Every finding on record at Moose Lake Village

Based on observation, interview, and document review, the facility failed to ensure minimum dishwasher temperatures were attained during the rinse cycle for 1 of 1 dishwasher. This had the potential to affect all current residents, as well as staff or visitors, who ate food served from dishes and tableware that were cleaned in the dishwasher.Findings include:During an observation on 7/6/26 at 1:58 p.m., the dishwasher wash cycle reached 153 degrees Fahrenheit (F) and the final rinse cycle reached 150 degrees F per the temperature gauges on the machine. A manufacturer sign posted next to the dishwasher instructed the final rinse cycle range should be 180-195 degrees F.During an interview on 7/6/26 at 1:58 p.m., culinary director (CD) indicated the dishwasher was a high temperature machine and stated the final rinse cycle must reach 180 degrees F. CD confirmed the low temperature and stated they needed to call the dishwasher company for service.During an interview on 7/9/26 at 9:25 a.m., the infection preventionist (IP) expected the dishwasher temperature to be hot enough to prevent the spread of any infectious materials. They stated if the dishwasher was not temping correctly, staff should report it to their supervisor or CD.During an interview on 7/9/26 at 9:46 a.m., the administrator expected the dishwasher temperature to be hot enough to sanitize dishes. They stated if the dishwasher was not reaching the correct temperature, staff should stop using the dishwasher and report it to their supervisor or CD so they could call the company that services it.Dishmachine Temperature Log dated 7/2026, the rinse temperature was logged at less than 180 degrees F for lunch use on 7/3/26 and for dinner use on 7/2/26, 7/3/26, and 7/7/26 with no indications of temperature correction.Sanitation policy revised 1/10/25, instructed the dishwasher rinse temperature specification was 180 degrees F, and if temperatures specifications were not reached, culinary staff was to stop using the machine immediately, contact their supervisor, and begin manually washing dishes.

Based on observation, interview and document review the facility failed to ensure medication refrigerators were kept within the recommended temperature range for 1 of 2 medication refrigerators. This deficient practice had the potential to affect any resident who received medications stored in the refrigerator.Findings include:During an observation on 7/7/26 at 2:07 p.m., the medication refrigerator in the main medication storage room had a reading of 42 degree's Fahrenheit (F). The medication log for July documented the last reading recorded as 39 degrees F. There were no temperatures recorded for July 1, 2, 3, 4, 6. The temperature log identified the safe range as 32 degrees to 41 degrees F (staff were using the food refrigerator temperature logs). Instructions identified staff were to report to the supervisor any time the temperature was out of range. Licensed practical nurse (LPN)-A verified the temperature for July was recorded only one time during July.A review of the medication temperatures for the past four months identified the following:-June there were only four temperatures recorded. There were 26 days were temperatures were not recorded. -The facility was unable to produce any temperature readings for the month of May.-The temperature readings for April had three readings recorded, with 28 days with no temperature readings recorded.A record of the medications in the refrigerator was as follows:R3, Lantus (long-acting insulin) and Trulicity (GLP-1 receptor lowers blood sugar)R62, Lantus and NovoLog (fast-acting man-made insulin)R32, Lantus, NovoLog, TrulicityR52, calcitonin spray (treats osteoporosis), Evenity (treats osteoporosis)R60, Humalog (fast-acting man-made insulin) and LantusR45, Lantus and NovoLogR17, LantusR31, Lantus, Basaglar (long-acting insulin) and NovoLogR37, Humalog vialsStock medications; Aplisol (diagnostic skin test to detect tuberculosis), Engerix B (vaccination to prevent hepatitis B virus), and Comirnaty (vaccine to prevent coronavirus).During an interview on 7/7/26 at 2:10 p.m., the director of nursing (DON) stated the concern was if the temperatures were too hot or too cold, it had the potential to ruin the medications. The DON stated she would expect staff to check refrigerator temperatures daily.During an interview on 7/8/26 at 10:31 a.m., LPN-B stated she knew there was an issue with the medication refrigerator temperatures, so she checked the medication refrigerator temperature in the main medication refrigerator at around 7:15 a.m., and noted the temperature was about was 50 degrees F. The medications were moved to a different refrigerator.During an interview on 7/8/26 at 12:43 p.m., the consultant pharmacist (CP)-G stated once the medication refrigerator exceeds the safe temperature all insulins should be dated as opened. CP-G stated the medication refrigerator should be between 36-46 degrees F. CP-G looked up all of the medications on the list and gave the following information:-Trulicity okay for 14 days-calcitonin spray would be okay for 35 days-Evenity would be okay for 30 days-Aplisol should be disposed of once out of the safe range-Enerix-B would be okay for seven days-Comirnaty would be okay for 12 hoursCP-G stated he would start counting the hours and days as when the last known temperature was recorded.The Medication Storage policy dated 6/30/23, identified nursing staff would be responsible for maintaining medication storage in a clean, safe, and sanitary environment. The policy further identified the refrigerator temperatures would be maintained between 36-46 degrees F.

Based on observation, interview, and document review, the facility failed to ensure that all staff (including outside contracted staff) wear appropriate personnel protective equipment (PPE) and perform appropriate hand hygiene while completing wound care on a resident. This affected 1 of 1 (R60) residents reviewed for infection control. The facility also failed to change oxygen tubing timely to decrease the risk of infection for 1 of 1 (R37) reviewed for respiratory care. Findings Include: Wound Care: R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated R60 had intact cognition. Diagnoses included peripheral vascular disease. Section M indicated R60 was at risk for pressure ulcers/injuries and had one stage two pressure ulcer that was not present on admission. R 60 also had one open lesion that was not a pressure ulcer, rash or cut. R60's infectious disease progress note dated 7/6/26, indicated R60 had an ulceration to the abdominal wall. On 11/6/26 at 3:48 p.m., a contact precautions sign was observed on R60's door frame, outside the room. The sign stated providers and staff must clean their hands, put on gloves, a gown, and use either dedicated equipment or disposable equipment. Clean and disinfect reusable equipment before us on another person. R8's quarterly MDS dated [DATE], indicated R8 had intact cognition. Diagnoses included anemia, heart failure and osteomyelitis in the sacral area. Section M indicated R8 was at risk for pressure ulcers and had a stage 4 pressure ulcer. On 11/6/26 at 4:18 p.m. an Enhanced Barrier Precautions (EBP) sign was observed on R8's doorframe before entering room. The sign stated providers, and staff must perform hand hygiene, wear gloves and gown when performing high contact resident care activities such as performing wound care: any skin opening requiring a dressing. During an observation on 7/8/26 at 9:03 a.m., three members of the contracted wound care clinic staff member (WCCSM)-D, wound care clinic registered nurse (WCCRN)-B, and wound care clinic medical doctor (WCCMD) approached R60s room, along with facility licensed practical nurse (LPN)-C. LPN-C washed her hands and then placed a gown and gloves on. WCCSM-D and WCCRN-B entered R60's room without placing appropriate PPE on and raised R60's bed and touched R60's bedding and other items in the room. WCCM-D and WCCRN-B then left R60's room. LPN-B then requested WCCRN-B to place PPE on and handed a gown to her. LPN-B also requested WCCSM-D and WCCMD place appropriate PPE on since the resident was on contact precautions. WCCRN-B placed gown and gloves on at that time and then handed WCCMD and WCCSM-D a gown. WCCMD asked what the gown was for and WCCSM-D stated, this is what they do here for wounds. WCCSM-D and WCCMD then proceeded into R60's room without placing PPE on. WCCMD stood at the foot of the bed, his clothing contacting the bedding and footboard, and next to the wound care cart. WCCRN stood to the right of the resident, and WCCSM-D sat next to the left side of R60, the same side of the abdominal wound. WCCRN-B held R60's abdominal fold out of the way while WCCSM-D removed R60's old dressing, performed measurements of the wound and applied a new dressing. All was done without changing gloves or performing hand hygiene after going from dirty to clean. While the abdominal wound was exposed WCCRN-B released the abdominal fold with the right hand, ungloved the right hand, reached into the wound cart with the ungloved, unwashed hand and grabbed a sterile package, opened the package and then handed it to WCCMD. WCCMD then proceeded to lean over R60's bedding, coming in contact and obtained a sample from the wound. All staff then left the room, removing what PPE they had on and performed hand hygiene. WCCSM-D, WCCRN-B and WCCMD then proceeded to walk into R8's room, without placing a gown on to perform wound care. WCCMD stopped surveyor from entering room while wound care was performed. During an interview on 7/8/26 at 9:13 a.m., LPN-B stated the other three members doing wound care were the contracted wound care providers for the facility. LPN-B stated the request was made for all three to place gown and gloves on prior to entering the rooms but WCCSM-D and WCCMD ignored the request and entered the room with only gloves on, instead of the gown and gloves as required. R60 had Methicillin-Resistant Staphylococcus aureus (a contagious staph infection that has become resistant to many common antibiotics) and LPN-B stated the infection preventionist and director of nursing should have been notified when WCCMD and WCCSM-D refused to place a gown on prior to going into the isolation rooms. When WCCSM-D, WCCRN-B, and WCCMD left R8's room they were requested to answer questions. WCCRN-B and WCCMD kept walking towards the front door and refused to answer questions. WCCSM-D did stop, provided her first name and stated, we don't work for the facility. All three WCC staff members left without answering questions. Oxygen Tubing: R37's admission Minimum Data Set (MDS) dated [DATE], indicated R37 was cognitively intact. Diagnoses included chronic obstructive pulmonary disorder (COPD) and sleep apnea ([NAME]). The MDS indicated R37 had oxygen therapy and non-invasive ventilation (use of continuous positive airway pressure (CPAP) machine). R37's care plan dated 5/29/26 indicated an altered respiratory status due to COPD and OSA. Interventions included oxygen therapy as ordered and CPAP. R37's Physician Order Report dated 6/9/26 to 7/9/26, indicated orders for CPAP, use home settings and use 2.5 liters(L) of oxygen with humidity. R37 also received oxygen at 1 to 2.5 L as needed. The orders lacked any orders to change oxygen tubing with a time limit. On 7/6/26 at 2:34 p.m., long dark green oxygen tubing was observed connect to the liquid oxygen compressor and ran to R37's CPAP machine. There was no label indicating the last time the oxygen tubing had been changed. During an interview on 7/6/26 at 2:36 p.m., R37 stated the facility had not changed the oxygen tubing going to his CPAP since he had been admitted about a month prior. R37 stated the current tubbing had been provided to the facility by the resident due to having an extra and the staff used it instead of getting one out of supply. During an interview on 7/8/26 at 10:34 a.m., licensed practical nurse (LPN)-A stated all oxygen tubing was changed on a weekly basis, the date was based on when the resident was admitted . An order would be placed by the health unit coordinator so the nursing staff was aware the tubing needed to be changed weekly, and the nursing staff would acknowledge the order every time the tubing was changed. The facility did not date the tubing so the only way to know when the tubing was last changed would be based on the actual tubing change order. LPN-A reviewed R37's orders and confirmed there were no orders to change the oxygen tubing weekly, so LPN-A was unsure when R37's oxygen tubing was changed last. During an interview on 7/9/26 at 9:37 a.m., the director of nursing (DON) stated an expectation that all staff, including contracted staff, would wear the appropriate PPE and perform hand hygiene correctly when doing wound care. There also was an expectation that oxygen tubing would be changed weekly and documented as such. During an interview on 7/9/26 at 10:20 the infection preventionist (IP) stated wearing the appropriate PPE and performing hand hygiene when going from dirty to clean wound care steps were important to prevent the increased risk of spreading infection to other residents in the facility. Changing oxygen tubing weekly was important to decrease the risk of infection for the resident's using oxygen. Oxygen and humidified air cause increased moisture which can harbor infection bearing bacteria. Facility policy Personal Protective Equipment last reviewed 7/2/25, indicated PPE appropriate to specific task requirements were always available. All staff (Center for Disease Control (CDC), and Center for Medicare and Medicaid (CMS) define to include contracted staff providing care in the facility) were required to wear the correct PPE (gowns, gloves, masks) when providing certain care and when certain levels of isolation were reached.Facility policy Oxygen, portable liquid tanks last reviewed 2/18/26, indicated oxygen tubing would be replaced weekly or more frequently if needed. The weekly changes would be documented in the EHR.

Based on observation, interview, and document review the facility failed to complete a Self-Administration of Medication (SAM) assessment and acquire a physician order for self-administration for 1 of 1 resident (R72) who was observed to have medications left at bedside.Findings include: R72's Brief Interview for Mental Health performed on admission indicated moderate cognitive impairment. R72's electronic medical record (EMR) indicated diagnoses of urinary tract infection and chronic obstructive pulmonary disease. The EMR Lacked a SAM assessment or orders to keep medications at bedside. R72's care plan undated lacked a care plan related to ability to self-administer medications On 7/6/26 at 3:05 p.m., medications including nystatin cream and refresh eye drops were observed in a pink wash basin on the counter in R72's room. On 7/7/26 at 1:21 p.m., nystatin cream, refresh eye drops, and diclofenac cream were observed in the pink basin in R72's room. On 7/8/26 at 10:32 a.m. nystatin cream, refresh eye drops, and diclofenac cream were again observed in the pink basin on the counter in R72's room.During an interview on 7/8/26 at 10:34 a.m., licensed practical nurse (LPN)-A stated prior to leaving medications at bedside a SAM assessment needed to be completed and orders received. The registered nurse did the SAM assessments usually a week after admission so the staff could get a good understanding of cognition and if it would be safe to leave medications at bedside and for the residents to self-administer medications. Before the week was up all medications were to be kept in the nurse's medication cart. R72 was admitted on Thursday 7/2/26, so the SAM would not be completed until around Thursday 7/9/26. LPN-A looked in R72's room and confirmed the nystatin cream, refresh eye drops, and diclofenac cream were in the room. LPN-A reviewed R72's EMR and confirmed there was no SAM assessment completed for R72.During an interview on 7/8/26 at 2:46 p.m., registered nurse (RN)-A stated the RN's would do the SAM assessments. Most SAM assessments were done about a week after admission, unless the resident requested, then they were completed quicker. A week gave the staff time to get a good understanding of cognition level.During an interview on 7/9/26 at 9:37 a.m., the director of nursing (DON) stated the expectation was the SAM assessment would be completed prior to medications being left at bedside.Facility policy Self Administration of Medication last reviewed 9/30/25, indicated a SAM assessment would be performed at admission and orders obtained, if approved, prior to medications left in the room. The care plan would also be updated, adding the SAM assessment to the care plan.

Based on interview and document review the facility failed to ensure orders for blood sugar readings were followed for 1 of 5 residents (R19) reviewed for unnecessary medications. Findings include:R19's Face Sheet dated 7/9/26, identified he had diagnoses which included chronic heart failure (a chronic progressive condition where the heart muscle does not pump blood effectively), recurrent dislocation of right shoulder, type 2 diabetes mellitus with diabetic neuropathy, and hypertension. R19's admission Minimum Data Set, dated [DATE], identified he was cognitively intact, had no rejections of care, and required substantial assistance with activities of daily living.R19's care plan identified he was at risk for a decline in medical condition related to diabetes mellitus. Interventions included to administer medications and treatments per the medical doctor's order.R19's Physician Order Report dated 6/1/26, identified the following: Test blood sugars QID (four times a day), before meals, and prior to bedtime. Special Instructions: Contact Hospice if blood sugar 450 or higher. Under 70 treat with juice and recheck 1 hour after.A review of R19's vital sign report identified the following:6/2/26 at 7:55 a.m., blood sugar reading was 626/2/26 at 9:55 a.m., over one hour later the reading was 2306/6/26 at 7:56 a.m., blood sugar reading was 686/6/26 at 12:24 p.m., over one hour later the reading was 1756/7/26 at 6:43 a.m., blood sugar reading was 616/7/26 at 9:18 a.m., over one hour later the reading was 1596/14/26 at 5:44 p.m., blood sugar reading was 500A review of R19's June 2026 progress notes did not identify a note indicating hospice had been called on 6/14/26, about the blood sugar reading.6/15/26 at 5:53 p.m., blood sugar reading was 453A review of R19's June 2026 progress notes did not identify a note indicating hospice had been called on 6/15/26, about the blood sugar reading.6/28/26 at 5:50 p.m., blood sugar reading was 516A progress note dated 6/29/26 at 2:37 p.m., identified they notified hospice staff in person of recent blood sugar.7/9/26 at 6:35 a.m., blood sugar reading was 657/9/26 at 8:29 a.m., over one hour later the blood sugar reading was 158During an interview on 7/6/26 at 2:09 p.m., R19 expressed concerns about having low blood sugars in the morning.During an interview on 7/8/26 at 10:53 a.m., registered nurse (RN)-C with hospice stated he had been very involved with his care and would speak up about what his needs were. RN-C stated she would expect the staff to follow the orders for blood sugars and recheck R19's blood sugar in one hour to ensure his blood sugar was coming up and to ensure it was trending downward. RN-C stated she would also expect them to follow the order to notify hospice when the blood sugar was greater than 450.During an interview on 7/8/26 at 11:47 a.m., licensed practical nurse (LPN)-C reviewed R19's orders and verified the order specified if the blood sugar was less than 70, they needed to give juice and recheck the blood sugar in one hour. LPN-C stated it was important to follow the order to ensure the blood sugar wasn't staying low. LPN-C stated the order also specified the order included to notify hospice if the blood sugar was 450 or higher.During an interview on 7/9/26 at 8:22 a.m., LPN-D stated when R19's blood sugar was low, they were supposed to recheck his blood sugar in one hour. LPN-D stated they needed to make sure the blood sugar was coming up and not going lower.During an interview on 7/9/26 at 9:24 a.m., the director of nursing (DON) stated when a blood sugar was low staff needed to get the blood sugar up. The DON stated it was important for staff to follow orders as written. The DON stated if the blood sugar was too low the resident could have cognition changes, potential for falls, confusion, and/or sedation. If the resident refused the recheck, she would expect staff to document the refusal.The Hypoglycemia management policy dated 11/21/19, identified the objective was to identify hypoglycemia and restore normal blood sugar as quickly as possible. Steps identified to take included to treat hypoglycemia promptly and follow the protocol, report and document the episode.

Based on observation, interview and document review, the facility failed to ensure hot water temperatures were at safe temperatures at point-of-use for 27 of 27 residents who resided on the 200 hallway and the specialty care unit. In addition, the facility failed to ensure staff provided adequate supervision for transfers and activities of daily living for 2 of 2 residents (R49 and R40) and the facility further failed to follow the care plan related to transferring for the prevention of falls for 3 of 5 (R49, R40, R44) residents at risk for falls. Findings include: During a resident screening on 5/13/25 at 10:19 a.m., the hot water in bathroom of R34 felt very hot to touch after running the hot water for a couple of minutes. R34 stated the water takes a while to get hot, but then it gets very hot, and she had to blend it with cold water to use it. R34 stated she and nursing assistants (NA)s had talked about it before. During an observation and interview on 5/14/25 at 2:17 p.m., maintenance worker (MW)-A, who identified as the director of maintenance, ran the hot water in R34's room and used a thermometer to measure the temperature at 134 degrees Fahrenheit (F). MW-A stated that was too hot and he felt 105 to 110 degrees F seemed to be a good spot for the hot water, but MW-A wasn't sure what the upper limit of the hot water should be. During an interview on 5/14/25 at 2:41 p.m., MW-A reported the blender valve that feeds the 200 hallway and specialty care unit was showing the temperature as 110 degrees, so it must not be working. At 2:50 p.m., room [ROOM NUMBER]'s hot water measured 129 degrees F; the dirty utility room across the hall from room [ROOM NUMBER] had hot water temperatures of 131 degrees F; the handwashing sink in the common area of the specialty care unit measured 127 degrees F. MW-A stated he had called a contractor to come take a look at it as soon as possible, and he turned down the blender valve 10 degrees F. At 3:10 p.m., the administrator stated all of the alert residents, and all of the staff had been updated on not using the tubs until they can consistently hold the temperatures below 120 degrees. MW-A stated he would continue to take the water temperature to ensure it got below 120 degrees. During an interview on 5/15/25 at 8:23 a.m., trained medication aid (TMA)-A stated she had started her shift at 3 a.m. this morning and had taken hot water temperatures in all the resident rooms and common areas and reported the temperatures were as low as 110 and up to 120 degrees F. A review of facility-submitted Monthly Water Temperature Chart for 2/7/25 revealed the following temperatures (recorded in degrees F): room [ROOM NUMBER] was 128 room [ROOM NUMBER] was 130 room [ROOM NUMBER] was 126 room [ROOM NUMBER] was 126 room [ROOM NUMBER] was 126 North nursing station sink was 130 West nursing station sink was 130 The kitchen sink in the specialty cares unit was 130 A review of the facility-submitted Event Summary Reports from 5/13/24 to 5/14/25 revealed no burn incidents. During an interview on 5/15/25 at 4:13 p.m., the administrator stated hot water temperature was taken monthly and recorded on the Monthly Water Temperature Chart. This would be done by MW-A or he may have delegated to another maintenance worker, but MW-A should be the one who reviewed the temperatures. The administrator stated she wasn't aware there had been temperatures above 120 degrees F in the past months, and unless there was an issue she wouldn't necessarily look through the temperature logs. She would expect it to be brought to her attention if there were temperatures above 120 degrees F. During an interview on 5/15/25 at 4:33 p.m., MW-A confirmed he was responsible for taking hot water temperatures monthly, if there were an instance where he was gone the other maintenance worker would take them. MW-A stated he noticed the temperatures creeped up a little bit in February, but it wasn't too extreme, and he speculated maybe they had been adjusting things. MW-A stated making sure the water wasn't too hot was important because it could mean hazards and burns. MW-A further stated he had continued to monitor the hot water temperatures, and they were coming in consistently under 120 degrees F and the new mixing valve had been ordered. He stated he would continue to monitor the temperatures until the valve was replaced. A policy, Preventative Maintenance Program SNF and AL dated 2/5/25, identified all Cassia sites shall have a standard preventative maintenance program that includes safety rounds, inspections and audits of all areas to maintain a safe, clean and well-maintained environment. This preventative maintenance program will also include a systematic method for reporting repairs and on-going mitigation of all safety risks. Maintenance tasks will be conducted as part of a systematic program to meet all local, state and federal regulations and additional Cassia standards of practice for building/grounds code compliance and general maintenance. The audit procedures didn't contain a line item for testing hot water. 47263 R49: R49's admission Minimum Data Set (MDS) dated [DATE], indicated R49 was cognitively intact. R49's Resident Profile dated 5/15/25, included diagnoses of osteomyelitis, pain, chronic respiratory failure, congestive heart failure, diabetes type II, repeated falls, muscle weakness, unsteadiness on feet, and unspecified abnormalities of gait and mobility. R49's Care plan dated 3/27/25 to 5/15/25, included the following: Resident needs assistance with ADL's, start date 3/27/25 ---Dressing: staff to provide assist of one for dressing. ---Toileting: staff to provide assist of one with toileting. ---Transfers: -----assist of 1 for transfers using a gait belt and hemi-walker (edited 4/7/25, from mod I) -----provide limited/extensive assist of one with walker for transfers. Cue before and after transfer (initiated 3/27/25) Falls, start date 3/27/25 ---follow toileting and repositioning schedule ---gripper socks or non-skid footwear ---monitor and assess if fall occurs, document circumstances/possible cause and notify MD and family ---monitor for medication side effects ---observe and meet resident needs ---OT and PT to treat Behaviors, start date 3/27/25 ---resident does not exhibit adverse behavior symptoms R49's Event Reports for falls at the facility indicated R49 had sustained 6 falls at the facility between the dates of 4/2/25 and 5/8/25. noted. During an interview on 5/14/25 at 1:46 p.m., R49 stated when they were in their room, they moved themselves between their wheelchair and bed, recliner and wheelchair and their wheelchair and toilet. However, if they had urgency to go, they called staff for help because when they rushed, they sometimes lost their balance. R49 stated they didn't think staff seemed to be concerned if they moved themselves from their chair to the wheelchair or if they went to the bathroom on their own. During an interview on 5/15/25 at 8:30 a.m., R49 stated they had therapy at 9:00 a.m., so they were going to get dressed and ready for therapy. R49 stated staff did not come in each morning and offer to assist her to the bathroom or with dressing, they got themselves to the bathroom and dressed on their own. During an interview on 5/15/25 at 8:33 a.m., nursing assistant (NA-A) stated R49 was independent with dressing and transfers. NA stated they got information on how residents transferred and dressed etc. during shift report from the off going shift. During an interview on 5/15/25 at 10:57 a.m., licensed practical nurse (LPN-A) stated if they noticed a resident was starting to transfer themselves, they would bring that forward to physical therapy (PT) and occupational therapy (OT) so they could re-evaluate the resident's transfer status and either advance them, or confirm they still needed assistance for transfers. R49 did try to transfer themselves on their own, because R49 wanted to be independent, however R49 knew they required assistance for transfers. Due to falls, R49 was moved closer to the nursing station. LPN-A stated when they went into R49's room, they educated R49 on calling for help for transfers and encouraged R49 to leave their door open for safety. During an interview on 5/15/25 at 12:38 p.m., the physical therapist assistant (PTA) stated R49 still require stand by assist for transfers. R49 should not be transferring themselves alone. The occupational therapist (OT) stated R49 should not transfer alone and explained R49 should also have standby to minimum assist with dressing and toileting. During an interview on 5/15/25 at 3:51 p.m., NA-B stated R49 did everything on their own and indicated if R40 needed help they would put their call light on, but otherwise R49 was doing everything by themselves for transfers and dressing. R40: R40's admission MDS dated [DATE], indicated R40 was cognitively intact. R40's Resident Profile dated 5/15/25, included diagnoses of unspecified fracture of upper end of right tibia, anemia, history of falling, repeated falls, weakness, unsteadiness on feet, and abnormalities in gait and mobility. R49's Care plan dated 3/29/25 to 5/15/25, included the following: Resident needs assistance with ADL's, start date 3/29/25 ---Resident to ambulate with therapy only --- Bed mobility: Assist of one ---Eating: Resident does require assist with setup ---Grooming: staff to provide 1 assist with grooming. ---Oral care: staff to provide 1 assist with oral care ---Dressing: staff to provide assist of one for dressing. ---Toileting: staff to provide assist of one with toileting. ---Transfers: Cue resident before/during, assist of 1 stand pivot using gait belt grab bars and w/c arm rest. Falls, start date 3/29/25 ---follow toileting and repositioning schedule ---gripper socks or non-skid footwear ---monitor and assess if fall occurs, document circumstances/possible cause and notify MD and family ---monitor for medication side effects ---observe and meet resident needs ---OT and PT to treat Behaviors, start date 3/29/25 ---resident does not exhibit adverse behavior symptoms During an interview on 5/12/25 at 3:39 p.m., R40 was wheeling self out of bathroom and indicated they had just finished using the restroom. R40 pointed to the transfer belt on the counter and stated therapy staff used the transfer belt but only one out of ten staff used it when they helped with transfers. R40 stated they had not had a fall at the facility and indicated they transferred themselves in the bathroom even though they had been told to call for help. During an interview on 5/15/25 at 8:33 a.m., NA-A stated R40 was independent with dressing and transfers. NA stated they got information on how residents transferred and dressed etc. during shift report from the off going shift. During an interview on 5/15/25 9:24 a.m., R40 stated they had washed and dressed themselves this morning, staff did not come in and help with getting dressed. R40 stated they had transferred themselves this morning. During an interview on 5/15/25 at 10:36 a.m., NA-C confirmed they were working on the transitional care unit (TCU). NA-C explained the residents on the TCU typically needed less assistance. NA-C stated they hadn't had to assist R40 with anything this a.m. They were not sure if R40 needed assistance with transfers/cares, but they could find that information in R40's care plan if they needed it. During an interview on 5/15/25 at 10:57 a.m., licensed practical nurse LPN-A stated R40 was an assist of one for transfers. R40 called when they needed assistance for transfers. During an interview on 5/15/25 at 12:38 p.m., with PTA and OT, PTA stated R40 had not been approved for self-transfers yet. The OT stated R40 required stand by assist with dressing. During an interview on 5/15/25 at 3:51 p.m., NA-B stated R40 needed partial assistance with stand pivot transfers but could dress self. NA-B stated they always used a transfer belt when they transferred residents. During an interview on 5/15/25 at 3:04 p.m., registered nurse (RN-A) stated R49 and R40 were not independent with transfers and could call for assistance. RN-A indicated all staff should know how a resident transferred. The transfer status was in the care plan and also got handed off at shift report. For TCU residents if OT or PT updated a transfer status the change would get posted for staff to see and then it would also get updated in the care plan. It is possible our short-term staff may not know the transfer status of a resident; they should be checking and following the care plan. We need to have a process in place to make sure staff know when residents need transfer assistance. During an interview on 5/15/25 at 4:13 p.m., the director of nursing (DON) stated R49 and R40 were not independent with transfers, and indicated they expected staff to follow the care plan for patient transfer status and activities of daily living. The facility policy Fall assessment and managing fall risk dated 11/6/23, included the following: --residents are assessed for fall upon admit, quarterly, with significant changes and as needed --fall risk and appropriate interventions to minimize the risk of falls/injury from falls are included in the care plan --based on fall review, interventions in the care plan are updated as indicated --interventions to reduce/prevent falls are reviewed with the resident and representative The facility policy Care plan and baseline care plan dated 10/14/25, included the following: --the interdisciplinary team in conjunction with the resident and their support people will develop a comprehensive person-centered care plan for each resident --the resident care plan is constantly changing. It is to be updated routinely to reflect the resident's current condition R44: R44's quarterly Minimum Data Set (MDS) dated [DATE], identified R44 was cognitively intact and had no behaviors or refusals of care. In addition, R44's MDS identified R44 had a diagnosis of paraplegia (a condition characterized by paralysis of the lower body typically the legs), schizophrenia, and neurogenic bladder (condition that causes loss of bladder control due to nerve, spinal cord, or brain issue). R44's Care area assessment (CAA) dated 8/11/24, identified R44 had the following risk factors for falls: psychotropic medication use, cognitive impairment related to schizophrenia, bowel incontinence, and presence of a foley catheter. R44's care plan dated 2/6/23, identified R44 required assistance with transfers and ambulation due to falls risk. Interventions included an assist of one staff for pivot transfers with a gait belt. R44's fall risk assessment dated [DATE], identified R44 was a moderate risk for falls related to toxic encephalopathy, cramp and spasms, pain, use of antipsychotic and antidepressant medications, Foley catheter. Last fall was 11/24/24. During an observation on 5/14/25 at 7:02 a.m., nursing assistant (NA)-D assisted R44 to the side of the bed, brought the wheel chair close to the bed locked the brakes on the wheel chair assisted R44 to stand, pulled up his pants and transferred R44 to the wheel chair. The gait belt was on the bedside table but was not used during the transfer. During an interview on 5/14/25 at 7:23 a.m., NA-D stated interventions for transfer did not include a transfer belt only needed to have him stand and pivot and needed to remind him to stand tall. During an interview on 5/15/25 at 10:30 a.m., licensed practical nurse (LPN)-A verified R44 could be transferred with the assist of one staff and a transfer belt needed to be used. During an interview on 5/15/25 at 11:05 a.m., the director of nursing (DON) verified staff should follow the care plan and use a transfer belt for safety with transfers as identified in care plans. Fall assessment and managing fall risk dated 11/6/23, identified Transfer/gait belt use is required during any transfer or ambulation where the resident needs stand by or higher level of assistance during transfers or ambulation.

Based on interview and document review, the facility failed to ensure medication orders for residents contained an indication for the medication for 3 of 5 (R19, R37, R49) residents reviewed for unnecessary medications. Findings include: R19: R19's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of frontotemporal neurocognitive disorder (a type of dementia), severe dementia with agitation, delusional disorders, paranoid delusions, hypothyroidism, asthma, restless leg syndrome, urinary incontinence, post-traumatic stress disorder (PTSD), major depressive disorder, weakness, and fatigue. R19's MDS also identified hallucinations, delusions, verbal behavior toward others, and behavior significantly disrupts the living environment. R19's care plan last reviewed 5/13/25, didn't identify diagnoses or problem statements for hypertension, constipation, fluid retention, or issues with the skin in the perineal area. R19's provider orders identified the following medications without indications: -2/11/25 Miralax (a powder medication used to treat constipation) 17 grams daily as-needed (PRN) daily -2/11/25 furosemide (a medication that helps rid the body of excess fluid) 40 mg daily -2/11/25 hydrocortisone cream (topical corticosteroid used to treat mild inflammatory skin conditions) 2.5% perineal application with non-pharmacologic interventions to wash and dry affected area thoroughly, warm bath, and lotion area two times a day PRN -2/12/25 Magnesium oxide (a mineral used to treat a variety of conditions from constipation to low blood levels of magnesium) tablet 400 mg give orally before morning meal -4/1/25 docusate (a stool softener) 200 mg daily -4/1/25 Senna S (a stool softener plus a stimulant laxative) daily PRN -4/7/25 lisinopril (a medication used primarily to treat hypertension) 5 mg daily R37: R37's quarterly MDS dated [DATE], identified severely impaired cognition and diagnoses of left-sided hemiplegia and hemiparesis after a cerebral vascular accident (CVA, or stroke), dysphagia (difficulty swallowing), diabetes mellitus, long-term use of insulin, major depressive disorder, hypertension, gastroesophageal reflux disorder (GERD), hyperlipidemia (high cholesterol), low back pain, urinary incontinence, thrombocytopenia (abnormally low number of platelets in the blood), hearing loss, and dementia with psychotic disturbance. R37's care plan dated 4/8/25, didn't identify diagnoses or problem statements for sleep disturbance or nausea. R37's provider orders identified the following medications without indications: -11/7/23, melatonin (a hormone that regulates sleep-wake cycle) 6 mg at bedtime -2/7/25, ondansetron (medication used to treat nausea) 4 mg every six hours PRN During an interview on 5/15/25 at 1:40 p.m., the assistant director of nursing (ADON) stated they had recognized there weren't diagnoses with the medications, and found the issue was that every time an order changed the diagnosis wasn't being carried forward with the medication. The ADON stated they had implemented education with their health unit coordinators (HUC)s, and with the providers so that moving forward the medications would have indications. The ADON stated it was important to have the indication, so they knew they were giving the right medication. A policy, Transcription of Orders dated 2/12/24, identified all resident orders would be transcribed per policy and procedure. Item number six of the policy indicated per regulations and practice standards all medication orders must include the name of medication, dosage, route, and frequency. Each medication must also include a diagnosis for usage. Under item 8b, the policy indicated the nurse who verified the order would review order documentation and ensure the full transcription of orders had been completed and was accurate and updated EHR via acknowledgment order is verified.

Based on interview and document review, the facility failed to provide a financial statement to 1 of 2 residents (R4) who had requested to receive a quarterly statement of their personal funds account. Findings include: R4's annual Minimum data Set (MDS) dated [DATE], identified R4 was cognitively intact. During an interview on 5/12/25 at 3:27 p.m., R4 stated she had a personal trust account but was not getting any statements. R4 stated she was not sure how much money she had in the account. During an interview on 5/14/25 at 1:46 p.m., business office manager (BOM)-F verified R4 had a personal trust account and identified the statements were going to her old home address. BOM-F verified R4 should have been receiving her statements. During an interview on 5/14/25 at 2:12 p.m., the administrator verified the facility should follow the procedure in their policy. During a phone interview on 5/14/25 at 2:27 p.m., the corporate associate vice president of revenue cycle management verified R4's statement should have been going to R4 and not to her former home address. The Trust fund policy and forms dated 11/15/24, identified the resident or financially responsible person would receive quarterly statements detailing deposits, withdrawals and interest earned.

Based on observation, interview, and record review the facility failed to identify and update the care plan with resident specific fall prevention interventions for 1 of 2 residents (R49) reviewed for multiple falls at the facility. Findings include: R49's admission Minimum Data Set (MDS) dated [DATE], indicated R49 was cognitively intact. R49's Resident Profile dated 5/15/25, included diagnoses of osteomyelitis, pain, chronic respiratory failure, congestive heart failure, diabetes type II, repeated falls, muscle weakness, unsteadiness on feet, and unspecified abnormalities of gait and mobility. R49's Care plan dated 3/27/25 to 5/15/25, included the following: Resident needs assistance with ADL's, start date 3/27/25 ---Dressing: staff to provide assist of one for dressing. ---Toileting: staff to provide assist of one with toileting. ---Transfers: -----assist of 1 for transfers using a gait belt and hemi-walker (edited 4/7/25, from mod I) -----provide limited/extensive assist of one with walker for transfers. Cue before and after transfer (initiated 3/27/25) Falls, start date 3/27/25 ---follow toileting and repositioning schedule ---gripper socks or non-skid footwear ---monitor and assess if fall occurs, document circumstances/possible cause and notify MD and family ---monitor for medication side effects ---observe and meet resident needs ---OT and PT to treat Behaviors, start date 3/27/25 ---resident does not exhibit adverse behavior symptoms R49's care plan showed the facility had changed R49's transfer assistance level to assist of one after R49's fall on 4/7/25. The care plan lacked evidence to show the facility had modified or implemented fall prevention interventions after review of 5 other falls that occurred at the facility between 4/2/25 and 5/8/25. Event Reports for falls at the facility included: 4/2/25 unwitnessed fall resident found on floor. Fall occurred in bathroom 4/7/25 unwitnessed fall, resident found on floor in bathroom. Nursing note indicated R49 was sent to the emergency room to rule out shoulder dislocation/fracture. IDT review indicated R49 had fractured their clavicle bone and R49 was down graded from mod I in room per therapies. 4/16/25 unwitnessed fall in resident room, Nurse note indicated R49 was found on floor in front of recliner. R49 indicated they had been attempting to pull pants up and lost their balance. Call light was on, R49 did not have slipper socks on. 4/17/25: witnessed fall resident lowered to the floor Nursing Note: indicated resident was in recliner with feet resting on their wheelchair. Resident had slipped down between recliner and wheelchair and staff were not able to reposition resident back to chair, so resident was lowered to the floor. 4/19/25: witnessed fall in resident room, resident lowered to floor with staff assistance during transfer 5/8/25: unwitnessed fall in resident bathroom. Nurse note indicated R49's call light was ringing and R49 was found sitting on the floor between the toilet and their wheelchair. R49 stated they lost their balance and bumped their head. Small, raised area on crown noted. During an interview on 5/14/25 at 1:46 p.m., R49 stated when they were in their room, they moved themselves between their wheelchair and bed, recliner and wheelchair and their wheel chair and toilet. However, if they had urgency to go, they called staff for help because when they rushed, they sometimes lost their balance. R49 stated they didn't think staff seemed to be concerned if they moved themselves from their chair to the wheelchair or if they went to the bathroom on their own. During an interview on 5/15/25 at 8:30 a.m., R49 stated they had therapy at 9:00 a.m., so they were going to get dressed and ready for therapy. R49 stated staff did not come in each morning and offer to assist her to the bathroom or with dressing, they got themselves to the bathroom and dressed on their own. During an interview on 5/15/25 at 8:33 a.m., nursing assistant (NA-A) stated R49 was independent with dressing and transfers. NA stated they got information on how residents transferred and dressed etc. during shift report from the off going shift. During an interview on 5/15/25 at 10:57 a.m., licensed practical nurse (LPN-A) stated if they noticed a resident was starting to transfer themselves, they would bring that forward to physical therapy (PT) and occupational therapy (OT) so they could re-evaluate the resident's transfer status and either advance them, or confirm they still needed assistance for transfers. R49 did try to transfer themselves on their own, because R49 wanted to be independent, however R49 knew they required assistance for transfers. Due to falls, R49 was moved closer to the nursing station. LPN-A stated when they went into R49's room, they educated R49 on calling for help for transfers and encouraged R49 to leave their door open for safety. During an interview on 5/15/25 at 12:38 p.m., the physical therapist assistant (PTA) stated R49 still required stand by assist for transfers. R49 should not be transferring themselves alone. The PTA indicated they had tried ambulating R49 without their oxygen on, but R49's had not tolerated it well, their oxygen saturation had dropped. The PTA stated R49 had been on oxygen for years, and based on observation, the PTA felt R49 was very aware of the positioning of their oxygen tubing. The occupational therapist (OT) stated agreement with PTA, and said R49 was very aware of their oxygen tubing when they worked on transfers with R49. The OT also confirmed R49 should not transfer alone and explained R49 should also have standby to minimum assist with dressing and toileting. During an interview on 5/15/25 at 3:51 p.m., NA-B stated R49 did everything on their own and indicated if R40 needed help they would put their call light on, but otherwise R49 was doing everything by themselves for transfers and dressing. During an interview on 5/15/25 at 3:04 p.m. registered nurse (RN-A) stated all staff should know how a resident transfers. The transfer status is in the care plan and is also handed off at shift report. For short term rehabilitation residents if OT or PT updated a transfer status the change would get posted for staff to see and then it would also get updated in the care plan. Each resident fall is reviewed by the interdisciplinary team. The team reviews the fall and looks at what interventions can be implemented to prevent falls from happening again. Therapy may be involved too. After, the care plan should be updated, for instances if anti roll backs are added to the wheelchair, that would get updated on the care plan. RN-A indicated interventions didn't necessarily have to go in the care plan. When reviewing R49's care plan, RN-A stated they had reviewed R49's care plan after each of R49's fall, but they hadn't marked it as reviewed. They normally just marked reviewed when changes were made to the care plan that staff needed to know about. For instance, R49 was moved closer to the desk after their fall on 4/16/25, but that was not put in the care plan. RN-A reviewed the EMR documentation for each of R49's six falls and confirmed R49 had had four unwitnessed falls related to self-transferring, three of which occurred in the bathroom, with one resulting in a collar bone fracture. RN-A stated they had changed R49's transfer status in the care plan from modified independence, to assist of one after the fall on 4/7/25. The IDT team had not identified any other fall prevention interventions to add to R49's care plan after they had reviewed each fall. There were other interventions not on the care plan. RN-A stated they could have added interventions to round on R49 more frequently and/or added interventions to address toileting needs to help prevent falls in the bathroom. RN-A indicated the IDT usually did look at bowel and bladder to see how the toileting schedule could be modified to prevent falls. It is possible our short-term staff may not know the transfer status of a resident but they should be checking the care plan. We need to have a process in place to make sure staff know when residents need transfer assistance. During an interview on 5/15/25 at 4:13 p.m., the director of nursing stated staff need to follow the care plan and indicated R49's care identified R49 required assistance for transfers. Each fall gets reviewed by the IDT team. The fall is discussed, possible contributing factors are identified and reviewed, the resident and staff involved may be interviewed for additional information. We would then determine appropriate actions were taken or do further actions to prevent future falls. R49 prefers to be independent and does not accept help very well. As an intervention R49 was moved closer to the desk. R49's transfer status was modified on 4/7/25, after R49's fall that resulted in a broken collar bone. The DON confirmed no other modification or fall prevention interventions had been added to R49's care plan after subsequent falls. The DON reviewed R49's EMR fall documentation and stated the facility had done interventions, but they were not things that the DON would put in the care plan. During a follow-up interview at 5/15/25 at 4:49 p.m., the DON stated they had reviewed R49's care plan and indicated they did not feel any additional fall prevention interventions should have been added to R49's care plan, however R49's self-transfer behaviors should have been added to the care plan under behaviors. The facility policy Fall assessment and managing fall risk dated 11/6/23, included the following: --residents are assessed for fall upon admit, quarterly, with significant changes and as needed --fall risk and appropriate interventions to minimize the risk of falls/injury from falls are included in the care plan --each fall is investigated as soon as possible --based on fall review, interventions in the care plan are updated as indicated --interventions to reduce/prevent falls are reviewed with the resident and representative The facility policy Care plan and baseline care plan dated 10/14/25, included the following: --the interdisciplinary team in conjunction with the resident and their support people will develop a comprehensive person-centered care plan for each resident --the resident care plan is constantly changing. It is to be updated routinely to reflect the resident's current condition.

Based on interview and document review, the facility failed to assess post-traumatic stress disorder (PTSD) symptoms and triggers and carry them forward to the care plan for 1 of 1 resident (R19) reviewed for trauma informed care. Findings include: R19's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of anxiety, major depressive disorder, psychotic disorder, PTSD, frontotemporal neurocognitive disorder, severe dementia with agitation, delusional disorder, and paranoid delusions. The MDS also identified R19 had hallucinations, delusions, verbal behavior toward others, and had behavior which significantly disrupted the living environment. R19's care plan dated 2/11/25, identified a problem statement for trauma-informed care related to a history of trauma of physical abuse as a minor from alcoholic parents including being tied up by the arms and legs to a bed, having socks placed in her mouth due to screaming, and was burned with cigarettes. The goal for R19 was for care provided to mitigate the risk of re-traumatization. The intervention on 2/11/25 was that R19 was fine with both male and female caregivers. Other problem statements related to behavior, psychotropic medication use, and mood state did not contain triggers or symptoms for PTSD. R19's electronic medical record (EMR) didn't contain an assessment of PTSD symptoms or triggers. During an interview on 5/15/25 at 9:49 a.m., social services designee (SSD)-A stated the facility didn't have a specific assessment for PTSD, it was screened for when a person was admitted by reading their history and diagnoses. SSD-A added she also would ask the resident on admission if there was anyone they didn't want to contact them, or if they had had any trauma. R19's daughter had talked with SSD-A about R19's history of abuse and learned one thing not to do would be to make her feel confined, so something she wouldn't like would be when you closed a door on her. SSD-A reviewed R19's care plan and confirmed this wasn't an intervention on her care plan, nor did the care plan indicate what may trigger her PTSD, and that would be helpful to put on there. SSD-A stated she had verbally talked with the staff about not closing doors on her. During an interview on 5/15/25 at 10:21 a.m., nursing assistant (NA)-E confirmed she worked in the specialty care unit and was familiar with R19. She stated approach was important for R19, and she would tell you who she liked and didn't like, and that you can't try to correct her. NA-E stated she was aware of R19's PTSD diagnosis, but wasn't aware of triggers, just knew she was abused by her parents. NA-E stated she would look in the care plan or ask social services if she had questions. During an interview on 5/15/25 at 10:25 a.m., trained medication aid (TMA)-A confirmed she worked in the specialty care unit and was familiar with R19. TMA-A stated she was aware of R19's PTSD, and knew R19 can't feel trapped. TMA-A provided an example where R19 wheeled her wheelchair backwards into a corner of the hallway and started to freak out because she thought she was stuck. TMA-A added it was important for staff not to close her bedroom door, R19 herself could close it, but staff could not. TMA-A stated she knew these things about R19 from word of mouth. During an interview on 5/15/25 at 3:57 p.m., the director of nursing (DON) stated they didn't have a PTSD assessment, but they did do a psychosocial history where abuse was asked about. The DON stated R19's PTSD interventions fell under psychotropic medications and/or mood and behavior on the care plan because it got complicated. A policy, Trauma Informed Care dated 11/15/24, identified as part of the admission comprehensive assessment the facility will identify history of trauma or interpersonal violence when possible, using the social history and psycho-social observation tool. If a resident shares a history of trauma, a trauma-informed care plan will be developed with appropriate information to help guide staff in an effort to avoid re-traumatization.

Based on observation and interview the facility failed to utilize beard coverings in the kitchen to ensure sanitary conditions were maintained in food preparation areas. This deficient practice had the potential to impact all residents who received nourishment from the facility dietary services. Findings include: During an observation on 5/12/25 at 1:26 p.m., the food service consultant (FSC-A) was in the main kitchen area without a beard covering. FSC-A provided a tour of the kitchen food prep area, food dry and cold storage areas, the dishwashing area, and dish storage area while not wearing a beard covering. During an observation on 5/14/25 at 8:00 a.m., the culinary director (CD) was located behind the cook's prep table and did not have a beard covering on. During a continuous observation on 5/14/25 at 10:42 a.m. to 11:46 a.m., both the CD and FSC-A did not wear a beard covering during the following observed events: --10:43 a.m. to 1048 a.m., FSC-A stood in front of the cook's prep area without a beard covering as cook (C-A) pulled food from the oven and temped it. --10:51 a.m., dietary aide DA-A entered the kitchen without placing a beard covering over their beard. DA-A remained in the kitchen and wrapped silverware in napkins without a beard covering. --10:57 a.m. to 11:10 a.m., FSC-A remained in front of cook's area without a beard covering. --10:59 a.m., DA-A was still wrapping silverware without beard covering on. --11:17 a.m., CD walked behind the prep area between C-A and the oven without a beard covering and returned with a plastic bin. C-A put chicken in the bin and CD removed the bin from the cook's work area. --11:23 a.m. the CD sanitized hands, applied gloves and removed a utensil from the cook's prep table and brought it over to where C-A was pureeing food. --11:24 a.m., FSC-A was at a workstation without a beard cover on placing dessert bars into lidded serving containers. --11:40 a.m., DA-A, CD, and FSC-A remained in the kitchen area without beard coverings. --11:41 a.m. CD removed chicken from the oven and temped the chicken and returned the chicken to the oven. --11:46 a.m., FSC-A removed chicken from the oven and temped it (no beard covering). During an observation on 5/15/25 at 10:00 a.m., the CD was in the kitchen without a beard covering standing at the cook prep table with C-B. During an interview on 5/14/25 at 12:01 p.m., the CD and FSC-A stated culinary staff get education on safe food preparation and handling, hand washing, infection prevention, and they also complete other required facility and food service topics. In addition, staff get training and coaching on the job. During an observation on 5/15/25 at 9:15 a.m., the CD was in the cook's area of the kitchen without a beard covering. During a follow-up interview on 5/15/25 at 12:14 a.m., the CD confirmed staff had not been wearing required beard coverings in the kitchen areas between 5/12/25 and 5/15/25. The CD explained they had just had mandatory mask wearing lifted and they had not implemented the switch back to wearing beard coverings. The CD stated beard coverings were required in the kitchen for sanitary and infection prevention reasons. The CD indicated beard coverings had been ordered and placed at the entrances to the kitchen and were to be worn by any staff with a beard who entered the kitchen area.

Based on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 24 residents (R106) reviewed for advanced directives. Findings include: R106's admission Minimum Data Set (MDS) dated [DATE], identified R106 had moderate cognitive impairment. Diagnoses included dementia and malnutrition. R106's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE], included: -Section A for cardiopulmonary resuscitation (CPR) patient has no pulse and is not breathing section, directed staff to Attempt Resuscitation/CPR (Note: selecting this requires selecting Full treatment in Section B). -Section B for Medical Treatments patient has a pulse and/or is breathing directed staff to do comfort-focused treatment (allow natural death)' R106's electronic medical record (EMR) banner undated, identified R106 was do not resuscitate (DNR). R106's Order Summary report dated [DATE], identified orders of DNR. During an interview on [DATE] at 6:43 p.m., licensed practical nurse (LPN)-B stated staff should look at the EMR banner to find if a resident is a full code or a DNR. She was unable to identify other areas she would look to confirm code status of a resident. During interview on [DATE] at 6:57 p.m., registered nurse (RN)-A stated staff should confirm code status by looking at the EMR banner and the POLST to confirm if a resident wanted to have CPR or was DNR. If there was a discrepancy between the two, staff would need to clarify. RN-A reviewed R106's EMR and confirmed the EMR banner and the POLST indicated different statuses. She was not aware if CPR should be started if a resident stopped breathing and there was a discrepancy between code statuses. During an interview on [DATE] at 10:42 a.m., the director of nursing (DON) stated staff should look at the EMR banner, the provider order and the POLST to verify the resident's Code status. If there was a discrepancy, then it would need to be verified with the patient and provider. The policy would have to be reviewed to confirm if CPR would need to be started if there was conflicted information between the POLST, the provider order, and the EMR banner. Facility policy POLST-MOST-IPOST- Advance Directive Form Implementation last reviewed [DATE], indicated in the event of a resident crisis, staff would be instructed to look at the resident's order for code status, the banner flag in EMR, and the electronic version of the POLST/MOST/IPOST. Facility policy Cardiopulmonary Resuscitation (CPR) last reviewed [DATE], indicated if a resident's code status is unclear, CPR would be initiated and continued until a resident regains a pulse or until a physician or paramedic arrived and directed to stop CPR.

Based on observation and interview, the facility failed to ensure eye drops were disposed of when they were past the 28 day post open date. This had potential to affect 2 of 16 residents who resided on 300 hallway. Findings include: On 3/14/24 at 11:07 a.m., a review of the 300-hallway medication cart was performed. Observation was made of Olopatadine 0.2% solution eye drops that had an open date of 1/31/24. There were also a bottle of artificial tears eye drops open dated on 1/6/24. During an interview on 3/14/24 at 11:16 a.m., licensed practical nurse (LPN)-A reviewed the medications and confirmed the dates on the medications were the open dated. She was unsure how long the medications were good for but believed they were safe to use for six months after opening. During an interview on 3/14/24 at 12:06 p.m., the pharmacy consultant (PC) stated eye drops such as Olopatadine and artificial tears were only good for 28 days after opened since the preservative in them would only be stable for 28 days. After the 28 days they may not be safe to use. During an interview on 3/14/24 at 12:10 p.m., the director of nursing (DON) stated an expectation that medication would be disposed of per facility policy. A facility policy on dating and disposal of multi-use medication was requested, however, none was provided.

Based on interview and document review, the facility failed to notify the medical provider of high blood sugar levels for 2 of 3 residents (R2, R3) reviewed for change in condition. Findings include: The facility Standing Orders revised 10/30/21 directed to notify the medical provider if two blood glucose levels were under 70 or over 300 in a 24-hour period and/or change in condition; if no condition change, notify provider the next business day. R2's Face Sheet indicated diagnoses of type 2 diabetes mellitus with diabetic nephropathy (kidney disease). R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 received insulin daily. R2's Vital Signs flow sheet indicated the following blood glucose (BG) levels: On 10/24/23 at 5:22 p.m., BG level was 301, and at 8:54 p.m., BG level was 371. On 10/26/23 at 11:24 a.m., BG level was 323 and at 5:39 p.m., BG level was 376. On 11/8/23 at 5:18 p.m., BG level was 313 and at 7:58 p.m. BG level was 465. R2's progress notes during this time frame lacked any entry of the medical provider being updated on the elevated blood glucose levels. R3's Face Sheet indicated diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood glucose levels). R3's quarterly MDS dated [DATE], indicated R3 received insulin daily. R3's Vital Signs flow sheet indicated the following BG levels: On 10/24/23 at 5:03 p.m., BG level was 318 and at 8:12 p.m., BG level was 408. On 10/27/23 at 4:38 p.m., BG level was 314 and at 7:54 p.m., BG level was 354. On 10/28/23 at 4:40 p.m., BG level was 348 and at 7:40 p.m., BG level was 343. On 10/29/23 at 5:05 p.m., BG level was 337 and at 7:27 p.m., BG level was 326. On 10/31/23 at 5:10 p.m., BG level was 310 and at 8:44 p.m., BG level was 336. R3's progress notes during this time frame lacked any entry of a medical provider being updated on the elevated blood glucose levels. On 11/9/23 at 3:23 p.m., licensed practical nurse (LPN)-A stated if a blood glucose level was over 400, she would call the medical provider for further instructions. On 11/9/23 at 3:31 p.m., the administrator stated if a resident had a high blood glucose level, she would expect the staff to follow the orders. On 11/9/23 at 3:45 p.m., the director of nursing (DON) stated no medical provider was updated on the elevated blood glucose levels for R2 and R3, and she would expect staff to follow the facility standing orders. On 11/9/23 at 3:51 p.m., R2 and R3's physician (MD)-A stated he would have expected the facility to update him either that day or the next day if blood glucose levels were over 300 twice in one day.

Based on observation, interview, and document review, the facility failed to ensure a comprehensive care plan was maintained to facilitate person-centered care planning for 1 of 2 residents (R27) reviewed for care planning. Findings include: R27's significant change Minimum Data Set (MDS) assessment, dated 10/5/22, indicated R27 was non-verbal, cognition was not assessed. R27 had diagnoses of epilepsy, non-traumatic intracerebral hemorrhage, arteriovenous malformation of cerebral vessels, and was dependent in all activities of daily living. Further, R27 received pain management on a regular and as needed basis including pharmacological and non-pharmacological interventions. R27's Care Area Assessment (CAA), dated 10/5/22, indicated R27 had non-verbal indicators of pain with other considerations of contractures, immobility, and insufficient pain relief. The CAA indicated a pain problem would be carried forward to the care plan. R27's care plan lacked pain management. R27's Physician Order Report, dated 5/12/23, contained the following: -acetaminophen suppository 650 mg rectally every six hours as needed for pain or mild fever -acetaminophen 650 mg every six hours as needed for pain rated 1-5 -baclofen (a medication used to treat muscle spasms) 5 mg twice a day -hydromorphone (an opioid used to treat moderate to severe pain) 1 mg scheduled two times per day in the AM and PM -hydromorphone 2 mg every one hour as needed for pain or shortness of breath During an interview on 5/8/23 at 2:38 p.m., family member (FM)-A indicated she was unsure what R27 was getting for pain or if the facility knew R27's non-verbal indicators of pain. During an interview on 5/12/23 at 9:04 a.m., the DON stated the initial care plan templates were put in by nurse managers, and then it was a team effort to keep it updated after that. The MDS nurse also updated nursing care plans with each MDS. Care plans were updated as needed depending on the resident's condition. The DON stated an up-to-date care plan was important so you can give the right care to the resident. During an interview on 5/12/23 at 9:21 a.m., RN-C stated she was responsible for adding the nursing parts of the care plan, including putting in the template on admission and making changes with resident needs. RN-C confirmed pain would be a nursing item included in the care plan. A facility memo, dated 10/14/22, with a subject line of care plan and baseline care plan indicated the resident care plan is constantly changing. It is to be updated routinely in the electronic record to reflect resident's current condition. The resident care plan is reviewed for accuracy, updated with quarterly MDS review and all other scheduled MDS assessments.

Based on observation, interview and document review, the facility failed to monitor edema (a medical term for fluid trapped in the body's tissues and is graded by trained healthcare professionals on a scale of plus one to plus four, with one being the least and four being the worst) and the potential complications to the lower extremities for 1 of 1 (R58) resident reviewed. Findings include: R58's admission Minimum Data Set (MDS)assessment dated [DATE], included diagnoses of spastic quadriplegia, chronic obstructive pulmonary disease (COPD), and muscle spasms of the back. R58's MDS indicated he was cognitively intact and required extensive for bed mobility, transfer, locomotion, and toilet use. R58's Care Area Assessment (CAA), dated 3/23/23, for skin conditions reviewed risk factors, but did not include edema as a risk factor. R58's care plan lacked edema monitoring. R58's progress notes included the following: -3/17/23 indicated 2 plus pitting edema to left lower extremity and trace pitting edema to right lower extremity -3/20/23 indicated R58 did not feel well, claimed he was dizzy and had shortness of breath that was getting worse every day. Head of bed moderate high, unable to elevate feet of bed due to increasing shortness of breath. Referred to on-call [name or doctor] and advised to send to the emergency room . Called resident's representative, [name], but was left voicemail. Resident informed. Resident said to wait it out as he thinks he feels better as compared to what he was feeling about an hour ago. Will monitor accordingly. -4/15/23 indicated one plus bilateral lower extremity edema -4/17/23 indicated one plus bipedal edema During an interview on 5/09/23 at 9:22 a.m., R58 confirmed he had edema in both of his feet and lower legs but does not have compression socks. R58 further stated his general doctor had noted the edema, but that nothing had been done. R58 was seated in wheelchair with feet in a dependent position. During an observation on 5/11/23 at 8:23 a.m., R58 was sitting in wheelchair with feet in a dependent position and verified he had edema in both lower legs. R58 elevating his feet would cause him more shortness of breath. During interview and observation on 5/11/23 at 9:10 a.m., registered nurse (RN)-B removed R58's socks. A sock line was visible on both feet. RN-B stated the right lower extremity had three plus pitting edema to the top of the right foot. RN-B stated the lower left extremity had three plus pitting edema to the top of the left foot, and the left calf had edema from the ankle to about halfway up to the knee. R58 stated this had been a concern for him and had mentioned it before but no one else seemed concerned about it. During an interview on 5/11/23 at 9:26 a.m., the director of nursing (DON) verified that an irregularity, such as edema, would be followed up on depending on whether it had been present during the hospital stay. The DON further stated if there were a change or worsening, they would need a plan to follow up on it and that this was important because edema can lead to a lot of different things. During an interview on 5/12/23 at 9:04 a.m., the DON stated the initial care plan templates were put in by nurse managers, and then it was a team effort to keep it updated after that. The MDS nurse also updated nursing care plans with each MDS. Care plans were updated as needed depending on the resident's condition. The DON stated an up-to-date care plan was important so you can give the right care to the resident. During an interview on 5/12/23 at 9:21 a.m., RN-C stated she was responsible for adding the nursing parts of the care plan, including putting in the template on admission and making changes with resident needs. RN-C confirmed edema would be included in the care plan under risks for skin impairment along with approaches to take. A facility memo, dated 10/14/22, with a subject line of care plan and baseline care plan indicated the resident care plan is constantly changing. It is to be updated routinely in the electronic record to reflect resident's current condition. The resident care plan is reviewed for accuracy, updated with quarterly MDS review and all other scheduled MDS assessments

Based on observation, interview, and document review, the facility failed to ensure catheter tubing with drainage bag was properly cleansed and stored to prevent cross contamination and infections for 1 of 2 residents (R42) reviewed for catheters. Findings include: R42's Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had moderately impaired cognition. Needed extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene, and had an indwelling catheter. R42's care plan reviewed 4/5/23, indicated R42 had a foley catheter related to having a neurogenic bladder and had previously failed trail removals. R42's face sheet printed 5/11/23, indicated R42's had the following diagnoses Parkinson's Disease, palliative care, dementia, major depressive disorder, anxiety, benign prostatic hyperplasia, obstructive and reflux uropathy, mixed incontinence, and neuromuscular dysfunction of bladder. During observation on 5/10/23 at 8:29 a.m., R42's bathroom had an undated catheter drainage bag hanging on a bar next to the left side of the toilet. The tip of the tubing was resting on the wall uncovered. During an interview on 5/10/23 at 8:34 a.m., nursing assistant (NA)-B stated nursing assistants clean the catheter bags with regular water and then they get store in bins in each resident's bathrooms. On 5/10/23 at 8:38 a.m., NA-C stated if the catheter bags need to be rinsed out with more than water the nurse would do that. If it is just a water rinse a nursing assistant can do that. R42's catheter bags are stored over the bar by the toilet in his bathroom. On 5/10/23 at 8:43 a.m., trained medication assistant (TMA)-A stated the nursing assistants are supposed to rinse the catheter bags with warm water and either place them in the bin or hang them over the bar in the bathroom next to the toilet. During observation on 5/11/23 at 10:02 a.m., R42's storage bin in his bathroom had an undated catheter drainage bag with yellow liquid in it. The catheter bag tubing was touching the outside of the bag uncovered. During an interview on 5/11/23 at 10:04 a.m., NA-A stated they would ran water through the catheter bag and cleansed both sides of the tubing with an alcohol wipe then place the catheter bag in R42's bin today. On 5/11/23 at 10:12 a.m., registered nurse (RN)-A verified R42's catheter bag had yellow liquid in it and that the tubing was uncovered. RN-A stated there should be a cover on the tubing and there should not be urine in the catheter bag. RN-A said they need to use an alcohol wipe to both sides of the tubing, rinse the bag with clear water, and allow to air dry and over the railing in the bathroom. On 5/11/2023 at 10:35 a.m., NA-D stated staff are supposed to rinse the catheter bag with vinegar and then hang it on the bar on the resident's side of the bathroom. On 5/11/2023 at 11:07 a.m., the director of nursing (DON) stated she expects staff to follow what the policy says when it comes to catheter and leg bags. The facility policy titled Urinary Indwelling Catheter Insertion and Management reviewed 4/14/2023, indicated the facility would immediately cover the end of the catheter bag tubing with a sterile cap or alcohol swab and packet. The facility would place collection bag and tubing in towel on bottom shelf of storage location.

Based on observation, interview, and documentation the facility failed to ensure proper hand washing/sanitization occurred for 1 of 1 resident (R)50 observed during cares. Finding include: During an observation on 5/10/23 at 9:40 a.m., nursing assistant (NA)-F entered R50's room and applied gloves. NA-E was already in the room and had R50's full body lift sling hooked up and ready for transfer. R50 was lowered to bed and foley catheter was placed on top of bed by right foot. NA-F removed R50's shoes. NA-E removed brace off R50's upper body. NA-F and NA-E rolled R50 away from NA-E's body towards window and NA-F. NA-F held R50 towards window on left side. Bottoms were lowered and NA-E cleaned peri area of stool, removed soiled brief, and placed new brief behind R50. Resident rolled back towards NA-E. to flat position. NA-F pulled new brief into place and secured tabs. With same gloves on NA-F rearranged R50's shirt for him. NA-E removed gloves, did not hand sanitize, and proceeded to helped NA-F get R50 positioned in bed. While still wearing the same gloves, NA-F handled the foley bag, and then put a new pillowcase on R50's pillow. NA-E did not hand sanitize, placed new gloves on, emptied foley, placed foley in dignity bag, brought graduated cylinder to bathroom, emptied urine in toilet, and then washed hands at sink. NA-F still wearing same gloves, gave call light to R50. NA-F and NA-E reposition R50 on to left side. NA-F went into drawer in room, retrieved a dressing and placed it over small open red area on R50's leg. NA-F then removed gloves and proceeded to wipe down the transfer lift with sanitizing wipes. NA-F then sanitized hands before leaving the room. NA-E sanitized hands prior to leaving the room. On 5/10/23 at 12:49 p.m., NA-F stated the clean field was broken after touching the foley bag and agreed hands should have been sanitized. NA-F touched R46's skin during brief change and said would normally have sanitized hands. Hand sanitize should have been used after helping with a brief change and before helping with repositioning or giving the resident a remote. NA-F stated they received training and education on hand sanitizing/washing, and personal protective equipment (PPE) for infection prevention. During an interview on 5/12/23 at 10:38 a.m., the infection preventionist (IP) and the director of nursing (DON). The IP stated glove removal and hand sanitization would be required after performing peri-care, assisting during peri care (skin touch/holding the resident on side), or after touching a foley bag. IP and DON stated they would expect staff to stop, remove gloves and perform hand sanitization after participating in peri-care, and prior to proceeding with repositioning resident, and handling items in the room. DON and IP indicated hand washing is assigned through Relias (computer-based education), and staff must complete an annual check off and hand washing competency. In addition, the facility conducts on going hand washing audits with immediate on the spot staff education as needed.

Based on interview and record review, the facility failed to provide written transfer notification to the Long-Term Care Ombudsman for 2 of 3 residents (R)32 & R17 transferred to the hospital or discharged from the facility. This failure had the potential to decrease support/direction from the Ombudsman related to their rights to appeal. Findings include: Resident Face Sheet, indicated R32 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/21 indicated R32 had a Brief Interview for Mental Status (BIMS) score that could not be determined and had short-and-long-term memory problems. Progress Notes dated 10/21/21, indicated R32 was transferred per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's electronic medical record (EMR) indicated admission on 05/06/15 and a change in medical condition which required transfer to the hospital on 10/30/21. During an interview on 01/05/22 at 12:09 p.m. the Social Worker confirmed the current facility policy and indicated she was not aware the Ombudsman was to be notified. Review of facility policy Transfer of a Resident to Hospital dated 12/09/19, indicated resident's primary contact/resident representative would be informed of a transfer. Staff were to obtain a written or verbal okay from resident or resident representative for the transfer and complete transfer form. This form was to be sent to Ombudsman following transfer per policy on Ombudsman notification. Review of facility Discharge Planning and Ombudsman Notification policy last reviewed on 09/14/19, indicated once per month Health Information Management (HIM) will submit a list of emergency transfers to the Office of the Ombudsman.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure proper hand hygiene was performed with dressing changes for 1 of 1 resident (R1) dressing change observed. Findings include: R1's Resident Face Sheet listed R1 had a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) on the left heel. On 01/04/22, at 10:14 a.m. TMA-A entered R1's room, briefly washed her hands at the sink, and approached R1 to visit. TMA-A went to the resident's sink and used soap and water to perform hand hygiene. TMA-A failed to perform hand hygiene for the required 20 seconds. TMA-A briefly washed her hands, pulled a paper towel from the dispenser, dried her hands, and then turned off the facet with the same paper towel. TMA-A then tossed the used paper towel into the trash. TMA-A spoke with R1. During the conversation, TMA-A touched her eye protection which was located on her face. TMA-A donned (put on) gloves, without first performing hand hygiene after she had adjusted her eye protection which was a potentially contaminated surface. At 10:16 a.m. TMA-A removed the slipper off R1's left foot, took an alcohol wipe out of its package and cleansed the big toe. At 10:17 a.m. TMA-A doffed (removed) her gloves and performed hand hygiene for less than the required 20 seconds. TMA-A took a paper towel from the dispenser, dried her hands, and used the same towel to turn off the facet before placing in the trash. TMA-A donned a fresh pair of gloves. TMA-A removed the gauze, which was wrapped around the resident's left ankle and foot. Observation was conducted of R1's left heel and the area was not open. TMA-A used wound cleanser on the resident's left heel and wiped the sprayed area with a clean washcloth. TMA-A applied [MEDICATION(S)] cream on the affected area of the left heel. At 10:20 a.m. TMA-A doffed her gloves and wrapped the resident's left heel and ankle. TMA-A dated the area. TMA-A donned the sock and then the resident's slipper. TMA-A went to the sink located in the resident's room and performed hand hygiene with soap and water for less than 20 seconds. During an interview on 01/04/22, at 10:26 a.m. TMA-A stated she typically sings Twinkle Twinkle Little Star, while washing her hands. TMA-A stated she typically performs hand hygiene for 20 seconds and performed hand hygiene before and after donning and doffing gloves. During an interview on 01/04/22, at 11:02 a.m. the Assistant Director of Nursing (ADON) stated the expectation was for staff to sanitize hands prior to donning gloves, after doffing gloves, and during a dressing change. During an interview on 01/05/22, at 12:16 p.m. the Infection Control Preventionist (ICP) stated she addressed TMA-A and directed the staff member not to sing for a measurement of time, since the singing could easily be [NAME] too fast. ICP stated the expectation was for staff to wash their hands for 20 seconds. Review of a facility's Hand Hygiene, Infection Control policy, dated 10/04/21, indicated handwashing/alcohol-based hand sanitizer be regarded as the single most important means of preventing the spread of microorganisms/transmission of infection. Hands must be washed with soap and water, if visibly soiled. Handwashing/sanitizing is necessary before and after providing care to resident, after removing gloves, after touching environmental surfaces or equipment near residents, after contact with your own face or mask and after handling dressings.

Based on interviews and records review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two on six residents, R1 and R2, reviewed for change of condition. R1 had fever, cough, and difficulty breathing for over 12 hours without effective intervention and nurses did not notify a physician or send R1 to the emergency department in a timely manner. R2 had a major injury after a fall, staff did not assess and intervene appropriately, did not notify the physician, and did not send R2 to the emergency department for timely evaluation. Findings include: R1's medial record indicated R1's [DIAGNOSES REDACTED]. R2's Brief Mental Interview Status (BIMS) dated (MONTH) 15, (YEAR) indicated R1 had severe cognitive impairment. R1 required total assistance for all activities of daily living (ADLs) and cares. R1's care plan required licensed staff to assess, monitor, and provide interventions for care and medical needs. R1's prescription order dated (MONTH) 19, (YEAR) indicated R1's physician ordered [MEDICATION NAME] sulfate solution for nebulization via inhalation every four hour as needed (PRN) for [MEDICAL CONDITION]. R1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R1's nebulizer administration at 4:45 p.m. had no reason and result documented for the treatment. R1's MAR indicated [REDACTED]. Nursing progress note dated (MONTH) 22, (YEAR) indicated R1 had fever of 101.8 degrees Fahrenheit and the staff gave her Tylenol at 9:30 a.m. The note indicated the staff rechecked R1's temperature two hours later and the fever was persistent with temperature at 101.7 degrees. Four hours after the temperature recheck, nursing progress note indicated R1 continued to have fever (temperature of 100 degrees) along with cough, congestion, wheezing, and diminished bilateral lung sounds. The note indicated R1 received a nebulizer treatment, but the treatment was effectiveness only for a short time and R1's skin was clammy and warm to touch. The note indicated R1 informed the staff that she did not feel well. The note indicated the staff did not notify R1's physician. Nursing progress note dated the same day and nine hours after the initial fever, indicated R1's family member told the nurse that she was concern about R1's condition. An hour later, the note indicated another family member called and expressed concern about R1's condition, but staff reassured the family member that the staff was monitoring R1 and would report R1's condition to the next shift nurse. R1's MAR indicated [REDACTED]. Nursing progress notes dated (MONTH) 23, (YEAR) indicated [REDACTED]. The note indicated an unlicensed staff reported R1's change of condition to the nurse. The note indicated the nurse assessed R1 and noted R1 had fast breathing and suggested the unlicensed staff gave another nebulizer treatment and cough syrup. The note indicated R1's condition change did not improve after the nebulizer and cough medication administration. The note indicated the nurse did not notify R1's physician, but instructed the unlicensed staff to notify R1's family member. An hour and half after the unlicensed staff reported R1's change of condition, the progress note indicated the nurse checked R1's vital signs and found temperature of 100.5 degrees, heart rate of 133 beats per minutes, respiration rate of 36 breaths per minutes, and decreased oxygen saturation as low as 85 percent. The note indicated the nurse was not able to obtain R1's blood pressure either manually or with a machine. The note did not indicate the nurse administered supplemental oxygen to R1. More than 16 hours following the initial fever, the progress note indicated the nurse notified the on-call physician and received an order to send R1 to the emergency department. The hospital discharge summary dated (MONTH) 9, (YEAR) indicated R1's was diagnosed with [REDACTED]. During an interview dated (MONTH) 3, (YEAR) at 2:47 p.m., licensed practical nurse (LPN)-H stated she worked with R1 on the night R1 discharged to the hospital. LPN-H stated R1 had trouble breathing that was fast, shallow, and short. LPN-H stated R1's symptoms had started a few days ago and had fever that night. LPN-H stated she sent R1 to the hospital after second nebulizer without improvement. LPN-H stated the prior nurses would have notified the physician and sent R1 to the hospital for persisting temperature over 100 degrees and trouble breathing. In an interview dated (MONTH) 3, (YEAR) at 4:45 p.m., the director of nursing stated staff should have notified R1's physician for her persisting fever. In an interview dated (MONTH) 9, (YEAR) at 3:20 p.m., R2's primary physician stated the nurses should have notified the physician for R1's breathing difficulty and fever over 102 degrees after considering other factors. R2's medical record indicated R2's [DIAGNOSES REDACTED]. R2's care plan indicated R2 at risk of pressure ulcer due to poor nutrition intake and decreased activity. The care plan indicated R2 was at high risk for falls due to cognitive impairment. The care plan required staff to ensure R2 had fall interventions, skin assessment skin with cares, complete body audit weekly, and report any changes to R2's physician as appropriate and per facility's policy. R2's Brief Mental Interview Status (BIMS) dated (MONTH) 15, (YEAR) indicated R2 had severe cognitive impairment and staff needed to monitor R2 per his care plan. Nursing progress note dated (MONTH) 27, (YEAR) indicated R2's hip had a very swollen and complained of pain with movement hours after an unwitnessed fall. The note indicated the nurse did not notify R2's physician immediately when R2 showed signs of major injury after the fall as evidenced by the swollen hip and pain with movement. Two hours the nurse noticed R2 had a change in condition, the nursing progress note indicated R2's nurse called another nurse, at home, for instruction and guidance on R2's possible injury. The note indicated the nurse at home instructed R2's nurse to apply ice to the area, wait until the morning shift comes in, instead of notifying the physician regarding R2's suspected injury. Nearly eight hours later, another nursing progress note indicated R2's next nurse assessed him and found the hip to be very [MEDICAL CONDITION]. The note indicated the nurse notify R2's physician via fax for this significant change instead of calling the physician immediately. More than 13 hours after the nursing progress note indicating R2's hip was swollen and painful with movement, R2's nurse paged the physician regarding R2's fall on the day before and the possible injury associated with the fall. The note indicated R2's physician ordered the nurse to send R2 to the hospital immediately for monitoring and surgery. Nursing progress note dated (MONTH) 2, (YEAR) indicated R2 had left hip surgery and discharged back to the facility with pain medication related to the left [MEDICAL CONDITION]. Two hours later, the nursing progress note indicated a nurse completed R2's readmission skin reassessment. The progress note did not indicate R2 had pressure ulcer of the left heel after readmission from the hospital. Nursing progress note dated (MONTH) 4, (YEAR) indicated R2 had left heel pressure ulcer, described as stage I fluid-filled blister, measured at 7.5 centimeters (cm) x 6.2 cm. The progress note did not indicate staff notified R2's physician and the family representative regarding the new pressure ulcer. Hospital medical record dated (MONTH) 4, (YEAR) indicated R2 discharged from the hospital on (MONTH) 2, (YEAR) to the facility. The medical record has no indication of left heel pressure ulcer at time of discharge. In an interview dated (MONTH) 2, (YEAR) at 5:27 p.m., licensed practical nurse (LPN)-B stated she assisted R2's assigned nurse with assessment on the night following R2's fall. LPN-B stated R2 had swollen hip, but the nurses did not touch or move R2's hip. LPN-B stated she told the nurse to call the on-call nurse for guidance. LPN-B stated the nurse on-call instructed them to put ice on R2's hip, and wait to notify the physician on the next shift. In an interview dated (MONTH) 3, (YEAR) at 4:45 p.m., the director of nursing stated nurses were supposed to notify the resident's physician for persisting fever, falls, and suspected major injury in a more timely manner than the did. In an interview dated (MONTH) 2, (YEAR), family member (FM)-K stated she was notified nine hours after R2's (MONTH) 16, (YEAR) fall and R2 had brain bleed after the fall. FM-K stated she received notification about R2's second fall and told R2 had no injury. FM-K stated she got another call from the facility late the following day that R2 had [MEDICAL CONDITION]. FM-K stated R2's nurse reported the resident had swollen hip after a fall, but the on-call nurse instructed the nurse to use ice, instead of sending him to the hospital. FM-K stated the facility's staff should have sent R1 and R2 to the hospital in a timely manner. FM-K stated when she first In an interview dated (MONTH) 9, (YEAR) at 3:20 p.m., the primary care physician stated he provided care for both R1 and R2. The primary care physician stated staff did not notify him in a timely manner regarding R2's fall with suspected major injury and pressure ulcer. The physician stated he expected nurses to, in a timely manner, notify him or the on-call physician for worsening breathing difficulty that was not responsive to interventions, and suspected major injury after a fall. The facility's policy and procedure, Maltreatment of [REDACTED]. The facility's policy and procedure, Change in Condition, dated (MONTH) (YEAR) indicated when a change in condition occurs, staff must consult with the resident's primary physician/nurse practitioner and notify the resident's responsible party. The policy described change in condition as an unexplained bruise or swelling or suspected injury due to trauma, injury, or pathology.

Based on interview and document review, the facility failed to provide effective interventions to reduce the risk for falls for 1 of 3 residents (R1) reviewed for falls. The facility failed to ensure an assistive device, a motion detector, was applied to R1's bed as directed by the interdisciplinary care team to prevent falls. Harm occurred when R1 fell resulting in a subdural hematoma and facial fracture and hospitalization . Findings include: R1's medical record was reviewed and established R1 was admitted to the facility for short term rehab. R1's [DIAGNOSES REDACTED]. The progress note summary dated 6/2/2014 indicated the Interdisciplinary team (IDT) met to review a fall R1 had on 5/28/2014. The progress note established the IDT planned to add motion sensor alarms to R1's bed to alert staff as soon as R1 swung her legs around and attempted to get out of bed. The fall care plan dated 6/9/2014 established R1 was at risk for falls related to a history of falls, short term memory impairment and unsafe decision making skills. The care plan specified interventions that included but were not limited to: motion sensor to each side of the bed with 2 fall mats, offer toileting every two hours and respond to requests promptly. The fall assessment dated [DATE] established R1 was at risk for falls related to advanced age, history of multiple falls, impaired mobility and balance. The assessment indicated R1 had poor safety awareness and poor judgement in addition to other risk factors. The assessment specified fall interventions as: staff to provide assistance with all mobility, every two hour toileting/positioning program, gripper socks on at all times, ambulation program, alarms on bed and wheelchair and motion sensor alarm on bed, 30 minute safety checks, bed against the wall with fall mat on the floor when in bed and hip protectors on at all times. The Progress Notes Summary dated 6/16/2014 at 2:20 p.m., provided information that R1 was found face down on the floor in R1's room. A 2.5 centimeter (cm) laceration was noted to the right side of R1's temple. R1 did not exhibit neurological changes at that time but had extensive bruising to the face. The fall incident report/review investigation document dated 6/16/2014 established R1 was found on the floor in her room approximately 2:20 p.m. R1 had not called for assistance and had not used the call light however, the report investigation determined the motion sensors had not been applied to R1's bed and the pressure sensor alarm had not been turned on by staff. Nursing Assistant (NA)-D was interviewed on 7/28/2014 at 9:30 a.m., and stated she was not R1's regular caregiver but was assigned the group with R1 the day R1 fell . NA-D explained that each group had an assignment sheet that was an extension of the care plan and directed what cares and fall interventions were to be provided to each resident on the group. NA-D stated she used the assignment sheet to provide care when she was unfamiliar with a resident. NA-D acknowledged she did not turn the bed pressure sensor alarm on when she assisted R1 into bed. NA-D stated that all of the other pressure alarms used in the facility turned on automatically (not manually) and she thought it had turned on. Although NA-D confirmed she did not listen for the beep when pressure was applied indicating the alarm was functioning properly. In addition, she acknowledged she did not apply the motion sensors to the bed because there was no indication on the group assignment sheet directing staff to apply them. NA-D stated she was unaware the motion sensors were to be applied however, she also did not turn on the pressure alarm mat that was on R1's bed. Registered Nurse manager (RN)-C was interviewed on 7/25/2014 at 11:20 a.m. and stated she was working the day R1 fell . She described the pressure sensor alarms were activated automatically when pressure was applied. She stated she was unaware the "old style" pressure alarms were still being used in the facility and was surprised to learn there was one on R1's bed at the time of the fall. RN-C was unsure how that alarm got on to R1's bed. She stated staff had gotten used to the new alarms that were automatic and NA-D did not turn it on manually. In addition, RN-C verified that the motion sensor alarm was not on R1's bed. RN-C confirmed that direction to apply the motion sensor was not on the group assignment sheet. RN-C stated there had been some miscommunication with the staff that was responsible for updating the group sheet and the information was not provided on the assignment sheets. The group assignment sheet that included R1 dated 6/17/2014 was reviewed. The area titled Fall Risk directed staff that R1 had a bed alarm, chair alarm, mat next to bed, bed against the wall and every 30 minute safety checks. The assignment sheet did not indicated the type of bed alarm used and did not direct staff to apply motion sensors to R1's bed. The Progress Notes Summary dated 6/19/2014 (three days after the fall) provided information that R1 had a decrease in the level of consciousness and other neurological changes. R1 was sent to the emergency room for an evaluation. The hospital History and Physical (H&P) dated 6/19/2014 established R1 required a CT of the brain and was admitted to the hospital with [REDACTED]. The H&P indicated R1 had been receiving a narcotic medication for pain associated with injuries sustained from the fall. The hospital Discharge Summary dated 6/23/2014 indicated R1 remained in the hospital for four days and received a blood transfusion for anemia, physical, occupational and speech therapy before returning to the nursing home. The director of nursing (DON) was interviewed on 7/28/2014 at 10:41 a.m., and stated she did not know if the group assignment sheet used by NA-C directed staff to use the motion sensors on R1's bed. The DON indicated the new pressure alarms were brought into the facility by the previous DON and thought all the old pressure alarms were removed. The DON stated she had since gotten rid of the old pressure alarms and all staff were educated on the new alarms. The DON stated she expected each nursing assistant to check and make sure that the pressure sensor alarms are functioning when using them for fall risk reduction with residents; regardless of the type of alarm being used. The facility Fall and Injury Reduction Program policy dated 7/13 directed that all interventions for fall and injury reduction are noted on the resident's plan of care.