Every finding on record at NHC Healthcare, Lawrenceburg

Based on facility policy review, the facility's Appropriate Bed Height education document, medical record review, and interview, the facility failed to ensure residents remained free from accident hazards for 1 of 3 (Resident #46) sampled residents reviewed for accident hazards. On 9/5/2025, Certified Nursing Assistant (CNA) E left Resident #46's bed at an unsafe height and the resident inappropriately positioned in the bed after bathing the resident when she exited the resident's room to retrieve supplies. Resident #46 fell from the bed, fractured and dislocated her right humerus (upper arm), requiring transfer to the emergency room (ER) and treatment for a fracture (FX). The facility's failure to ensure an environment free from accident hazards resulted in an actual Harm to Resident #46. The findings include: 1. Review of the undated facility policy titled, Fall Prevention Program, revealed .Purpose.To reduce patient's risk of falling.Objective.To reduce the number of incidents of patient falls.Complete Morse Fall [a fall risk assessment tool that predicts the likelihood that a resident will fall] Observation.The patient is assigned a Fall Risk category.Apply fall risk interventions as appropriate for the patient. Review of the facility in-service document titled, Appropriate Bed Height, with in-service sign in sheet dated 11/5/2025, revealed For resident safety (especially to prevent falls).When the resident is in bed and not receiving care, the bed should be in the lowest safe position. If a patient self-adjust bed into a high position we need to lower it back down to a safe position and let nurse know so they can chart that patient self adjust in to high position.Low bed positioning reduces injury risk if the resident accidentally rolls or tries to get out of bed unassisted.The bed height should allow the resident, when seated at the edge, to have.feet flat on the floor.knees at a 90-degree angle or slightly lower.Typical low- bed heights 17-23 inches from the floor to the mattress top, depending on the resident's height and mobility.Residents with severe fall risk may use ultra-low beds.Rule of thumb.If the resident's feet dangle.the bed is too high.For Staff Safety (during care activities like turning, wound care, hygiene .) Raise the bed to waist height or comfortable working height for the caregiver.After care is finished, the bed must be returned to the lowest position unless otherwise indicated in the care plan.Quick bed height safety checklist.Bed is low enough for resident's feet to touch the floor when sitting.Bed is raised temporarily for staff care tasks.Bed is returned to low position after care.Check call light is within easy reach before leaving.Lock wheels after positioning bed.Simple phrase to teach staff.Low and locked before you walk! (Meaning lower the bed and lock the wheels before leaving a resident's room.) 2. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Vascular Dementia, History of Falling, Hemiplegia and Hemiparesis following Cerebral Infarction, Insomnia, and Anxiety Disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #46 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact, required setup or clean up assistance of staff for eating, was dependent on staff for toileting and transfer, and required substantial/maximal assistance of staff for bed mobility (where staff does more than half of the effort). Review of the Morse fall scale dated 8/13/2025 revealed a score of 60.0, which indicated Resident #46 was high risk for falls. Review of Resident #46's Care Plan revised 8/24/2025, revealed .Falls: At risk for r/t [related to] hx [history] of fall with right humerus fx [fracture] with repair, difficulty walking, muscle weakness, dementia, morbid obesity, hemiplegia/hemiparesis with left side affected, osteoarthritis, and hx of falls.Assist with bed mobility, transfers and toileting as needed.Assist with bath/shower as needed.Anticipate ADL [activities of daily living] needs.Bilateral side rails used to assist with bed mobility.Cognitive Deficit: At risk for complications r/t dementia.SPECIALTY MATTRESS - air mattress.Ensure safe environment.Transfers with 4 prong [Named mechanical lift] lift and assist of 2 staff into electric wheelchair with foot cradle as tolerates. Review of the undated Fall Scene Investigation Report completed by Certified Nursing Assistant (CNA) E stated, .[Resident #46] was in her bed 3 hours prior to fall. I was giving [Resident #46] a bath and went to get a brief heard a crash and she was in the floor. Resident said she thought she was close to the edge and moved her leg and slipped out bed . Review of the Event Report progress note dated 9/5/2025 at 10:01 PM, revealed .AT APPROXIMATLY 7:50PM THIS NURSE HEARD A LOUD THUD AND PT [patient-Resident #46] AND ROOMATE YELLING WENT INTO ROOM AND PT WAS GETTING HER BATH AND CNA STEPPED AWAY AND PT ROLLED OFF OF BED .FOUND LAYING ON LEFT SIDE BESIDE BED C/O [complaint of] RIGHT ARM HURTING AND RIGHT KNEE AND TOES HURTING SCRATCH NOTED TO R [right] KNEE DAUGHTER AND [Named telemedicine company] PHYSICIAN NOTIFIED AND PT WAS TRANSPORTED TO THE ER [emergency room] FOR EVALUATION FOR FX.e-signed [electronically signed] by [Licensed Practical Nurse (LPN) F]. Review of the Progress Note for Resident #46 dated 9/5/2025 at 10:36 PM, revealed HOSPITAL CALLED WITH UPDATE, PT HAS A RIGHT HUMURUS FRACTURE NO OTHER FRACTURES PT IS COMING BACK TO CENTER BY EMS [emergency medical services] WITH SLING AND PAIN MEDS HAS AN APT [appointment] WITH [Named Physician] OFFICE AT 8AM [8:00 AM] MONDAY MORNING Review of the Emergency Department Note for Resident #46 dated 9/5/2025, revealed .21:10 [9:10 PM] [AGE] year-old female presenting to ER from nursing home dating [stating] rolled out of bed. Patient states she is unsure of how she fell.complaining of right upper arm pain.22:44 [10:44 pm] X-ray interpreted by MD [Medical Doctor], right humeral fracture [right arm] with dislocation.plan to send patient home with a prescription for hydrocodone [pain medication].instructed to continue to monitors [monitor] circulation and neuro [neurological] exam and right arm. Review of the Progress Note for Resident #46 dated 9/5/2025 at 11:29 PM, revealed .I am a [Named telemedicine company] post acute provider and I am conducting this visit.Patient had an unwitnessed injury fall. She was being changed by the CNA [certified nursing assistant] who stepped away to grab adiaper [a diaper] and patient rolled over the railing and landed ion [on] the floor. She reports pain allover [all over] but worse in the left arm, left knee and bilateral toes. She did not report head trauma or LOC [loss of consciousness]. She does not take any antiplatelets or anticoagulants.Patient with unwitnessed fall due to generalized weakness and gait instability in the setting of morbid obesity .Prompt ED [emergency department] transfer recommended.Due to repeated falls, patient has a moderate to high risk of requiring ER [Emergency Room] visit or hospitalization. Review of the Discharge Instructions for Resident #46 from (Hospital #1) dated 9/5/2025, revealed .humerus fracture treated with immobilization .prescriptions .Hydrocodone-Acetaminophen 5-325mg [milligram] oral tablet take 1 tablet by oral route every 6 hours as needed .quantity .10 tablet . Review of the Morse fall scale dated 9/5/2025 revealed a score of 60.0, which indicated Resident #46 was high risk for falls. Review of the Care Plan for Resident #46 revealed a revision date of 9/5/2025 which stated, .2 person assist with all personal care . Review of the Progress Note for Resident #46 dated 9/6/2025 at 1:05 AM, revealed PT BACK FROM [Hospital #1] WITH SLING TO RIGHT ARM.NOTED PT IN BED RESTING WITH EVEN AND NONLABORED RESPIRATIONS UNABLE TO REACH DAUGHTER AND HOSPITAL REPORTED THEY WERE UNABLE TO REACH HER AS WELL Review of the Progress Note for Resident #46 dated 9/9/2025 at 10:12 AM, revealed Orthopedist wants patient to be direct admit to the hospital at 2pm [2:00 PM] today in preparation for surgery . Review of the Progress Note for Resident #46 dated 9/12/2025 at 5:46 PM, revealed return from brief hospital stay for closed right humeral fx [fracture], drsg [dressing] d/I [dry and intact], no c/o [complaint of] pain at this time, she does require assist with meals. Review of Resident #46's Discharge Summary from (Hospital #1) dated 9/12/2025, revealed .patient getting admitted for elective right humeral fracture for ORIF [open reduction and internal fixation which is a surgical procedure to repair broken bones].9/11/2025 .waiting ORIF today, continue on current pain control regimen, maintain arm sling . 9/12/2025 .patient cleared for discharge from orthopedic standpoint and physical and occupational therapy to her nursing home to continue her recovery .arm sling applied . assessment and plan .closed right distal humeral fracture .fall, patient fell from bed, patient was [does] not remember circumstance of the fall from bed .Diagnostic results .x-ray from ER on [DATE] reviewed; right humeral fracture displaced and angulated [A displaced fracture where the ends of the bone fragments are at an angle to each other] . Review of the significant change MDS assessment dated [DATE] revealed Resident #46 scored a 15 on the BIMS assessment, which indicated she was cognitively intact, dependent on staff for eating, toileting, bed mobility, and transfer, always incontinent of urine and bowel, and had a surgical wound. Review of the Partner Meeting sign in sheets dated 10/14/2025, revealed, Falls in-service, Elopement, Center Happenings, Nurse Manager. The sign in sheets did not reflect the signature of CNA E. The in-service material provided did not reflect resident bed positioning or bed height during care. During an observation and interview in Resident #46's room on 7/6/2026 at 1:30 PM, Resident #46 was asked to describe the events that led to her fall from the bed on 9/5/2025. Resident #46 stated, A lady [later determined to be CNA E] left me on the edge of the bed and I fell off the bed and broke my right arm, I have 9 screws in the right arm.This lady had rolled me up on my side, left me there and went to get some diapers, and I rolled off. Resident #46 was asked if staff have left her like that anymore. Resident #46 stated, No, I wouldn't let them. It's been about a year. Resident #46 was asked if she could recall how high the bed was at the time of the fall. Resident #46 stated, About like it is now. The bed frame was approximately knee high to this surveyor (6 feet 2 inches) and the top of the mattress was approximately 6 inches higher than that. During an interview on 7/7/2026 at 11:06 AM, the Director of Nursing (DON) was asked to describe the fall that involved Resident #46 on 9/5/2025. The DON stated, .the CNA [CNA E] was giving her a bath, she keeps her diapers [briefs] under the sink, there wasn't any [briefs under the sink], she [CNA E] went 2 doors down to get a pack of diapers, by the time she [CNA E] came back she [Resident #46] had fell in the floor. The resident had moved her leg, and it caused her to fall out of the bed. The DON was asked how Resident #46 was positioned in the bed. The DON stated, She was on her side. I would say she was on her right side; she went off the right-side of the bed. The DON was asked what height the bed was at the time of the incident. The DON stated, I do not know the height of the bed during the bath. I am assuming the height of the CNA. The DON was asked if the bed's siderails were in position at the time of the occurrence. The DON stated, They were up, upper rails, quarter rails used as an enabler. She holds onto them. The DON was asked if the Resident should have been left on her side in the bed unattended. The DON stated, Leaving her alone, it depends on where she was at in the bed, I don't know how close to the edge of the bed she was . The DON was asked what was put in place to prevent a reoccurrence of the event. The DON stated, Intervention was 2 person assist for care, and I put her in a bariatric bed, she did not like it, it took up too much room, she didn't want to leave her roommate, the resident and daughter wanted her back in a regular bed. The DON was asked if there were any witness statements completed or in-services provided to staff after the fall. The DON stated, There should be, she [the Assistant Director of Nursing (ADON)] has talked to them about care with 2 people during rounds, and multiple fall in-services.The ADON does a fall orientation and multiple fall in-services, multiple types for fall interventions, bed heights, lots of different topics that surround falls. We start fall in-services on hire. During an interview on 7/7/2026 at 1:28 PM, the DON stated, I misspoke, [regarding her answer provided during previous interview about Resident #46's positioning in bed at the time of the fall on 9/5/2025] the statement doesn't say she was on her side when the incident occurred. During a phone interview on 7/7/2026 at 3:31 PM, CNA E was asked if she remembered Resident #46's fall on 9/5/2025. CNA E stated, Yes. CNA E was asked to describe what happened. CNA E stated, I was giving her [Resident #46] a bath, she was out of briefs, I went to get a pack of briefs, a nurse said something to me in the hall, and we heard a crash from the hallway. Me and the nurse entered the room. [Resident #46] was in the floor by her bed. I said, Oh my gosh [Resident #46] what happened? She said that she felt that she was slipping out of the bed, so she moved her leg over and she slipped out of the bed. CNA E was asked if Resident #46 appeared to be in pain. CNA E stated, I feel like she was in shock. When we got her up, she seemed like her arm was hurting. CNA E was asked how she got Resident #46 up. CNA E stated, Got her up with the lift.The nurse called the [Named Telemedicine] Physician, and they said to send her out. CNA E was asked when she left the room to go get a brief was the resident left on the edge of the bed or in the middle of the bed. CNA E stated, She was on her back toward the edge, she was rolled over, then I rolled her back. She wasn't hanging off the edge or anything, her bed is just so small. CNA E was asked if the bed was left in a high or low position at the time of the occurrence. CNA E stated, It was about to my waist. CNA E was asked how tall she is for reference. CNA E stated, I am 5'6. CNA E was asked if Resident #46 was in a safe position in the bed. CNA E stated, Yes, before I left, I felt she was in a normal position. CNA E was asked if Resident #46 normally kicked her legs over in the bed. CNA E stated, No, she doesn't normally do that, she's not one I would think would do that. CNA E was asked if the bed's siderails were up at the time of the event. CNA E stated, Yes, she had her arm on it [siderail] but she can't hold her weight on it. CNA E was asked if she received any training or in-services after the event. CNA E stated, I really don't remember that. We do a lot of in-services, I'm just not sure. CNA E was asked how long she was out of the room at the time of the event. CNA E stated, Probably a minute. During an interview on 7/8/2026 at 10:28 AM, the DON was asked if anyone interviewed Resident #46 after the fall regarding her positioning or the bed height. The DON stated, The night it happened, the height of the bed was never mentioned, she just said she rolled out of the bed. The in-depth interview would have happened later. I don't know that the height of the bed was ever mentioned to my knowledge. The DON was asked if Resident #46 was a fall risk at the time of the fall on 9/5/2025. The DON stated, She was, she couldn't stand or bear weight or anything. The DON was asked if Resident #46 was on an air mattress at the time of the event. The DON stated, She was on an air mattress. The DON was asked how residents should be positioned in bed by staff prior to them leaving the room. The DON stated, On their back, in the middle of the bed. If they are on their side, it depends on how you have them positioned. The DON was asked what is an appropriate bed height to ensure safety for a resident who is a fall risk. The DON stated, It needs to be normal bed height. The DON was asked what normal bed height was. The DON stated, Their [residents] preferred. The DON was asked do you think waist level is a safe bed height. The DON stated, No. The DON was asked if staff were expected to lower the bed after providing care. The DON stated, Yes. The DON was asked what is the appropriate bed height. The Administrator (who was present during the interview) stated, It would depend on preference. I'm sure [Resident #46] likes to be at waist height. The DON was asked if anyone had asked Resident #46 if that was her preference. The DON stated, I have asked her to lower her bed and she won't. The DON was asked even if it is the resident's preference to have their bed in a high position, is the CNA not responsible to lower the bed to ensure safety. The DON stated, I think a lot of education goes into residents who want to have their bed high. I think every time we see it [bed in high position] we need to be asking can we lower the bed. The DON was asked if the bed should have been lowered when the CNA left the room. The DON stated, It would not have prevented the fall but it would change how far she fell. The DON was asked if the resident should have been recentered in the bed and the bed lowered prior to staff leaving the room. The DON stated, Yes. The DON was asked if having the bed lower could have changed the outcome of the fall, possibly less injury. The DON stated, Because she grabbed the rail, I think she hung on to the rail as she went down, I think that is what injured the arm. The facility in-service document titled, Appropriate Bed Height was reviewed with the DON. The DON was asked per the in-service provided to staff in 11/2025, should the bed have been returned to the lowest position prior to staff leaving the room. The DON stated, Yes. The facility failed to ensure a safe bed height was maintained, and resident was appropriately positioned in the bed, which resulted in Resident #46 sustaining a fall with fracture and actual harm.

Based on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of accident hazards related to elopement for 1 of 1 (Resident #33) sampled resident when Resident #33 was able to exit the facility without the knowledge of the staff. The findings include: 1. Review of the facility's policy titled, Wandering and Elopements, dated 2001, revealed .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . Review of the facility's policy titled, .Incident and Accident Process, revised 8/13/2013, revealed .Investigation into the incident/accident .Obtain info [information] on what happened .Never move the patient until the assessment is completed unless immediate treatment is needed .Do first aid .Initiate neuro [neurological] checks if head struck or evidence of a patient striking their head .Document all known facts, results of assessment including a complete description of injuries, treatment .Review care plan for updated required related to a change/update .Accidents not resulting in injuries should still be reported .Documentation that addresses the status and/or progress of the patient in relation to the incident/accident is to be completed at least every shift for 72 hours . 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction with Hemiplegia, Altered Mental Status, Disorientation with Confusion, and Metabolic Encephalopathy. Review of Elopement Risk assessment dated [DATE] revealed Resident #33 had a score of 0. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #33 was moderately cognitively impaired. Review of the Event Report dated 4/16/2025, revealed .Found on floor .Patient's w/c [wheelchair] was found in front of the front doors. He was found by the railing by doors attempting to get up. Patient stated that he was trying to get fresh air .Location of Fall .Outside on Center Grounds .Was Fall Witnessed .No . Review of the Progress Note dated 4/16/2025, revealed .Patient was found outside on ground near front door by staff member He stated that he wanted to get some fresh air and looking to see if his car was here. Instructed patient that he needs to be accompanied by staff member to go outside. Patient verbalized understanding .Patient has 2 abrasions .1 on each knee . Review of the Physician Orders dated 4/16/2025, revealed an order for wander guard, and to check wander guard placement every shift. Review of the Elopement Risk assessment dated [DATE], revealed Resident #33 had a score of 1, indicating Resident #33 was at risk for elopement. The facility failed to identify and investigate an elopement on 4/16/2025 for Resident #33. During an interview on 4/29/2025 at 2:30 PM, the Director of Rehabilitation confirmed she was at the front door and leaving the building for the day and observed an unoccupied wheelchair at the front door. The Director of Rehabilitation confirmed she began to look around to see who the wheelchair belonged to and observed Resident #33 unassisted and without staff outside of the facility on the ground to the right side of the metal handrail. The Director of Rehabilitation confirmed she yelled out to the Administrator to see if he was in his office with no answer and then used her cellular phone to call back into the facility for assistance. The Director of Rehabilitation confirmed the Administrator and the Director of Nursing (DON) arrived and a brief assessment of Resident #33 was conducted to his head, bilateral hips but she failed to look under his clothes. The Director of Rehabilitation confirmed that Resident #33 stated he was just trying to go out to get air and to check on his car. The Director of Rehabilitation confirmed that the front door is usually unlocked and if you push the door or press the exit button the door will open. During an observation and interview on 4/29/2025 at 2:53 PM, the Director of Rehabilitation measured the distance where Resident #33 was observed on the ground outside of the facility. The Director of Rehabilitation confirmed upon measurement that Resident #33 was found at approximately 10 feet on the ground from the front entrance. During an interview on 4/29/2025 at 3:16 PM, Certified Nursing Assistant (CNA) B confirmed Resident #33 did not display any exit seeking behavior until he was witnessed outside of the facility on 4/16/2025 without staff assistance or knowledge. During interview on 4/29/2025 at 3:39 PM, the DON confirmed she received a call indicating that Resident #33 was found outside of the facility at the front door unassisted and without staff knowledge. The DON confirmed that she and the Administrator responded to the call and went to the front door entrance and found Resident #33 on the ground outside of the front door. The DON confirmed that Resident #33 had abrasions to both knees. The DON confirmed that the front doors remain unlocked from 7 AM to 7 PM and anyone can come and go freely. The DON confirmed they failed to identify and investigate an elopement for Resident #33. The DON confirmed that Resident #33 was moderately cognitively impaired and should not have been outside without staff knowledge and assistance.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders for oxygen for 1 of 3 (Resident #46) sampled residents reviewed for oxygen therapy. The findings include: 1. Review of the undated facility policy titled, RESPIRATORY: NASAL CANNULA, revealed .must perform an oxygen check and document .Verify physician order for liter flow, device of delivery and duration . 2. Review of the medical record review revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Oxygen, Chronic Obstructive Pulmonary Disease, Respiratory Failure, Dementia, Palliative Care, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 with cognition skills severely impaired. Resident #46 also received oxygen therapy. Review of the Physician's orders dated 11/29/2024, revealed .Oxygen at 3 liters/min [minute] BNC [bi-nasal cannula] Every Shift . Observation in the resident's room on 4/28/2025 at 3:59 PM, 4:47 PM, 4/29/2025 at 7:43 AM, 10:39 AM, and 1:25 PM, and 5:35 PM revealed Resident #46 was lying in bed with head of bed elevated with oxygen at a flow rate of 2 liters/min. During an interview on 4/29/2025 at 4:55 PM, the Director of Nursing confirmed that oxygen flow rate should be set at the correct rate and that physician orders should be followed.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter (a plastic tube inserted into the bladder to drain urine) when nursing staff failed to provide catheter care for an indwelling urinary catheter for 1 of 2 (Resident #32) sampled residents reviewed for the use of an indwelling urinary catheter. The findings include: 1. Review of the facility's undated policy titled CATHETER CARE, INDWELLING (MALE AND FEMALE), revealed .Indwelling Catheter Care will be provided once daily .Catheter care will be provided using approved techniques in order to decrease the risk of catheter-associated urinary tract infection. 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Dementia, Obstructive and Reflux Uropathy, Retention of Urine, and Functional Urinary Incontinence. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 10, which indicated Resident #32 was moderately cognitively impaired, dependent on staff for toileting and bathing, required the use of an indwelling urinary catheter, and had an active diagnosis of obstructive uropathy. Review of the Care Plan dated 4/14/2025, revealed .Foley Catheter .At risk for complications r/t [related to] obstructive uropathy and urinary retention .Foley catheter care daily and prn [as needed] . Review of the Physician Orders for 3/1/2025-3/31/2025, revealed the facility failed to have orders for foley catheter care daily and prn for Resident #32. Review of the facility Treatment Administration Records (TAR) for March 2025 and April 2025, revealed no documentation of foley catheter care for Resident #32. Observation in Resident #32's room on 4/29/2025 at 1:49 PM and 4/30/2025 at 8:12 AM, revealed resident sitting up in chair with yellow urine draining to urinary catheter bedside bag. During an interview on 4/30/2025 at 3:28 PM, the Director of Nursing (DON) confirmed there should be an order for urinary catheter care when a resident has an indwelling urinary catheter. The DON confirmed Resident #32 has had an indwelling urinary catheter since 3/10/2025. The DON confirmed urinary catheter care should be done daily and if it is on the care plan it should be completed and on the TAR.

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to follow proper infection control practices during tracheostomy care for 1 (Resident #62) of 4 sampled residents reviewed for respiratory care. The facility further failed to store oxygen tubing and a nasal cannula when not in use in accordance with the facility policy for 1 (Resident #29) of 4 sampled residents reviewed for respiratory care. Findings included: 1. A facility policy titled, Tracheostomy Care, revised in July 2014, revealed, The inner cannula of the double-cannula tracheostomy tube may be disposable or non-disposable. The disposable tube is changed daily and as needed to maintain a patent airway. The non-disposable tube is cleaned when necessary but a minimum of one time per shift or every 12 hours. Both procedures are sterile and are performed by the RN [Registered Nurse] or LPN [Licensed Practical Nurse]. The policy revealed, Equipment: 1. Sterile suction kit 2. Trach [tracheostomy] care kit containing the following sterile equipment: two solution containers, hemostat or forceps, gloves, cotton-tipped applicators, brush and/or pipe cleaners, 4x4 sponges, towel, and tracheostomy dressing. 3. Sterile normal saline 4. Water-proof trash bag 5. If disposable, a same size sterile inner cannula According to the policy, 4. Put a sterile glove on the dominant hand and a nonsterile glove on the nondominant hand. The nonsterile hand will control the suction port or Y connector. 5. Using the sterile hand, prepare a sterile filed with the trach care kit. A Face Sheet revealed the facility admitted Resident #62 on 04/18/2022, with diagnoses to include paralytic syndrome following cerebral infarction, encounter for attention to tracheostomy and chronic respiratory failure with hypoxia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2024, revealed Resident #62 had a Staff Assessment for Mental Status (SAMS), which indicated the resident has severely impaired cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff for most activities of daily living (ADLs). The MDS indicated, Resident #62 required oxygen therapy, suctioning, and tracheostomy care. Resident #62's Care Plan, with a problem start date of 04/19/2022 and edited on 04/27/2024, revealed the resident was at risk for respiratory complications related to paralytic syndrome, locked in state, tracheostomy, and chronic respiratory status. Interventions directed the staff to provided tracheostomy care as ordered. On 05/08/2024 at 9:42 AM, the surveyor observed Respiratory Therapist (RT) #12 provide tracheostomy care for Resident #62, in the presence of the Infection Preventionist (IP). There was a table prepared with a barrier and unopened supplies that were to be used during the tracheostomy care. RT #12 wore nonsterile gloves to open and handle sterile items that included a humidifier, inner cannula, and the tracheostomy kit, which included two cotton-tip applicators and split gauze. RT #12 handled all these items then placed sterile gloves on top of gloves she already had on. RT #12 proceeded to remove the dirty humidifier and placed it on the barrier next to the clean humidifier. During the provision of the tracheostomy care, RT #12 used the same gloved right hand to perform all tasks, to include the removal of soiled items and placement of clean items. After application of soaked split gauze, with her same gloved right hand, RT #12 removed the old inner cannula, discarded it, applied a new inner cannula, and cleaned around the stoma of the resident's tracheostomy. During an interview on 05/08/2024 at 10:01 AM, RT #12 stated she only washed her hands before and after the resident's tracheostomy care and not in between clean and dirty tasks. RT #12 stated it was not the facility policy to put sterile gloves on top of nonsterile gloves. During an interview on 05/08/2024 at 10:07 AM, the Director of Nursing (DON) stated it was not the policy of the facility to double glove for any procedure. The DON stated the staff's hands should be washed prior to application of gloves, after removal of soiled items and gloves, and when tracheostomy care was completed. The DON stated she expected nurses and respiratory therapists to follow the facility policy and always maintain infection control practices when tracheostomy care was performed. During an interview on 05/08/2024 at 10:25 AM, the IP stated staff were never to double glove and there were several infection control breaches during the tracheostomy care provided by RT #12 to Resident #62. The IP stated RT #12 failed to wash her hands between clean and dirty tasks. The IP explained that she was rather shocked by the way the tracheostomy care was performed by RT#12. 2. A facility policy titled, 306 Respiratory, updated in April 2024, revealed, 1. Equipment associated with machines such as oxygen, nebulizers, IPPB [intermittent positive pressure breathing] machines and suction machines are not shared among patients. 2. Respiratory equipment is dated when placed at bedside and replaced on a schedule. The policy indicated, 3. Respiratory equipment (i.e. [id est, Latin for that is], nasal cannula, aerosols, etc. [et cetera, and so forth]) at bedside will be covered with a plastic bag when not in use. A Face Sheet revealed the facility admitted Resident #29 on 05/29/2020, with diagnoses to include Alzheimer's disease, hypertension, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/2024, revealed Resident #29 had had a Staff Assessment for Mental Status (SAMS), which indicated the resident has severely impaired cognitive skills for daily decision making. The MDS indicated the resident required the use of oxygen therapy. Resident #29's Care Plan, with a problem start date of 05/21/2021, revealed the resident was at risk for complications related to hypertension and oxygen dependency. On 05/06/2024 at 10:06 AM, the surveyor observed Resident #29 lying in bed and a nasal cannula was draped over the top of the resident's geriatric chair uncovered, attached to an oxygen cylinder on the back of the geriatric chair. On 05/06/2024 at 10:44 AM, Certified Nurse Aide (CNA) #13 verified Resident #29's nasal cannula and oxygen tubing was uncovered and draped on the geriatric chair. On 05/07/2024 at 12:10 PM, the surveyor observed and Licensed Practical Nurse (LPN) #14 confirmed that Resident #29's nasal cannula was uncovered and draped over the back of the geriatric chair. During an interview on 05/08/2024 at 10:07 AM, the Director of Nursing stated she expected staff to store respiratory tubing covered.

Based on interviews, record review, and facility policy review, the facility failed to investigate an allegation of potential abuse for 1 (Resident #44) of 1 sampled resident reviewed for abuse. Findings included: A facility policy titled, Patient Protection and Response Policy for Allegations/Incident of Abuse, Neglect, Misappropriation of Property and Exploitation, revised on 02/01/2023, revealed, Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect, misappropriation of patient property of exploitation if it meets any of the following criteria: 1. Any allegation (or) indication of possible willful infliction of injury to include unexplained bruising. 2. Unreasonable confinement, to include unwanted restriction of access to all patient areas of the building. 3. Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others. Per the policy, A. Internal Investigation Policy 1. Policy All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident. A Resident Face Sheet indicated the facility admitted Resident #44 on 05/19/2022, with diagnoses to include congestive heart failure, protein-calorie malnutrition, left shoulder arthritis, age-related osteoporosis, and osteoarthritis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #44 was dependent on staff for toileting hygiene, showering/bathing, and upper and lower body dressing; and required substantial/maximal assistance with personal hygiene and rolling left and right. Per the MDS, Resident #44 was always incontinent of bowel and bladder. Resident #44's Care Plan, with a start date of 05/20/2022, revealed the resident had a self-care deficit related to congestive heart failure, adult failure to thrive, tremors, and incontinence. A handwritten note on a Physician's Orders form, written by Licensed Practical Nurse (LPN) #4 and dated 04/24/2024, revealed as Certified Nurse Aide (CNA) #1 provided Resident #44 a bath, the resident stated the CNA hurt them by cleaning them roughly. According to the handwritten note, a nurse spoke with the resident on 04/24/2024 to explain good perineal care. A handwritten note on a Physician's Orders form, written by LPN #4 and dated 05/02/2024, revealed Resident #44's Responsible Party (RP) called the facility and stated they did not want CNA #1 to go into Resident #44's room again due to concerns with home the CNA cleaned the resident. During an interview on 05/06/2024 at 10:20 AM, Resident #44 stated last month, CNA #1 shoved them back and forth violently. Resident #44 stated they complained enough about the CNA and now the CNA had not entered their room again. During an interview on 05/07/2024 at 8:43 AM, the Social Worker, who also served as the Abuse Coordinator, stated she was not aware of Resident #44's perineal care concerns or that the resident's RP called the facility about a CNA until 05/06/2024. The Social Worker stated the facility did not investigate the resident's concerns. The Social Worker stated had she been aware, she would have interviewed the resident. During an interview on 05/07/2024 at 1:11 PM, Resident #44's RP stated Resident #44 contacted them regarding a CNA that twisted their legs and hit their head against the bed. The RP stated Resident #44 did not want the CNA to care for them again. According to the RP, they did not inform the nurse of the resident's allegation. During an interview on 05/08/2024 at 11:04 AM, LPN #4 stated on 04/24/2024, CNA #1 came out of Resident #44's room and informed her that Resident #44 was upset with her. LPN #4 stated she went into Resident #44's room and the resident told her that CNA #1 had been rough. LPN #4 stated she did not notify anyone about Resident #44's statement and there was no documented evidence of any further action that was taken to investigate the resident's concerns. According to LPN #4, she spoke with Resident #44's RP on 05/02/2024 and the RP stated they did not want CNA #1 to provide care to Resident #44 anymore. LPN #4 stated she notified the Director of Nursing (DON) on 05/02/2024 of the RP's wishes for CNA #1 not to work with the resident anymore. During an interview on 05/08/2024 at 12:54 PM, the DON stated after Resident #44's RP called the facility, LPN #4 notified her that the RP did not want CNA #1 to provide care to Resident #44 anymore. The DON stated LPN #4 only informed her there were issues with perineal care, which the DON stated she did not feel was abusive. However, the DON stated, if staff were rough, the facility should talk to the resident. The DON stated after the resident's RP called the facility on 05/02/2024, the facility did not conduct an investigation because they had residents that did not like staff, and they tried to accommodate changes. According to the DON, any suspicion of abuse must be investigated. The DON stated the Administrator was ultimately responsible for abuse allegations. During an interview on 05/08/2024 at 2:31 PM, CNA #1 stated Resident #44 became upset during perineal care and stated the CNA hurt them. According to CNA #1, the resident was raw in their perineal area and stated their perineal area hurt. CNA #1 stated she left the resident's room and notified LPN #4. Per CNA #1, she was not assigned to care for the resident for at least one week after the resident reported they were hurt during perineal care. CNA #1 stated no one at the facility interviewed her regarding the incident. During an interview on 05/09/2024 at 9:46 AM, the Administrator stated the facility should have completed an investigation into Resident #44's reported allegations of a CNA being rough to determine what happened and to ensure a resident was not harmed.

Based on interviews, record review, and facility policy review, the facility failed to report an allegation of potential abuse for 1 (Resident #44) of 1 sampled resident reviewed for abuse. Findings included: A facility policy titled, Patient Protection and Response Policy for Allegations/Incident of Abuse, Neglect, Misappropriation of Property and Exploitation, revised on 02/01/2023, revealed, It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. A Resident Face Sheet indicated the facility admitted Resident #44 on 05/19/2022, with diagnoses to include congestive heart failure, protein-calorie malnutrition, left shoulder arthritis, age-related osteoporosis, and osteoarthritis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #44 was dependent on staff for toileting hygiene, showering/bathing, and upper and lower body dressing; and required substantial/maximal assistance with personal hygiene and rolling left and right. Per the MDS, Resident #44 was always incontinent of bowel and bladder. Resident #44's Care Plan, with a start date of 05/20/2022, revealed the resident had a self-care deficit related to congestive heart failure, adult failure to thrive, tremors, and incontinence. A handwritten note on a Physician's Orders form, written by Licensed Practical Nurse (LPN) #4 and dated 04/24/2024, revealed as Certified Nurse Aide (CNA) #1 provided Resident #44 a bath, the resident stated the CNA hurt them by cleaning them roughly. According to the handwritten note, a nurse spoke with the resident on 04/24/2024 to explain good perineal care. A handwritten note on a Physician's Orders form, written by LPN #4 and dated 05/02/2024, revealed Resident #44's Responsible Party (RP) called the facility and stated they did not want CNA #1 to go into Resident #44's room again due to concerns with home the CNA cleaned the resident. During an interview on 05/06/2024 at 10:20 AM, Resident #44 stated last month, CNA #1 shoved them back and forth violently. Resident #44 stated they complained enough about the CNA and now the CNA had not entered their room again. During an interview on 05/06/2024 at 10:27 AM, the Administrator stated he was not aware of any incidents that involved Resident #44. Per the Administrator, the facility had not reported any incidents regarding Resident #44 to the state agency. During an interview on 05/06/2024 at 2:37 PM, the Director of Nursing (DON) stated she was not aware of an incident in which Resident #44 reported that staff turned them violently or roughly. During an interview on 05/06/2024 at 3:28 PM, the Assistant DON stated based on an interview with the resident, staff should have notified social services or the abuse coordinator of the incident so they could determine if it was abuse. During an interview on 05/07/2024 at 1:11 PM, Resident #44's RP stated Resident #44 contacted them regarding a CNA that twisted their legs and hit their head against the bed. The RP stated Resident #44 did not want the CNA to care for them again. According to the RP, they did not inform the nurse of the resident's allegation. During an interview on 05/08/2024 at 11:04 AM, LPN #4 stated on 04/24/2024, CNA #1 came out of Resident #44's room and informed her that Resident #44 was upset with her. LPN #4 stated she went into Resident #44's room and the resident told her that CNA #1 had been rough. LPN #4 stated she did not notify anyone about Resident #44's statement and there was no documented evidence of any further action that was taken to investigate the resident's concerns. According to LPN #4, she spoke with Resident #44's RP on 05/02/2024 and the RP stated they did not want CNA #1 to provide care to Resident #44 anymore. LPN #4 stated she notified the Director of Nursing (DON) on 05/02/2024 of the RP's wishes for CNA #1 not to work with the resident anymore. During a follow-up interview on 05/08/2024 at 12:54 PM, the DON stated after Resident #44's RP called the facility, LPN #4 notified her that the RP did not want CNA #1 to provide care to Resident #44 anymore. The DON stated LPN #4 only informed her there were issues with perineal care, which the DON stated she did not feel was abusive. However, the DON stated, if staff were rough, the facility should talk to the resident. The DON stated after the resident's RP called the facility on 05/02/2024, the facility did not conduct an investigation because they had residents that did not like staff, and they tried to accommodate changes. According to the DON, any suspicion of abuse must be investigated. The DON stated the Administrator was ultimately responsible for abuse allegations. During an interview on 05/08/2024 at 2:31 PM, CNA #1 stated Resident #44 became upset during perineal care and stated the CNA hurt them. According to CNA #1, the resident was raw in their perineal area and stated their perineal area hurt. CNA #1 stated she left the resident's room and notified LPN #4. Per CNA #1, she was not assigned to care for the resident for at least one week after the resident reported they were hurt during perineal care. CNA #1 stated no one at the facility interviewed her regarding the incident. During an interview on 05/08/2024 at 7:02 PM, LPN #7 stated about a week or two ago, Resident #44 mentioned to her that a dayshift CNA was rough with them. According to LPN #7, she passed the information on to the dayshift nurse and told the dayshift nurse the CNA should not be assigned to care for the resident.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 4 nurses (Licensed Practical Nurse (LPN) #1 and #2) failed to perform hand hygiene for 2 of 5 sampled residents (Resident #4 and #42) observed during medication administration. The findings include: Review of the facility's undated policy titled, Hand Washing and Hand Sanitizer revealed .Hand hygiene is the primary means to prevent the spread of infection .Wash or sanitize hands after removal of gloves . Observation in the resident's room on 1/26/2022 at 9:15 AM, revealed LPN #1 touched Resident #42's over bed table, moved the bed covers, and handed her a glass of water. LPN #1 then donned gloves, administered the scheduled eye drop to the resident's left eye, and removed her gloves. LPN #1 donned another pair gloves, administered the scheduled eye drop to Resident #42's right eye, then removed her gloves. LPN #1 failed to perform hand hygiene before and after donning and doffing gloves while administering the eye drops to Resident #42. Observation outside of Resident #4's room on 1/26/2022 at 10:00 AM, revealed LPN #2 prepared oral medications in a medication cup, and the medications spilled on top of the medication cart. LPN #2 opened the medication cart drawer, moved the cart, donned gloves, picked up the spilled medication tablets off of the top of the medication cart, and placed the spilled medications back in the medication cup. LPN #1 then removed her gloves without performing hand hygiene. LPN #2 knocked on the door, entered Resident #4's room, moved the privacy curtain, and touched the over bed table. LPN #1 then administered the spilled oral medications to Resident #4. During an interview on 1/26/2022 at 10:20 AM, LPN #2 was asked if the top of the medication cart was cleaned prior to medication administration. LPN #2 failed to respond. During an interview on 1/26/2022 at 4:15 PM, the Director of Nursing (DON) confirmed hand hygiene should be performed before and after donning gloves and the spilled medications should have been discarded.

Based on policy review, medical record review, observation, and interview, the facility failed to complete assessments before or during use of a position change alarm for 2 of 2 (Resident #63 and #346) sampled residents reviewed for physical restraints. The findings included: 1. The facility's undated RESTRAINTS policy documented, .Restraints shall only be used for the safety and well-being of the patient(s) and only after other alternatives have been tried unsuccessfully .Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body .Restraints shall only be used upon the written order of a physician .The order shall include .The specific reason for the restraint .How the restraint will be used to benefit the resident's medical symptom .the type of restraint, and period of time for the use of the restraint . 2. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #63's room on 4/29/19 at 11:57 AM, and 4/30/19 at 4:04 PM, revealed Resident #63 was sitting in a scoot chair with a position change alarm attached to the cushion she was sitting on. Observations in the Activity Room on 4/29/19 at 2:51 PM, and 4/30/17 at 10:17 AM, revealed Resident #63 sitting in a scoot chair with a position change alarm attached to the cushion she was sitting on. Interview with Certified Nursing Assistant (CNA) #1 on 5/1/19 at 8:40 AM, at the 300 Hall Nursing Station, CNA #1 was asked what type of alarms Resident #63 had. CNA #1 stated, She has a pull-away (alarm) in the bed, and a pressure alarm in her chair. CNA #1 was asked why the alarms were in use. CNA #1 stated, She tends to like to stand up, and she is a fall risk. CNA #1 was asked if Resident #63 could remove the pull-away alarm herself. CNA #1 stated, Not that I'm aware of. CNA #1 was asked how long the alarms would be used. CNA #1 stated, I'm not sure. 3. Medical record review revealed Resident #346 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline Care Plan dated 4/18/19 documented, .Problem Start Date .4/18/2019 .Fall Risk .Approach .Personal alarm/s to alert partners of unsafe attempts to transfer . Observations in Resident #246's room on 4/29/19 at 10:29 AM and 4:43 PM, revealed Resident #346 was lying in bed with a pull-away position change alarm in place. Observations in Resident #346's room on 4/29/19 at 11:41 AM and 12:31 PM, and 4/30/19 at 11:53 AM, revealed Resident #346 sitting in a wheelchair with a pull-away position change alarm in place. Observations in Resident #346's room on 4/30/19 at 5:01 PM, revealed Resident #346 sitting in a bedside chair with a pull-away position change alarm in place. Interview with CNA #1 on 5/1/19 at 8:40 AM, at the 300 Hall Nursing Station, CNA #1 was asked what type of alarms Resident #63 had. CNA #1 confirmed she had pull away alarms for the bed and chair. CNA #1 was asked why the alarms were in use. CNA #1 stated, She is a fall risk. CNA #1 was asked if Resident #63 could remove the pull-away alarm herself. CNA #1 stated, Not that I'm aware of. Interview with the Director of Nursing (DON) on 5/1/19 at 11:17 AM, in the Conference Room, the DON was asked if any other interventions were attempted before the pull-away alarms were put in place for Resident #346 on the day of her admission. The DON stated, I think her family insisted for it to be on her. I think that was why that got put on immediately. The DON was asked if there were any assessments related to resident alarms. The DON confirmed there were no assessments. The facility was unable to provide any policies or protocols for the use of position change alarms. The facility was unable to provide assessments for the alarms before use or ongoing evaluations during use, and was unable to provide documentation for the expected duration of the alarm use.

Based on policy review, medical record review, [MEDICAL TREATMENT] Communication Worksheets, and interview, the facility failed to provide appropriate care and services of a resident receiving [MEDICAL TREATMENT] for 1 of 1 (Resident #60) sampled residents receiving [MEDICAL TREATMENT]. The findings include: 1. The facility's undated [MEDICAL TREATMENT] Communication policy documented, .PR[NAME]EDURE .Complete [MEDICAL TREATMENT] Communication Worksheet form a. Center (Nursing Home) nurse complete on [MEDICAL TREATMENT] days . 2. Medical record review revealed Resident #60 was admitted to the facility with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] and the 60 day MDS dated [DATE] documented Resident #60 was cognitively intact and received [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] Communication Worksheet dated 4/25/19, 4/27/19, and 4/30/19 revealed the pre-[MEDICAL TREATMENT] information for Resident #60 was not completed. 3. Interview with the Director of Nursing (DON) on 5/1/19 at 10:29 AM, in the Conference Room, the DON was asked to explain the [MEDICAL TREATMENT] communication process. The DON stated, .supposed to send a [MEDICAL TREATMENT] Communication Worksheet with the resident to [MEDICAL TREATMENT] and they are to bring the form back .the pre-[MEDICAL TREATMENT] part of the sheet is supposed to be completed by the staff . The DON was asked did the facility communicate a pre-[MEDICAL TREATMENT] report to the [MEDICAL TREATMENT] center on the [MEDICAL TREATMENT] Communication Worksheets dated 4/25/19, 4/27/19, and 4/30/19. The DON stated, No .

Based on policy review, medical record review, observation, and interview, the facility failed to maintain a resident's dignity and respect during dressing changes for 1 of 2 (Resident #73) sampled resident's reviewed. The findings include: The facility's undated Privacy policy documented, .Privacy is also maintained during toileting, bathing and other activities . Medical record review revealed Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #73's room on 5/1/19 beginning at 9:20 AM, revealed the Assistant Director of Nursing (ADON) assisted with Resident #73's dressing changes. The ADON exposed the resident from the waist down, exposing Resident #73's genitalia from 9:20 AM until 10:02 AM. Interview with the Director of Nursing (DON) on 5/1/19 at 11:24 AM, in the Conference Room, the DON was asked if she expected residents to be covered during a dressing change. The DON stated, We should keep the private parts covered.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 5 of 25 (Certified Nursing Assistant (CNA) #2, Nursing Assistant (NA) #1, CNA #3, #4, and NA #2) staff members failed to perform proper hand hygiene during dining. The findings include: The facility's .INFECTION CONTROL MANUAL .HANDWASHING policy dated 10/1/08 documented, .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . Observations in Resident #29's room on 4/29/18 beginning at 12:15 PM, revealed CNA #2 touched the overbed table, positioned the table, then placed her bare hands on the Resident #29's sandwich while cutting the sandwich into 4 sections. Observations in Resident #15's room on 4/29/19 at 12:26 PM, revealed NA #1 delivered Resident #15's meal tray and placed it on the overbed table. NA #1 moved the overbed table around the bed, picked up a wedge pillow and placed it on the top of the bed, moved a chair around the bed, applied a clothing protector to Resident #15, put a straw in the tea using her bare hands, removed a glove from her pocket and placed it on her right hand, and assisted Resident #15 with her meal. NA #1 failed to perform hand hygiene after touching objects in Resident #5's room and assisting the resident with her meal. Observations in Resident #29's room on 4/30/18 beginning at 8:03 AM, revealed CNA #3 touched the bed control, touched the overbed table, donned gloves, and handled Resident #29's biscuit. CNA #3 did not perform hand hygiene prior to donning the gloves and touching Resident #29's biscuit. Observations in Resident #50's room on 4/30/19 at 8:05 AM, revealed CNA #4 donned gloves and assisted Resident #50 with her dentures. CNA #4 continued to set up the breakfast tray wearing the same gloves. CNA #4 did not remove her gloves and perform hand hygiene after touching the dentures and before setting up Resident #50's meal tray. Observations in Resident #37's room on 4/30/19 at 4:50 PM, revealed CNA #2 delivered Resident #37's meal tray. Resident #37 stated, I'm wet . CNA #2 applied gloves and performed pericare. CNA #2 removed her gloves, set up the meal tray, placed a spoon in the bowl, opened the straw, and placed it in the drink without performing hand hygiene. Observations in Resident #5's room on 4/30/19 at 5:48 PM, revealed NA #2 delivered Resident #5's dinner tray an placed it on the overbed table. NA #2 repositioned Resident #5 in bed, removed a pillow from Resident #5's roommate's chair and placed it on the roommate's bed, pulled the chair from the roommate's bedside to Resident #5's bedside, sat in the chair, raised the head of bed using the remote, unwrapped Resident #5's silverware, applied a clothing protector to Resident #5, and assisted Resident #5 with her meal. NA #2 failed to perform hand hygiene after touching objects in Resident #5's room and before assisting the resident with her meal. Interview with CNA #2 on 4/30/19 at 5:36 PM, in the 200 Hall Nurses' Station, CNA #2 was asked what she should have done after performing pericare and before setting up the meal tray. CNA #2 stated, .wash my hands .just forgot . Interview with the Director of Nursing (DON) on 5/1/19 at 9:36 AM, in the DON office, the DON was asked if it was appropriate to perform perineal care, then set up a meal tray without performing hand hygiene. The DON stated, No . Interview with the (DON) on 5/1/19 at 11:21 AM, in the Conference Room, the DON was asked when she expected staff to perform hand hygiene during dining. The DON stated, Before and after, and if they contaminate themselves, touch part of their body, adjust the patient, or touch another item . The DON was asked if she expected them to perform hand hygiene before and after glove use. The DON stated, Yes, before and after. Interview with the DON on 5/1/19 at 11:28 AM, in the Day Room, the DON was asked if it was appropriate for staff to touch residents' food with their bare hands. The DON stated, No. The DON was asked it it was appropriate for staff to touch inanimate objects in the resident's room with gloves and wear those same gloves to handle the residents' food and tray items. The DON stated, No.

Based on policy review, observation and interview, the facility failed to ensure medications were stored properly and safely in 1 of 6 (300 Hall Medication Cart) medication storage areas. The findings include: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy dated 6/2016 documented, .Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams .by physical barrier including but not limited to baggies, storage containers, boxes . 2. Observations in the 300 Hall Medication Cart on 4/30/19 at 12:20 PM, revealed the following items in the same drawer with no separation: a. 1 container of menthol roll-on pain reliever labeled, .External use only . b. 1 container of aspirin c. 1 container of [MEDICATION NAME] d. 1 container of stool softener e. 1 container of antidiarrheal medication Observations in the 300 Hall Medication Cart on 4/30/19 at 12:24 PM, revealed the following items in the same drawer with no separation: a. 2 containers of antacid b. 1 container of eye drops c. 1 container of foot cream Interview with Licensed Practical Nurse (LPN) #1 on 4/30/19 at 12:27 PM, at the 300 Hall Medication Cart, LPN #1 was asked if external and internal medications should be stored together without a divider. LPN #1 stated, No. Interview with the Director of Nursing (DON) on 5/1/19 at 11:31 AM, in the Day Room, the DON was asked if internal and external medications should be stored side by side with no divider in the medication cart. The DON stated, No .should be separated by a divider.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 1 of 25 (Certified Nursing Assistant (CNA) #5) staff members failed to cover a bedside commode while transporting it through the hall and when 2 of 3 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1) nurses failed to change gloves and perform hand hygiene before administering eye drops, failed to rinse and dry a used nebulizer before placing it in a storage bag, and failed to obtain a new piston syringe to administer gastrostomy medications to a resident. The findings include: 1. The facility's .INFECTION CONTROL MANUAL .HANDWASHING policy dated 10/1/08 documented, .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . The facility's .RESPIRATORY SERVICES PROGRAM policy dated 10/99 documented, Cautions .Nebulizer can become contaminated resulting in infection .INFECTION CONTROL .The nebulizer should be allowed to air dry . 2. Observations in Resident #78's room on 4/29/19 at 12:14 PM, revealed CNA #5 had a glove on her right hand only and took a bedside commode with urine in it out into the hall and emptied it in the Soiled Linen Room. CNA #5 did not cover the commode prior to transporting it through the hall to the Soiled Linen Room. Interview with the Director of Nursing (DON) on 5/1/19 at 11:21 AM, in the Conference Room, the DON was asked how staff should empty bedside commodes. The DON stated, They should wear gloves, take them out of the room to the hopper room. They should have a lid or a cover. The DON was asked if it was appropriate for a CNA to take an uncovered commode containing urine out into the hall. The DON stated, It should have been covered. 3. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #80's room on 4/30/19 beginning at 9:30 AM, revealed RN #1 donned gloves, listened to Resident #80's breath sounds, and checked her oxygen level. RN #1 then placed medication in the breathing treatment nebulizer, attached it to the mask, placed the nebulizer mask on Resident #80, and turned on the breathing treatment machine. RN #1 then administered 1 drop of eye medication to both of Resident #80's eyes. RN #1 did not remove her gloves and perform hand hygiene between preparing the breathing treatment and administering the eye drops. Interview with the DON on 5/1/19 at 11:32 AM, in the Day Room, the DON was asked if it was appropriate to touch the patient and other items in the room while wearing gloves and continue to wear those same gloves to administer eye drops to a resident. The DON stated, No. 4. Observations in Resident #80's room on 4/30/19 at 9:50 AM, revealed RN #1 removed the breathing treatment mask and reservoir from Resident #80 and handed it to LPN #1. LPN #1 placed the used mask and nebulizer in the nebulizer storage bag. LPN #1 did not rinse the used nebulizer and allow it to air dry prior to placing it in the storage bag. Interview with the DON on 5/1/19 at 11:34 AM, in the Day Room, the DON was asked what staff should do after a breathing treatment was completed. The DON stated, .Wash the medicine reservoir after removing it from the mask, let it dry .then place it in the bag . Interview with LPN #1 on 5/1/19 at 11:58 AM, in the 300 Hall, LPN #1 was asked if the nebulizer should have been rinsed and air dried before it was placed in the storage bag. LPN #1 confirmed the nebulizer should have been rinsed and allowed to air dry before it was placed in the storage bag. 5. Observations in Resident #80's room on 4/30/19 at 9:58 AM, revealed RN #1 used a 60 ml (milliliter) piston syringe dated 4/29/19 to administer medications through Resident #80's gastrostomy tube. Interview with RN #1 on 4/30/19 at 10:00 AM, in Resident #80's room, RN #1 looked at the date on the piston syringe and stated, Oh, today's the 30th .it should have been changed . Interview with the DON on 5/1/19 at 11:42 AM, in the Day Room, the DON was asked how often piston syringes for gastrostomy tube medication administration should be changed. The DON stated, Daily .there should have been a new one with the current date for the nurse when she came to the room for med (medication) pass.

Based on policy review, medical record review, and interview, the facility failed to provide appropriate care and services for 2 of 2 (Resident #22 and #73) residents with an indwelling catheter. The findings include: 1. The facility's undated Catheter Drainage System, Closed policy documented, .Never allow drainage bag to be at a level above the bladder . 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed moderate cognitive impairment, total dependence on staff for all activities of daily living, and use of an indwelling urinary catheter. Observations in Resident #22's room on 4/30/19 at 11:55 AM, revealed Resident #22 lying in bed with the indwelling catheter drainage bag lying in bed beside her. Interview with the Director of Nursing (DON) on 5/1/19 at 11:12 AM, in the Conference Room, the DON was asked if it was acceptable for staff to leave the indwelling catheter drainage bag in the bed with the resident. The DON stated, .They are supposed to put it right back down. 3. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed moderate cognitive impairment, required extensive to total assistance with activities of daily living, and had an indwelling catheter. Observations in Resident #73's room on 5/1/19 beginning at 9:20 AM, revealed the Assistant Director of Nursing (ADON) assisted with Resident #73's dressing changes. She placed Resident #73's bed side drainage bag on the bed with the resident from 9:20 AM to 10:02 AM. Interview with the DON on 5/1/19 at 11:25 AM, in the Conference Room, the DON was asked if a bedside drainage bag should be lying on the bed during a lengthy dressing change. The DON stated, No.

Based on medical record review, observation, and interview, the facility failed to provide nutritional supplements for 1 of 5 (Resident #28) sampled residents reviewed for nutrition. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nutrition Narrative Note dated 6/15/18 documented, She (Resident #28) has lost 7.5 # (pounds) in the past month (6% (percent)) .Will continue to provide regular diet with strawberry mighty shakes to provide extra calories and protein . The Care Plan dated 4/26/18 and revised on 6/15/18 documented, .is a dependent diner .with significant weight .loss .APPROACHES .Regular diet provided .with strawberry mightyshake (mighty shake) at mealtime . Observations in Resident #28s room on 6/19/18 at 2:20 PM and 6/20/18 at 8:23 AM, revealed Resident #28 did not receive a strawberry mighty shake at meal time. Interview with the Dietary Manager (DM) on 6/20/18 at 9:05 AM, in the Dietary office, the DM was asked about Resident #28s diet. The DM stated, .strawberry mighty shakes with meals . The DM was asked when does Resident #28 get her mighty shakes. The DM stated, We will provide on her meal trays. The DM was asked how the staff knew to send the mighty shakes on her tray. The DM stated, It should be on the tray card. The DM was shown the tray card and she confirmed the mighty shakes were not on the tray card. The DM stated, It should be on there. The DM was asked if she expected the mighty shakes to be on the meal trays. The DM stated, Um'huh and shook her head yes.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored securely and safely as evidenced by unattended medications in 3 of 54 (room [ROOM NUMBER], 114, and 301) resident rooms. The findings included: Review of the MEDICATION STORAGE IN THE FACILITY policy documented, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications . Review of the For Your Guidance form (from the Admission packet) documented, To assure our safety of our patients, we have developed the following list to help you with items the patient may use .Items that the patient cannot keep in their room .Any medicated items .Over the counter medications . Observations in room [ROOM NUMBER] on 6/18/18 at 7:06 AM,10:13 AM, and 4:05 PM, revealed a [MEDICATION NAME] inhaler in the room. Observations in room [ROOM NUMBER] on 6/18/18 at 7:17 AM, 10:25 AM, and 12:53 AM, revealed 1 bottle of aspirin, 1 box of medicated pain patches, and a jar of [MEDICATION NAME] skin protectant in the room. Observations In room [ROOM NUMBER] on 6/18/18 at 4:18 PM, revealed a tube of Icy Hot (pain relieving cream) sitting by the sink. Interview with the Director of Nursing (DON) on 6/18/18 at 3:55 PM, in the DON office, the DON was asked if it was acceptable for a resident to have a [MEDICATION NAME] inhaler at the bedside. The DON stated, No . The DON was asked if it was acceptable to have a bottle of aspirin stored in the resident's room. The DON stated, No. The DON as asked if it was acceptable to have a box of medicated pain patches stored at the bedside. The DON stated, No. The DON was asked if it was acceptable to have [MEDICATION NAME] skin protectant stored at the bedside. The DON stated, No. Interview with the DON on 6/18/18 at 4:19 PM, in room [ROOM NUMBER], the DON confirmed a tube of Icy Hot was sitting by the sink.

Based on the For Your Guidance form, observation, and interview, the facility failed to keep the environment free of accident hazards as evidenced by the presence of mouth wash and aerosol cans in 2 of 54 (room [ROOM NUMBER], and 113) resident rooms. The findings included: Review of the For Your Guidance form (from the Admission packet) documented, To assure our safety of our patients, we have developed the following list to help you with items the patient may use .Items that the patient cannot keep in their room .Any items in aerosol cans . Observations in room [ROOM NUMBER] on 6/8/18 at 7:06 AM, 10:13 AM and 4:05 PM, revealed a can of aerosol hair spray sitting on the bedside chest. Observations in room [ROOM NUMBER] on 6/18/18 at 7:14 AM, 10:50 AM, and 4:10 PM, revealed a can of aerosol hair spray sitting on the bedside table. Interview with the Director of Nursing (DON) on 6/18/18 at 3:55 PM, in the DON office, the DON was asked if it was acceptable to have aerosol cans of hairspray at the bedside. The DON stated, No.

Based on policy review, observation, and interview 1 of 5 (Licensed Practical Nurses (LPN) #1) nurses observed during medication administration and 1 of 16 (Nurse Aide #1) staff members observed during dining failed to perform hand hygiene to prevent the spread of infection. The findings included: 1. Review of the facility's MEDICATION ADMINISTRATION PER FEEDING TUBE policy documented .1. Knock on patient's door .4. Wash hands and DON gloves 5. Check tube placement .7. Administer medications . Observations at the 100 hall nurses station on 5/30/17 at 11:54 AM, revealed LPN #1 prepared Resident #74's medication, donned gloves, walked to Resident's 74's room, knocked on the door, stopped the tube feeding pump, turned on the faucet with her gloved hand, obtained a cup of water, and turned the water off with her gloved hand. LPN #1 then disconnected the feeding, checked placement by aspiration and auscultation, flushed the tube with water, administered the medication through the tube, flushed the tube with water, reconnected the feeding, discarded her trash, rinsed the syringe used to administer the medication, and placed the syringe in a bag. LPN #1 failed to remove her soiled gloves and perform hand hygiene prior to administering medication to Resident #74. Interview with the Director of Nursing (DON) on 5/31/17 at 10:11 AM, in the DON office, the DON was asked if it was acceptable to put on gloves at the nurses station, touch items in the room, obtain water from a faucet, turn off the faucet and administer medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube without performing hand hygiene and changing gloves. The DON stated, No. 2. Review of the facility's INFECTION CONTROL MANUAL, HANDWASHING policy documented, .wash hands before and after contact with each patient . Observations during dinning on 5/30/17 at 12:19 PM, revealed Nurse Aide #1 washed her hands, touched the remote control to the bed, set up the meal tray, touched the chair, then began feeding the resident without performing hand hygiene. Interview with Certified Nursing Assistant (CNA) #1 and Nurses Aid #1 on 5/30/17 2:39 PM, on the 200 hall CNA #1, and Nurses Aid #1 were asked if it was appropriate to touch the remote control on the bed, move the bedside table, touch a chair and set up the meal tray and not wash their hands before assisting a resident with their meal. CNA #1 stated .we are to wash our hands or use hand sanitizer after touching anything . Interview with the Assistant Director of Nursing (ADON) on 6/1/17 at 8:11 AM, in the day room, the ADON was asked if it was appropriate to touch the remote control on the bed, move the bedside table, and touch the chair without performing hand hygiene, before assisting a resident with a meal. The ADON stated .she should have washed her hands . Interview with Registered Nurse (RN) #1 on 6/01/17 at 10:52 AM, in the conference room, RN #1 was asked if it was appropriate for the nurses aid to touch the remote control, move the bedside table and touch the chair and assist a resident without performing hand hygiene. RN #1 stated, .No, they are taught to wash their hands .

Based on policy review, medical record review, and interview, the facility failed to ensure the medical record was complete and accurate for 1 of 14 (Resident #51) sampled residents of the 32 residents included in the stage 2 review. The findings included: 1. Review of the facility's DOCUMENTATION GUIDELINES policy documented .Nurses Notes/Progress Notes are used to record the patient's status and track changes in condition .b) Pertinent nursing observations c) Nursing interventions .2) Progress notes also document: a) Any occurences which are not consistant with the routine care of the patient, b) Nursing interventions to those occurences . Review of the facility's POLICIES AND PROCEDURES REGARDING CHANGE IN PATIENTS STATUS policy documented .The charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's family/legal representative . 2. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #51 expired at the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated [DATE] at 11:00 PM, revealed Resident #51 was alert and oriented, receiving oxygen at liters per minute, and had no shortness of breath or pain. The Discharge Summary dated [DATE] documented , .Staff was tending to roommate (roommate) then proceeded to check on Pt (patient) found him w/ (with) (symbol for no) BP (blood pressure), (symbol for no) P (pulse), (symbol for no) Resp (Respirations) . Resident #51 was discharged to the funeral home at 2:20 AM. The facility was unable to provide documentation that the charge nurse, physician or family was notified. Interview with the Director of Nursing (DON) on [DATE] at 2:43 PM, in the DON office, the DON was asked if there was a nurse's note that documented the events between [DATE] at 11:00 PM and the discharge to the funeral home on [DATE] at 2:20 AM. The DON stated, .but we were unable to find it in the chart .