Every finding on record at Lynchburg Nursing Center

Based on review of the medical record, observations and interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments related to medications for 2 residents (Residents #47 and #44) and related to hearing impairment for 1 resident (Resident #5) of 15 residents reviewed.The findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, revealed .High-Risk Drug Classes: Use and Indication .Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look-back period .Anticoagulant .Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period .Antiplatelet: Check if any antiplatelet medication (e.g. [example] .clopidogrel .) was taken by the resident at any time during the 7-day observation period .Do not code antiplatelet medications such as as .clopidogrel as .Anticoagulant .Antipsychotic Medication Review .Review the resident's medication administration records to determine if the resident received an antipsychotic medication since admission/entry .If the resident received an antipsychotic medication, review the medical record to determine if a gradual dose reduction [GDR] has been attempted .If a gradual dose reduction was not attempted, review the medical record to determine if there is physician documentation that the GDR is clinically contraindicated .Enter the date of the last attempted Gradual Dose Reduction .Do not include gradual dose reductions that occurred prior to admission to the facility . Further review revealed, hearing .code .minimal difficulty .has difficulty hearing when not in quiet listening conditions or when not in one-on-one situations .moderate difficulty .Speaker has to increase volume and speak distinctly .Although hearing-deficient, the resident compensates when the speaker adjusts tonal quality and speaks distinctly; or the resident can hear only when the speaker's face is clearly visible . Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Atherosclerotic Heart Disease (heart disease caused by plaque buildup in arterial walls), Aortic Valve Stenosis (a condition restricting blood flow from the heart to the body), Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Paroxysmal Atrial Fibrillation. Review of Resident #47's comprehensive care plan revised on 6/25/2025, revealed .The resident is on antiplatelet therapy . Review of a physician's order for Resident #47 dated 8/27/2025, revealed .Clopidogrel Bisulfate [antiplatelet medication used to decrease risk of heart disease and stroke] Oral Tablet 75 MG [milligrams] .by mouth one time a day for anticoagulant . Review of Resident #47's Medication Administration Record (MAR) dated 9/1/2025 – 9/30/2025, revealed the resident received .Clopidogrel Bisulfate Oral Tablet 75 MG .for anticoagulant . daily. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #47 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. It was noted Resident #47 received anticoagulant medication during the 7-day look back period. Continued review revealed Resident #47 did not receive antiplatelet medication during the 7-day look back period. Review of Resident #47's MAR dated 11/1/2025 – 11/30/2025, revealed the resident received .Clopidogrel Bisulfate Oral Tablet 75 MG .for anticoagulant . daily. Review of the quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. It was noted Resident #47 received anticoagulant medication during the 7-day look back period. Continued review revealed Resident #47 did not receive antiplatelet medication during the 7-day look back period. During an interview on 12/2/2025 at 4:30 PM, the MDS Coordinator stated Resident #47's quarterly MDS assessment dated [DATE] states the resident received anticoagulant medications during the 7-day look back period. The MDS Coordinator confirmed Resident #47 was receiving Clopidogrel which is an antiplatelet medication, not an anticoagulant medication. The MDS Coordinator confirmed the quarterly MDS assessment was not coded accurately and should have been coded as receiving antiplatelet and not anticoagulant medications. The MDS Coordinator confirmed Resident #47's quarterly MDS assessment dated [DATE] was also coded inaccurately related to anticoagulant and antiplatelet medications. The MDS Coordinator confirmed Resident #47 did not receive any anticoagulant medications during the look back period for the quarterly assessments dated 9/24/2025 and 11/13/2025. The MDS Coordinator stated the RAI manual was used as a guide for MDS assessments. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including Fracture of Lower End of Left Femur, Dementia, Major Depressive Disorder, and Alzheimer's Disease. Review of a physician's order for Resident #44 dated 5/21/2025, revealed an order for Rexulti [an antipsychotic used to treat agitation that may happen with dementia] 2 mg by mouth daily for Dementia. Review of Resident #44's comprehensive care plan dated 5/21/2025, revealed .resident uses antipsychotic medications .dementia with agitation . Review of Resident #44's comprehensive care plan revised on 6/2/2025, revealed .impaired cognition with intermittent delirium r/t [related to] dementia, Alzheimer's disease .Administer medications as ordered . Review of the quarterly MDS assessment dated [DATE], revealed Resident #44 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #44 received antipsychotic medications during the 7-day look back period. Continued review revealed .Antipsychotics were received on a routine basis only .GDR has been documented as clinically contraindicated .Date physician documented GDR as clinically contraindicated .05-05-2025 [5-5-2025 - 15 days prior to Resident #44's admission to the facility] . During an interview on 12/3/2025 at 2:25 PM, the Licensed Practical Nurse (LPN) MDS nurse stated Resident #44 was admitted to the facility on [DATE]. Resident #44 had an order dated for 5/21/2025 for Rexulti (antipsychotic medication) daily. The LPN MDS nurse stated Resident #44's quarterly MDS assessment dated [DATE] revealed the resident received antipsychotic medications on a routine basis and the physician documented that a GDR was clinically contraindicated dated 5/5/2025. The LPN MDS nurse confirmed the MDS assessment was coded in error because the GDR date listed was prior to Resident #44's admission to the facility on 5/20/2025. The LPN MDS nurse stated the RAI manual was used to code MDS assessments. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Diabetes, and Peripheral Vascular Disease. Review of an Audiology visit dated 12/9/2024, revealed Resident #5 was referred by the facility for decreased hearing. A hearing test was performed, which revealed moderate to severe hearing loss in the right ear, moderate to profound hearing loss in the left ear, word recognition was good in the right ear and poor in the left ear. Further review revealed hearing aids were recommended. Review of the medical record for Resident #5 revealed a diagnosis of Bilateral Hearing Loss was added on 2/12/2025. Review of a quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact and had adequate hearing. Review of the comprehensive care plan for Resident #5 dated 10/23/2025, revealed interventions including .allow extra time for resident to respond .communicate with resident/family/caregivers regarding resident's capabilities and needs .face the resident .make eye contact .reduce distractions .simple direct sentences .provide necessary cues . During an observation and interview on 12/02/2025 at 9:58 AM, Resident #5 stated, .I can't hear, you'll have to get closer .I have trouble hearing the church singing . The resident complained of hearing difficulty, stated she had an ear test about a year ago, and was told she needed hearing aids. During interview, the resident had difficulty hearing the speaker despite being close to the resident and using an elevated tone of voice. The resident missed and/or misinterpreted words during the conversation. During an observation on 12/2/2025 at 3:30 PM, Resident #5 was observed in the Resident Council Meeting having difficulty hearing the conversation. The resident required frequent repeating and rewording for her to comprehend what was said. During an interview on 12/3/2025 at 4:50 PM, the MDS Coordinator confirmed Resident #5's MDS dated [DATE] was coded incorrectly as adequate hearing and should have been coded for hearing loss.

Based on facility policy review, medical record review, observations and interviews, the facility failed to ensure medical information was not visible for 1 resident (Resident #47) of 60 residents observed.The findings include:Review of the facility's policy titled, Dignity, reviewed on 9/26/2025, revealed .The resident has a right to be treated with respect and dignity .including .Staff should not .document .where others can see a resident's information . Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Depression, Anxiety, and Dementia.Review of the comprehensive care plan dated 6/18/2025, revealed .Congestive Heart Failure .O2 [oxygen] via nasal cannula @ [at] 2L/M [2 liters per minute] continuously, as tolerated .Review of the comprehensive care plan revised on 6/30/2025, revealed .impaired cognition r/t [related to] dementia .Review of a physician's order dated 8/27/2025, revealed .Oxygen at 2 liters/minute continuously per nasal cannula .Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #47 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Resident #47 received oxygen therapy at the facility. During an observation and interview on 12/1/2025 at 9:48 AM, in Resident #47's room, the resident was seated in a wheelchair beside the bed. There were 2 signs posted above Resident #47's bed. The first sign read, .Please Do Not wrap [Resident #47's] bed control around the bottom of the bed frame . The second sign read .While You're Here, Please check my concentrator/O2 tank . Resident #47 stated, .I don't know why they [the signs] are there .I have wondered .I don't know who would put them there . Both signs were visible to anyone that entered the room. During an observation on 12/1/2025 at 1:29 PM, in Resident #47's room, the resident was seated in a wheelchair beside the bed. There were 2 signs posted above Resident #47's bed. The first sign read, .Please Do Not wrap [Resident #47's] bed control around the bottom of the bed frame . The second sign read .While You're Here, Please check my concentrator/O2 tank . Both signs were visible to anyone that entered the room.Attempted telephone interview on 12/01/2025 at 1:14 PM with Resident #47's responsible party. During an observation on 12/2/2025 at 8:43 AM, in Resident #47's room, the resident was seated in a wheelchair beside the bed. There were 2 signs posted above Resident #47's bed. The first sign read, .Please Do Not wrap [Resident #47's] bed control around the bottom of the bed frame . The second sign read .While You're Here, Please check my concentrator/O2 tank . Both signs were visible to anyone that entered the room.Attempted telephone interview on 12/3/2025 at 10:31 AM with Resident #47's responsible party. Review of Resident #47's medical record revealed no documentation that Resident #47 or Resident #47's representative had requested that signage be posted in the resident's room.During an observation and interview on 12/3/2025 at 10:36 AM, with the Director of Nursing (DON), in Resident #47's room, there were 2 signs posted above Resident #47's bed. The first sign read, .Please Do Not wrap [Resident #47's] bed control around the bottom of the bed frame . The second sign read .While You're Here, Please check my concentrator/O2 tank . The DON confirmed the signage above the resident's bed was visible to anyone that entered the room. The DON was unaware who or why the signage was posted. The DON confirmed the care plan was used to communicate specific resident care needs to staff and signage was not to be posted in resident's rooms and visible to others unless requested by the resident or family. If signs were requested by the resident or their family, it was to be documented in the resident's medical record. During an interview on 12/3/2025 at 2:59 PM, the DON confirmed there was no documentation in Resident #47's medical record to indicate that family requested the signage be posted.

Based on review of medical records, observations and interviews, the facility failed to ensure medical records were complete and accurately documented 1 resident (Resident #2) of 26 records reviewed. The findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Muscle Wasting, Atrophy, and Encephalopathy. Further review revealed the resident was hospitalized from [DATE] to 6/12/2025. Review of the medical record for Resident #2 from 6/12/2025 to 12/4/2025 revealed no documentation pressure-ulcer prevention interventions had been implemented according to the resident's care plan, which currently included an air mattress and multi-podus boots (heel protective devices with removal of the heel area) to both feet. Continued review revealed no documentation the interventions had been verified for placement daily and no documentation of the resident's behaviors related to the removal of heel protectors and/or multi-podus boots. During an observation on 11/1/2025 at 10:15 AM and 1:45 PM, Resident #5 was lying in the bed on his back, with an air mattress in place and multi-podus boots on both feet. Further observation at 1:45 PM revealed the resident was lying in the bed on his left side, with an air mattress in place and multi-podus boots on both feet. During an observation on 11/2/2025 at 8:15 AM, Resident #5 was lying in the bed on his back, with an air mattress in place and multi-podus boots on both feet. Further observation at 11:30 AM revealed the resident was lying in the bed on his right side, with an air mattress in place and multi-podus boots on both feet. During an observation on 11/3/2025 at 9:45 AM, Resident #5 was lying in the bed on his back, with an air mattress in place and multi-podus boots on both feet. Further observation at 1:30 PM revealed the resident was lying in the bed on his left side, with an air mattress in place and multi-podus boots on both feet, and at 3:55 PM the resident was lying in bed on his back with an air mattress in place and multi-podus boots on both feet. During an interview on 11/3/2025 at 2:45 PM, Certified Nursing Assistant (CNA) A stated, .we used to use heel booties [thick cloth heel protectors] on [Resident #2's] feet .they changed to the heel boots [multi-podus boots] .when [Resident #2 gets up we put the non-skid socks on him instead of shoes because of his heel .we turn and reposition [Resident #2] every two hours .we check the air mattress and make sure it's working every day . During an interview on 11/3/2025 at 2:50 PM, CNA B stated, .we used to float [Resident #2's] heels on a pillow, but he would kick his feet off [of the pillow] .[Resident #2] had the heel booties, but they've been changed to the bigger heel boots [the date was unable to be determined due to lack of documentation] .[Resident #2] is repositioned every two hours .every day, we check and make sure the air mattress is working . During an interview on 11/3/2025 at 2:55 PM, CNA B stated, .we used to float his heels on a pillow, but he fidgets in bed and would kick his feet off sometimes .[Resident #2] had the heel booties, but they've been changed to the bigger heel boots .[Resident #2] is repositioned every two hours . we check and make sure the air mattress is working when we do our rounds . During an interview on 12/3/2025 at 4:15 PM, the Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC) stated the staff monitored residents regularly with pressure ulcers and those who are at high-risk for pressure ulcers the staff made sure the residents' protective equipment was in place. During an interview on 12/3/2025 at 5:20 PM, the Director of Nursing (DON) confirmed Resident #2's behavior of kicking off heel protection was not recorded in the medical record, and confirmed resident behaviors should be documented. The DON confirmed that despite observations and staff interviews confirming the pressure-ulcer prevention activities were performed, the interventions were not documented in the resident's medical record. During an interview on 11/4/2025 at 7:30 AM, the Medical Director stated Resident #2 had received appropriate treatment and preventative measures at the facility, evidenced by the resolution of prior ulcers the resident was admitted with, and the improvement documented for the current ulcer the resident had. Continued interview revealed Resident #2 had clinically unavoidable pressure ulcers due to multiple co-morbidities. During an interview on 12/4/2025 at 11:30 AM, the Executive Director confirmed the resident's medical record should contain accurate and complete documentation of the care provided for Resident #2.

Based on medical record review, observations and interviews, the facility failed to provide assistance or utilize available resources related to hearing loss for 1 resident (Resident #5) of 15 residents reviewed.The findings include:Review of the facility policy titled, Hearing Impaired Resident Care, dated 9/18/2025, revealed .the facility will provide Hearing Impaired Resident Care in accordance with professional standards of practice .the right .to receive services in the facility with reasonable accommodation of resident needs . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Diabetes, and Peripheral Vascular Disease. Review of an Audiology visit dated 12/9/2024, revealed Resident #5 was referred by the facility for decreased hearing. A hearing test was performed, which revealed moderate to severe hearing loss in the right ear, moderate to profound hearing loss in the left ear, word recognition was good in the right ear and poor in the left ear. Further review revealed hearing aids were recommended. Review of the medical record for Resident #5 revealed a diagnosis of Bilateral Hearing Loss was added on 2/12/2025. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the MDS reflected Resident #5 had adequate hearing (which was an inaccurate assessment). Review of the comprehensive care plan for Resident #5 dated 10/23/2025, revealed interventions including .allow extra time for resident to respond .communicate with resident/family/caregivers regarding resident's capabilities and needs .face the resident .make eye contact .reduce distractions .simple direct sentences .provide necessary cues . During an interview and observation on 12/02/2025 at 9:58 AM, Resident #5 stated, .I can't hear, you'll have to get closer .I have trouble hearing the church singing . The resident complained of hearing difficulty, stated she had an ear test about a year ago, was told she needed hearing aids, but hadn't heard anything further about it. During interview, the resident had difficulty hearing the speaker despite being close to the resident and using an elevated tone of voice. The resident missed and/or misinterpreted words during the conversation. During an observation and interview on 12/2/2025 at 3:30 PM, Resident #5 was observed in the Resident Council Meeting having difficulty hearing the conversation. The resident required frequent repeating and rewording for her to comprehend what was said. During an interview on 12/2/2025 at 3:45 PM, the Activities Director (AD) acknowledged Resident #5 was very hard of hearing, but she did continue to attend activities of her preference and served as the Resident Council President. During an interview on 12/3/2025 at 4:15 PM, the Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC) stated she thought the family had told the facility they were unable to purchase hearing aids due to the high cost. During a telephone interview on 12/3/2025 at 4:32 PM, Resident #5's daughter stated she had been contacted a year ago about hearing aids but could not afford them. The daughter stated she was not offered assistance in locating any alternatives or utilizing other available resources to help the resident's hearing. During an interview on 12/3/2025 at 4:38 PM, accompanied by the Social Service Director (SSD), Resident #5 confirmed she did not have any type of aid for hearing and she had not been provided with any information, other resources, or items that might be available to assist in hearing loss. During an interview on 12/3/2025 at 4:45 PM, the SSD confirmed Resident #5 had no documentation of follow-up since the audiology testing. The SSD stated the facility had hearing amplifiers available for residents who had hearing loss and were unable to get hearing aids and the hearing amplifier had not been provided to Resident #5.

Based on facility policy review, medical record review, and interview, the facility failed to ensure two Residents (R1 and R18) of three residents reviewed and/or their representatives were invited to participate in the resident's quarterly care plan meeting. In addition, the facility failed to ensure that the clinical records contained evidence that the residents and/or their representatives participated in the development or revision of the care plans. Findings include: Review of a facility policy titled .Comprehensive Care Plans and Conferences, dated 08/22/23 indicated, .The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team .The facility has a responsibility to assist residents to engage in the care planning process .The facility should provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation . 1. Review of R1's electronic medical record (EMR) titled Admission Record, indicated the resident was admitted to the facility on [DATE]. Review of R1's EMR titled communication with family Progress Notes, dated 02/21/24, indicated the resident's responsible party was called and updated on the status of the resident. There were no other entries which indicated the resident and/or her representative were invited to participate in additional quarterly care conferences after this date. Review of R1's EMR titled quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 09/09/24 at 1:06 PM, R1 stated she was not invited to her quarterly care conferences. 2. Review of R18's EMR titled Admission Record, indicated the resident was admitted to the facility 05/06/22. Review of R18's EMR titled annual MDS with an ARD of 06/27/24, indicated the resident had a BIMS score of eight out of 15 which revealed the resident was moderately cognitively intact. During an interview on 09/09/24 at 11:32 AM, R18's representative (F) 1 stated she had not been invited to the resident's care conferences. Review of R18's EMR titled communication with family Progress Notes, dated 02/08/24, indicated F1 participated in a care conference for the resident. There were no other entries which indicated the resident and/or her representative were invited to participate in additional quarterly care conferences after this date. During an interview on 09/10/24 at 8:43 AM, the Social Services Director (SSD) stated her process for inviting residents and/or their representatives included to call the family and alert the family of the upcoming care conferences. The SSD stated she would also send out a follow-up letter to the family too. The SSD stated she attempted to document the quarterly meetings. During a subsequent interview on 09/10/24 at 9:29 AM, the SSD stated did not document the invitations to R1 and R18's care conferences nor with their representatives. During an interview on 09/10/24 at 5:13 PM, the Administrator presented the facility's care conference policies and stated the policy did not address the quarterly care conferences.

Based on facility policy review, medical record review, and interview, the facility failed to notify the resident and resident's representative of a transfer or discharge in writing for one of one resident (R18) reviewed for hospitalization of 17 sampled residents. This created a potential for the resident or their resident representative to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process. Findings include: Review of a facility policy titled Transfers and Discharges, dated 05/12/23 indicated, .The facility will also provide transfer/discharge notice to the resident/responsible party in accordance with federal regulations .When residents are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges . There was no evidence in the facility's policy that addressed the requirement to send a written transfer notice to the resident and resident representative when there was an urgent medical need of the resident to be sent out to the hospital. Review of R18's electronic medical record (EMR) titled Admission Record, indicated the resident was admitted to the facility on [DATE]. Review of R18's EMR titled alert note Progress Note, dated 07/17/23, indicated the resident sustained a fall. The resident was assessed, and the physician and representative were notified. On 07/19/23 the resident sustained a change in her condition and was transported to the local hospital for evaluation and treatment. Review of R18's EMR failed to contain evidence the resident and resident representative was provided with a written transfer notice which identified the location of where the resident was to be transported and appeal rights if the facility chose to readmit the resident back to their facility. During an interview on 09/09/24 at 11:32 AM, R18's family member (F) 1 stated she had not received any written transfer notice from the facility and stated she saves all of the resident's documents. During an interview on 09/10/24 at 11:14 AM, the Administrator stated that the facility has never given a written transfer notice to the resident and resident representative during an urgent medical need and transfer to the hospital.

Based on facility policy review, medical record review, and interviews, the facility failed to revise the care plans for 2 of 4 sampled residents (Residents #1 and #2) reviewed. The findings include: Review of the facility's policy titled, Comprehensive Care Plans and Revisions, revised 8/17/2022, revealed, .The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge or the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care .When these changes occur, the facility should review an update the plan of care to reflect the changes to care delivery, this can include; a. Additional interventions on existing problems, b. Updating goal or problem statements . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report for Resident #1 dated 9/13/2022, revealed orders for Hospice Services, DNR (Do Not Resuscitate) with Comfort Measures, Oxygen 5-9 liters/minute continuously per nasal cannula, Oxygen with [CONDITION(S)] (Continuous Positive Airway Pressure)/[CONDITION(S)] (Bilateral Positive Airway Pressure): Pressure setting, Size and type of mask, and liter of oxygen 5-10 liters/minute, frequency of use: daily except for meals. Review of the current Care Plan for Resident #1 revealed problems/assessments for, .The resident has altered cardiovascular status r/t [related to] hypertensive [CONDITION(S)], CAD [Coronary Artery Disease], heart failure and cardiomegaly .The resident has a pacemaker/cardiac defibrillator. Resident is a DNR [Do Not Resuscitate]-Comfort Measures .The resident is on pain medication therapy r/t [related to] end of life, SOB [Shortness of Breath] .Resident expresses pain/discomfort. Resident admitted to Hospice care .The resident has [CONDITION(S)]/[CONDITION(S)] . Appropriate goals and interventions were implemented, but there was no mention in the problems nor interventions for the use of a [CONDITION(S)] machine. Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes for Resident #2 revealed it was charted the resident's bed was kept in the lowest position and there were fall mats present on the floor bilaterally due to her being a fall risk. Review of the current Care Plan for Resident #2 revealed problems/assessments for, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Activity Intolerance, Confusion, Dementia, Limited ROM [Range of Motion] .Resident is at risk for falls . Review of the care plan did not mention the use of fall mats bilaterally to the bed, nor the bed in the lowest position. During an interview on 10/18/2022 at 1:08 PM with the Administrator present, the Director of Nursing (DON) confirmed Resident #1 did not have a care plan for the use of a Bi-pap machine, and she would expect her to. During an interview on 10/18/2022 at 3:12 PM, the DON confirmed there were no fall interventions for fall mats to both sides of the bed and the bed to be in the lowest position on Resident #2's care plan. She confirmed Resident #2 had fall mats bilaterally beside her bed and her bed was kept in the lowest position due to being at risk for falls.

Based on policy review, medical record review, and interview the facility failed to ensure Resident #1 was safely and properly transferred with a mechanical lift, which resulted in a fall. This affected 1 resident (Resident #1) of 3 residents reviewed for falls. The facility identified 8 residents who required assistance with ambulation or an assistive device. Finding include: Review of the facility policy titled, Mechanical Lift Use, dated 5/12/2020, revealed . the resident's ability to communicate and identify physical limitations or to aid in transfer will help determine the need for an assistive device, such as a mechanical lift .it is important to train staff regarding resident assessment, safe transfer techniques, and the proper use of mechanical lifts including device weight limitations .the facility will utilize the Lippincott Procedure .refer to the care plan/Kardex for the resident's transfer requirements. Mechanical lift transfers require the assistance of 2 associates . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Spinal Stenosis, Muscle Weakness, Abnormal Posture, Dementia Without Behavioral Disturbance, Dorsalgia, Heart Failure, History of Falling, and Presence of Artificial Right Hip Joint. Medical record review of the Minimum Data Set (MDS) assessment, dated 3/5/2021, revealed Resident #1 scored an 8 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Continued review revealed no [CONDITION(S)] or behaviors noted. The resident required extensive, two-person assistance for bed mobility and was total dependence with two-person assistance with transfers and toileting. Review of the Care Plan, dated 2/27/2020, revealed the resident was at risk for falls with interventions including to use a mechanical lift for transfer, to assist with Activities of Daily Living (ADLs) as needed, and to complete fall risk assessment. Review of the Kardex, dated 5/1/2021, revealed Resident #1 required a mechanical lift for transfers. Review of the Physical Therapy Notes, certification period 5/4/2021 through 5/17/2021, revealed the following assessment summary: patient presents with decreased positioning while seated in wheelchair, increasing her risk of contractures, skin integrity, and pain. Review of a Nursing Progress Note, dated 2/3/2021 at 12:38 AM, revealed .resident fell while tech was transferring with sit to stand. Nurse came in after tech called for help. Nurse assessed the resident, took vitals, and asked the resident if she was in any pain. Resident denied any pain. Vitals were within normal limits . Review of a Nursing Progress Note, dated 5/11/2021 at 4:12 AM, revealed .resident has been transferred back to the facility via ambulance. Resident was taken back to her room and is back in her bed. emergency room (ER) nurse stated there was no pelvic fracture. Resident does not complain of any pain at this time . Review of the ER Discharge Summary, dated 5/11/2021, revealed no fractures or dislocations. During interview conducted on 7/8/2021 at 1:05 PM, the Director of Nursing (DON) confirmed Resident #1 was improperly transferred with a sit-to-stand mechanical lift by one staff instead of two. The DON confirmed the facility policy is for two staff members to transfer residents with mechanical lifts. Following the incident, all staff were in-serviced on the use of mechanical lifts and visual observation audits have been conducted weekly. During interview conducted on 7/8/2021 at 1:10 PM, the Administrator confirmed Resident #1 should have been transferred by two staff members. The Administrator further stated all direct care staff was educated on the proper use of mechanical lifts following the incident. During interview conducted on 7/8/2021 at 1:47 PM, Licensed Practical Nurse (LPN) #1 stated one of the techs transferred Resident #1 alone with a mechanical lift when the fall occurred. I checked the patient and there was nothing out of the ordinary, no pain or injury. I contacted her son and he wanted his mother sent to the hospital. During interview conducted on 7/8/2021 at 1:52 PM, Certified Nursing Assistant (CNA) #1 stated she improperly transferred Resident #1 with a sit-to-stand lift, and that she did this alone. CNA #1 stated, I should not have transferred her alone, I don't know why I did this, I should have asked for assistance, there were 3 CNAs working on my hall that night.

Based on review of the 2013 Food Code, observation and interview, the facility failed to provide a safe, functional, and sanitary kitchen environment for 6 of 6 air vents observed leaking liquid in 1 of 1 (Main Kitchen) kitchen. The findings include: Review of the 2013 Food Code from the U.S Department of Health and Human Services, page 177, revealed Heating, ventilating and air conditioning systems shall be designed and installed so that make-up air intake and exhaust vents do not cause contamination of food, food contact surface, equipment or utensils. Observation of the main kitchen on 7/17/17 at 11:00 AM revealed a ventilation duct near the fryer and steam table area leaking liquid droplets onto the floor. Observation of the main kitchen on 7/19/17 at 8:24 AM revealed a ventilation duct near the food prep table and the pureed prep station leaking liquid droplets onto the floor. Interview with Maintenance Director #1 on 7/19/17 at 8:49 AM in the kitchen, revealed the air conditioner was causing the condensation due to the humidity. He said there was nothing they could do to stop the leaks. They had renovated the kitchen about 2 years ago and covered up some of the external water damage outside of the vents about a year ago. At 9:08 AM on 7/19/17, he stated they called the heating and air company for consultation and had some options to try. Interview with the Administrator on 7/19/17 at 9:20 AM in the kitchen confirmed they needed to research options to contain the leaks. Observations of the main kitchen on 7/19/17 at 9:25 AM revealed the following: One vent located near the fryer and steam table area leaking droplets onto the floor. One vent located near the food prep table and the pureed prep station leaking droplets onto the floor. One vent located near the meal tray set up station contained small black specks along the outside of the vent edges. One vent located near the ice cream freezer leaking droplets onto the floor. One vent located near the 3-pan sink and the steam table leaking droplets onto the floor. One vent located near the clean pan drying area, next to the dish machine, had external water damage. Interview with the Certified Dietary Manager (CDM) on 7/19/17 at 9:55 AM in the kitchen, revealed they try to avoid walking under the leaks with food and have been aware of the leaks for a while but had not seen the black specks before this day.

Based on record review, observation and interview, the facility failed to use an assistive transfer device to prevent a potential accident during a transfer for 1 of 2 (Resident #42) sampled residents reviewed for accidents. The findings included: Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 required extensive assistance of 2 staff members for bed mobility and transfers. Review of the form identified by the Therapy Director as the Summary of Care for Resident #42 completed on 2/16/17 revealed Resident #42 had passive range of motion of 30 degrees on the right side and 50 degrees on the left side. Review of the care plan for Resident #42 revealed the resident had an altered ability to perform activities of daily living due to decreased mobility with approaches that included a sit to stand lift for all transfers. A hand-written intervention dated 7/11/17 documented Golvo lift (an extensive mechanical lift that uses a sling to transfer residents) for transfers. Review of the physician's orders [REDACTED]. (maximum assistance lift that uses a sling). Review of Resident #42's Care Directive dated 7/12/17 which provided instructions for the care that Certified Nursing Assistants (CNA) were to provide the resident noted under the transfer section that staff were to use a Golvo lift for all transfers. Interview with Nursing Assistant (NA) #2 on 7/18/17 at 3:42 PM, outside Resident #42's room, NA #2 stated, We do a 2 person transfer with a gait belt. We don't use a lift. We put her in the wheelchair. (Resident #42) doesn't move the wheelchair much, but if we roll her, she will walk her feet on the floor. Observation of Resident #42 being transferred from her bed to the wheelchair by NA #1 and NA #2 on 7/18/17 at 4:35 PM, Resident #42 was transferred using a gait belt. and a Golvo lift was not used to transfer Resident #42 from the bed to the wheelchair. Interview with NA #2 on 7/18/17 at 4:45 PM in Resident #42's room, NA #2 verified there is a Care Directive that tells them how to transfer the residents. Interview with the Director of Nurses (DON) on 7/18/17 at 5:32 PM, on the 200 hall, the DON stated that when the order was changed on 7/11/17 to the Golvo lift, staff had been inserviced on the change.

Based on medical record review, observation and interview, the facility failed follow the care plan interventions to transfer a resident with a lift and apply assistive devices to a wheelchair 1 of 7 residents (Resident #42) sampled residents. The findings included: Medical record review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 required extensive assistance of 2 staff members for bed mobility and transfers. Review of Resident #42's care plan revealed the resident had altered ability to perform activities of daily living due to decreased mobility and had an onset date of 6/12/17. Interventions included a leg rest on the wheelchair to aid with posture/positioning in the wheelchair and a hand-written intervention dated 7/11/17 that specified a Golvo lift (a maximum assistance mechanical lift that uses a sling) be used for transfers. Review of the physician's orders [REDACTED]. Review of Resident #42's Care Directive dated 7/12/17 which provided nursing assistants (NA) instructions on resident care required Mechanical Lift. Golvo for all transfers and leg rest for posture/positioning. Observations of Resident #42 on 7/18/17 at 3:40 PM revealed the resident in bed . The wheelchair at the bedside did not have leg rests on the wheelchair. Interview with Nursing Assistant (NA) #2 on 7/18/017 at 3:42 PM, outside Resident #42's room, NA #2 stated We do a 2 person transfer with a gait belt. We don't use a lift. We put her in the wheelchair. (Resident #42) doesn't move the wheelchair much, but if we roll her, she will walk her feet on the floor. Observation of Resident #42 being transferred from the bed to the wheelchair by NA #1 and NA #2 on 7/18/17 at 4:35 PM revealed there was no Golvo lift used. NA #1 and NA #2 used a gait belt to transfer Resident #42 from the bed to the chair. there were no leg rests were on the wheelchair. Interview with NA #2 on 7/18/17 at 4:45 PM in Resident #42's room, NA #2 stated, .(Resident #42) doesn't use leg rests on the wheelchair. There is a care directive that tells us how to transfer the residents . Interview with the Director of Nursing (DON) on 7/18/17 at 5:32 PM on the 200 hall, the DON stated that when the order was changed on 7/11/17 to the Golvo lift, staff had been inserviced on the change.

Based on policy review, observation and interview, the facility failed to ensure medications were not stored past their expiration date, failed to ensure internal and external medications were not stored together and medications were stored in locked compartments at all times in 4 of 6 (300 hall medication cart, medication room, emergency crash cart, and treatment cart) medication storage areas. The findings included: 1. The facility's Medication Storage & Security in the Facility policy documented, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier .carts, and medication supplies are locked .Orally administered medications are kept separate from externally used medications (e.g. (for example), suppositories .Potentially harmful substances .cleaning supplies, and disinfectants are clearly identified and stored in a locked area separately from medications .Outdated, contaminated, or deteriorated medication .are immediately removed from stock . 2. Observations in the 300 hall of the medication cart on 5/3/16 at 4:55 PM, revealed 1 opened vial of Tuberculin Purified Protein Derivative (TB) with an open date of 3/15/16. An interview with Licensed Practical Nurse (LPN) #3, on 5/3/16 at 4:55 PM, on the 300 hall, LPN #3 was asked how long should the vial of the TB skin test be stored for use after opening. LPN #3 stated, Twenty-eight days. LPN #3 was asked if it should be in the cart. LPN #3 stated, No .It shouldn't have even been in the med (medication) room . 3. Observations in the medication room on 5/4/16 at 10:55 AM, revealed 1 box of Gericare Bisacodyl suppositories and 2 boxes of hemorrhoidal suppositories stored beside a bottle of sodium chloride tablets for oral use; and 1 tube of Preparation H hemorrhoidal medication and 1 container of Tucks wipes for rectal administration stored beside a container of Unifiber supplement for oral administration. An interview with Licensed Practical Nurse (LPN) #1 on 5/4/16 at 10:56 AM, in the medication room, LPN #1 was asked if the rectal medications should be stored together with the oral medications. LPN #1 confirmed that they should not and stated, It should be over here by the bowel preps (preperations). 4. Observations in the emergency crash cart across from the nurses' desk on 5/4/16 at 12:15 PM, revealed 3 packages of intravenous (IV) catheters with expiration dates of 4/16. An interview with LPN #3 on 5/4/16 at 12:20 PM, at the nurses' desk, LPN #3 was asked if the IV catheters should be in the crash cart. LPN #3 stated, No . 5. Observations in the treatment cart on 5/4/16 at 2:20 PM, revealed 1 box of Calcium Alginate dressings, 1 spray bottle of Antiseptic Wound and Skin Cleanser, and 1 container of Tubifast 2-way stretch dressing stored in same compartment with 1 container of Sanicloth Bleach Wipes, and 3 packages of Allevyn Gentle Border Heel dressings with expiration dates of 10-2015. An interview with LPN #5 on 5/4/16 at 2:22 PM, in the 300 hall, LPN #5 was asked if she normally stores the bleach wipes in the same compartment with the dressings and wound cleanser. LPN #5 stated, It should be in the bottom . LPN #5 was asked if the Allevyn heel dressings should still be stored in the cart. LPN #5 stated, No . 6. Observations in the lobby on 5/4/16 at 10:15 AM, revealed an unlocked treatment cart. An interview with LPN #5, on 5/4/16 at 10:17 AM, at the nurses' desk, LPN #5 was asked if the treatment cart should be locked. LPN #5 stated, Yes . An interview with the Director of Nursing (DON) in the conference room on 5/4/16 at 5:00 PM, the DON was asked if having expired medications and supplies in the medication storage areas was acceptable. The DON stated, No. The DON was asked how long she expected staff to keep opened vials of TB skin test. The DON stated, Twenty-eight days . The DON confirmed it was not acceptable to have an opened vial of TB skin test in use 49 days after opening. The DON was asked if rectal and po (oral) medications should be stored side by side. The DON stated, No. The DON was asked if bleach wipes should be stored in the same compartment with sterile wound dressings and wound cleanser in the medication carts. The DON stated, No.

Based on review of the 34th Edition Nursing2014 DRUG HANDBOOK, medical record review, and interview, the facility failed to ensure a physician's order was written and transcribed accurately for the frequency of administration. The findings included: 1. The 34th Edition Nursing2014 DRUG HANDBOOK, by Lippincott Williams & Wilkins documented, .Traditionally, nurses have been taught the five rights of medication administration .1. The right drug .2. The right patient .3. The right dose: Verify that the dose .check the drug label with the prescriber's order .4. The right time: Ensure that the drug is administered at the correct time and frequency . 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 5/4/16 documented, .01/06/2016 [MEDICATION NAME] 100 unit/mL (milliliters) subcutaneous solution inject 25 units Subq (subcutaneously) three times daily twice daily bid before meals .Type 2 diabetes mellitus with other diabetic ophthalmic complication . This order revealed a frequency of three times daily and twice daily bid. 3. An interview with the Director of Nursing (DON) on 5/4/16 at 5:24 PM, in the conference room, the DON was asked whether Resident #12 was supposed to receive scheduled [MEDICATION NAME] twice a day or three times a day. The DON stated, Three times a day. The DON was asked what the twice daily bid (twice daily) meant. The DON stated, I just coded it wrong.

Based on observation and interview, the facility failed to ensure the there was sufficient staff present to ensure meal trays were passed in a timely manner for 1 of 57 (Residents #70) residents served a lunch meal on 200 hall. The findings included: 1. Observations on the 200 hall on 5/4/16 revealed cart #1 was delivered to the floor and meal serve started at 11:45 AM. At 12:29 PM, Resident #70 received her meal tray. 2. An interview with Certified Nursing Assistant (CNA) #1 on 5/4/16 at 3:24 PM, in the conference room, CNA #1 was asked how long does it take to get everyone served. CNA #1 stated,About a hour . An interview with the Director of Nursing (DON) on 5/5/16 at 10:22 AM, in the conference room, the DON was asked if it was appropriate for a resident to sit and watch another resident eat for 45 minutes until her meal tray arrived. The DON stated, No, I'm not going to make excuses .I wouldn't want to do that .

Based on the GERIATRIC MEDICATION HANDBOOK, medical record review, observation, and interview, the facility failed to ensure 1 of 4 nurses (Licensed Practical Nurse (LPN) #4) administered medications free of a significant medication error. LPN #4 failed to administer insulin within the proper time frame related to meals for Resident #12 who received insulin injections. The findings included: 1. The GERIATRIC MEDICATION HANDBOOK, Eleventh Edition, page 41, documented, .DIABETES: INJECTABLE MEDICATIONS .[MEDICATION NAME] .Rapid-Acting Insulin Analog .ONSET .15 min (minutes) .TYPICAL ADMINISTRATION COMMENTS .5-10 minutes before meals . 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. Observations in Resident #12's room on 5/4/16 at 11:20 AM, revealed LPN #4 administered [MEDICATION NAME] 25 units subcutaneously to Resident #12. Resident #12 did not receive a meal until 11:55 AM, 35 minutes after receiving [MEDICATION NAME]. 4. An interview with the Director of Nursing (DON) at 5/4/16 at 5:00 PM, in the conference room, the DON was asked how soon after a [MEDICATION NAME] injection should a resident receive a meal. The DON stated, Usually within 30 to 45 minutes. An interview with Physician Assistant Certified (PAC) on 5/5/16 at 9:35 AM, in the conference room, PAC was asked when a resident should receive a meal in relation to receipt of a [MEDICATION NAME] injection. PAC stated, Per guidelines, it is a rapid insulin. It works anywhere from 5 to 30 minutes .

Based on policy review, observation, and interview, the facility failed to ensure residents were treated with dignity and respect when 1 of 14 staff members (Certified Nursing Assistant (CNA) #2) stood over a resident while assisting with feeding, and 1 of 14 staff members (Licensed Practical Nurse (LPN) #1) referred to a resident as feeder observed during dining. The findings included: 1. The facility's Dignity policy documented, .All residents are treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality .Treating residents with dignity and respect maintains and enhances each resident's self worth and improves his or her psychosocial well-being and quality of life .Through example, education, and monitoring, the Social Services staff promote the following types of staff interactions with residents to maintain their dignity .Focusing on residents as individuals when speaking to them .Respecting residents' social statuses, speaking respectfully, listening carefully, and addressing the residents by preferred names .Promoting residents' independence and dignity in dining . 2. Observations in Resident #64's room on 5/3/16 at 8:07 AM, revealed CNA #2 stood over #64 while assisting her with dining. An interview with the Director of Nursing (DON) on 5/5/16 at 8:45 AM, in the conference room, the DON was asked if it was acceptable for staff to stand over residents while feeding them. The DON stated, No. 3. Observations in the Main Dining Room on 5/4/16 at 12:05 PM, revealed LPN #2 stated, She's a feeder, while pointing to a resident seated at a table in the dining room. Other staff and residents were present. An interview with the DON on 5/4/16 at 5:00 PM, in conference room, the DON was asked how she expected staff to address residents. The DON stated, By the way they want to be . The DON was asked if using the term feeder was acceptable. The DON stated, .No.

Based on policy review, medical record review, observation and interview, the facility failed to ensure 1 of 6 (Resident #111) residents observed during medication pass was capable of self administration of medications. The findings included: 1. The facility's Self-Administration of Medications policy documented, .Each resident who desires to self-administer medication is permitted to do so if the facilities interdisciplinary team has determined the practice would be safe for the resident and other residents in the facility .If a resident desires to self-administration medication, an order for [REDACTED]. 2. Observations in Resident #111 room [ROOM NUMBER]/4/16 at 10:00 AM, revealed Resident #111 sitting in a bedside chair. The nebulizer mask and tubing was lying on the bed, with a visible mist diffusing from the mask. The nebulizer was powered on and functioning. Resident #111 stated, I had to lay it down. My nose was running. 3. An interview with Licensed Practical Nurse (LPN) #2 on 5/4/16 at 10:03 AM, in the hall outside Resident #111's room, LPN #2 was asked if Resident #111 was receiving a breathing treatment. LPN #2 stated, Yes. He's getting one now. LPN #2 was asked if Resident #111 was allowed to self-administer medications. LPN #2 stated, No . An interview with the Director of Nursing (DON) on 5/4/16 at 10:20 AM, in the DON's office, the DON was asked if anyone in the facility could self-administer medications. The DON stated, No. The DON was asked if any of the residents could self-administer nebulizer treatments. The DON stated, No. An interview with LPN #3 on 5/5/16 at 10:50 AM, in the conference room, LPN #3 was asked if Resident #111 had an assessment for medication self-administration. LPN #3 stated, He does not have one. Nobody in this building has one. The facility was not able to provide a medication self-administration assessment or a physician's orders [REDACTED].#111.

Based on policy review, observation and interview, the facility failed to ensure food was stored and prepared under sanitary conditions as evidenced by an open bag of frozen chicken breasts not dated, sheet rock dust and dirt on the floor of the walk-in cooler and sanitized dishes pulled back into the dirty area of dish room. This had the potential to affect 60 of the 60 residents residing in the building. The findings included: 1. Review of the facility's "Infection Control and Prevention of Contamination" policy documented, "...All refrigerated foods if removed from their original container, are securely covered, labeled and dated appropriately..." Observations in the "pull-open" freezer in the dining room on 4/13/15 at 11:30 AM, revealed an open bag of frozen chicken breasts with no open date. Interview with the Certified Dietary Manager (CDM) on 4/13/15 at 11:32 AM, in the kitchen, the CDM was asked what the facility's policy is for dating and bagging stored food after it is removed from it's original packaging. The CDM stated, "Should be in a sealed bag with the open date and the use through date on the bag it is stored in. Bag should be closed." 2. Review of the facility's "Food Safety" policy documented, "...Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth..." Review of the facility's "Dietary Housekeeping" policy documented, "...All floor surfaces must be wet-mopped daily, and as needed, using a bucket with wringer and germicide..." Observations in the walk-in cooler on 4/13/15 at 11:38 AM, revealed sheet rock dust and dirt on the floor of the walk-in cooler. Interview with the CDM on 4/13/15 at 11:40 AM, in the walk-in cooler, the CDM was asked if it was acceptable for dirt and dust to be on the floor of cooler. The CDM stated, "No, that's from rolling in over the dirt. It should not have that dirt like that even with the remodeling." Observations in the walk-in cooler on 4/14/15 at 8:30 AM, revealed that a mat had been put in place inside the walk-in cooler still with sheet rock dust and dirt on and around the mat inside the cooler. Interview with the CDM on 4/14/15 at 8:35 AM, in the walk-in cooler, the CDM was asked the purpose for placing the mat inside the walk-in cooler. The CDM stated, "I thought it would catch the dirt." The CDM was asked how the mat kept the dust and dirt out of the walk-in cooler and if the mat kept the dust and dirt out of the cooler. The CDM replied, "No, I guess it's really not. I see how it wouldn't." 3. Review of the facility's "Infection Control and Prevention of Contamination" policy documented, "...All equipment, utensils and counters are cleaned and sanitized per department guidelines..." Review of the facility's "Proper Food Handling" policy documented, "...Utensils, cups, glasses, and dishes must be handled in such a way as to avoid touching the surfaces with which food or drink will come in contact..." Observations in the dish room on 4/14/15 at 8:05 AM, the CDM demonstrated the process of washing utensils and food trays. The CDM did push a tray of dishes into the washer and after the cycle was completed, the CDM then pulled the clean tray of dishes back into the dirty side of the dish room. Interview with the the CDM on 4/14/15 at 8:05 AM, in the dish room, the CDM explained the procedure for washing the utensils and the food trays. The CDM stated, "The dishes are washed by hand. We rinse them off, bring them in here (to the dish room), run them through the washer, then pull them back out and put them on a sanitized cart to air dry." The CDM was asked if the clean, sanitized dishes are pulled back into the dirty side of the dish room, over the dirty section of the counter, over the dirty sink, then placed onto a cart. The CDM stated, "Yeah."

Based on observation and interview, the facility failed to ensure water temperatures were comfortable for the residents on 1 of 3 (200 hall) halls. The findings included: Observations of the water temperatures on 4/14/15 starting at 8:52 AM on the 200 hall revealed the following: a. 200 hall shower room sink was 82 degrees Fahrenheit (F). b. room [ROOM NUMBER]-213 bathroom sink was 94 degrees. c. room [ROOM NUMBER]-214 bathroom sink was 94 degrees. c. room [ROOM NUMBER]-217 bathroom sink was 88 degrees. d. room [ROOM NUMBER]-218 bathroom sink was 88 degrees Observations of water temperatures on 4/15/15 starting at 8:24 AM with the Maintenance Director revealed the following: a. 200 hall shower room sink temperature after running 5 minutes was 81.3 degrees F, after another 5 minutes the temperature was 83.2 degrees F. b. room [ROOM NUMBER]-213 bathroom sink after 1 minute was 115 degrees F and continued dropping down to 105.5 then to 98.3 degrees F. c. room [ROOM NUMBER]-218 bathroom sink after 5 minutes was 95.3 degrees after another 5 minutes was 96.6 degrees F. d. room [ROOM NUMBER]-217 bathroom sink after 5 minutes was 95.3 degrees F. Observations of water temperatures on 4/15/15 starting at 9:38 AM revealed the following: a. room [ROOM NUMBER]-209 bathroom sink was 98 degrees F. b. room [ROOM NUMBER]-213 bathroom sink was 100 degrees F. c. room [ROOM NUMBER]-214 bathroom sink was 100 degrees F. d. room [ROOM NUMBER]-217 shower in the bathroom was 100 degrees F. e. room [ROOM NUMBER]-218 shower in the bathroom was 96 degrees F. Interview with the Maintenance Director on 4/14/15 at 10:15 AM, in the Maintenance Director's office, the Maintenance Director was asked what the water temperatures were supposed to be. The Maintenance Director stated, "110 to 112, check temps (temperatures) every week." Interview with the Maintenance Director on 4/15/15 at 8:10 AM, in the 300 hall, the Maintenance Director was asked to go check water temperatures on the 200 hall. The Maintenance Director stated, "That's on the dementia hall. I have to let the water run 5 minutes and at the end of the hall have to run 15 to 20 minutes. The 200 hall has one 75 gallon tank, kitchen and shower room is all on that one tank, not enough water flow to keep at proper temperature. [MEDICATION NAME] line sucks the temps out of the hot water, don't have this problem on the 100 and 300 hall. That water is used all the time. This one is the dementia hall, don't use." The Maintenance Director was asked what would the facility have to do for the residents on the 200 hall to have proper water temperatures. The Maintenance Director stated, "Would have to have constant water flow to keep it at the proper temperature." The Maintenance Director was asked how do you assure water is going to be consistent. The Maintenance Director stated, "Not much way you can do that." The Maintenance Director was asked if it was sort of hit or miss if the residents get the water at the correct temperature. The Maintenance Director stated, "Yes." Interview with Certified Nursing Assistant (CNA) #1 on 4/15/15 at 9:05 AM, on the 200 hall, CNA #1 was asked if she had ever had the residents to complain about the water being too cold. CNA #1 stated, "Yes." CNA #1 was asked if she ever had to turn the cold water on to mix with the hot water. CNA #1 stated, "No." Interview with CNA #2 on 4/15/15 at 9:10 AM, on the 200 hall, CNA #2 was asked if she had ever had the residents to complain about the water being too cold. CNA #2 stated, "Yes." CNA #2 was asked how long does it take for the water to get at the proper temperatures in the residents' room. CNA #2 stated, "I turn the water on before I ever start and turn the heat on." Interview with Resident #110 (resides on the 200 hall) on 4/15/15 at 9:35 AM, in Resident #110's room, Resident #110 was asked if he has taken a shower in his bathroom. Resident #110 stated, "No, get baths in room. Resident #110 was asked if the water temperature is warm enough. Resident #110 stated, "Takes it forever to get warm, baths are not good, they turn it up, don't get any better." Interview with the Administrator on 4/15/15 at 9:50 AM, in room [ROOM NUMBER]-214's bathrooms the Administrator came in the bathroom while I was checking water temperatures and asked how it was going. The Administrator was asked if it was acceptable for the residents to have to wait 15 to 20 minutes for the water to be at the proper temperature. The Administrator stated, "No." The Administrator was asked if he would want to take a bath in cold water. The Administrator stated, "No."

Based on policy review, review of the "CNA (certified nursing assistant) Candidate Handbook, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained by 2 of 4 (Registered Nurses (RN) #1 and 2) nurses administering medications, 1 of 1 (Certified Nursing Assistant (CNA) #3) providing perineal (peri) care and for 1 of 1 (Resident #110) residents in isolation. The findings included: 1. Review of the facility's "Hand Hygiene" policy documented, "...Purpose... To decrease the risk of transmission of infection by appropriate hand hygiene... Handwashing... 6. Use a towel to turn off the faucet then discard..." Observations in Resident #32's room on 4/14/15 at 10:15 AM, revealed RN #1 administered a nebulizer treatment to Resident #32. RN #1 did not rinse the medication reservoir prior to or after the nebulizer treatment. Observations in Resident #41's room on 4/14/15 at 5:17 PM, revealed RN #2 entered the bathroom, washed her hands, turned off the water faucet barehanded, applied gloves, and performed an accucheck on this resident. RN #2 removed her gloves, returned to the bathroom, washed her hands, and turned off the water faucet barehanded. At 5:21 PM, RN #2 returned to Resident #41's room, went into the bathroom, washed her hands, turned off the water faucet barehanded, applied gloves, and administered insulin to Resident #41. Interview with the Director of Nursing (DON) and the Regional Director of Clinical Services on 4/15/15 at 10:45 AM, in the DON's office, the DON and the Regional Director of Clinical Services were asked what should be done with the medication reservoir after a nebulizer treatment. The Regional Director of Clinical Services stated, "It should be rinsed with water." Interview with the DON on 4/15/15 at 10:45 AM, in the DON's office, the DON was asked if the water faucet should be touched with bare hands after washing hands. The DON stated, "No." 2. Review of the facility's "Personal hygiene Care for the Female Resident" policy documented, "...ensures the female resident receives appropriate personal hygiene to prevent infections... Infection Control Measures... 5... wash hands... 14. Always proceed from the least contaminated area to the most contaminated area... 21... Dry area thoroughly... " Review of the "CNA Candidate Handbook" March 2012 version, "Skill #20 - Perineal Care for a Female" documented, "...12. ...cleans one side of labia from top to bottom using clean portion of washcloth with each stroke. 14. Cleans vaginal area from top to bottom using clean portion of washcloth with each stroke. 15. ...pats dry the area from top to bottom. 18. with a clean washcloth, cleans the rectal area. 20. ...Pats dry area from front to back. 24. Removes gloves... 27. Identifies that hands should be washed..." Medical record review revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a laboratory (lab) report dated 12/18/14 and 3/19/15 revealed Resident #7 had a Urinary Tract Infection. Review of a culture and sensitivity report dated 12/18/14 and 3/19/15 revealed Resident #7's urine was contaminated with Escherichia Coli present. Observations of peri care for Resident #7 on 4/14/15 at 12:50 PM, revealed CNA #3 washed her hands prior to assembling supplies and preparing the resident for peri care. CNA #3 donned gloves, obtained several wipes out of the package and laid the opened wipes on top of the container with edges of the wipes touching the bed. CNA #3 picked up several wipes and sprayed with peri wash and then dropped the periwash bottle on the bed. CNA #3 again obtained several wipes from the package and placed them on top of the package with edges touching the bed and picked the peri wash bottle up from the bed, sprayed the wipes with the peri wash 6 different times cleaning the right groin area of the resident. Each time the CNA touched the bed while picking up the periwash bottle and dropped the bottle on the bed each time. CNA #3 assisted to position Resident #7 touching the bed with her gloved hands. CNA #3 continued with pericare cleaning the left groin, perineum and catheter tubing. Resident #7 did have a bowel movement and was turned using same gloves. CNA #3 removed the catheter bag from the rail and handed the bag over the resident to the CNA assisting and proceeded to clean Resident #7's buttocks, cleaning the stool off her buttocks and between her buttocks. Peri care was completed. CNA #3 helped roll the resident back to her back and then pulled the pads under the resident to position the resident. CNA #3 took the catheter back from the other CNA over the resident to place the catheter back on the rail. Both CNAs positioned the resident, covered the resident and CNA #3 adjusted the resident's pillow. CNA #3 then removed the gloves used for pericare. CNA #3 did not dry the resident during peri care and contaminated her gloves and peri wipes each time she obtained peri wipes and wash. CNA #3 did not change her gloves after cleaning bowel movement from the resident's buttocks or before repositioning the resident and adjusted the resident's pillow. Interview with the Director of Nursing (DON) on 4/14/15 at 1:50 PM, in the conference room, the DON was asked if it was the policy to change gloves during peri care. The DON stated, "What does the policy say." The DON was asked if it was acceptable for the peri cloth to be placed on the bed. The DON stated, "The package can be as long as the wipes aren't." The DON was asked if the peri wash bottle could be placed on the bed. The DON shook her head no indicating the bottle should not be on the bed. The DON was then asked if the CNA should remove the gloves before positioning the resident or her pillow. The DON did not respond. 3. Review of the facility's "Contact Precautions" policy documented, "...Gloves should be changed after having contact with infected material (...fecal material and wound drainage) followed by hand washing..." Review of the facility's "Clostridium Difficile" policy documented, "...Gowns and gloves should be removed before leaving the resident's room and hands must be washed immediately following hand hygiene guidelines. Alcohol-based hand rubs do not kill spore-forming organisms. Staff will use anti-microbial soap and water... for hand washing..." Observations in Resident #110's room (contact isolation for Clostridium Difficile) on 4/15/15 at 8:25 AM, revealed Licensed Practical Nurse (LPN) #1 was changing Resident #110's left ankle dressing. LPN #1 put on gown and gloves, did not wash her hands before gloving, and knocked before entering room. LPN #1 removed the sheet and the blanket from the resident's left foot, removed the prevalon boot, and removed the sock from his foot. LPN #1 reached around her protective gown, reached into her right uniform pocket, reached around her protective gown, and reached into her left uniform pocket withdrawing a pair of scissors. LPN #1 proceeded to cut the dressing off of Resident #110's foot revealing a small pit- type wound on the ankle bone. LPN #1 placed the scissors in a wheelchair at the end of the resident's bed. LPN #1 touched the left heel wound. LPN #1 propped Resident #110's foot on a bed trough, proceeded to the door, removed her left glove, removed her gown by rolling gown from the neck down with her bare hand and right gloved hand, touching the outside of the gown with her bare hand and placing items in a biohazard container inside the room. LPN #1 then used the wall hand sanitizer before leaving the room. Interview with the DON on 4/15/15 at 10:07 AM, in the DON's office, the DON was asked if it was appropriate to lay scissors that have been used to remove a dressing of a resident that is in contact isolation in a wheelchair. The DON stated, "No ma'am, there should be a barrier." The DON was then asked if it was appropriate to use hand sanitizer before leaving an isolation room. The DON stated, "No." The DON was asked if it was appropriate to reach around your protective gown into your uniform pockets after touching blankets and socks of a resident with[DIAGNOSES REDACTED] (clostridium difficile). The DON stated, "No." The DON was asked if it was appropriate to touch the outside of an isolation gown with your bare hands when removing the gown. The DON stated, "No." Interview with LPN #1 on 4/15/15 at 10:12 AM, at the nurse's station, LPN #1 was asked if it was appropriate to lay scissors that have been used to remove a dressing of a resident that is in contact isolation in a wheelchair. LPN #1 stated, "No ma'am. I was just thrown off because I didn't have my dressing supplies." LPN #1 was asked if it was appropriate to use hand sanitizer before leaving an isolation room. LPN #1 stated, "No." LPN #1 was asked if it was appropriate to reach around your protective gown into your uniform pockets after touching blankets and socks of a resident with[DIAGNOSES REDACTED]. LPN #1 stated, "No, I didn't have my supplies and was just thrown off." LPN #1 was asked if it was appropriate to touch the outside of an isolation gown with your bare hands when removing the gown. LPN #1 stated, "No."

Based on policy review, medical record review, and interview, it was determined the facility failed to assess, treat, accurately document assessments and notify the physician of a decline of a pressure ulcer for 1 of 6 (Resident #1) sampled residents with pressure ulcers. The failure to perform weekly skin assessments and to notify the physician of a decline in a pressure ulcer from Stage III to Stage IV resulted in actual harm to Resident #1. The findings included: Review of the facility's "Post-admission Weekly Skin Assessments" policy documented, "...On a weekly basis, a licensed professional searches for areas of skin that differ from surrounding tissue... The results of the skin assessment are documented on the Weekly Skin Integrity Data Collection form... The Weekly Pressure Ulcer Status Record and the Non-pressure Skin Condition Record are used for weekly assessment of existing wounds..." Review of the facility's "Assessment and Monitoring of Healing" policy documented, "...Pressure ulcers are assessed and monitored once a week to determine if the treatment plan is working or should be re-evaluated..." Medical Record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the weekly skin integrity data collection sheets documented, "...Skin condition... stage III L (left) buttock... 9/26/11... st (stage) IV L buttock... 10/24/11..." No weekly skin assessments were documented from 9/26/11 to 10/24/11. Review of the pressure ulcer status record with assessment dates of 9/12/11 to 9/26/11 documented, "IDENTIFY SITE BELOW (diagram of body with a circle on the left buttock to indicate the site of the pressure ulcer)... Date first observed: 9/12/11... Location: L hip Recurrent Stage III... DATE 9/26/11 STAGE III SIZE IN CM (centimeter) (Length x (by) Width) 3 x 3 DEPTH 1... COLOR Pink dark edge... APPEARANCE OF WOUND... dark area outer edges..." Review of the pressure ulcer staus record with assessment dates of 9/26/11 to 10/21/11 documented, "...RISK FACTORS RELATED TO HEALING... Recurrent wound... IDENTIFY SITE BELOW (diagram of body with a circle on the left buttock to indicate the site of the pressure ulcer)... Date First Observed: 7/15/11... Location R (right) buttock... 9/26/11 STAGE III SIZE IN CM (Length x Width) 3 x 3 DEPTH 1... COLOR Pink... APPEARANCE OF WOUND... Pink wound bed 25% (percent) slough... 10/14/11 STAGE IV SIZE IN CM (Length x Width) 3.5 x 3 DEPTH 1.3... COLOR Pink yellow... APPEARANCE OF WOUND... 50% pink wound bed 50% yellow slough..." No weekly pressure ulcer status records were completed from 9/26/11 to 10/14/11. The "Date First Observed" and "Location" of pressure ulcer was documented inaccurately on the 9/26/11 to 10/21/11 pressure ulcer status record. Review of the September 2011 treatment record documented, "[MEDICATION NAME] to Stage II (2) to buttock Change every 3 days and prn (as needed)..." Review of the treatment record dated October 2011 documented, "...Maxab to Stage III wound to L buttock cover with Allevyn bolder dressing daily (10/1/11 to 10/16/11)... Stage IV L buttock clean wound. Place [MEDICATION NAME] wound gel to wound bed Cover c (with) allevyn border Change daily (10/18/11 to 10/31/11..." No dressing change was documented on 10/13/11, 10/17/11, 10/19/11, 10/22/11 and 10/23/11. During an interview at the nurses' station on 1/4/11 at 4:55 PM, Nurse #1 was asked for the weekly skin assessments from 9/26/11 to 10/24/11. Nurse #1 stated, "...I was working the floor and the floor nurses were supposed to do the skin assessments... I have been unable to locate them (weekly skin assessments)..." During an interview in the conference room on 1/5/11 at 11:20 AM, the Director of Nursing (DON) confirmed no skin assessments were done from 9/26/11 to 10/24/11 and no pressure ulcer status records were done from 9/26/11 to 10/14/11. The DON was asked if there was any physician notification of decline of the Stage III pressure ulcer to Stage IV. The DON was unable to provide any documentation that the physician had been notified of the decline between 9/26/11 and 10/14/11. During an interview in the conference room on 1/5/11 at 11:20 AM, Nurse #1 confirmed that the 7/15/11 date on the 9/26/11 to 10/21/11 pressure ulcer status record should have been 9/12/11 and the location should have been left buttock instead of right buttock. Nurse #1 confirmed he had charted inaccurately. The failure to perform weekly skin assessments and to notify the physician of a decline in a pressure ulcer from a Stage III to a Stage IV resulted in an actual harm to Resident #1.