Every finding on record at Medilodge of Green View

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by outdated and expired food present in the facility's dietary department.Findings include: On 7/7/26 at 12:16 PM, the kitchen was toured with the Food Service Manager (FSM) H. The following observations were made:Refrigeration units were observed to contain multiple items not dated or expired and past use by date as follows:Four gallons of milk dated with the manufacture's use by date of 6/30/26.One gallon of milk 50% filled with a manufacturer's use by date of 6/29/26.Sour cream dated as opened on 7/1/26 and manufacture's use by 7/1/26.Freezer units were observed to contain multiple items not dated or expired and past the use by date as follows:Two packages open to air of individual pizzas (one package with one pizza and the other with 5 pizzas). Both were not dated with an opened date or a use by date. One frozen tube of meat had an unreadable use by date and an unreadable opened on date. The Dietary Manager was to clarify the dates on the meat and stated, I can't read the date. It is just scribbles.A clear plastic bag of sausage patties with a use by date of 3/2026.A clear plastic bag of polish sausages with a use by date of 5/23/26.A clear plastic bag of frozen cookie dough without any labeling or dating.A cardboard box with an internal clear plastic bag open to air containing country fried steaks without any dating as to when it was opened or the expiration / use by date.A cardboard box with an internal clear plastic bag open to air containing chicken nuggets without any dating as to when it was opened or the expiration / use by date.A cardboard box with an internal clear plastic bag open to air containing bulk Italian sausage without any dating as to when it was opened or the expiration / use by date.A cardboard box with an internal clear plastic bag of Italian meatballs with a use by date of 7/4/26. The related portion of the FDA Food Code 2017 are as follows: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO_EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on interview and record review, the facility failed to obtain consent for psychotropic medications for one Resident (#6) of five residents reviewed for unnecessary medications. Findings include: Resident #6 (R6)Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R6 was admitted to the facility on [DATE], with diagnoses that included: depression, bipolar disorder, and non-Alzheimer's dementia. Review of R6's Electronic Medical Record (EMR) included active physician orders for the following medication:Clonazepam [an antianxiety medication] Tablet 0.5 MG Controlled Drug Give 0.5 mg by mouth two times a day for panic attacks related to anxiety disorder.During an interview on 7/7/26 at 3:11p.m., when asked about a consent and risk/benefit of antianxiety medications, Social Services Director (SSD) A reported, There is no consent that has been signed for Clonazepam.there is no documentation of a consent in the EMR.Review of policy titled Medication-Psychotropic date reviewed/revised 10/30/23, read in part .A psychotropic drug is any drug that affects brain activities.psychotropic drugs include.antidepressant, antianxiety, and hypnotics.residents and/or representative shall be educated on the risks and benefits of psychotropic drug use as well as alternative treatments/non-pharmacological interventions.

Based on observation, interview, and record review the facility failed to provide restorative therapy services and/or application of splints for two Residents (#8, #13 & #15) of two Residents reviewed for restorative therapy needs.Findings include: Resident #15 (R15) Review of R15's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 5/21/25, with diagnoses that included: Cerebrovascular accident (CVA) [stroke], hemiplegia [severe or complete paralysis of one side of the body] or hemiparesis [unilateral paralysis or weakness], and malnutrition. R15 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. Review of R15's Electronic Medical Record (EMR) revealed a physician order dated 3/20/26 read in part .Palm protector [a specialized medical cushion device used to prevent severe finger contractures, stop fingernails from digging into the palm, and reduce skin breakdown] to be worn at all times. R15's care plan revealed the following: .Resident has an ADL [Activities of Daily Living] self-care performance deficit.intervention.Palm protector to be worn at all times. date initiated 3/20/26. During an observation and interview conducted on 7/6/26 at 1:20 p.m., It was noted that R15 did not have a palm protector on her contracted left hand. The resident reported that staff have not been applying the blue palm protector due to an inability to locate the device. During an observation and interview on 7/7/26 at 7:05 a.m., R15 was in the dining room without a palm protector for her contracted hand. When questioned, R15 noted that staff had been unable to locate the device. R15 was noted to be without a palm protector on her contracted left hand on 7/7/26 at 11:11 AM and 7/8/26 at 7:25 AM. During an interview on 7/8/26 at 7:40 a.m., Certified Nurses Aide (CNA) B reported [R15] is supposed to have the palm protector in her hand. During an interview on 7/8/26 at 8:43 a.m., Rehab Director E reported, I assessed [R15] and it was my recommendation for the resident to have a palm protector. During an interview on 7/8/26 at 8:54 a.m., Nursing Home Administrator (NHA) acknowledged that R15 had a physician order for a palm protector to be used at all times. Resident #8 (R8) During an interview on 7/8/2026 at 12:49 PM, R8 stated, I would like to be home and would like to go places. R8 said she could walk but was at the facility because she fell. She felt like she needed more practice walking. During an interview on 7/8/2026 at 1:58 PM, R8 stated, I would like to be more independent. R8 said she would like to be able to walk without a walker and be able to move about in a kitchen to cook. R8 said no one has worked with her and thought it might be because of her insurance. Resident #8 (R8) was admitted on [DATE] with diagnoses including congestive heart failure. The electronic medical record (EMR) for R8 included a Minimum Data Set (MDS) assessment dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating intact cognition. The EMR for R8 included a care plan that read in part, Resident would benefit from a restorative ambulation program related to decreased endurance Date Initiated: 04/06/2026. The goal for this focus was listed : Resident will ambulate 200 feet and or up to tolerance with a FWW (Front Wheeled Walker) with gait belt and supervision through the next review. Date Initiated: 04/06/2026 Revision on: 04/29/2026 Target Date: 9/30/2026. Interventions for this focus included: Provide ambulation program 5 days per week for 200 feet with FWW with gait belt and supervision Date Initiated: 04/06/2026 Resident #13 (R13) A review of the medical record revealed R13 was admitted on [DATE] with diagnoses including a stroke affecting the right side. The current Physician Orders for R13 originally written on 4/23/26 read Apply tubigrip (a tubular multipurpose bandage designed to provide tissue support) on BL (both) arms every AM (morning) and remove every PM (evening) before bedtime two times a day. During a room visit on 7/6/2026 at 2:29 PM, R13 was observed with her right hand contracted and without any wrap or tubular bandage on her arm and without a splint on her right hand. R13 stated she does not have anything to place in her fist which was clamped tightly closed. She said she wanted to go home but needed physical or restorative therapy and said no one was working with her. During a room visit on 7/7/2026 at approximately 8:00 AM, R13 was observed at breakfast without the tubigrip on her arms and without a splint on her contracted hand. R13 again stated no one was working with her to keep her contracted fist from getting worse. The care plan for R13 revealed a focus of Resident has an ADL (activity of daily living) self-care performance deficit related to Stroke effecting R (right) side . Initiated: 09/28/2024 Revision on: 10/17/2024 and a focus of Resident would benefit from a restorative maintenance passive range of motion program related to Limitation in range of motion Date Initiated: 12/12/2024 Revision on: 02/26/2026 Interventions for this focus included: Observe for verbal and non-verbal signs/symptoms of pain during splint application/removal (e.g., voices complaints of pains, grimacing, guarding, crying, moaning) Date Initiated: 12/12/2024 Provide range of motion program (SEVEN) days per week for (FIVE) minutes. Date Initiated: 12/12/2024 Revision on: 12/12/2024 PT/OT (Physical Therapy/ Occupational Therapy) screen / eval / treat as needed Date Initiated: 12/12/2024 Other: CENA (Competency Evaluated Nurse Aide) to complete 15 reps of finger extension/flexion and 15 reps of wrist flexion/extension Date Initiated: 12/12/2024 Revision on: 12/12/2024 Other: Geri sleeves or Geri gloves (provided by hospice) to be worn while out of bed if resident is wearing long sleeve shirt resident should still have gloves on Date Initiated: 12/02/2025 Revision on: 12/02/2025 During an interview on 7/8/2026 at 9:08 AM, Occupational Therapist Registered (OTR) E stated a restorative program was recommended following the discontinuation from the occupational therapy regime. OTR E provided the recommendations dated 11/20/2024 for R13 and stated the recommendations were current. The recommendation read Right hand splint to be worn 4 hours on and 4 hours off during waking hours. The recommendation were revised on 12/5/24 and read, Right hand splint to be worn 2 hours on and 4 hours off during waking hours only. Palm protector can be worn at all time splint is not worn. On 7/8/2026 at 9:39 AM, R13 was observed wearing geri sleeves not tubigrips as ordered. R13 had not been observed without any protective wear on her arms on for two days. During an interview on 7/8/2026 at 9:23 AM, Registered Nurse (RN) F stated she was the RN in charge of the restorative program. She said, I just educated my staff because they were not applying the tribi grips and there had to be follow up. RN F reviewed the chart and stated there were orders, therapy notes and care plans for differing things geri sleeves, tubigrips, splints and palm protectors. She stated, They all should match. During an interview on 7/8/2026 at 10:00 AM, CENA G stated he only did restorative 15-20 % of the time now that his job duties had changed to scheduling and transporting. He did not think there was a full time CNA responsible for restorative since he had left the position. During an interview on 7/8/2026 at 10:00 AM, Certified Nurse Aide (CNA) G stated he only did restorative 15-20% of the time now that his job duties had changed to scheduling and transporting. He did not think there was a full time CNA responsible for the restorative program since he had left the position. During an interview on 7/8/2026 at 1:48 PM, Registered Nurse (RN) F stated she was the person working on the Restorative Program. RN F reviewed the EMR and stated R8 was not currently working with therapy and was not on a restorative program. The facility presented a policy titled, Restorative Nursing Programs dated as Reviewed/Revised on 1/1/2022. The policy read in part, The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility. Once determined that the resident would benefit from a restorative nursing program, implement the following: Determine if the resident is willing and able to participate. Determine resident and/or family goals for restorative care. Restorative documentation requirements include: .Monthly review by a licensed nurse. Implementation of program review by nursing staff, therapy, and others as appropriate to monitor program including addition of new residents and removal of programs. Review of entire program to the facility quality assurance program.

Based on observation, interview, and record review, the facility failed to provide adaptive equipment during meals for one Resident (#15) of one resident reviewed for adaptive equipment.Findings include:Resident #15 (R15)Review of R15's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 5/21/25, with diagnoses including cerebrovascular accident (CVA) [commonly known as a stroke that occurs when blood flow to a part of the brain is interrupted or reduced], hemiplegia [severe or complete paralysis of one side of the body]or hemiparesis [weakness or partial paralysis affecting only one side of the body], and malnutrition. R15 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition.A dining observation on 7/7/26 at 7:34 a.m., revealed R15 made forceful strikes with a fork at the waffles on her plate and pushed them across her plate which caused the waffles to fall on the table surface. R15 poked the fork at her eggs as the eggs fell apart. No divided plate, lipped plate, or plate guard was in place to assist R15 with eating independently.A dining observation on 7/8/26 at 7:32 a.m., revealed R15 having breakfast in the dining room with no divided plate.During an interview on 7/8/26 at 7:37 a.m., Certified Nurse Aide (CNA) B reported, [R15] used to have a divided plate.During an interview on 7/8/26 at 7:52 a.m., Registered Dietician (RD) D reported, In [R15's] EMR there is a physician order for a divided plate dated 5/27/25 with no discontinued date for the order.the order for the divided plate is not on her meal ticket and should be located on her meal ticket to inform staff in the dietary department to use a divided plate for all meals.Review of R15's care plan read in part .Resident is at risk for altered nutritional status.provide adaptive equipment: divided plate date initiated 5/27/25.Review of R15's Electronic Medical Record (EMR) revealed Registered Dietician (RD) D documented R15 is to have a divided plate to assist with meals.During an interview on 7/8/26 at 7:57 a.m., Nursing Home Administrator (NHA) acknowledged the dietary department was not following a physician order for a divided plate during all meals for R15.Review of policy titled Use of Assistive Devices date reviewed/revised 10/26/23, read in part .Assistive devices are tools products, types of equipment or technology that help individuals perform tasks and activities. They may help the individual.eat.assistive devices include.eating utensils.

Based on interview and record review the facility failed to establish a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for one Resident (#5) of one resident reviewed for hospice services.Findings include:Resident #5 (R5)The electronic medical record (EMR) revealed R5 was most recently admitted on [DATE] with diagnoses including relapsing-remitting multiple sclerosis. An order for a hospice evaluation and treatment was written on 8/21/2025. The care plan for R5 included: Resident has a terminal prognosis with (Hospice) Care related to end of life diagnosis.During an interview on 7/6/2026 at 3:44 PM, R5 stated she was on hospice but was not sure when they visited her.During an interview on 7/8/2026 at 10:19 AM, Registered Nurse (RN) F explained she had set up the EMR with rights for hospice nurses to document their visits. The EMR was reviewed, but there were no notes written for R5 describing hospice visits or services provided. There were shower sheets signed by the hospice aide, but no documentation with concerns or communication on visits from the hospice nurse, social services, or chaplain services could be found.During an interview on 7/8/2026 at 11:20 AM, Regional Consulting RN I stated she could not find documentation from the hospice providers personnel.The facility provided a policy titled Hospice dated as reviewed/revised 10/26/2023 which read in part, .1. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the residents' care. 4. The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility. 6. The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities.

Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living among all residents. Findings Include:On 07/30/2025 at 10:27 AM, it was noted that the drain line on the ice machine in the main dining room off the kitchen had black slime growing on end of the pipe. Maintenance Director F observed the drain pipe, and stated he cleans the ice machine and the drain tray weekly, but not the drain line that hangs above the floor drain.On 7/29/25 at 10:31 AM, the register cover in room [ROOM NUMBER] was observed dirty with brown splatters on the wall and had been re-enforced to hold the front and the top of the unit together. On 7/29/25 at 12:42 PM, during an interview with Guardian/Conservator G she was asked about the heater/register in room [ROOM NUMBER] and stated that it looks terrible, but functions fine. She stated the register was beat up and could be replaced.On 7/30/2025 at 8:05 AM, a follow-up observation found that the heating register cover in room six was damaged.On 07/30/2025 at 8:25 AM, during a tour of the soiled utility room with the Senior Maintenance Director E , an interview found that the facility flushes water fixtures weekly to prevent stagnate lines and Legionella from growing and spreading. The hopper was observed full of clear water. When the over hopper fill faucet was turned on, the water coming from that fixture was noted brown and discolored. Senior Maintenance Director E continued to run it for approximately a minute until a small clog dislodged, and the water ran clear. Senior Maintenance Director E stated that this fixture would now be added to the fixture flushing schedule.On 7/30/2025 at 8:40 AM during a tour of the A Wing with Maintenance Director F, it was observed that the heat register covers were damaged, or loose in Rooms 1, 5, 6 and 8. The cover in room [ROOM NUMBER] was loose in several places. The cover in room [ROOM NUMBER] was not attached completely. The cover in room [ROOM NUMBER] was observed to be damaged and pried up, exposing the heating coils inside. The wall behind the heat register in room [ROOM NUMBER] was noted soiled and splattered with brown and black debris. The heating register cover in room [ROOM NUMBER] was pulled away slightly, partially exposing the heating coil underneath.On 7/30/25 at 8:58 AM, the Maintenance Director F stated that he has been trying to order parts to repair these registers, but the parts have not been available.

Based on interview and record review, the facility failed to ensure the physician documented the clinical rationale and duration of use in the medical record for a PRN (as needed) psychotropic medication for one Resident (#6) of five residents reviewed for unnecessary medications. Findings include: Resident #6 (R6) was admitted to the facility 6/23/25. A Minimum Data Set (MDS) assessment dated [DATE] documented R6 had severe cognitive impairment and received psychotropic medications. There were no behaviors coded in the MDS.The Electronic Medical Record (EMR) of R6 contained a physician's order dated 7/9/25 for alprazolam (an antianxiety medication) 0.25 mg (milligrams) every 24 hours PRN for anxiety. A medication history review revealed the PRN alprazolam was initially ordered on 6/24/25.A pharmacist medication regimen review (MRR) for R6 dated 6/24/25 read, in part: .Note to attending physician/prescriber.This resident has an order for PRN alprazolam. Please evaluate current diagnosis, behaviors and usage patterns and evaluate continued need. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale [sic] in the resident's medical record and indicate the duration for the PRN order [sic]. Review of the EMR on 7/31/25 revealed no documentation by the physician regarding the PRN alprazolam, including the clinical rationale or duration of use for the PRN antianxiety medication for R6. A nurse's progress note dated 7/9/25 at 8:56 PM documented, PRN Xanax [brand name of alprazolam] reviewed with Dr. [physician's name redacted]. Orders received to continue current order and review in 2 weeks. There were no further nurse progress notes regarding the alprazolam.The Director of Nursing (DON) was interviewed on 7/31/25 at 8:33 AM. The DON said the use of PRN psychotropic medications was limited to 14 days before the physician was required to re-examine and evaluate the continued use of the medication. The DON was asked if the physician had evaluated the PRN alprazolam for R6 and if the physician documented the duration of use and clinical rationale for the continued use of the antianxiety medication. The DON said she would review the EMR.On 7/31/25 at 10:34 AM, the DON reported the physician of R6 did not document on the alprazolam including the continued need for the medication or duration of use. The policy Medication - Psychotropic dated as reviewed/revised 10/30/23 documented, in part: .PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on interview and record review, the facility failed to ensure one Resident (#2) of one resident reviewed for PASARR (Preadmission screening/Annual Resident Review) had a Level one (1) OBRA (Omnibus Budget Reconciliation Act) screening sent to the Community Mental Health Services Program (CMHSP) for a level two (2) OBRA evaluation. Findings include:The Electronic Medical Record (EMR) of Resident #2 (R2) revealed an admission date of 6/19/25. R2's diagnoses included but were not limited to: Bipolar Disorder and Major Depressive Disorder. A Level 1 screening dated 6/11/25 documented R2 had a diagnosis of mental illness and had received treatment for mental illness, including psychotropic medications within the last 14 days. The EMR did not contain a Level 2 OBRA evaluation, and no documentation was in the EMR indicating a Level 1 had been referred to the CMHSP for evaluation.The MDS Nurse (Registered Nurse (RN) C) was interviewed on 7/30/25 at 1:41 PM. RN C confirmed she was the staff member responsible for completing the PASARR. RN C said there was not a Level 2 for R2 because a Level 1 assessment for R2 was not sent to the CMHSP for evaluation for services that may be needed for R2. RN C said R2 had transferred to the facility from a different nursing facility and the person in the company responsible for admissions did not transfer the OBRA from the facility from which she was transferred to the current facility, so RN C did not receive a notification to follow-up with the local CMHSP. The Social Services Coordinator (SSC) was interviewed on 7/30/25 at 2:11 PM. The SSC confirmed R2 was not receiving services for mental illness. The SSC was asked regarding R2 receiving services for mental illness. The SSC said the Resident Representative (RR) of R2 would need to approve the services. The SSC was asked if the RR of R2 was provided with the option to accept or decline services for R2. The SSC confirmed the RR was not approached regarding mental health services for R2. The SSC said, [R2] fell through the cracks.The policy PASARR - Pre-admission Screen and Resident Review dated as reviewed/revised 10/30/23 documented, in part: . All residents are required to have a level 1 PASRR [sic]screen prior to or upon admission the facility [sic]. When indicated on the level 1 screen that a level 2 is required, the facility will complete notification to the State's PASRR [sic] program notice for the level 2 screen.

Based on observation, interview, and record review, the facility failed to ensure a mobility bar was properly fixated to a bed frame for one resident (Resident #21) of 6 residents reviewed for accident hazards and bed safety. This deficient practice resulted in two separate falls from bed resulting in a concussion and a hip fracture requiring surgical intervention. Findings include: Resident #21 (R21): Review of R21's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), right foot amputation, and depression. Review of R21's most recent Brief Interview for Mental Status (BIMS) assessment revealed a score of 15, indicative of intact cognition. Review of the facility census revealed R21's most recent hospitalization was 7/30/24 - 8/5/24. On 8/6/24 at 10:38 AM, R21 was observed lying in bed with a fall mat placed on the floor on the left side of her bed and a mobility bar attached to the left side of the bed frame. When asked if she utilized the mobility bar, R21 replied, Yes, but it was broken when I fell . R21 stated her right hip was, very sore. Review of an Unwitnessed Fall Event Report written by Registered Nurse (RN) H, dated 5/30/24 read, in part: Nursing Description: heard yelling . I moved quickly to the end of b-wing and when I got there, I could tell it was coming from [R21's] room. I entered [the] room to find [R21] on the floor, laying on her back with her bilat [bilateral] knees bent, small scratch visible on left knee and left 5th finger . Immediate Action Taken: Kept her on the floor .tried to straighten bilateral legs to check hips, she yelled out in pain so I called [physician] and he ordered to ship her to ER [emergency room ] . Review of the Predisposing Situation Factors on the Unwitnessed Fall Event Report revealed Other (describe) was selected via checkmark. Other Info read, in part: Predisposing equipment=Left side of rail was not locked, and it swung out of the way toward the head of the bed. On 8/7/24 at 8:10 AM, an interview was conducted with RN H regarding R21's fall on 5/30/24. RN H verified the mobility bar was not locked in the closed position at the time of the fall assessment. When asked if the instability of the mobility bar contributed to R21's fall, RN H replied, I would assume it did. Review of R21's ER discharge summary, dated 5/30/24, read, in part: Reason for visit: Fall . Diagnoses: Closed head injury . Review of an Unwitnessed Fall Event Report written by RN I, dated 6/19/24 read, in part: This nurse was walking down the hall and heard a garbage can tip over and a resident yelling for help. This nurse went to [R21's] room and saw resident laying on the floor next to her bed. Resident was bleeding from her R [right] forearm and R knee . Resident c/o [complains of] 10/10 pain . Review of the Predisposing Situation Factors on the Unwitnessed Fall Event Report revealed Equipment (describe in note) was selected via checkmark. No additional narrative was provided. Review of a progress note dated 6/20/24, read, in part: RTC [return to clinic] at 1500 [3:00 PM] . shouting out with pain during transfers and repositioning . Review of R21's ER discharge summary, dated 6/20/24 read, in part: Reason for visit: Fall, Leg Pain . Diagnoses: nondisplaced fracture of greater trochanter of right femur . referral was sent to orthopedic clinic for outpatient follow-up . Review of a Standards of Care (SOC) Meeting, dated 6/20/24 read, in part: .Initial SOC Fall note for fall occurring 6/19. Resident stated that she rolled out of bed and onto the floor .Fall resulted in 3 skin tears and increased pain in R [right] leg. Resident shipped to ER for evaluation . CT [computed tomography scam] shows r [right] hairline femur fracture . This is the second occurrence of resident rolling out of bed. Last fall 5/30. Resident mobility bar was unlocked and moved away when she rolled against it . Review of a progress noted dated 7/30/24 read, in part: Resident had appointment for ortho [orthopedics] .for previous fracture . The doctor stated a significant change in the fracture and that the resident needed to have surgery. Resident was transferred from ortho to ER to have surgery today . On 8/07/24 at 9:32 AM, an interview was conducted with Maintenance Director (MD) J who verified he oversaw mobility bar audits and maintenance. MD J verified he was notified of R21's faulty mobility bar after her second fall from bed which resulted in a hip fracture. MD J verified a spring was broken preventing the mobility bar from properly locking in place. On 8/7/24 at approximately 9:05 AM, an interview was conducted with the Director of Nursing (DON) who verified R21's mobility bar was not in working order at the time of both the 5/30/24 and 6/19/24 falls, the latter which resulted in a hip fracture. When asked why the mobility bar was not repaired after the first fall despite the documentation by RN H recognizing it as a predisposing environmental factor, the DON replied, I didn't realize the rail was not fixed after the first fall .I review the incident reports and that was just something I missed. The DON confirmed all residents with a mobility bar in place should have an active physician's order. Review of R21's EMR did not reveal a physician order for a mobility bar at present date nor at the time of the falls. Review of facility policy titled, Proper Use of Bed Rails revised 10/24/22 read, in part: .if bed rails are used, the facility ensures correct installation, use, and maintenance of the rails . the facility will obtain a physician's order for the use of the specified bed rail and medical diagnoses, condition, symptom, or functional reason for use of the bed rail . The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: .conducting routine preventative maintenance of bed and bed rails to ensure they meet current safety standards and are not in need of repair . Review of the Manufacturer's User-Service Manual for the mobility bar read, in part: .Warning: Risk of Serious Injury or Death. Do not use this assist device until you have verified that it is locked in place. Injury to resident of caregiver may result if this procedure is not followed .

Based on observation, interview, and record review, the facility failed to ensure medications were safely administered in an environment of a residents choosing for one Resident (R191) of twelve residents reviewed for Residents' Rights. Findings include: During medication administration observation on 8/7/24 at 7:24 a.m., Registered Nurse (RN) E provided Resident #191 (R191) her prescribed medications while R191 was eating breakfast in the dining room with other residents. RN E placed the medications directly on the table next to R191 and exited the dining room without observing R191 take the medications. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:30 a.m. The DON agreed medications should not be provided in the dining room unless a resident prefers to take his or her medications in the dining room. The DON said the resident preference for administration locale would be in the care plan if a resident wants medications administered in a public area such as the dining room. R191 was interviewed on 8/7/24 at 11:51 a.m. When asked about receiving medication while in the dining room, R191 said the nurses usually provide her with medications in her room. When asked how she felt about receiving medications while in the dining room, R191 replied, I don't want them in the dining room. I never want them in there. I want to get them in here [resident's room]. The policy Promoting/Maintaining Resident Dignity dated 10/26/23 read, in part: .It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residents' quality of life by recognizing each resident's individuality . An undated, attached addendum for Residents' Rights read, in part: .(d) a patient or resident is entitled to privacy, to the extent feasible in treatment and in care for personal needs with consideration, respect, and full recognition of his or her dignity and individuality .

Based on observation, interview, and record review, the facility failed to ensure assistance was provided with donning a back brace for one Resident (R20) of four residents reviewed for range-of-motion and mobility. Findings include: Resident #20 (R20) On 8/5/24 at approximately 9:15 a.m., a Thoracolumbosacral orthosis (TLSO - a type of back brace) was observed on a chair in R20's room. R20 was sitting in a wheelchair talking on the phone and was not visibly wearing a different brace or device to stabilize or support the spine. On 8/5/24 at 12:47 p.m., the TLSO remained in the chair in R20's room. When asked about the TLSO, R20 said, I broke my back and I'm supposed to wear that when I'm out of bed, but I can't put it on by myself. R20 indicated she was admitted to the facility for skilled rehabilitation services after experiencing a fall at home that resulted in a spinal fracture. R20 was asked if the staff assisted with donning the brace. R20 said the therapist was assisting with the brace but skilled therapy had ended in July, and no one helped her put on the TLSO since. On 8/6/24 at 10:22 a.m., R20 was observed in her room using a walker to ambulate. R20 was not wearing the TLSO. R20 said, No one helps me put it on since therapy stopped. I'm supposed to wear it when I'm not in bed, but I can't buckle it by myself. On 8/6/24 at 10:26 a.m., the nurse manager, Registered Nurse D (RN D) was asked if R20 should be wearing her TLSO every day when out of bed. RN D said R20 always refuses to wear it [the TLSO]. RN D accompanied the surveyor to R20's room and asked R20 if she would like help with placing her back brace. R20 responded, yes - it's about time! Resident #20 (R20) was admitted to the facility on [DATE] with a spinal fracture. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating R20 was cognitively intact. Section E did not code any behavioral concerns. Section E0800 of the MDS documented R20 did not exhibit rejection or refusal of care necessary to achieve R20's goals for health and well-being. R20 had a physician's order for TLSO brace with activity every shift. Transfer records from the hospital documented the need for R20 to wear the TLSO when out of bed. R20's care plans included an intervention for TLSO as ordered. There was no documentation of refusing to wear the TLSO in the care plan or in behavior tracking tasks. The Physical Therapist Assistant (PTA) and Occupational Therapist (OT) were interviewed on 8/06/24 at 10:53 AM. The OT reviewed R20's record and said skilled therapy did not have any documentation on R20's TLSO. The PTA said he worked with R20 for the duration of her skilled therapy, and confirmed he assisted her each day with applying the TLSO. The PTA said R20 wore the brace willingly and never refused to wear it for him. The PTA said R20 was unable to apply the brace independently and required assistance with placing the brace. When asked who was supposed to be aiding with the brace, the PTA said, nursing. The PTA and OT confirmed R20 should be wearing the brace every day when out of bed. The OT said occupational therapy and physical therapy ended on 7/23/24 and 7/26/24 so nursing should have been applying the brace each day since skilled therapy services ended. The Treatment Administration Record (TAR) revealed the order for the TLSO. The brace was signed out as being applied every day, each shift in August including 8/5/24 and 8/6/24 when the observations were made of R20 not wearing the brace. There were no documented refusals by R20 to wear the brace. RN A, the nurse who initialed the TAR indicating the TLSO had been applied on 8/5/24 and 8/6/24, was interviewed on 8/6/24 at 12:52 p.m. RN A confirmed he had not assisted R20 with applying the TLSO. RN A said, I've never assisted (R20) with application of the brace. When asked why he signed the TAR with his initials indicating the brace was applied, RN A said the Certified Nursing Assistants (CNAs) applied the TLSO. The tasks in R20's medical record did not include documentation by CNAs indicating R20 was assisted with placing the TLSO when out of bed. Progress notes in R20's record did not document the daily donning and doffing of the brace. A physician's progress note on 6/17/24 read, in part: .Generalized weakness. To wear TLSO brace when up . The Director of Nursing (DON) was interviewed on 8/7/24 at 10:38 a.m. The DON said the expectation is for staff to assist R20 with placement and removal of the TLSO. The policy Use of Assistive Devices dated 10/26/23 read, in part: .The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function .facility staff will provide appropriate assistance .set up assistance, supervision, or physical assistance as needed .

Based on interview and record review, the facility failed to: 1. Document the rationale for declining gradual dose reductions for an antipsychotic medication for one Resident (R1) of five residents reviewed for unnecessary medications, and 2. Document the rationale and duration of PRN use of a psychotropic medication for one Resident (R6) of five residents reviewed for unnecessary medications. Findings include: Resident #1 (R1) A review of the physician's orders for R1 included an order for Abilify (an antipsychotic medication) 10 milligrams (mg) daily. A review of R1's medical record did not reveal any attempts at Gradual Dose Reduction (GDR) of the Abilify since R1 was admitted to the facility on [DATE]. A form Antipsychotic Gradual Dose Reduction Form dated 11/23/23 was in R1's record. The form documented the Antipsychotic medication to be addressed was Abilify for Bipolar disorder and hallucinations. A box was checked that read: a gradual dose reduction is contraindicated for the following reason: . but no documentation followed - the area to document the response was blank. R1's physician did not provide a written response documenting the reason for declining a GDR attempt for Abilify. Staff F was interviewed on 8/6/24 at 1:37 p.m. Staff F confirmed she was the social services designee and oversaw GDR of psychotropic medications. When asked when the last GDR of Abilify was attempted for R1, Staff F said a dose reduction had not taken place since she assumed the social services designee position in January 2023. Staff F was asked if the physician had attempted a GDR of the Abilify since R1 was admitted to the facility. Staff F replied, No, I don't think so. Staff F was asked if the physician had documented any rationale for not attempting a GDR or if there was documentation of clinical contraindication of a GDR. Staff F reviewed R1's medical record and said, I can't find any documentation. Staff F said a GDR for Abilify was submitted to the physician on 11/23/23 but the physician had declined the GDR request. Staff F was asked for the documented reasoning for declination. Staff F reviewed R1's medical record and confirmed there was no physician documentation indicating the physician's reason for not attempting a GDR. Staff F was asked if the facility's contracted provider of psychiatric services was involved with R1's psychiatric needs and psychotropic medication. Staff F said contracted psychiatric services were not involved because R1 is followed by Community Mental Health (CMH). Staff F was asked the location of CMH documentation, facility communication, and collaboration with the facility regarding R1's Abilify and GDR history. Staff F reviewed R1's medical record and confirmed there was no documentation in the medical record from CMH. Staff F confirmed the medical record was the only place documented reasoning for declination of GDR attempts would be located. On 8/6/24 at 3:34 p.m., the Corporate Regional Nurse (CRN) provided a medication history for Abilify. The CRN said, No GDR's have been tried since (R1) was admitted in 2021 - (R1) has been on 10 milligrams [of Abilify] since (R1) has been here. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:34 a.m. The DON said GDRs should be attempted every 6 months the first year of admission, then annually. The DON said physician documention of reasoning is required if a physician determines a GDR would be detrimental for a resident. The DON was asked where the physician documented a reason for declining a GDR for R1. The DON replied, He [the physician] didn't document a reason. The policy Use of Psychotropic Drugs and Gradual Dose Reductions dated 10/24/22 read, in part: .Residents who use psychotropic drugs receive gradual dose reductions .unless clinically contraindicated .The physician has documented the clinical rationale for why .attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior . Resident #6 (R6) R6 was prescribed lorazepam (an antianxiety medication) every 8 hours PRN (as needed) for anxiety for 14 days. The most recent admitted R6 was 8/18/23. A review of the lorazepam order history revealed R6 was prescribed the lorazepam PRN since readmission to the facility at varying time intervals and varying durations of therapy without adequate indications for use or rationale provided by a physician. A Medication Regimen Review (MRR) by the consultant pharmacist dated 7/8/24 read, in part: .This resident currently has an order for lorazepam PRN .PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicates the duration for the PRN order. Please consider ( )discontinue PRN lorazepam or ( ) If PRN lorazepam is to be continued, please write a new PRN order and include the duration of therapy and rationale for continued use . The physician response on the July MRR read in chart. Physician notes in R6's medical record from 8/18/23 through 8/7/24 did not reveal documented rationale by the physician for the PRN lorazepam nor did the documentation contain an indication of the duration of use for the PRN lorazepam. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:21 a.m. The DON said R6's anxiety increased at bedtime. The DON stated, We've tried melatonin [a hormone that regulates the sleep cycle] and things like that, but it wasn't effective. (R6) can't sleep because of anxiety so we are using lorazepam to help her sleep. The DON was told R6 was currently being administered melatonin at night. The DON said the melatonin is not effective with assisting R6 with sleeping. When asked why R6 was being administered melatonin if it wasn't working, the DON responded, Good question! When asked why an antianxiety medication was being utilized in lieu of a hypnotic medication to assist with sleep, the DON did not provide an answer. The policy Use of Psychotropic Drugs and Gradual Dose Reductions dated 10/24/22 read, in part: .PRN orders for psychotropic drugs shall be used only when the medication is necessary .and for a limited duration i.e., 14 days. A. If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order .

Based on observation, interview, and record review, the facility failed to ensure medications were appropriately administered for two Residents (R4 and R17) of four residents reviewed for infection control practices during medication administration. Findings include: During medication administration observation on 8/6/24 at 7:41 a.m., Registered Nurse (RN) A was preparing medications for Resident #4 (R4) at the medication cart. RN A picked up a plastic water cup by the lip of the cup with ungloved hands to set the cup on the med cart. RN A poured water into the cup they had just touched with bare fingers and gathered the medications and cup of water and entered R4's room. RN A placed the cup of water, a medication cup containing R4's medications, and an insulin syringe on R4's bedside table without a barrier. RN A handed R4 the medication cup containing the medication. When R4 attempted to place the medications from the cup into his mouth, three medications fell from the cup onto R4's bed. RN A picked up the medications with bare, ungloved fingers and placed the three medications back into the medication cup. RN A provided R4 the cup of water. R4 placed the rim of the cup RN A had touched with bare fingers to his mouth to swallow the medications including the three medications RN A had touched with his bare fingers. RN A administered medications to Resident #17 (R17). RN A obtained a water cup containing a flexible straw then adjusted the straw by bending the top of the straw (the portion that is placed in the mouth when drinking from a straw) with bare hands. RN A placed the portion of the straw they had just touched with bare, ungloved fingers into R17's mouth for the resident to drink. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:30 a.m. When the medication administration observations were conveyed to the DON, the DON confirmed the actions by RN A were unacceptable. The DON said, It's not ok - it's an infection control issue. The policy Infection Prevention and Control Program dated 12/27/23 read, in part: .Licensed staff shall adhere to safe infection and medication administration practices . The policies Administration Procedures for All Medications and Oral Medication Administration, both dated 8/2020, read in part: .Medications will be administered in a safe and effective manner .Use a barrier to carry medication containers into the resident's room and to separate the supplies and the over-the-bed table or other surface .taking care to avoid touching the tablet or capsule .

Based on observation, interview, and record review, the facility failed to implement a comprehensive, facility-wide Infection Control Program as evidenced by failure to: 1. Don, doff, and disinfect PPE (personal protective equipment) for residents with confirmed or suspected of COVID-19 infection. 2. Assess for COVID-19 symptoms and implement transmission-base precautions timely. 3. Complete infection control analysis, correlation, and trending of resident and staff infections. 4. Maintain timely and accurate infection control line listings and surveillance mapping. 5. Properly retrieve meal room trays from COVID-19 positive rooms. 6. Ensure disinfectant chemicals used to clean and disinfect transmission based precaution (TBP) rooms met the minimum concentration specified by the vendor of the chemical. This deficient practice has the potential to result in the transmission of pathogens between residents rooms and the spread of infectious organisms to all 32 vulnerable residents. Findings include: On 9/19/23 at approximately 9:00 AM, upon entering the facility, an observation was made of the facility entry door indicating there were COVID-19 positive residents within the building. On 9/19/23 at approximately 9:15 AM, an entry introduction was made with the Nursing Home Administrator (NHA) during the screening of the Surveyor Team. The NHA guided the Surveyor Team into his office and provided a list of facility residents who were COVID-19 positive. The list revealed COVID-19 positive residents down the B-hall located in rooms: 16, 17, 19, 20, 21, 23, and 28 (a total of seven residents). The list also revealed a COVID-19 positive resident down the A-hall located in room [ROOM NUMBER] who no longer remained in the facility because they were sent to the local hospital. Further review of the resident list revealed one other resident who was located down the B-hall in room [ROOM NUMBER] (grayed out on the list) who returned home on 9/18/23 per the NHA. During the above interview on 9/19/23 with the Nursing Home Administrator (NHA), the survey team was informed the facility had a total of eight COVID-19 positive residents and one staff member. The NHA said the first identified resident case of COVID-19 was identified on Saturday, 9/16/23. During an interview on 9/19/23 at 12:20 p.m., The facility provided an Infection Control (IC) line listing of residents who had tested positive for COVID-19 since the first case identified on 9/16/23. Two Residents (R35 and R32) were not on the list of residents who were identified as positive for COVID-19. When asked about why R35 and R32 were missing from those identified as COVID-19 positive, IP C stated, They (IC line list and IC tracking map) are not completed yet because we do them at the end of the month. Documentation of all Resident COVID-19 testing during September 2023 was requested at that time. During an interview on 9/20/23 at 8:55 a.m., COVID-19 Resident testing documentation for September 2023 was again requested from the Director of Nursing (DON), who also performed IC tasks in the facility, but no documentation was provided. During an observation and interview on 9/19/23 at 10:50 a.m., two survey team members entered R35's room. The room door was open, no transmission-based precaution (TBP) signage was on the door, and no personal protective equipment (PPE) was positioned in a wheeled cart outside of the room door. This indicated R35's room should not have had any COVID-19 symptomatic or positive residents. When R35 was asked if they routinely got up into their wheelchair during the day, R35 said they had been sleeping the past couple of days because they did not feel well. R35 said they had a sore throat and a fever for the last several days. Facility staff were observed to enter R35's room wearing surgical masks with no other PPE. During an interview on 9/19/23 at approximately 10:55 a.m., Registered Nurse (RN) H was asked about R35's self-report malaise, sore throat, and increased temperatures. RN H confirmed R35 was experiencing increased temperatures and fatigue. R35 was subsequently tested for COVID-19 on 9/19/23 following the above observation and tested positive. Record review of R35's documented temperatures in the Electronic Medical Record (EMR) revealed R35 had an increased temperatures of 100.3 F (Fahrenheit) on 9/17/23 with continued elevated temperatures through 9/20/23. During an interview on 9/20/23 at 1:06 p.m., IP C was asked about R35's increased temperature, in the midst of the COVID-19 outbreak. IP C said facility nursing staff would usually test a resident when they were symptomatic (such as an increased fever). IP C reported being unaware of the elevated temperature until Monday morning 9/18/23. IP C acknowledged R35 was not placed in TBP until 9/19/23, even though she had an increased temperature, and self-reported sore throat and malaise. Review of the Centers For Disease Control, Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 [COVID-19]), updated 5/8/23, revealed the following, in part: HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the facility COVID-19 Prevention, Response, and Reporting policy, implemented 8/20/20 and updated on 5/26/23, revealed the following, in part: HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. Record Review of the facility's Monthly Infection Prevention and Control Binder was conducted on 9/20/23 at 9:00 a.m. The review revealed the facility experienced an outbreak of COVID-19 in February of 2023, with 16 residents identified as positive for COVID-19 infection. The facility Infection Control Mapping tool which was used to track and trend infections did not contain all of the 16 Residents with COVID-19 in February. Review of the monthly Infection Control line listings from March 2023 through August 2023, did not document the symptoms identified for each resident infection. The Infection Control Line listing only included Residents on antibiotics - no residents with symptoms indicative of a potential infection were identified on any line listing unless an antibiotic was prescribed. During an interview on 9/20/23 at 1:06 p.m, Infection Preventionist (IP) C was asked to verify the discrepancy between the February 2023 Infection Control Line listing and the February 2023 Infection Control Mapping tool. IP C confirmed the infection mapping did not show 16 residents were tracked for COVID-19 during February 2023. Review of the Monthly Infection Prevention and Control Binder for the month of March 2023 was reviewed and revealed an outbreak of a gastrointestinal illness affecting 16 residents. The organism was identified on the line listing as Norovirus for all 16 affected residents. According to The Monthly Infection Prevention and Control Binder, Norovirus continued into the month of April 2023 with at least 10 more identified cases of Norovirus. Review of the Centers for Disease Control and Prevention (CDC) Reporting and Surveillance for Norovirus, last reviewed May 24, 2023, revealed the following, in part: Healthcare providers should report all outbreaks of acute gastroenteritis, including suspected outbreaks of norovirus, to the appropriate state, local, or territorial health department. During an interview on 9/21/23 at 10:41 a.m., documentation of sign-in sheets and education provided for dietary and housekeeping staff was requested from IP C. IP C stated, I don't have any proof that I did any Norovirus education with dietary staff or the housekeeping staff. IP C, RN B, and the DON all confirmed no staff education was documented on sign-in sheets during the Norovirus outbreak of the February 2023 COVID-19 outbreak. IP C also confirmed no dietary or housekeeping audits were performed during the outbreaks of illness in February and March of 2023. The facility IC Monthly Analysis and Summary documented handwashing observations with on the spot corrections but did not indicate what concerns were identified or what corrections were needed. The line listing for April 2023 reflected 10 cases of Norovirus in April 2023, and the April 2023 mapping showed 18 gastrointestinal illnesses. IP C again confirmed the discrepancy between the line listing and the infection mapping in April 2023. Review of an employee call-in log for March 2023 showed an employee call-in on March 13, 2023 (onset date) for a gastrointestinal illness. Documentation indicated the illness lasted for seven days and was resolved on 3/20/23. This employee call-in on March 13th was the first documented indication of gastrointestinal illness in the facility. Review of April 2023 documentation reflected three employee call-ins for gastrointestinal infections which lasted five days, four days, and six days according to onset and resolution dates. The infectious organism was not reflected on any of the employee tracking logs for any of the three employees. The number of illness related employee absences was documented as zero (0) on the March 2023 Monthly Analysis and Summary and documented in April as 2 employee illnesses. There was no indication the facility correlated resident illnesses with employee illnesses. During an interview on 9/20/23 at approximately 1:15 p.m., IP C, RN B and the DON were queried regarding the facility line listing for infections. IP C said the line listing was for tracking antibiotic usage. When asked about the lack of signs and symptoms of infection on the line listing, IP C said the symptoms were entered into an external Infection Control program, but not necessarily into the medical records of each resident experiencing an infection. 45123 On 9/19/23 at 10:20 AM, an observation was made of the B-hall. The B-hall double doors were both shut, and no signs were on the outside of the door to alert staff, residents, or visitors of the COVID-19 positive cases on the other side of the doors. On 9/19/23 at 10:22 AM, an interview was conducted with Registered Nurse (RN) I. RN I was asked how many COVID-19 positive residents she was caring for and when the outbreak started. RN I replied, This past Friday or Saturday is when the outbreak started. I came back into work on Monday (9/18/23) morning and there were six and then we retested yesterday and now there are eight, but one went home. RN I was asked what kind of precautions were being taken to protect the other residents and staff from contracting COVID-19. RN I replied, We have the signs on their doors indicating airborne precautions, we are gowning, wearing N-95's, gloving, and wearing eye protection. We don and doff personal protective equipment (PPE) as necessary and hand hygiene. On 9/19/23 at 10:35 AM, an observation was made of B-hall and there were seven rooms that indicated droplet precautions with instructions on how to don and doff PPE. B-hall contained three PPE carts with surgical masks, N-95 masks, gloves, gowns, eye protection, red bags, disposable vital signs equipment, and three different kinds of sanitizing wipes (one sanitizing wipe canister for hands only and 70% alcohol based, one with a disinfection time of two minutes and one with a disinfection time of four minutes and with bleach). On 9/19/23 facility staff were observed on B-hall and the following observations were made: a.) At 12:09 PM, an observation was made of Certified Nurse Aide (CNA) L who exited room [ROOM NUMBER], a COVID-19 positive room with her prescription glasses with side shields on her face. CNA L failed to sanitize her eye wear off and then proceeded to enter room [ROOM NUMBER] a non-COVID-19 positive room. On 9/19/23 at 12:15 PM, an interview was conducted with CNA L. CNA L was asked if she sanitized her eye wear off when she exited room [ROOM NUMBER] and replied, Am I supposed to? b.) At 12:20 PM, an observation was made of CNA L who entered room [ROOM NUMBER], a COVID-19 positive room with goggles on and had removed her prescription glasses. CNA L exited room [ROOM NUMBER] and removed her goggles from her prescription glasses and placed them on top of the table of the PPE cart with her bare hands and left them sitting there. CNA L failed to sanitize her hands or the goggles. c.) At 12:21 PM, an observation was made of Housekeeper N who removed a lunch tray from room [ROOM NUMBER], a COVID-19 positive room. Housekeeper N failed to cover the lunch tray which was already consumed, with a red bag, walked down B-hall approximately 48 feet to the tray cart, walked past non-CVOVID-19 resident rooms, and placed the lunch tray on the tray cart. On 9/19/23 at 12:22 PM, an interview was conducted with RN I who was asked if trays should be removed from COVID-19 positive rooms without a red bag covering them after they had been eaten from. RN I replied, No. Why? RN I was made aware of the observation and confirmed Housekeeper N should have covered the lunch tray from room [ROOM NUMBER] before placing it back on the tray cart. d.) At 12:25 PM, an observation was made of the tray cart located in the middle of B-hall on the left (East) side of the hall, there were two COVID-19 resident's lunch trays in red bags. The bags were both open on the ends and did not 100% cover the trays. e.) At 12:31 PM, an observation was made of room [ROOM NUMBER], a COVID-19 positive room, where the door was wide open for approximately five minutes until CNA M came by and closed the door. f.) At 12:40 PM, an observation was made of RN / Infection Preventionist C walking down B-hall, stopped at the PPE cart, picked up the goggles that were on top of the cart, opened the top drawer of the PPE cart, put the goggles in the top drawer, and closed the drawer (the same PPE cart where CNA L doffed her eye protection earlier without sanitizing the eye wear when she exited room [ROOM NUMBER], a COVID-19 positive room). g.) At 12:43 PM, an observation was made of RN I who exited room [ROOM NUMBER], a COVID-19 positive room, improperly wearing her eye wear on top of her head. RN I failed to sanitize her eye wear and proceeded to the medication cart to dispense another resident's medication. RN I then completed her task, and entered room [ROOM NUMBER] a non-COVID-19 positive room to pass medications at 12:53 PM. h.) At 12:47 PM, an observation was made of CNA K who entered room [ROOM NUMBER], a COVID-19 positive room. CNA K exited room [ROOM NUMBER] at 1:00 PM. CNA K then entered room [ROOM NUMBER] a non-COVID-19 positive room at 1:02 PM. No sanitization of the eyewear was observed which CNA K used when she exited room [ROOM NUMBER], a COVID-19 positive room before she entered room [ROOM NUMBER] a non-COVID-19 positive room. i.) At 12:56 PM, an observation was made of CNA O who entered room [ROOM NUMBER], a COVID-19 positive room. CNA O had her prescription eyeglasses on without side shields and wore a surgical mask. CNA O exited room [ROOM NUMBER] at 1:01 PM and failed to sanitize her eyeglasses. On 9/20/23 facility staff were observed on B-hall and the following observations were made: a.) At 7:57AM, an observation was made of room [ROOM NUMBER], a COVID-19 positive room. room [ROOM NUMBER]'s door was wide open. At 8:11 AM, an interview was conducted with RN I. RN I confirmed that room [ROOM NUMBER] was COVID-19 positive, on droplet precautions, and the resident was in her room with the door wide open. At 8:28 AM, an observation was made of room [ROOM NUMBER] with the door wide open, and a coughing noise coming from the room was heard while this Surveyor was observing staff on B-hall. At 8:39 AM, an observation was made of CNA K shutting the door of room [ROOM NUMBER]. room [ROOM NUMBER]'s door remained wide open for 42 minutes. b.) At 8:18 AM, an observation was made of RN I who entered through the B-hall double doors. RN I adjusted her face mask with her hands, pulling the surgical mask over her nose, and failed to sanitize her hands after she touched her surgical mask. RN I then entered room [ROOM NUMBER] a non-COVID-19 positive room and shut the door behind her to provide direct resident cares. c.) At 8:04 AM, an observation was made of CNA L who exited room [ROOM NUMBER], a COVID-19 positive room, doffed her goggles on top of the PPE cart without sanitizing her hands, and went to assist CNA K. At 8:06 AM, CNA L was observed back at the PPE cart, picked up the goggles with her bare hands, sanitized the goggles by wiping them off with a purple sanitizing wipe, placed the goggles back in the top draw of the PPE cart, and failed to sanitize her hands after cleaning the goggles (disinfection time on the purple wipes is two minutes per manufacturer instructions). d.) At 8:08 AM, an observation was made of CNA K who exited room [ROOM NUMBER], a COVID-19 positive room, sanitized her eye protection with bare hands, placed eye protection back on the top of her head, and failed to sanitize her hands after sanitizing the eye protection (disinfection time on the orange wipes is four minutes per manufacturer instructions). e.) At 8:28 AM, an observation was made of CNA O transporting resident from room [ROOM NUMBER], a COVID-19 positive room, in a wheelchair. CNA O was carrying shampoo and shower gel which came from room [ROOM NUMBER] with the resident and was located next to her body under her arm. f.) At 8:31 AM, an observation was made of CNA L who exited room [ROOM NUMBER], a COVID-19 positive room, doffed goggles by placing them on top of the PPE cart and wiped the googles off with bare hands (disinfection time on the purple wipes is two minutes per manufacturing instructions). g.) At 8:42 AM, an observation was made of RN I who exited room [ROOM NUMBER], a COVID-19 positive room, wearing an N-95 and did not replace her mask. RN I returned to the medication cart to prepare medications, then proceeded to room [ROOM NUMBER] a non-COVID-19 room to deliver medication, and then exited and proceeded to room [ROOM NUMBER] again. RN I was asked if she had changed her mask and replied, No. I did not. I guess I forgot. On 9/20/23 at 9:30 AM, and interview was conducted with Minimum Data Set / Infection Control / RN B who was made aware of the infection control concerns observed by this Surveyor. RN B confirmed she had done a couple of infection control audits yesterday on proper PPE usage with CNA L and CNA K. RN B was asked about the audit results and replied, They both did fine. RN B confirmed goggles needed to be sanitized when exiting COVID-19 positive rooms and should be allowed to dwell for either two or four minutes depending on the sanitizing wipes being used. RN B also confirmed gloves should be worn during the sanitization process and eye protection should not be worn on the top of a staff member's head. RN B was asked what kind of mask should be worn in a COVID-19 positive room. RN B replied, An N-95, and these should be discarded in the room just prior to exiting and a new mask should be applied after the staff exit and can be a new surgical mask. RN B was asked about the room trays that were inside the COVID-19 positive rooms. RN B replied, When they are brought out of the COVID-19 positive rooms they need to be in a red bag and should be entirely covered and then placed on the tray cart, so kitchen staff are aware the tray was removed from a COVID-19 positive room. RN B confirmed COVID-19 positive doors need to be always closed unless staff are entering and exiting the room. 13791 6. On 9/20/23 at approximately 8:50 AM, an interview was conducted with the regional director of Housekeeping and laundry services (RDH) A. It was learned during this interview the facility utilized a peroxide based chemical for the disinfection of surfaces in Transmission Based Precaution (TBP) rooms (isolation) with COVID-19 positive residents. Observations were made with RDH A while tests were conducted of the dispensing unit of the peroxide based disinfectant and the testing of the concentration of the chemical. RDH A filled a small bucket with the solution discharged from the dispenser, then using the appropriate test strips and measured the concentration of the peroxide. The test strip indicated a concentration below 2350 ppm (parts per million) in the solution being discharged from the dispenser and being used by staff in resident rooms. A review of the instructions provided by the vendor of the chemicals was conducted with RDH A and confirmed the minimum concentration of the peroxide chemical was 3500 PPM, well above the measured and demonstrated level shown by the test strips. At 9:30 AM RDH A was requested to produce any documentation demonstrating the last time the solution from the dispenser was tested and showed the minimum concentration required for proper disinfection of COVID-19 was met. RDH A stated the facility did not have any documentation to show the solutions had been tested to determine the solution was dispensed at the appropriate concentration for the disinfecting chemical. Review of the Infection Prevention and Control Program policy, revised 5/22/23, revealed the following, in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . The designated Infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases . Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards . COVID-19 Testing: . If healthcare-associated transmission is suspected or identified, the facility may consider expanded testing of HCP and residents as determined by the distribution and number of cases throughout the facility and ability to identify close contacts . Review of facility policy titled, Transmission-Based (Isolation) Precautions, dated 5/22/23, read in part, Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission .Definitions: Airborne precautions refers to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air .Policy Explanation and Compliance Guidelines: 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission .11. Airborne Precautions .d .staff will wear a fit-tested N-95 or higher-level respirator and other appropriate PPE while delivering care to the resident . Review of facility handout titled, Sequence for Removing Personal Protective Equipment (PPE), undated, read in part, Except for respirator, remove PPE at doorway or in anteroom. Remove respirator after leaving patient room and closing door .2. Goggles or face shield - outside of goggles or face shield is contaminated! To remove, handle by head band or earpieces. Place in designated receptacle for reprocessing or in waste container .4. Mask or respirator - Front of mask/respirator is contaminated - DO NOT TOUCH! Grasp bottom, then top ties or elastic and remove. Discard in waste container. Perform hand hygiene between steps if hands become contaminated and immediately after removing all PPE. On 9/25/23 the disinfectant products manufacturer instructions were reviewed online using website: SuperSaniCloth_EnglishFrench_LCan_.pdf (pdihc.com), read in part, .Directions for use: .To disinfect and deodorize: To disinfect nonfood contact surface only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry . On 9/25/23 the disinfectant products manufacture instructions were reviewed online using website: SaniClothBleachEnglish-French_LgCan.pdf (pdihc.com), read in part, .Directions for use: .To clean, disinfect and deodorize: Use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain viably wet for 4 minutes. Use additional wipes if needed to assure continues 4-minute wet contact time .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent, for two Residents (#2 & #7) of five residents reviewed for medication administration. This deficient practice resulted in lack of assessments to determine efficacy of respiratory medications and the potential for undesirable therapeutic effects from inaccurate insulin administration. Findings include: Resident #2 (R2) Medication administration for R2 on 9/20/23 at 12:10 PM, was observed performed by Registered Nurse (RN) H. This included the administration of Albuterol Sulfate Inhalation Nebulizer Solution 2.5 mg (milligrams) / 3 ml (milliliters), 3 ml inhale orally via nebulizer (machine that turns liquid medication into a fine mist and inhaled though the mouth into the lungs). RN H did not have a stethoscope with her. RN H failed to listen to R2's lung sounds, check heart rate and respiration rate, and obtain a pulse ox (oxygen saturation level in the blood) prior to treatment. On 9/20/23 at 12:30 PM, an interview was conducted with RN H who was asked if she had a stethoscope and replied, Yes. It is in my medication cart. RN H confirmed she failed to assess the vital signs and lung sounds of R2 prior to and post nebulizer treatment. Review of R2's active Physician Orders, as of 9/20/23, revealed the following: Albuterol Sulfate Inhalation Nebulizer Solution 2.5 mg / 3 ml, 3 ml inhale orally via nebulizer, Start Date 5/16/23. On 9/20/23 at 12:50 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the nebulizer policy for medication administration. The DON confirmed all residents required a respiratory assessment prior to and following treatment and stated no resident was exempt from this policy. Resident #7 (R7) Medication administration for R7 on 9/20/23 at approximately 11:35 AM, was observed performed by RN H. This included administration of Insulin Glargine injection 25 units subcutaneously. RN H administered the injection by pushing down on the syringe plunger and then immediately pulled out the needle. RN H failed to hold the needle in the subcutaneous tissue following the injection site for ten seconds after pushing the plunger down and administering the insulin to R7. On 9/20/23 at 12:35 PM, an interview was conducted with RN H regarding the administration of insulin for R7 earlier that day. RN H confirmed she did not hold the needle in the injection site for ten seconds. RN H replied, I thought I just had to do that with the insulin pens. Review of R7's active Physician Orders, as of 9/20/23, revealed the following: Insulin Glargine injection 25 units subcutaneously, Start Date 8/30/23. On 9/20/23 at 2:43 PM, an interview was conducted with Regional Director of Operations J who confirmed medication administration by licensed staff should follow the manufacturer's guidelines. Review of the manufacturer's guidelines for insulin glargine, provided by Regional Director of Operations J, read in part, Injecting insulin glargine with a vial and syringe .Step 4: Complete the injection - administer insulin - slowly push in the plunger of the syringe all the way, making sure you have injected all the insulin. Leave the needle in the skin for 10 seconds . Review of facility policy titled, Medication Administration, dated 1/1/22, read in part, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .8. Obtain and record vital signs, when applicable .14. Administer medication as ordered in accordance with manufacturer specifications . Review of facility policy titled, Nebulizer Therapy, dated 1/1/22, read in part, Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: 1. Care of the Resident .f. Obtain resident's vital signs and perform respiratory assessment to establish a baseline . Two medication administration errors out of 31 opportunities, resulted in a medication error rate of 6.25 percent.

Based on observation, interview, and record review, the facility failed to provide the proper incontinence care products to ensure the highest possible practicable physical, mental, and psychosocial well-being was achieved for three (Resident #104, Resident #101, and Resident #102) of five residents reviewed. This deficient practice resulted in the potential for impaired self esteem and reduced level of confidence. Findings include: Resident #104 Resident #104's Electronic Medical Record (EMR) revealed an admitted [DATE] and medical diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, and falls. Resident #104's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14/15, indicating Resident #104 was cognitively intact. During an interview on 1/18/23 at 10:53 a.m., Resident #104 was observed holding onto a pull up incontinent brief. Resident #104 said this was the only large sized one left and she was saving it for night time. Resident #104 reported the facility frequently did not have the correct size and they put an extra extra large brief on her instead. A package of extra extra large size incontinent pull up briefs was observed at Resident #104's bedside. Resident #104 said the extra extra large briefs leaked and did not feel comfortable. Resident #104 said she had tried wearing shorts over the briefs in an attempt to make them more snug but it had not worked. When Resident #104 has had to wear the extra extra large briefs to bed, her bed became soaked because they leaked. When asked how wearing a leaking brief made her feel, Resident #104 said, No wonder a baby cries whey they are wet. I do not like sitting in wet briefs. Resident #101 Resident #101's EMR contained an admitted [DATE] and indicated medical diagnoses which included multiple sclerosis, morbid obesity, and urinary tract infections. Resident #101's MDS assessment dated [DATE] included a BIMS score of 15/15 which indicated Resident #101 was cognitively intact. On 1/18/23 at 9:45 a.m. Resident #101 said there had been several times when there were not the correct size incontinent briefs available. Resident #101 reported the facility had the blue briefs and the pull ups, but not the bariatric large size that she required. Resident #101 said, I pay money to be here, the last thing I expected would be they [the facility] would run out of briefs .I find it ridiculous, briefs need to be available. Resident #101 said she had been placed in the yellow briefs which cut into her groin area. She reported she has had multiple urinary tract infections and identified the incorrect brief size as a contributing factor. Resident #101 said wearing the wrong size brief was uncomfortable and worried about the brief leaking because it was too small. Resident #102 Resident #102's MDS assessment dated [DATE] included an admitted [DATE], a BIMS score of 13/15, which indicated Resident #102 was mildly cognitively impaired. Resident #102's Medication assessment revealed Resident #102 was receiving a diuretic (a medication which works be removing excess fluid in the body through the kidneys) daily. Resident #102's medical diagnoses included morbid obesity, depression, and anxiety. During an interview with Resident #102 on 1/18/23 at 10:37 a.m., Resident #102 said the facility often ran out of incontinence briefs. When this happened, there was approximately a 3-4 day waiting period to get the correct briefs back in stock. Resident #102 reported that when the briefs were not available for her, the staff placed an incontinence pad in her underwear instead. Resident #102 voiced concerns around wearing a pad instead of the proper brief because she felt as though the pad would leak and said she would be very embarrassed if this happened during an activity. On 1/18/23 at 11:12 a.m., Certified Nurse Aide (CNA)/Central Supply Staff F and this Surveyor observed the supply closet, the closet contained included blue briefs and large briefs. Staff F and This surveyor then observed the basement storage supply area. Five boxes of small/medium briefs were observed and four boxes of large briefs were observed. Staff F said the facility was currently out of bariatric briefs and pull ups. Staff F was said there had been a mishap with the order and the incontinant supplies had been delayed. Staff F said she was not aware of residents not having the correct incontinent supplies and was not able to offer any further explanation as to why this would happen. Staff F' said each resident was measured to ensure they would be placed in the correct incontinent materials per their preference and this is what the orders were based from. On 1/18/23 at 11:51 a.m., CNA D said she the facility was out of bariatric briefs. CNA D said she had to place a bariatric pull on Resident #102 after she was showered this morning. CNA D said when she put the pull up on Resident #102, it looked like it fit her a little too snug. CNA D said the incontinent pads were not effective and leaked. CNA D said the bariatric briefs were better for Resident #102 because the tabs allowed room for it to shift. CNA D reported it seemed like they had been running out of the correct pull ups for Resident #104 frequently. CNA D said Resident #104 is on diuretics and goes through a lot of pull up briefs. The blue briefs did not work on Resident #104 because she was so active. On 1/18/23 at 12:10 p.m., CNA C reported the facility was out of bariatric briefs. CNA C said several residents wore the bariatric briefs and when there were not any available, they have to substitute them for something different. Resident #101 had to be placed in a yellow incontinence brief which are a little bit smaller and may be a little snug. CNA C explained it was difficult to keep some sizes in stock because certain residents wanted to be changed even when their briefs were barely damp. On 1/18/23 at 3:03 p.m. CNA E said there were times when the correct sizes of incontinent supplies were not available to residents. CNA E said they had to use a bigger or smaller size than what the resident had been measured for or what they preferred. CNA E said residents often complained the incontinence supplies were either to big and slid off or too snug and were uncomfortable. CNA E said Resident #104 urinated often and overflowed her pull up briefs when she went. A review of the Resident's Pull-Up & Brief Size which was updated 1/17/22 indicated Resident #101 required bariatric sized briefs and she did not wear pull ups. Resident #102 required extra extra large pull ups or bariatric briefs, and Resident #104's information on the size list indicated she wore the yellow briefs and pull ups were not indicated. In an interview with the Director of Nursing (DON) on 1/18/22 at 3:12 p.m., the DON said the expectation was for residents to be placed in the proper sized incontinent supplies. The DON voiced concerns over potential problems with dignity, and preferences and choices not being honored if they improper briefs were placed on residents. Generally they borrow from other facilities or go to the store to get more. Last CNA meeting they were asked to resize the bariatric and the oversize bariatric size. DON confirmed problems with dignity, preferences, and choices and residents should have the proper fitting briefs. The facility's Promoting/Maintaining Resident Self-Determination policy with the most recent revision date of 2/6/22 contained the following information, in part, It is the practice of this facility to protect and promote resident rights by promoting and facilitating resident self-determination through the support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her self autonomy regarding those things that are important in his/her life such as opportunity and preferences .1. All staff members involved in providing care to residents will promote and facilitate resident self-determination .3. Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .9. The facility will accommodate the resident preferences to the extent possible and as agreed upon by the resident sponsor and physician.

Based on observation, interview and record review, the facility failed to ensure appropriate assessment, according to professional standards of practice, for one Resident (#10) of one Resident reviewed for infections. This deficient practice resulted in the potential for unidentified complications and worsening of condition. Findings include: Resident #10 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #10's most recent Minimum Data Set (MDS) assessment, dated 6/20/2022, revealed Resident #10 was cognitively intact, used an indwelling urinary catheter and required extensive assistance with toilet use (including how the Resident managed the urinary catheter and cleansed after elimination). An observation on 8/30/2022 at 7:30 a.m., revealed Resident #10 lying in bed. Further observation revealed catheter tubing containing cloudy, yellow urine, leading from the Resident's left pant leg to a dependent drainage bag attached to the lower, left side of the bed frame. During an interview at the time of the observation, Resident #10 reported being recently hospitalized for a urinary tract infection ([CONDITION(S)]) and [CONDITION(S)]. Resident #10 stated he was currently taking an antibiotic to treat the [CONDITION(S)]. A review of Resident #10's electronic health record (EHR) revealed the resident was transferred to the emergency department on 8/23/2022 for evaluation of [CONDITION(S)] pain. Further review of a progress note, dated 8/23/2022 at 1:30 p.m., revealed the following, in part: Late Entry: Resident has requested to be sent to the ER to determine the source of his ongoing pain, Resident has been complaining of pain in his [CONDITION(S)] area, resident has chronic foley catheter. Catheter had been flowing properly. A review of Resident #10's ED (emergency department) Triage Note, dated 8/23/2022 at 2:00 p.m., revealed the following: Pt to ED via EMS (emergency medical services) for (complaints of) urinary retention and diarrhea. Pt reports bladder spasms starting and worsening x 2 days ago . Pt arrives with chronic foley (indwelling, urinary catheter) in place, reports it is not draining . A review of Resident #10's hospital H & P (history and physical), dated 8/23/2022 at 10:29 p.m., revealed the following, in part: When patient presented to the ED his Foley catheter was changed. He was told that the (former) catheter was not fully inserted and that 800 (milliliters) of urine was returned once the catheter was placed in the proper spot . Assessment & Plan: 1) [CONDITION(S)] . 3) AKI (acute kidney injury) - Post renal. Foley catheter has been repositioned. A review of Resident #10's hospital Discharge Summary, dated 8/25/2022 at 10:55 a.m., revealed the following, in part: Present on Admission: [CONDITION(S)] . AKI . Acute prostatitis . He was initially admitted for an acute kidney injury. After replacement of his foley catheter in the ED, he had immediate improvement of his abdominal pain and had 800 (milliliters) of urine released. His UA (urinalysis) was consistent with infection . he will be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10's EHR revealed the Resident returned to the facility on [DATE]. A review of Resident #10's assessment, titled Skilled Daily - Medically Complex, dated 8/25/2022 at 3:09 p.m. revealed the following vital signs documented under Section C (cardiac and respiratory): Blood pressure: 158/94. Date: 8/23/2022, 11:00 (a.m.) . Pulse: 84. Date: 8/23/2022, 11:00 (a.m.) . Respiration: 16. Date: 8/23/2022, 11:00 (a.m.) . O2 sates: 97%. Date: 8/23/2022, 11:00 (a.m.) . A review of Section D (Other conditions and skin) of the assessment revealed the following: Temperature: 98.2 (degrees Fahrenheit). Date 8/23/2022, 11:00 (a.m.) . A review of Resident #10's documented vital signs in the EHR confirmed the vital signs documented on the assessment dated [DATE] were originally documented on 8/23/2022 at 11:00 a.m., prior to the Resident's transfer to the ED. Further review of Resident #10's August 2022 progress notes, assessments, point of care documentation, MAR (medication administration record) and TAR (treatment administration record), revealed no documentation of Resident #10's vital signs upon the Resident's return to the facility on [DATE] until 8/27/2022. There was no record of measurement of Resident #10's urinary output documented in the Resident's EHR for August 2022, including after the Resident returned from hospitalization for [CONDITION(S)] and urinary retention on 8/25/2022. During an interview on 9/01/2022 at 8:07 a.m., the Director of Nursing (DON) reported vital signs are to be obtained and documented upon initial assessment of a resident returning from hospitalization . The DON confirmed that Resident #10 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated there was a risk of unidentified complications and worsening of condition when residents were not appropriately assessed. The DON was unaware Resident #10's urinary output was not being measured. When queried as to the importance of measuring urinary output for a resident with a history of [CONDITION(S)] and urinary retention, the DON stated having an accurate record of urinary output would allow for quick identification of a possible blockage of the catheter, retention of urine, and signs of infection. The DON confirmed Resident #10 was currently being monitored for infection and [CONDITION(S)]. On 9/01/2022 at 9:45 a.m., the DON presented documents titled Vital Signs A-Hall, for the dates 8/25/2022 and 8/26/2022. The DON reported the CNA staff use the paper record to record the vital signs when obtained and then provide the record to the licensed nurses to review and document in the EHR. The DON stated she found the documents in the trash to be shredded and was not sure a licensed nurse reviewed the findings. The DON confirmed the vital signs recorded on the paper record were not documented in Resident #10's EHR. Further review of the records revealed the following, in part: 8/25/22 . afternoons (2:00 p.m.- 10:00 p.m.). (Resident #10) . BP (blood pressure) 97/63, Pulse 65, Temp 96.9, O2 Sats 99% It was noted the reference for normal range of blood pressure, listed on the top of the vital sign sheet was 100-120/60-80. Resident #10's blood pressure listed on the 8/25/2022 (afternoon) record was out of range of the normal value referenced on the sheet. Further review of the record revealed a licensed nurse did not sign off as being notified of or evaluating the findings on the record. On 9/01/2022 at 10:07 a.m., the DON reported the facility did not have formal policies related to obtaining and documenting vital signs upon a resident's return from hospitalization , for resident's being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] .

This citation pertains to Intake #MI 226 Based on interview and record review, the facility failed to prevent abuse of one Resident #133 from 16 residents reviewed for abuse. This deficient practice resulted in Resident #133 sustaining verbal abuse, and having the potential for psychosocial harm. Findings include: A facility reported incident was filed with the State Agency (SA) on 4/20/22, alleging Resident #133 (R133) was abused by an employee. According to that report, two Certified Nurse Assistant (CNA's) were providing cares for Resident #133 when CNA L allegedly verbally abused the resident. The facility investigation summary, dated 4/20/22, revealed, [R133] was being provided assistance with activities of daily living (ADL's) in his room from CNA [N] and CNA [L]. CNA [L] was lowering the head of the bed when [R133] quietly asked her to wait. CNA [L] did not hear him [R133] and continued, then CNA [N] told CNA [L] to pause. [R133] became agitated and began yelling at CNA [L]. CNA [L] then told [R133] not to yell at her. [R133] told CNA [L] to leave his room and not to come back. CNA [L] walked out of the room and while exiting told [R133] You're a d*ck. According to the face sheet, undated, printed from the electronic medical record (EMR), R133 had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment (MDS) revealed, R133 was cognitively intact. A facility progress note, dated 4/20/22 at 17:24 [5:24 PM] revealed, .Resident stated that he did not want the CNA who provided his care for him .to work with him again. He stated she became upset when his remote control fell to the floor, and he was attempting to help her find it. He acknowledged that she was rude but did not state what she said to him . Facility progress note, dated 4/20/2022 at 17:26 [5:26 PM] revealed, NHA [Nursing Home Administrator] talked with resident this morning, approximately 9:00 am, about possible incident that happened early this morning with staff. Resident stated CNA [L] called him a name while he was yelling at her and did not want her back in his room . The witness statement by CNA L dated 4/20/22, stated that, She [CNA L] was helping other CNA [N] with Resident [#133]. CNA L put his head and feet down to get him ready to roll and he had asked CNA L to pause and CNA L could not hear him, so CNA N said CNA L's name and then CNA L stopped and he [R133] started to yell at CNA L and she [CNA L] said there is no need to yell at me and he [R133] continued to yell at me telling me to get out and to not come back in and something slipped out of my mouth that shouldn't have and I [CNA L] really regret it. During a phone interview on 9/1/22 at 8:03 AM, CNA L confirmed the information in her witness statement, dated 4/20/22. The witness statement by CNA N dated 4/20/22, stated that, .R133 became agitated and yelled at CNA L I said wait! CNA L yelled back at R133 Don't yell at me. CNA N redirected CNA L and stated they need to stop yelling at each other. R133 became more agitated and told CNA L to leave and get out of his room and not to come back. CNA L stopped everything immediately and while exiting the room stated directly to R133 You're a dick . Unsuccessful attempts were made to interview CNA N by phone on 9/1/22 at 8:06 AM and at 9:45 AM. Review of facility document titled Educational Opportunity, dated 12/10/21 revealed, Take opportunity to be a team player. Approach and the way we say things can be the difference between a good day and a bad day with co-workers. Document signed by CNA L and Director of Nursing (DON). On 9/1/22 at approximately 11:30 AM, an interview was conducted with the DON. The DON was asked if she knew why CNA L did not excuse herself from caring for R133 when he began to yell at her and responded, I am not sure. The DON stated that CNA L had a poor approach with residents at times and she had had a discussion with her prior to the incident regarding this concern. The policy, Abuse, Neglect and Exploitation, dated 7/28/2020, read in part, Policy: It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Verbal Abuse: Means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory term to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Policy Explanation and Compliance Guidelines: .3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written .

Based on observation, interview and record review, the facility failed to ensure unnecessary use of an as needed antianxiety medication for one Resident (#25) of three residents reviewed for unnecessary medications. This deficient practice resulted in the potential for altered mental status and other undesired medication side effects. Findings include: Resident #25 was admitted to the facility on [DATE] and had diagnoses including: dementia without behavioral disturbance, stroke and depression. A review of Resident #25's most recent Minimum Data Set (MDS) assessment, dated 8/02/2022, revealed Resident #10 had severe cognitive impairment. An observation on 8/30/2022 at 7:17 a.m., revealed Resident #25 sitting in her room in a wheelchair. When asked how the morning was going, Resident #25 stated it's going. Resident #25 would not engage in further conversation or make eye contact. During an interview immediately following the observation, Certified Nurse Aide (CNA) P reported Resident #25 did not like to be bothered and often lashed out verbally and physically toward staff during provision of care. A review of Resident #25's medication administration record (MAR) for August 2022, revealed the following order: [MEDICATION(S)] (controlled, antianxiety medication) Tablet 0.5 MG (milligrams) . Give 0.5 MG by mouth as needed for anxiety an hour before every shower. Start Date: 7/29/2022 1745 (5:45). Further review of the Resident's August 2022 MAR revealed [MEDICATION(S)] was administered per the order as follows: 8/02/2022 at 8:34 a.m. 8/05/2022 at 4:55 a.m. 8/05/2022 at 4:30 p.m. A review of Resident #25's point of care documentation for Bathing revealed documentation of showers on 8/02/2022 at 1:55 p.m. and 8/05/2022 at 7:49 a.m. A review of Resident #20's electronic health record (EHR) for August 2022, including progress notes, behavior charting, and assessments revealed no targeted behaviors or non-pharmacological interventions documented prior to administration of the doses of [MEDICATION(S)] 0.5 mg administered on 8/02/2022 at 8:34 a.m., 8/05/2022 at 4:55 a.m. and 8/05/2022 at 4:30 p.m. A review of Resident #25's Pertinent Charting - Behavior notes for August 2022 revealed the following: 8/02/2022 6:17 a.m. - No behaviors noted. PRN (as needed) [MEDICATION(S)] given prior to showering. Effective . It was noted this documentation occurred prior to the dose being administered on 8/02/2022 at 8:34 a.m. per the Resident's August MAR. 8/02/2022 2:17 p.m. - No behaviors noted. Resident received prn [MEDICATION(S)]. Effective. 8/05/2022 6:11 a.m. - No noted behaviors during this shift. 8/05/2022 11:00 p.m. - No noted behaviors during this shift. During an interview on 9/01/2022 at 9:48 a.m., the Director of Nursing stated all behavior charting is completed within each Resident's EHR. The DON stated all as needed doses of [CONDITION(S)] medications, including antianxiety medications, should be administered for a targeted behavior and according to physician order. On 9/01/2022 at 10:08 a.m., the DON reported she reviewed Resident #25's EHR and found no documentation to justify the administration of [MEDICATION(S)] 0.5 mg on 8/02/2022 and two doses on 8/05/2022. The DON stated the facility did not have a formal policy regarding administration on as needed medications, but administration and documentation should be completed per professional standards of practice. The DON reported Resident #25 exhibited difficult behaviors, but she could not be sure why the as needed doses of [MEDICATION(S)] were administered to Resident #25 on 8/02/2022 and 8/05/2022.

Based on observation, interview and record review, the facility failed to ensure appropriate indwelling urinary catheter care according to professional standards of practice for one Resident (#10) of one Resident reviewed for catheter care. This deficient practice resulted in the potential for infection and pain. Findings include: Resident #10 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #10's most recent Minimum Data Set (MDS) assessment, dated 6/20/2022, revealed Resident #10 was cognitively intact, used an indwelling urinary catheter and required extensive assistance with toilet use (including how the Resident managed the urinary catheter and cleansed after elimination). An observation on 8/30/2022 at 7:30 a.m., revealed Resident #10 lying in bed. Further observation revealed catheter tubing containing cloudy, yellow urine, leading from the Resident's left pant leg to a dependent drainage bag attached to the lower, left side of the bed frame. During an interview at the time of the observation, Resident #10 reported being recently hospitalized for a urinary tract infection ([CONDITION(S)]) and [CONDITION(S)]. Resident #10 stated he was currently taking an antibiotic to treat the [CONDITION(S)]. On 8/30/2022 at 8:17 a.m., Certified Nurse Aide (CNA) P was observed providing catheter care to Resident #10. CNA P removed Resident #10's brief revealing a yellow discharge surrounding the Resident's urethral meatus (opening at tip of penis leading to the urethra, a tube connected to the bladder). The portion of the catheter leading from the urethral meatus to the catheter securing device attached to the Resident's left upper thigh was observed to have a yellow substance dried to the catheter. Further observation revealed a dried white substance clinging to the skin of Resident #10s scrotum and groin folds. CNA P used a washcloth to clean the catheter tubing leading from the urethral meatus to the catheter secure device attached to Resident #10's leg. CNA P was observed using the washcloth in a scrubbing motion, down the catheter and back toward the Resident's urethral meatus. CNA P stated the yellow substance attached to the catheter was dried and difficult to remove. During the observation, Resident #10 reported this observation was the first instance catheter care was provided since he returned from the hospital. Once catheter care was complete, CNA P was observed standing at the foot of the bed preparing a brief to place on Resident #10 by holding the urinary catheter dependent drainage bag up in the air, approximately 2 feet above the Resident lying flat in the bed and threading the bag through the left leg of the brief. The bag was then reattached to the left lower bedframe and the brief pulled up on the Resident. After catheter care was provided, CNA P and non-Certified Nurse Aide I prepared Resident #10 to be transferred from the bed to the wheelchair. CNA P positioned the wheelchair adjacent to the bed to the right side of Resident #10. The urinary catheter drainage bag was observed to be attached to the bedframe just under the Resident and between his legs. Upon assisting the Resident to stand, Resident #10 was observed to step on the dependent drainage bag, dislodging the clamp used to close the drain on the bottom of the bag. Urine was observed to be flowing from the dependent drainage bag onto the floor, covering the area from the Resident seated on bed to the armoire located on the wall across from the end of the bed. CNA cleansed the tip of the drainage port, resecured the port with the clamp and proceeded to clean up the urine with dry bath towels and no disinfectant. Resident #10 was transferred to the wheelchair at which time he was noted to be seated directly over the portion of the floor where the urine was spilled and dried with towels. The Resident's catheter was observed to be attached under the seat of the wheelchair with the tubing resting directly on the floor and leading up into the Resident's left pantleg. A review of Resident #10's electronic health record (EHR) for August 2022, revealed Resident #10 was hospitalized from 8/23/2022 through 8/25/2022. A review of Resident #10's hospital Discharge Summary, dated 8/25/2022 at 10:55 a.m., revealed the following, in part: Present on Admission: [CONDITION(S)] . AKI . Acute prostatitis . He was initially admitted for an acute kidney injury. After replacement of his foley catheter in the ED, he had immediate improvement of his abdominal pain and had 800 (milliliters) of urine released. His UA (urinalysis) was consistent with infection . he will be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #10's point of care documentation titled B&B (bowel and bladder) - Catheter Care, for August 2022, revealed catheter care documented as provided every shift prior from 8/01/2022 until the Resident's hospitalization on [DATE]. No catheter care was documented as provided from the Resident's return to the facility on [DATE] until the observation on 8/30/2022. During an interview on 9/01/2022 at 7:57 a.m., the Director of Nursing reported catheter care was expected to be provided every shift for Resident's with indwelling urinary catheters. The DON confirmed there was no documentation of catheter care for Resident #10 from his return from the hospital on 8/25/2022 until 8/30/2022. The DON stated staff admitting the Resident after hospitalization must have forgotten to reinstate the task alerting staff to the need for catheter care. When asked about the appropriate procedure for cleaning the catheter tubing, the DON explained catheter tubing should always be cleaned away from the Resident and never back toward the insertion site in order to prevent introduction of bacteria into the urethra and to prevent infection. When asked about appropriate positioning of the tubing and dependent drainage bag the DON stated the tubing and bag should always be kept off the floor and below the level of the bladder. A request for the facility policy for catheter care was requested at the time of this interview. A review of the facility policy, Catheterization, provided by the DON and dated 1/01/2022, revealed the following, in part: Urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma . Indwelling urinary catheters will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include, but are not limited to: urinary tract infection, blockage of the catheter, expulsion of the catheter, pain, discomfort and bleeding. It was noted the policy did not include information regarding the facility procedure for catheter care or positioning of catheter tubing and dependent drainage bags.

This citation pertains to intake number MI 192. Based on observation, interview, and record review, the facility failed to prevent falls for one of three residents (Resident #4) reviewed for fall risk issues. This deficient practice resulted in Resident #4 experiencing an unwitnessed fall from her recliner to the floor of her room, striking her head and sustaining a closed head injury with right temporal laceration to her head, transfer to a local hospital for emergent care, and subsequent closure of the laceration with staples. Findings include: Review of the medical facesheet revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#4 was in the care of hospice. Review of the Minimum Data Set assessment dated [DATE], revealed Resident #4 was severely cognitively impaired (no BIMS score was entered as the Resident was unable to answer assessment questions), and was dependent on 1 to 2 facility staff members for activities of daily living (ADLs). The Falls Clinical Protocol, revised (MONTH) (YEAR), was provided to the State Surveyor by the Nursing Home Administrator (NHA) on 2/19/2019 at 12:57 pm, and identified as the current policy/procedure in use by the facility; it states (entries 1 through 4), staff will help identify individuals with a history of falls and risk factors for subsequent falling . based on the assessment, a care plan will be developed and implemented to address identified risk . The Minimum Data Set (MDS) and subsequent CAA's will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls . interventions should be developed and implemented per the assessed needs. A fall risk assessment dated [DATE], identified Resident #4 at risk for falls. Identified as risk factors were the Resident's severely impaired cognition, occurrence of 1 to 2 falls within the past 90 days, her mobility status which was defined as confined to a chair, and severe impairment of her vision. Review of the care plan initiated 8/2/2017, and revised 9/17/2018, revealed Resident #4 was identified at risk for falls. Issues related to her risk for falls were identified as confusion related to her [DIAGNOSES REDACTED]. A revision to her care plan on 9/17/2018, specified that the remote control device (a hand-held device utilized to electronically control the recliner) to Resident #4's recliner . is to be kept out of her reach. Review of the Certified Nurse Aide (CNA) Kardex initiated 9/17/2018 (untimed), specified control to the resident's recliner is to be kept out of her reach. Review of the incident report (undated), revealed that on 12/9/2018 at 4:39 pm, Resident #4 was observed to be on the floor in her room, in front of her recliner chair. She was laying on her side and seen to have a laceration on the right lateral side of her head and bruising of her right upper arm. The report revealed that incontinence care had been provided to the Resident approximately 15 minutes prior to the fall, by Nurse Aide (NA) B. NA B was documented to have provided the care to the Resident while she remained seated in her recliner, and remained so after the NA left the room on completion of the incontinence care. Per this report, NA B returned to the Resident's room [ROOM NUMBER] to 15 minutes later with CNA D to provide care to Resident #4's roommate; at that time, Resident #4 was found on the floor of her room. The recliner was found in the elevated position. During a phone interview on 2/19/2019 at 2:15 pm, NA B said, I was one of two people on that hall that night (12/9/2018). I saw her (Resident #4) about 10 minutes before she was found with the laceration. I changed her brief while she was in the recliner; I did it by myself. It was an electric chair. I didn't touch the remote; it was on the arm of the chair. The legs of the chair, the recliner, were already up. I didn't touch the remote at all. She was reclined, and she remained reclined in the chair while I changed her. When I left the room she had her legs up on the leg rest and she was reclined. I came back to her room about 10 minutes later to help another resident, her roommate, with (CNA D). We were getting residents ready for dinner. (CNA D) and I came into the room and found (Resident #4) on the floor. She was known for playing around with the remote for her chair; I didn't know that until that day. We have a Kardex we're supposed to look at before we work with residents. I didn't look at her Kardex . I was supposed to take a look at her Kardex before I worked with her. I was too busy to look at it. Her remote was electric and it was on the arm of her recliner. I left it just like I found it. During a phone interview on 2/20/2019 at 9:53 am, CNA D acknowledged she had been in Resident #4's room approximately one hour before the fall on 12/9/2018; she said she observed the recliner in a low position. She (Resident #4) was known to fidget with her remote and position her recliner higher than was safe for her. That's why she had a sign above her bed, even before her fall, that said to keep the remote to her recliner, her chair, out of her reach. She had had the risk of falling from the recliner, before, because she fidgeted with the remote and put herself up too high in it. (NA B) saw the Resident on the floor by the recliner from the doorway, and called down for me to come. We entered the room at the same time. (Resident #4) was on the floor, her head was off to the side of the recliner. Her head was on the floor. She had a laceration on the right side of her head. There was a lot of blood. The recliner was up as far as it could go. I didn't see the remote 'cause I went right away for the nurse. Review of the Emergency Department Provider Notes dated 12/9/2018 at 5:31 pm, revealed Resident #4 had sustained a closed head injury and a right temporal laceration to her head, which required closure with four staples. The report included the Resident's responsible party refused further treatment options as the Resident was in hospice in advanced stages of dementia and preferred her laceration be repaired, and her return to the hospice program at the nursing home. During an initial tour of the facility on 2/19/2019 at 11:55 am, and again on 2/20/2019 at 9:25 am, Resident #4 was observed asleep in her manual recliner (recliner which had no remote). However, a sign was present above her bed on both days of observation that read, Please keep the remote to (Resident #4's) recliner out of her reach at all times. Thank You. During an interview on 2/19/2019 at 12:40 pm, shortly after entrance of this Surveyor to the facility, the NHA acknowledged she had not been aware that the facility had recliners which were controlled by remote devices.