin prep to skin around wound, and cover with foam dressing every day and as need for soiling and dislodgement, dated 03/11/25. Observation on 03/28/25 at 10:45 A.M. of Resident #100's peri and wound care showed: - Registered Nurse (RN) E washed hands and donned gloves; - Without donning a gown, RN E performed wound care to the resident's left heel and coccyx; - Without donning a gown, RN E performed peri care to the resident; - Resident #100 did not have an EBP sign on his/her door or EBP supplies available outside or near his/her door. During an interview on 03/28/25 at 1:15 P.M., RN E said gowns should be worn for residents on EBP. During an interview on 03/28/25 at 1:17 P.M., RN J said he/she is responsible for putting out EBP signage and supplies. RN J said Resident #100 was not on EBP because his/her wound is not infected or draining. 4. Observation of suprapubic catheter (SPC - a type of urinary catheter inserted through a small incision in lower abdomen, above the pubic bone and directly into the bladder to drain urine) care and wound care for Resident #131 on 03/28/25 at 10:26 A.M. showed: - Registered Nurse (RN) A pushed table with barrier and supplies, including a clean, packaged gown, to Resident #131's bedside; - RN A washed hands, gloved, explained SPC care procedure, removed blanket, and pulled the resident's brief down; - RN A failed to don a gown; - RN A removed gloves, washed hands, donned clean gloves and cleaned the area around SPC with soap and water that had been placed in a small cup; - RN A removed gloves, donned clean gloves and pat-dried the area with a clean cloth; - RN A pulled the brief back up, placed soiled cloths in a plastic bag, removed gloves and washed hands; - RN A explained wound care to Resident #131 and donned clean gloves before wound care on the resident's toe; - RN A realized the gown was still in the package and donned gown; - RN A cleaned the resident's left, second toe with wound cleanser, removed gloves and washed hands; - RN A donned clean gloves, applied skin prep around wound, placed fibracol (a non-adherent, easy to remove type of dressing) dressing and two bandages; - RN A removed gown and gloves and washed hands before leaving the room. During an interview on 03/28/25 at 10:43 A.M., RN A said the EBP gowns were kept in the hall closet with the other EBP supplies because the residents are confused and get into them, if not. RN A tearfully said he/she always wears a gown and had just got ahead of himself/herself. During an interview on 03/28/28 at 3:29 P.M., the Administrator and Director of Nursing said they would expect staff to follow EBP and wear proper PPE when providing care for residents with wounds, foley catheters, suprapubic catheters, and other indwelling devices. They would also expect EBP signage and supplies to be located upon entry to the residents' rooms, and they would expect employees to perform hand hygiene during peri care and catheter care both before and after, between dirty and clean. Staff should not be touching here, there, and everywhere. When staff take gloves off, they should wash or sanitize hands. 46460 49999

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 168. Review of the facility's policy titled, Cleaning and Sanitation of Dining and Food Service Areas, dated 11/14/23, showed: - The dining service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule; - The Certified Dietary Manager (CDM)/dining service director/kitchen manager/designee will record all cleaning and sanitation tasks for the department; - All staff will be trained on the frequency of cleaning necessary; - A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed; - Staff will be held accountable for cleaning assignments. Review of the kitchen's cleaning schedule, undated, showed: - After each use: all small equipment, utensils and appliances; - Daily: exterior of dishwashers, kitchen sinks and other appliances; - Weekly: garbage containers; - Twice per month: ice machines, ovens, cabinets and drawers; - Monthly: clean behind and under major appliances. Observations on 02/06/24 at 9:52 A.M., 02/07/24 at 9:59 A.M., and 02/08/24 at 2:27 P.M., of the 200 Hall kitchen area showed: - A buildup of a dried white residue on the outside lid, inside lid, crevices and surface area of the ice machine; - A buildup of a dried white grime on the upper part of the left and right-side corner crevices of the ice dispenser machine located in the steam table serving area; - A buildup of a dried white residue on the bottom area and side surfaces of the ice dispenser machine located in the steam table serving area. Observations on 02/06/24 at 10:14 A.M., 02/07/24 at 9:53 A.M., and 02/08/24 at 2:38 P.M., of the 300 Hall kitchen showed: - A buildup of grime on the front surface sliding doors located by the two-compartment sink; - A buildup of grime, debris and residue on the tops and side surfaces of the dishwasher machine; - Three metal-like panels connected to the ceiling above the chemical machine with dried residue; - A white trash can with a flip lid overflowed with paper towels on the floor located under the handwashing sink; - A large gray trash can and lid with buildup of dirt and grime on the top, sides and wheels located near the handwashing sink; - A trash can with no lid with visible trash and other miscellaneous items located under the far right-side three-compartment sink counter; - A deep fryer with a buildup of dirt, debris and grime; - The robo-coup (mixer) with dirt, debris and loose French fries on the surface area under the plastic covering; - A buildup of grime and dried residue on the surface areas and backsplash of the three-compartment sink; - An opened bag of brussel sprouts in a zip lock with no date located in the left-side walk-in freezer; - An opened bag of chicken strips in a zip lock with no date or label in the left side walk-in freezer; - An opened bag of broccoli in a zip lock bag with no date located in the left-side walk-in freezer; - A buildup of a dried white residue on the outside lid, inside lid, crevices and surface area of the ice machine; - A buildup of a dried white residue on the left and right-side corner crevices of the upper area of the ice dispenser machine located in the steam table serving area; - A buildup of a dried white residue on the bottom area and side surfaces of the ice dispenser machine located in the steam table serving area. Observations on 02/07/2024 at 1:18 P.M., 02/08/2024 at 10:39 A.M., and 02/09/2024 at 9:20 A.M., of the 600 Hall dining room showed: - A buildup of dried liquid and food on the steam lid covers and surface areas located on the portable steam table; - Dirt and food debris on the floor located behind the portable steam table; - A buildup of dried liquid and food inside the microwave located near the portable steam table; - A quart-size measuring cup containing white sugar with no date, label, and uncovered located on a counter behind the kitchenette. During an interview on 02/06/24 at 9:41 A.M., Dietary Aide A said the kitchen equipment should be free of grime, dirt, debris build up and dried visible residue. Dried smears just did not look sanitary and should be wiped off better. There was a daily cleaning checklist that was completed and initialed after a kitchen task was done. Not everybody cleaned the same way and it should be consistent. The ice machine and lids should be free of dried residue and grime buildup because it could make the ice taste funny. During an interview on 02/06/24 at 3:11 P.M., the Food Services Director said he/she would expect kitchen equipment to be free of buildup of grime, dirt, debris and dried residue. He/She would expect staff to label and date frozen foods after it was opened for consumption purposes. The kitchen staff should be making sure the cleaning tasks were being done before initialing off as completed. Both kitchens in the facility should meet the same standard requirement. There shouldn't be a difference in cleaning techniques. During an interview on 02/06/24 at 3:14 P.M., the CDM said he/she would expect kitchen equipment to be free of buildup of grime, dirt, debris and dried residue. Opened foods should be labeled and dated. The kitchen staff should be making sure the cleaning tasks were being done before initialing off as completed. Both kitchens in the facility should meet the same standard requirement. The staff that worked in the 200 Hall kitchen may clean differently than the staff that worked in the 300 Hall kitchen and there shouldn't be a difference. During an interview on 02/06/24 at 3:25 P.M., the Registered Dietician (RD) said he/she would expect the kitchen equipment be free of buildup of grime, dirt, debris and dried residue. Opened foods should be labeled and have a date for consumption purposes. The kitchen staff should be making sure the cleaning tasks were being done before initialing off as completed and monitored by the CDM. Both kitchens in the facility should meet the same standard requirement. The RD said recommendations were made during weekly/monthly inspections. Any concerns were brought to the attention of the CDM and the Food Services Director to be addressed. The RD said the kitchen equipment could be cleaner. During an interview on 02/09/24 at 11:02 A.M., the Administrator said she would expect the kitchen equipment to be free of buildup of grime, dirt, debris and dried residue. Opened foods should be labeled and dated. The kitchen staff should be making sure the cleaning tasks were being done before initialing off as completed and monitored by the kitchen supervisor. Both kitchens in the facility should meet the same standard requirement.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 29 opportunities with two errors made, resulting in an error rate of 6.9% for two residents (Resident #49 and #105) out of six sampled residents. The facility's census was 168. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (Insulin in a pen-type device) instructions, revised, July 2023, showed: - Remove cap; - Attach needle; - Prime pen by turning dose selector to two units; - Hold pen with needle pointing up, press and hold button until it stops and the zero is seen in the dose window along with visible insulin at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. Review of the facility's policy titled, Administration of Insulin by Subcutaneous Injection, undated, showed it did not address insulin pens. Review of an undated letter, written by Pharmacist D, and received on 02/09/24, showed: - In terms of clinical significance, failure to prime an insulin pen would result in very little, if any, clinical impact on controlling a patient's blood sugar level; - Priming units should be required each and every time a dose is administered from an insulin pen; - Once a small bead of insulin appears at the end of the pen needle, priming should be deemed sufficient; - This instruction may or may not be always be printed on the pharmacy label but should generally be considered a best practice. 1. Review of Resident #49's Physician Order Sheet (POS), dated February 2024, showed: - An order for lispro Solution Pen 100 units per milliliter (ml) subcutaneous (an injection just below the skin) with meals per a sliding scale of blood sugar of 151-200 = 1 unit, 201-250 = 2 units, 251-300 = 3 units, 301-350 = 4 units, 351-400 = 5 units, 401-999 = 6 units and call the medical doctor (MD), dated 02/09/22. Observation of Resident #49 on 02/07/24 at 10:40 A.M., showed: - Registered Nurse (RN) A administered two units of lispro subcutaneously per order of the sliding scale for blood sugar of 201 with the resident's lispro Flex Pen; - RN A failed to prime the lispro Flex Pen per the manufacturer's instructions prior to the administration to the resident. 2. Review of Resident #105's POS, dated February 2024, showed: - An order for lispro 100 units per ml, inject 25 units subcutaneously two times a day, dated 12/14/23; - An order for lispro 100 units per ml with meals per a sliding scale of blood sugar of 151 - 200 = 3 units, 201 - 250 = 6 units, 251 - 300 = 9 units, 301 - 350 = 12 units, 351 - 400 = 14 units, 401 - 999 = call the MD, dated 12/14/23. Observation of Resident #105 on 02/07/24 at 10:48 A.M., showed; - RN A administered 25 units of lispro, with no sliding scale, as blood sugar was below 151, with the resident's lispro Flex Pen; - RN A failed to prime the lispro Flex Pen per the manufacturer's instructions prior to the administration to the resident. During an interview on 02/07/24 at 10:55 A.M., RN A said he/she had been told it was unnecessary to prime the pen unless using a new insulin pen. During an interview on 02/07/24 at 11:00 A.M., Licensed Practical Nurse (LPN) B said she/he did not think it was protocol to prime insulin pens. During an interview on 02/07/24 at 12 :55 P.M., the Director of Nursing (DON) said the first dose from an insulin pen was primed but it wasn't necessary after that. The pharmacy told them it did not matter as the amount was so minimal. During an interview on 02/07/24 at 3:32 P.M., Pharmacist C said she/he would expect a brand new insulin pen to be primed. During an interview on 02/07/24 at 3:35 P.M., Pharmacist D said she/he would expect an insulin pen to be primed the first time, but it would depend on the manufacturer's instructions after that. The problem occurred when insurance did not cover for the primed amount with each pen use and and that could end up costing the resident out of pocket. However, the best practice would be to prime the insulin pen prior to each use to assure the correct dose was received.

Based on observation and interview, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pest out and/or to keep the garbage contained in the dumpster. The facility census was 168. The facility did not provide a policy regarding the dumpsters. Observations on 02/06/24 at 10:30 A.M., and 02/06/24 at 3:01 P.M., of the outside 200 Hall kitchen showed a two-lid dumpster with both lids opened with visible trash bags and other miscellaneous items. Observations on 02/06/24 at 10:54 A.M., and 02/06/24 at 3:18 P.M., of the outside 300 Hall kitchen, showed a two-lid dumpster with both lids opened with visible trash bags and other miscellaneous items. Observation on 02/07/24 at 10:01 A.M., of the outside 300 Hall kitchen showed a two-lid dumpster with one lid opened with visible trash bags and several broken down cardboard boxes. During an interview on 02/06/24 at 9:41 A.M., Dietary Aide A said dumpster lids should be closed after trash was placed inside for pest control purposes. During an interview on 02/06/24 at 10:34 A.M., the Food Services Director said trash dumpster lids should be closed after staff discards trash and other miscellaneous items. During an interview on 02/07/24 at 9:25 A.M., Certified Nursing Assistant (CNA) B said nursing placed the bags of trash in a designated location and the maintenance supervisor disposed the trash for them. During an interview on 02/07/24 at 9:27 A.M., Housekeeper C said the housekeeping department places the bags of trash in a designated location and the maintenance department disposed the bags of trash for them. During an interview on 02/08/24 at 9:49 A.M., the Maintenance Supervisor (MS) said there were staff designated daily to take out the trash for the facility. The dumpster lids should be closed after staff throw away trash and other discarded items. During an interview on 02/09/24 at 11:02 A.M., the Administrator said she would expect the dumpster lids to be closed at all times and after staff discarded trash and other miscellaneous items for disposal purposes.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of the advance directive (a written statement of a person's wishes pertaining to medical treatment) regarding the cardiopulmonary resuscitation (CPR) (a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped) status for one resident (Resident #105) out of 35 sampled residents. The facility's census was 178. Record review of the facility's Advanced Directive policy, undated, showed: - Do Not Resuscitate (DNR) - in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative directed no CPR or other life-saving methods to be used; - The Social Service staff will review annually with the resident their advance directives to ensure that such directives continue to be the wishes of the resident; - Changes or revocations of a directive must be submitted in writing to the facility and the facility may require new documents with any extensive changes. 1. Record review of Resident #105's face sheet showed: - An admitted [DATE]; - A code status of full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - A code status of DNR. Record review of the resident's Request Concerning Life-Prolonging Procedures, dated [DATE], showed: - No CPR. Record review of the resident's Code Status form, dated [DATE], showed: - Code status to be DNR and signed by a physician. Record review of the resident's care plan, revised on [DATE], showed: - On the top and bottom of page one, DNR hand-written and undated; - On the middle of page one, code status: full code - DNR hand-written and undated, full code - DNR marked through with error/staff initials hand-written and undated, full code hand-written again under the marked through code statuses and undated; - A code status of full code addressed under the Activities of Daily Living (ADL) self-care focus section with a revision date of [DATE]. Observation of the resident's hard chart at the nurse's station showed: - A blue sticker on the spine of the binder. During an interview on [DATE] at 2:02 P.M., Registered Nurse (RN) A said staff look at the the sticker on the binder or if the computer is unlocked, then the face sheet of a resident, to quickly see if the resident is a full code or a DNR. All documentation for the code status should match each other. The blue sticker on the binder means the resident is a full code. The profile page in the computer shows the resident to be a DNR. The care plan shows both a full code and a DNR. During an interview on [DATE] at 1:05 P.M., the Director of Nursing and the Administrator said they would expect code status orders to be documented on the resident's face sheet, POS, and the care plan. All documentation should match. The facility policy does not include using stickers to indicate a resident's code status. They would expect the wishes of the resident and/or the responsible party to be what is ordered.

Based on observation, interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, for three residents (Residents #116 and #125) out of 35 sampled residents. The facility's census was 178. 1. Record review of Resident #116's medical record showed: - An admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - No orders for an anticoagulant (medications to help prevent blood clots) medication. Record review of the resident's significant change MDS, dated [DATE], showed: - Resident received anticoagulant medication. During an interview on 4/21/22 at 9:00 AM, the MDS Coordinator said aspirin is used as a preventive. During an interview on 4/21/22 at 1:00 P.M., the DON said the MDS Coordinator is responsible for the completion and accuracy of the resident's MDS and aspirin should not be coded as an anticoagulant. 2. Record review of Resident #125's medical record showed: -An admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's POS, dated dated March and April 2022, showed: - No order for [CONDITION(S)] (process of purifying the blood of a person whose kidneys do not work normally); - Hospice care services. Record review of the resident's quarterly MDS, dated [DATE], showed: - Received [CONDITION(S)] treatments; - Did not receive hospice services. During an interview on 4/19/22 at 2:00 P.M., the Director of Nurses (DON) said the resident never received [CONDITION(S)] treatments, only hospice care services. The DON said the MDS Coordinator must have coded [CONDITION(S)] by mistake. The facility follows the Resident Assessment Instrument (RAI) manual, therefore, did not provide a policy.

Based on observation, interview, and record review, the facility failed to accurately assess for the risks and benefits for the use of side rails for one resident (Resident #142) out of 35 sampled residents. The facility's census was 178. 1. Record review of Resident #142's face sheet showed: - An admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Side Rail Evaluation, dated 4/16/21, showed: - The resident did not wish to have side rails at that time; - The facility failed to assess the resident for the use of side rails. Observations of the resident showed: - On 4/18/22 at 11:30 A.M., the resident lay in bed with both upper half side rails up; - On 4/19/22 at 10:25 A.M., the resident lay in bed with both upper half side rails up; - On 4/20/22 at 2:06 P.M., the resident grabbed onto a half side rail when assisted by the staff to turn onto his/her side; - On 4/21/22 at 8:55 A.M., the resident sat up in bed with both upper half side rails up. During an interview on 4/21/22 at 12:58 P.M., the Director of Nursing (DON) said she would expect a resident with side rails to have an assessment. Record review of the facility's Proper Use of Side Rails policy, undated, showed: - Will use side rails to treat the resident's medical symptoms and assist the resident to attain or maintain his/her highest practical physical and psychosocial well-being as requested by the resident; - Side rails will only be permissible if used to treat a resident's medical symptoms, or to assist with the mobility and transfers of a resident per the resident's request.

Based on observation, interview, and record review, the facility failed to ensure proper transfer techniques for two residents (Resident #37 and #79) out of 35 sampled residents. The facility's census was 192. 1. Record review of Resident #37's annual Minimum Data Set, (MDS) (a federally mandated assessment to be completed by the facility staff), dated 6/28/19, showed the resident required extensive assist of two or more persons for transfers. Observation on 9/25/19 at 9:15 [NAME]M., showed: - The resident sat in his/her wheelchair; - Certified Nurse Aide (CNA) I placed a gait belt (an assistive device used to help safely transfer a person) around the resident's waist; - CNA I placed one of his/her hands on the gait belt and placed his/her other arm under the resident's right arm and lifted under the arm to assist the resident to stand; - CNA M placed one of his/her hands on the gait belt and placed his/her other arm under the resident's left arm and lifted under the arm to assist the resident to stand; - CNA I and CNA M did not place both hands on the gait belt to provide a safe transfer. 2. Record review of Resident #79's significant change MDS, dated [DATE], showed the resident required extensive assist of two or more persons for transfers. Observation on 9/25/19 at 8:20 [NAME]M., showed: - The resident sat on a shower chair; - CNA H placed a gait belt around the resident's waist; - CNA I placed one hand on the gait belt, with the other arm, CNA I grabbed the resident under his/her right arm and lifted under the arm to assist the resident to stand; - CNA I placed one hand on the gait belt, grabbed the resident under his/her right arm with the his/her other arm and held under the resident's arm and lowered the resident back on the shower chair; - CNA I did not place both hands on the gait belt to provide a safe transfer. 3. During an interview on 9/25/19 at 1:40 P.M., CNA I said that both of his/her hands should have been on the gait belt when transferring the resident. He/she shouldn't have put their arm under the resident's arm to help lift the resident up. During an interview on 9/25/19 at 1:51 P.M., CNA M said he/she didn't know to put both hands on the gait belt during a two-person gait belt transfer. During an interview on 9/26/19 at 11:04 [NAME]M., the Director of Nursing (DON) said she would expect staff not to grab a resident under the arms when a gait belt transfer is performed. The staff are trained by the Physical Therapy department on proper gait belt transfers. 4. Record review of the facility's policy titled, Safe Lifting and Movement of a Resident with a Gait Belt, revised 4/2017, showed: - A gait belt will be used unless otherwise care planned; - Staff members will receive education and must pass a one and two person pivot transfer competency during the orientation process; - The policy did not address on how to transfer a resident with a gait belt.

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the spread of infection for three residents (Resident #47, #82, and #85) out of 35 sampled residents. The facility's census was 192. 1. Record review of the facility's undated policy titled Perineal Care, showed: - Wash your hands thoroughly with soap and water at the following intervals: a. Before the procedure; b. Before resuming the procedure after an interruption; c. Anytime they become soiled with blood or body fluids; d. When in doubt; e. Upon completion of your task or procedure; - Wear appropriate personal protective equipment (e.g. gloves, gown, mask, eyewear, etc) to prevent exposure to spills or splashes of blood or other potentially infectious materials; - Maintain clean techniques and isolation precaution as indicated. Record review of the facility's undated policy titled, Using Gloves, showed: - Wash hands after gloves removed; - Gloves should be removed before removing a mask and gown; - Wash hands and change gloves when more than one treatment performed on a resident; - Never do resident care below the waist and then go to the face or upper body with the same gloves; - Change gloves as often as necessary, when grossly contaminated with excretions or when torn. Record review of the Centers for Disease Control indications for hand hygiene: - Decontaminate hands before having direct contact with patients (IB) (68,400); - Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) (25.53). 2. Observation on 9/25/19 at 2:06 P.M. showed: - Certified Nursing Assistant (CNA) L wore gloves and provided peri-care for Resident #47; - CNA L wore soiled gloves and cleaned fecal material from the resident; - CNA L wore soiled gloves, touched the barrier cream tube, and applied barrier cream to the resident's buttock's: - CNA L did not change gloves or wash hands before touching the barrier cream tube and the application of barrier cream. During an interview on 9/25/19 at 2:35 P.M., CNA L said gloves should be changed between different areas and gloves should be changed if you leave the room. CNA L also said he/she should have changed gloves after peri-care and before applying the barrier cream to the resident. 3. Observation on 9/25/19 at 8:45 [NAME]M. showed: - CNA J and CNA K wore gloves and provided peri-care for Resident #82; - CNA K wore soiled gloves, touched the barrier cream tube, and applied barrier cream to buttocks; - CNA K did not change gloves or wash hands before touching the barrier cream tube, and the application of the barrier cream; - CNA J and CNA K did not wash their hands after direct care. During an interview on 9/25/19 at 1:50 P.M., CNA K said he/she should have washed his/her hands and changed gloves before applying barrier cream to buttocks. 4. Observation on 9/25/19 at 9:25 [NAME]M. showed: - CNA I wore gloves and provided front peri-care for Resident #85; - CNA I wore soiled gloves and touched the resident's clean top sheet; - CNA I did not change gloves and wash hands before touching the resident's clean top sheet. During an interview on 9/25/19 at 1:45 P.M., CNA I said he/she should have changed gloves between dirty care and before touching any clean items. 5. During an interview on 9/26/19 at 11:04 [NAME]M., the Director of Nursing (DON) said she would expect hand washing and glove change prior to applying barrier cream during incontinent care. The DON said she would expect gloves to be removed, hands sanitized and new gloves between dirty and clean areas.

Based on interview and record review, the facility failed to ensure five of five randomly selected Certified Nurse Aides (CNAs) received the required annual 12 hour resident care training including dementia training, based on performance reviews. This deficient practice had the potential to affect all residents. The facility's census was 192. Review of the CNA individual in-service records, showed the following: - CNA A, hired 8/10/15, with 7.25 hours of in-service training from 4/3/18 - 5/23/19, no documentation of a training needs assessment based on performance reviews, no documentation of dementia training; - CNA B, hired 7/23/18, with 7 hours of in-service training from 11/24/18 - 6/19/19, no documentation of a training needs assessment based on performance reviews, no documentation of dementia training; - CNA C, hired on 1/2/17, with 10.25 hours of in-service training from 3/21/18 - 5/23/19, no documentation of a training needs assessment based on performance reviews; - CNA D, hired 10/9/08, with 2.5 hours of in-service training from 6/21/18 - 5/8/19, no documentation of a training needs assessment based on performance reviews, no documentation of dementia training; - CNA E, hired 9/11/95, with 8.5 hours of in-service training from 1/31/18 - 6/18/19, no documentation of a training needs assessment based on performance reviews, no documentation of dementia training. During an interview on 9/25/19 at 4:11 P.M., the Director of Nursing (DON) said mandatory in-services are offered multiple days and times throughout the year but the facility is unable to force the CNAs to attend the in-services. The facility is moving to an on-line training program to improve compliance. During an interview on 9/26/19 at 11:04 [NAME]M., the DON and Administrator said they would expect all CNAs to receive at least 12 hours of in-service training that includes dementia care and abuse prevention training annually. Record review of the facility's undated policy titled, Orientation of Certified Nursing Aides, showed: - All newly hired nurse aides must attend an orientation program for their first three days of employment; - An introduction to resident care procedure which includes: - A review of the facility's in-service training program; - An Alzheimer's dementia/depression training; - A legal and ethical discussion regarding resident care: - Abuse and neglect reporting. The facility did not provide a policy for on-going training and in-services.

Based on interview and record review, the facility failed to revise and update comprehensive care plans with specific interventions to meet the individual needs of five residents (Resident #29, #79, #85, #87, and #90) out of 35 sampled residents. The facility's census was 192. 1. Record review of Resident #29's physician's orders [REDACTED]. - admitted on [DATE]; - Regular diet. Record review of the resident's Registered Dietician's (RD) Notes showed: - On 3/21/19, current weight 201 pounds (lbs). Weight history 210 lbs (12/18); 218 lbs (1/19); 198 lbs (2/19); weight fluctuations since admission. Resident stabilizing at current weight. Resident is inconsistent where meals are eaten. Resident's weight recorded with fluctuations in history. Weight stabilizing over time. Continue current diet regimen; - On 6/17/19, current weight 185.6 lbs. Weight history: 201 lbs (3/19); 201 lbs (4/19); 186.6 lbs (5/19). Weight loss 16 lbs in four months. Resident has had a change from one unit to another and spouse has been having difficulty which may be impacting resident. Resident is ordering full meals and consuming, but is also very active in facility, ambulating extensively throughout the day. Continue current diet regimen; - On 9/17/19, current weight 189 lbs. Weight history:185.6 lbs (6/19); 191.6 lbs (7/19); 188.4 lbs (8/19). Resident eating well. Behaviors have improved and is more cooperative. Resident's weight stable. Continue current diet regimen. Record review of the resident's care plan, last reviewed 6/26/19, showed the facility did not update the care plan to address the resident's significant weight loss and interventions. 2. Record review of Resident #79's POS, dated 9/1/19 through 9/30/19, showed: - admitted on [DATE]; - admitted to hospice on 7/19/19; - Order for high back wheelchair, (a specialized wheelchair with a higher back used for positioning), a kidney pillow (a special shaped positioning pillow) and a foot buddy (a positioning device added to the foot pedals of a wheelchair) with a start date of 8/23/19. Record review of the resident's care plan, last reviewed on 7/30/19 and updated on 8/20/19, showed the facility did not update the care plan to address the resident's high back wheelchair, kidney pillow and foot buddy and their interventions. 3. Record review of Resident #85's POS, dated 9/1/19 through 9/30/19, showed: - admitted on [DATE]; - an order for [REDACTED].>- An order to cleanse the coccyx (the tailbone) wound with hypochlorous acid (a wound disinfectant), apply skin prep (a protective barrier) to the peri-wound (skin that surrounds a wound), apply [MEDICATION NAME] (an antibiotic ointment) and Santyl (a medication used to treat wounds) to the wound bed, apply Calcium Alginate (a medication used to treat wounds), cover with a gauze pad and a super absorbent dressing, change daily and as needed, dated 9/25/19. Record review of the skin integrity initial assessment, dated 9/9/19, showed a Stage 2 pressure ulcer (a partial thickness loss of the dermis that presents as a shallow, open ulcer) to the coccyx. Record review of the resident's care plan, revised on 8/13/19, showed the facility did not update the care plan to address the resident's pressure ulcer and treatment. 4. Record review of Resident #87's POS, dated 9/1/19 through 9/30/19, showed a dietician consult due to recent weight loss of greater than 10 lbs in one month, ordered 8/26/19. Record review of the resident's RD consult and recommendations, dated 8/28/19, showed: - Restorative Aide to oversight at meals; - Convenient placement of foods and encourage resident; - Order food items easily handled and simple in content and resident preference. Record review of the resident's care plan, last reviewed 5/17/19, showed the facility did not update the care plan with the RD's recommendations. 5. Record review of Resident #90's POS, dated 9/1/19 through 9/30/19, showed: - admitted on [DATE]; - An order dated 7/9/19 for skin prep to bilateral heels twice daily; - An order dated 7/26/19 for wound care evaluation and treatment. Record review of the resident's progress notes showed: - On 7/3/19, resident with complaint of heel pain. Upon assessment, heels with no redness, not mushy and with no injury noted; - On 7/9/19, resident with complaint of heel pain. Heel remains with no redness, not mushy and no injury noted. Fax sent to physician. Order received to apply skin prep to heels twice daily; - On 7/21/19, resident admitted to hospital; - On 7/23/19, readmitted to the facility with new orders to be turned and repositioned every two hours and heel protectors while in bed; - On 7/25/19, resident has had no complaints during this shift, blister to heel still intact. Record review of the resident's care plan, last reviewed 8/14/19, showed the facility did not update the care plan to address the resident's pressure ulcer and treatment. 6. During an interview on 9/26/19 at 9:34 [NAME]M., the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility staff) Coordinator Q said he/she was unaware of Resident #85 having a wound to his/her coccyx, but it should be care planned. During an interview on 9/26/19 at 11:04 [NAME]M., the Director of Nursing (DON) said she would expect the care plan to be updated to reference a wound or pressure ulcer. The care plan should also be updated for a resident with a significant weight loss and for any specialized equipment used by the resident. The Registered Dietician (RD) is going to write her own care plans. 7. Record review of the facility's undated policy titled, Care Planning-Interdisciplinary Team, showed: - The care planning/interdisciplinary team is responsible for the periodic review and updating of care plans: - When there has been a significant change in the resident's condition; - When there is a response to care and treatment with progress towards goals; - When the desired outcome is not met; - When the resident has been readmitted to the facility from a hospital stay; - At least quarterly.

Based on observation, interview and record review, the facility failed to ensure safe transfers using a Hoyer Lift (a mechanical device used to transfer a resident from one place to another) for two residents (Residents #1 and #2) of four sampled residents. Facility staff failed to follow the manufacturer's guidelines for the Hoyer Lift which resulted in injuries to Resident #1 and a fall for Resident #2. The facility census was 200. Record review of the Hoyer Lift manufacturer's guidelines, as provided by facility staff showed to lift the patient from the bed: - Ensure the legs of the lift with patient in the sling are in the open position; - Move the wheelchair into position; - Engage the rear wheel locks of the wheelchair to prevent movement of the chair; - Do not place the patient in the wheelchair if the locks are not engaged. The wheelchair locks must be in a locked position before lowering the patient into the chair for transport, otherwise injury may result; - Use the straps or handles on the side and the back of the sling to guide the patients' hips as far back as possible into the seat for proper positioning; - Position the patient over the seat with their back against the back of the chair; - Begin to lower the patient either by opening the control valve or by pressing the boom down button; - Two assistants are recommended for this step. One assistant stands behind the chair and the other operates the patient lift. The assistant behind the chair pulls back on the grab handles or sides of the sling to seat the patient well into the back of the chair; - This will maintain a good center of balance and prevent the chair from tipping forward; - Do not lock the rear casters of the patient lift when lifting an individual. Locking the rear casters could cause the patient lift to tip and endanger the patient and assistants; - Do not move the patient if the sling is not properly connected to the hooks of the hanger bar; - When the sling is elevated a few inches off of the stationary surface and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem otherwise, injury or damage may occur; - Adjustments for safety and comfort should be made before moving the patient; - When the patient is lifted from the bed (with the patient's head supported by the sling and/or an assistance), he/she will be raised to a sitting position; - Swing the patient's feet off the bed when the patient is clear of the bed surface; - Move the patient lift away from the bed using the steering handle; - Turn the patient so that he/she faces assistant operating the patient lift when moving the patient lift away from the bed. Record review of the facility's undated policy and procedure manual for safe lifting and movement of a resident using a total assist mechanical device showed: - The use of the total assist mechanical lift must be ordered by a physician as a functional level and care planned appropriately. It is acceptable to request an order for [REDACTED].>- Two staff members must be utilized at all times for transfers involving the total assist lift unless care planned differently; - Staff members must verify the residents' weight and ensure the correct lift and sling are utilized; - Staff members will receive education and must pass the competency outlined in the user's manual prior to independent usage. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 2/11/19 showed: - Cognition impaired; - Assist of two staff for transfer and bed mobility. Record review of the most recent Physician order [REDACTED]. - [DIAGNOSES REDACTED]. and perceptions); - An order dated 1/14/19 for transfer with help of two and mechanical lift. Record review of the care plan updated on 3/29/19, showed: - At risk for falls; - Transfer with assist of two and mechanical lift. Record review of the nurse's notes showed: - On 4/4/19 the nurse was alerted the resident had a fall; - The nurse found the resident laying on the floor on his/her left side rocking back and forth with the lift pad under the resident; - The resident complained of severe back pain and shortness of breath; - The resident refused to be assessed or have vital signs performed; - The physician ordered the resident to be sent to the emergency room for evaluation of injuries; - The nurse called the hospital for updates on the resident's condition with the hospital reporting the resident was admitted to the hospital with [REDACTED]. Record review of the facility investigation dated 4/4/19, showed: - The facility investigation determined the fall was not the result of mechanical failure or inadequate equipment; - Interviews with the Certified Nurse's Aides (CNA) involved were completed; - The most plausible conclusion found from scenario re-enactments, which were based on interviews with the CNAs involved, showed one of the loops slipped out from the left/bottom of the lift resulting in the resident slipping out of the sling while suspended in air; - The facility re-educated staff on transferring techniques. During a phone interview on 4/17/19 at 1:45 P.M., CNA D stated: - He/she and CNA E had just given the resident a shower and transferred the resident back to bed using the Hoyer lift; - After dressing the resident, he/she hooked the three straps on the right side of the Hoyer and CNA E hooked the other three straps on the left side, he/she looked across the bar and believed all six hooks were in place; - As he/she began using the remote, the resident was raised in the air and when the resident's feet cleared the bed, the resident began to fall, noting the strap on the left side that holds the right leg was not in place allowing the resident to slid out of the sling; - The resident fell on his/her back from being suspended in the air landing on the Hoyer lift leg and the floor; - CNA D stated he/she could not stop or lower the Hoyer in time to keep the resident from falling; - After the resident's body hit the Hoyer legs and floor, he/she lowered the lift and un-strapped five of the Hoyer sling straps, noting the one strap on the left side was not in place; - CNA E then left the room and got help from the nurse. During a phone interview on 4/17/19 at 3:30 P.M., CNA E stated: - He/she and CNA D transferred the resident to the bed using the Hoyer lift after giving the resident a shower; - After dressing the resident for lunch, CNA D hooked one side of the sling and he/she hooked the other side, unsure if right or left side; - CNA D used the remote to lift the resident while CNA E retrieved the resident's wheelchair; - While being lifted and moved away from the bed in the Hoyer sling, the resident began to fall out of the sling; - When the resident hit the floor, he/she ran out of the room and got help. 2. Record review of Resident #2's annual MDS, dated [DATE] showed: - Cognition moderately impaired; - Total dependence of two staff for transfers. Record Review of the POS [REDACTED] Record review of the care plan updated on 3/20/19, showed: - At risk for falls; - Resident has history of kicking the mechanical lift; - If the resident kicks and pushes, staff are to stop the transfer and make sure someone is behind him/her in the chair; - When transferring the resident with the mechanical lift, staff beside the resident are to make sure tension is placed on the lift and straps are intact; - Staff to monitor positioning of the resident in any transfer per transfer training; - Staff avoid transfer in lift when the resident is agitated, allow time to calm down. Record review of the nurse's notes showed: - On 3/20/19 the nurse was called to the resident's room to find Resident #2 and the Hoyer lift on the floor; - The resident was laying on his/her back with his/her head on the dresser; - The resident was shaking from anxiety; - The resident was able to move all extremities except his/her right arm which is baseline for this resident; - Resident assisted up via a different lift from the floor and requested to be in his/her wheelchair; - No injuries at this time that are noted, will continue to monitor. Record review showed the resident weight recorded on 4/7/19 to be 345 pounds. Record review of the fall risk assessment dated [DATE] fall risk score of 10, being at high risk for falls. During an interview on 4/16/19 at 12:00 P.M., Resident #2 said he/she had been dropped out of the lift recently, so he/she was scared during transfers. Record review of the facility investigation dated 3/20/19, showed: - CNA C reported the resident was kicking at the Hoyer lift at the time of the lift tipped over; - CNA A denied the resident was kicking at the Hoyer lift at the time the Hoyer lift tipped over, reporting CNA C was maneuvering and jerking the Hoyer lift around and caused the lift to fall; - Staff were re-educated if resident demonstrates any behaviors or aggression at any time during a transfer, do not proceed with the transfer and allow the resident to calm down; - The Quality Assurance nurse performed education with the resident regarding remaining calm during transfers; - CNA C as a result is no longer employed by the facility. Observation on 4/16/19 at 2:30 P.M., showed: - Resident #2 lay on the bed in his/her room with the Hoyer sling under his/her body; - Resident #2 had a wide seat wheelchair; - CNA B positioned the Hoyer lift facing the resident's bed; -Facing the left side of the Hoyer Lift, CNA A tilted the wheelchair back to lift the front wheels over the lift's right leg. With his/her back against the wall, CNA A continued to hold the wheelchair in the tilted position, front wheels off the floor, waiting for the resident to be transferred. CNA A did not lock the wheels of the wheelchair; - CNA B standing at the front of the lift then raised the resident up in the Hoyer sling using the remote; - CNA B moved the resident in the sling sideways directing by pushing the resident with his/her hand back towards the back of the wheelchair while CNA A kept the wheelchair tilted upwards with the front wheels off the floor and in an unlocked position; - CNA B lowered the resident to the wheelchair while CNA A continued to hold the wheelchair in a tilted position with the front wheels off the ground and in an unlocked position. CNA A visibly strained to hold the wheelchair in a titled position as the resident entered the chair; - CNA B attempted to move the Hoyer lift. The right leg of the Hoyer lift hit the front wheels of the wheelchair, which were still lifted off the ground, and prevented the CNA from removing the lift; - CNA A visibly strained to tilt the unlocked wheelchair with the resident back even further for the Hoyer Lift to clear the front wheels of the wheelchair; - With CNA A tilting the wheelchair with the resident, CNA B moved the Hoyer lift: - CNA A brought the unlocked wheelchair to an upright position and the wheelchair's downward momentum allowed the front wheels to hit the floor forcefully. During an interview on 4/16/19 at 2:40 P.M., CNA A stated: - The resident's wider wheelchair will not fit far enough into the Hoyer Lift's opened position to position the resident appropriately; - Resident #2 fell a few weeks ago when CNA A used the Hoyer Lift facing forward. The resident was not properly positioned in his/her wheelchair, so he/she used his leg to push on the lift which resulted in the lift, the resident and CNA A all falling in the floor; - The resident was not injured in the fall although CNA A said he/she is receiving physical therapy over injuries received when the Hoyer lift fell sideways causing both the resident and him/herself to fall to the ground; - CNA A had not been directed by anyone to perform the transfer by tilting the wheelchair backwards or to perform the transfer without locking the wheelchair. During an interview on 4/16/19 at 2:45 P.M., CNA B stated: - He/she had not been trained to use the Hoyer lift by putting any wheelchair over the sides of the Hoyer legs or to hold a wheelchair in a tilted position before, during or after transfer; - He/she had never transferred Resident #2 before and just followed CNA A's directions. During an interview on 4/16/19 at 2:55 P.M., the Director of Nursing (DON) said she was not aware staff transferred any residents in the manner of tilting the wheelchair back without locking the wheels. The DON said the Hoyer lift was not designed to be used in such a manner and doing so was unsafe. During an interview on 4/16/19 at 3:00 P.M., the Physical Therapy Coordinator, said performing a transfer by placing a wheelchair sideways towards the lift or lifting the wheelchair wheels over the Hoyer legs is inappropriate and against the manufacture's guidelines for use. Complaint #MO 1

Based on interview and record review, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for thirteen residents (Resident #43, #52, #56, #64, #72, #107, #130, #141, #144, #151, #161, #181, and #197) out of 35 sampled residents. The facility's census was 194. 1. Record review of Resident #43's Nurses's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 05/08/18. 2. Record review of Resident #52's Nurse's Notes showed; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 2/28/18, 5/20/18, and 7/4/18. 3. Record review of Resident #56's Nurse's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 5/12/18. 4. Record review of Resident #64's Nurse's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 5/7/18. 5. Record review of Resident #72's Nurse's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 7/11/18. 6. Record review of Resident #107's Nurse's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 7/21/18. 7. Record review of Resident #130's Nurse's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 8/3/18. 8. Record review of Resident #141's Nurse's Notes showed; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 7/25/18 and 8/5/18. 9. Record review of Resident #144's Nurse's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 06/13/18. 10. Record review of Resident #151's Nurse's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 08/16/18. 11. Record review of Resident #161's Nurses Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 7/2/18. 12. Record review of Resident #181's Nurses Notes showed; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 6/14/18 and 7/12/18. 13. Record review of Resident #197's Nurse's Notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation that the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer on 06/08/18. 14. During an interview on 8/23/18 at 2:00 P.M., the Director of Nursing (DON) said they don't have a bed hold policy and don't charge for bed holds. The information is in the admission packet and gone over on admission. During an interview on 8/24/18 at 2:05 P.M., the Admissions Coordinator said residents are given the bed hold 'policy' in the admission packet (and provided an admission packet) that provides information related to the bed hold process. The resident/family has the option of requesting a bed be held when a resident is out for medical or personal reasons. If the business office believes the resident may not return, they may call the family/resident and ask what their plans are. The facility has a 30 day courtesy bed hold 'policy' and if the resident returns during that time they are given an available bed. If they want to keep the exact bed they left there is a charge. There is not a bed hold policy that is given to resident/family when the resident leaves the facility.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of possible accident hazards when medications were left unattended on one resident's (Resident #124) meal tray out of a sample of 35 residents. This practice had the potential to affect all 24 residents on the Memory Care Unit (A distinct part of the facility that cares for resident's with memory problems such as dementia.) The facility's census was 194. Record review of the facility's policy titled Medication Administration, undated, directed the staff to never leave a medication with the resident and remain with the resident while they take the medication. Observations of the Memory Care Unit dining room on 8/23/18 at 8:20 A.M., showed: - Resident #124's breakfast tray remained on the table with a medicine cup that contained three pills; - Resident #249 wandered through the dining room and reached for items on remaining breakfast trays. Record review of Resident #124's Care Plan showed: - The resident resided on the Memory Care Unit; - [DIAGNOSES REDACTED]. - Trouble remembering commands, even if understood commands. Record review of Resident #249's Care Plan showed: - The resident resided on the Memory Care Unit; - [DIAGNOSES REDACTED]. - Wanders around the facility daily; - Likes to wander and rummage. During an interview on 8/23/18 at 8:45 A.M., Dietary Staff (DS) B said he/she is the one who usually picks up the trays in the dining room of the Memory Care Unit. DS B said sometimes medicine cups containing pills are left on the meal trays and DS B notifies the nurse. During an interview on 8/23/18 at 9:11 A.M., LPN A said he/she passed medication this morning to the residents on the Memory Care Unit. Resident #124 had food in his/her mouth and could not take the medicine at that time. LPN A said the resident must have forgotten to take the medicine. During an interview on 8/24/18 at 8:45 A.M., the Director of Nursing (DON) said he/she would expect the staff to watch the residents take their medicine and should not leave the medication on the tray.

Based on observation, interview, and record review, the facility failed to verify placement of a Gastrostomy Tube ([DEVICE]) (a tube surgically placed into the stomach for administration of nutrition and medications), for one resident (Resident #188) out of 35 sampled residents. The facility's census was 194. Record review of the facility's policy titled Maintaining Patency of a Feeding Tube, undated, showed the placement should be verified before flushing [DEVICE] by injecting air into tube while listening to abdomen with a stethoscope for a bubbling sound. Record review of Resident #188's Demographics Face Sheet, showed the resident admitted to facility on 3/12/18 with [DEVICE] in place. Record review of the resident's (MONTH) (YEAR) physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. - [MEDICATION NAME] 1.5 Cal (a calorically dense, fiber fortified therapeutic nutrition which can be given through tube feeding); - Medications may be given through [DEVICE]; - (MONTH) crush medications and give through [DEVICE]; - Flush the [DEVICE] with 150 milliliters (ml) of water, every four hours. Observation on 08/23/18 at 1:00 P.M. showed Registered Nurse (RN) C did not verify the [DEVICE] placement and flushed the [DEVICE] with 50 ml of water. RN C administered crushed medications through the [DEVICE] and flushed with 150 ml of water. During an interview on 08/23/18 at 1:00 P.M., RN C said placement is usually just checked every shift and it had been checked that morning. During an interview on 08/24/18 at 2:31 P.M., the Director of Nursing (DON) said she would expect staff to follow the facility's policy with [DEVICE] placement checks prior to flushing, tube feeding, or administering medications.

Based on observation, interview and record review, the facility failed to investigate and report allegations of abuse and mistreatment of [REDACTED].#3 and #4) of eight reviewed residents. The facility did not investigate allegations on 6/24/12 related to mistreatment of [REDACTED].#4) by Certified Nurse Aide (CNA) A. On 8/20/12, staff did not investigate an allegation of mistreatment of [REDACTED]. The facility's census was 207. 1. Review of the facility's abuse and neglect prohibition policy showed it directed staff to immediately report any incident or suspected incident of abuse, immediately remove suspect from area, perform a head to toe assessment of the resident and document and notify the resident's family and physician. 2. Record review of a handwritten note located in Certified Nurse Aide (CNA) A's personnel file, dated 6/24/12, showed Licensed Practical Nurse (LPN) D reported he/she heard CNA A yelling at Resident #1, telling the resident to be quiet. Review of the resident's medical record showed no documentation of an investigation related to the allegation of verbal abuse on 6/24/12. 3. Record review of a handwritten note located in CNA A's personnel file, dated 6/24/12, showed LPN D reported he/she witnessed CNA A, unhappy that he/she had to assist Resident #3 to the toilet and said in front of the resident "this is what he/she does all night and does not do anything". LPN D noted the resident heard CNA A and shook his/her head. Review of the resident's medical record showed no documentation related to an investigation of the allegation made on 6/24/12. 4. Record review of a handwritten note located in CNA A's personnel file, dated 6/24/12, showed LPN D reported he/she witnessed CNA A sling Resident #4 into bed while assisting with repositioning. Review of the resident's medical record showed no documentation of an investigation related to the allegation of the incident on 6/24/12. 5. Review of an allegation of abuse report, dated 8/20/12, showed staff reported CNA A said he/she "fixed" Resident #2 from saying he/she was cold by turning the heat up as high as it would go, opening the curtain so the heat would blow in the resident's face and closing the door. CNA A said he/she was tired of answering the resident's call light. LPN B reported the incident to the in house Registered Nurse (RN) Supervisor. Staff did not initiate an investigation until 8/28/12. During interviews on 9/5/12 at 9:10 A.M. and 10:25 A.M., 2:00 P.M. and on 9/19/12 at 9:20 A.M., the Administrator said during the investigation of the abuse allegation related to another resident being slapped by CNA A on 8/21/12, it was found that the RN Supervisor had been made aware of the incident concerning Resident #2 but did not investigate or remove CNA A from the facility. The Administrator said, although he reported the allegation of abuse of the other resident to the police, he did not report the allegation of the abuse of Resident #2. During an interview on 9/5/12 at 1:00 P.M., the RN supervisor said he/she knew the incident with Resident #2 was abuse when notified by LPN B but did not initiate an investigation or remove CNA A from the facility because he/she was busy. 6. Record review a nurse's note, dated 8/21/12, showed that at 7:30 A.M., staff reported Resident #1 had a bruise on the right side of the face. The resident said someone hit him/her during the night. Observation and interview on 9/5/12 at 8:35 A.M. showed Resident #1 said he/she could not recall staff's name but "that girl" wanted him/her to get out of bed faster. When the resident couldn't, the girl slapped him/her, open-handed, across the face. Resident #1 touched his/her opened hand to the right side of his/her face. The resident said it hurt and he/she didn't deserve to be slapped as he/she went as fast as he/she could. During an interview on 9/5/12, the DON said the resident had a deep purple irregular shaped bruise on the right cheekbone. The resident said that the girl slapped him/her due to not being quick enough when getting up. The facility determined that CNA A slapped the resident. During interviews on 9/5/12 at 9:10 A.M. and 10:25 A.M. and 2:00 P.M. and on 9/19/12 at 9:20 A.M., the Administrator said during the investigation of the abuse allegation related to Resident #1 being slapped by CNA A on 8/21/12, it was found that the RN Supervisor had been made aware of an allegation of abuse concerning CNA A earlier in the evening (8/20/12) but did not investigate or remove CNA A from the facility. During the facility's investigation, they found that there had been previous allegations against CNA A on 6/24/12 but that the former DON did not initiate an investigation. During an interview on 9/5/12 at 9:25 A.M., the DON said that the RN Supervisor had been made aware of the incident concerning Resident #2 but allowed CNA A to continue working which led to Resident #1 being slapped by CNA A. During the investigation, the DON became aware of incidents in June, 2012 in which CNA A had been reported as mistreating and/or being rude to residents. The facility did not investigate these allegations. During an interview on 9/5/12, LPN D said on 6/24/12, said he/she had previously reported CNA A's actions on 6/24/12 but no one investigated the report. During an interview on 9/20/12 at 12:47 P.M., the Administrator said CNA A had been arrested and charged with elder abuse. Complaints MO , MO , MO , MO and MO

Based on observation, interview and record review, the facility failed to provide an environment free of verbal and physical abuse for four (Residents #1, #2, #3 and #4) of eight reviewed residents. The facility's census was 207. 1. Review of the facility's Abuse and Neglect prohibition policy showed staff directed to; immediately report any incident or suspected incident of abuse, immediately remove suspect from area, perform a head to toe assessment of the resident, and document and notify the resident's family and physician. 2. Review of Resident #2's face sheet, showed the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), a federally mandated instrument required to be completed by facility staff, dated 6/19/12, showed staff identified the resident as cognitively intact and required assistance with transfers and locomotion. Review of the care plan, updated 6/27/12, showed staff identified the resident required assistance with transfers, received a diuretic (increases the production of urine and assists in decreasing fluid retention) and had a history of [REDACTED]. Review of a Registered Dietitian's (RD) note, dated 8/14/12, showed the resident had been identified at risk of dehydration due to poor fluid intake. Review of an allegation of abuse report, dated 8/20/12, showed staff identified Certified Nurse Aide (CNA) A turned the heat up to 90 degrees Fahrenheit (?F) in the resident's room and closed the door, leaving the resident in his/her room because the resident kept using his/her call light and reported being cold. Review of nurses' notes, dated 8/28/12, showed staff did not assess the resident following the allegation of abuse on 8/20/12 until 8/28/12. On 8/28/12, the resident had no signs of distress and said he/she did not recall the incident. Staff first notified the next of kin at that time. Staff did not document notification of the physician. During interviews on 9/5/12 at 9:25 A.M. and 9/19/12 at 9:20 A.M., the Director of Nursing (DON) said, while investigating an allegation of the abuse of another resident which occurred on 8/21/12, she found out that on 8/20/12, CNA A turned the heat up to 90?F and left the resident in his/her room. Licensed Practical Nurse (LPN) B reported the incident to the Registered Nurse (RN) Supervisor who did not initiate an investigation or remove CNA A from the facility. The facility did not assess the resident or notify the resident's next of kin until 8/28/12. During an interview on 9/5/12 at 10:43 A.M., Resident #2 said one girl came into his/her room and "turned the heat up high." During an interview on 9/5/12 at 11:06 A.M. LPN B said he/she told CNA A to answer Resident #2's call light. CNA A later told LPN B that the resident reported being cold so he/she "fixed' the resident by turning the heat as high as it would go, opening the privacy curtains so the heat would blow in the resident's face and shutting the door. CNA A said he/she was tired of answering the resident's call light. Certified Medication Technician (CMT) J checked the resident's closed room and found the thermostat set on 90?F. The resident was sweating and yelling it was hot. LPN B reported the incident to the in house RN Supervisor who told LPN B to write a note and turn it in but did not remove CNA A from the facility. During an interview on 9/5/12, the RN Supervisor said when LPN B reported the incident, he/she knew that abuse occurred. The RN Supervisor told LPN B to do a write up but did not initiate an investigation or remove CNA A from the facility because he/she "was busy." During an interview on 9/5/12 at 1:25 P.M., CMT J said he/she heard Resident #2 screaming "help me" from his/her room. CMT J opened the resident's door and "heat hit me in the face." The resident sat in his/her wheelchair with the privacy curtain pulled open and the door shut. The resident was sweating. CMT J checked the temperature of the room and the thermostat read 90?F. During an interview on 9/19/12 at 9:30 A.M., the Administrator said he did not report the allegation of abuse by CNA A to Resident #2, to the police department. 3. Record review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed staff identified the resident had short and long term memory problems and required extensive assistance with care. Review of a handwritten note located in CNA A's personnel file, dated 6/24/12, showed LPN D reported he/she heard CNA A yelling at Resident #1, telling the resident to "be quiet." Review of the resident's medical record showed no physical assessment and no notification of the physician or next of kin. 4. Record review of Resident #3's face sheet showed the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS, dated [DATE], showed the resident had severe cognitive impairment, a history of falls and required assistance with toileting. Review of a handwritten note located in CNA A's personnel file, dated 6/24/12, showed LPN D reported he/she witnessed CNA A, "unhappy" that he/she had to assist Resident #3 to the toilet, and said in front of the resident, "this is what he/she does all night and does not do anything." LPN D noted the resident heard CNA A and shook his/her head. Review of the resident's medical record showed no physical assessment and no notification of the physician or next of kin. During an interview on 9/15/12, the resident said he/she did not remember the incident. 5. Record review of Resident #4's face sheet showed the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS, dated [DATE] showed the resident had short and long term memory problems and required assistance with care. Review of a handwritten note located in CNA A's personnel file, dated 6/24/12, showed LPN D reported he/she witnessed CNA A "sling" Resident #4 into bed while assisting with repositioning. Review of the resident's medical record showed no physical assessment and no notification of the physician or next of kin. During an interview on 9/5/12 at 8:45 A.M., Resident #4 said said he/she did not remember the incident. 6. During an interview on 9/5/12 at 9:32 A.M., the DON said during the course of an investigation for another allegation of abuse, CNA A's personnel file was reviewed and a handwritten note, dated June 2012, containing allegations of mistreatment and/or rudeness towards Resident's #1, #3 and #4 was found. The DON said the allegations on the handwritten note were not investigated further. During an interview on 9/5/15 at 10:25 A.M., the Administrator said that while investigating another allegation of abuse by CNA A, he found an uninvestigated report in CNA A's personnel file. The Administrator said the former DON had not investigated the allegation. 7. Record review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the care plan, dated 3/1/12, showed staff identified the resident required assistance with care and was hard of hearing. The care plan directed staff to speak to the resident in a calm voice while being gentle and reassuring. Review of a nurses' note, dated 8/21/12, showed that at 7:30 A.M., CNA staff reported the resident had a bruise on the right side of the face. CNA staff reported the resident said that someone hit him/her during the night. Observation and interview on 9/5/12 at 8:35 A.M. showed Resident #1 said he/she could not recall staff's name but "that girl" wanted him/her to get out of bed faster (during the 8/21/12 incident). The resident said when he/she could not, the girl slapped me, open-handed, across the face. Resident #1 touched his/her opened hand to the right side of his/her face and said "It hurt," and "I didn't deserve to be slapped." The resident said he/she was going as fast as he/she could. During an interview on 9/5/12, the DON said the resident had a deep purple irregular shaped bruise on the right cheekbone after the 8/21/12 incident. The DON said the resident reported that the girl slapped him/her due to not being quick enough when getting up. During an interview on 9/5/12 at 9:55 A.M., LPN D said CNA A called him/her into Resident #1's room at 6:00 A.M. on 8/21/12 and pointed out a bruise on the right side of the resident's face. CNA A said he/she did not know how the resident got the bruise and the resident "did not speak up." Later, LPN D heard CNA A speaking in a hateful tone to Resident #1 during toileting. LPN D had previously reported CNA for speaking rudely to the resident "but no one did anything." During an interview on 9/5/12 at 10:10 A.M., CNA F said CNA A said the resident had laid on his/her hand all night or hit his/her face on the bed rail causing a bruise. The resident had a black and purple bruise in the shape of a hand print on the right check. CNA F asked the resident how the bruise occurred and the resident said the girl who got him/her up "slapped the fire" out of him/her because he/she wasn't moving fast enough. CNA F said the resident's story remained consistent. During an interview on 9/5/12 at 12:55 P.M., CNA G said Resident #1 had a bruise on the right cheek. CNA G said when he/she asked the resident what happened, the resident said he/she wasn't getting up fast enough and "the lady smacked the hell out of me." CNA G said the resident's story remained consistent. During an interview on 9/5/12 at 1:15 P.M., CNA H said the resident had a hand shaped bruise on his/her face. CNA A showed CNA H the bruise and said that the resident had been acting up that morning and CNA A guessed the resident got the bruise from lying in bed all night. CNA A then said he/she would probably get called to the office over the resident's bruise. During an interview on 9/5/12 at 1:25 P.M., CMT J said Resident #1 said that CNA A hit him/her because he/she was not getting up fast enough. During an interview on 9/20/12 at 12:47 P.M., the Administrator said CNA A had been arrested and charged with Elder Abuse. Complaints MO , MO , MO , MO and MO