Every finding on record at NHC HealthCare - North Augusta

Based on review of facility policy, interview, and record review, the facility failed to ensure Resident (R)12 received his nasal spray, based on physician orders, for three consecutive days, for 1 of 3 residents reviewed.Findings Include:Review of the facility policy, Preparation and General Guidelines: Medication Administration - Guidelines, with a revision date of 01/01/19, revealed, Policy.Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. D. Documentation.7) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at the scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the MAR for that dosage administration is initialed and circled if using a paper MAR, if electronic MAR follow manual's direction for documentation of such.Review of R12's Face Sheet revealed he was originally admitted to the facility on [DATE], with a current return date of 12/27/25. His diagnoses included, but were not limited to, spinal stenosis, lumbar region with neurogenic claudication, other spondylosis with radiculopathy, and chronic pain syndrome.Review of R12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/25, revealed R12 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R12 had no cognitive deficits. Further review of the R12's MDS revealed resident is receiving PRN (as needed) medications.Review of R12's Care Plan revealed he may self-administer nasal sprays, but medications is to be kept in the medication cart. Approaches include R12 self-administration revaluated quarterly for appropriateness and staff to check expiration dates of nasal sprays. Review of R12's Physician's Order, dated 02/21/26, revealed R12 had orders for Saline Nasal (sodium chloride) aerosol, spray; 0.65%; 1 spray; nasal; Nasal spray four times a day for 1 month. Further review revealed R12 also had Physician's Order, dated 02/20/26, for Afrin No Drip (oxymetazoline) mist; 0.5%; 2-3 sprays; nasal; Nasal spray to nose three times a week.During an interview on 03/05/26 at 6:24 PM, Register Nurse (RN)1 revealed, I only document that the medication was administered on the Medication Administration Record (MAR). I didn't know I was supposed to document anywhere else. The pharmacy knew that the medication wasn't there. The order was put in over the weekend, and they don't deliver on the weekends. The medication was available Monday.During an interview on 03/05/26 at 5:40 PM, RN1 stated, We have an emergency kit box located on [NAME] and Palmetto Wings. On February 23, the nasal spray was not available on the medication cart or the emergency kit box. It was waiting to come from the pharmacy.During an interview on 03/05/26 at 7:19 PM, the Unit Manager (UM)1 revealed, If a medication is on order, but unavailable, it is documented as unavailable on the MAR and waiting to come from pharmacy. If we get it in the system before 5, we usually get it the same night. My expectations are to give pharmacy a call if medications are not available, but I don't know what the policy is here.During an interview on 03/05/26 at 7:40 PM, the Director of Nursing (DON) revealed, If a medication is on order, but unavailable, it is expected to call the pharmacy to see when the medications will be available. If the medication is on back order, let the facility know when the medications are available. If it's a significant medication, sometimes the Nurse Practitioner (NP) will order the medication within 2 - 3 days.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure pharmaceutical services were provided to meet Resident (R)12's needs for 1 of 1 resident reviewed. Specifically, R12's Afrin nasal spray and Saline nasal spray was ordered by the physician on 02/21/26 and was not administered for three days due to unavailability.Findings Include: Review of the facility policy, titled Preparation and General Guidelines: Medication Administration - Guidelines, last revised January 01, 2019, documented, Policy: Medications are administered as prescribed in accordance with good nursing principles . 12) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility are searched, if possible. If the medication cannot be located. the pharmacy is contacted or medication removed from the night box/emergency kit.Review of R12's Face Sheet revealed he was originally admitted to the facility on [DATE], with diagnoses including, but not limited to: long term current use of aspirin, paroxysmal atrial fibrillation, and hypertensive heart and chronic kidney disease.Review of R12's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/25, revealed R12 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R12 was cognitively intact. Review of R12's Care Plan revealed, Problem: Medication and Treatment orders are considered part of the active care plan. Approach: Administer medications and treatments as ordered. Review of R12's Physician's Orders revealed the following: Start date/End date 02/21/26-02/28/26, Afrin (oxymetazoline) [over the counter] OTC mist; 0.5%; 1 spray; nasal; Nasal spray to nose [three times a day] TID for 1 week. Start/End date 02/21/26-03/31/26, Saline Nasal (sodium chloride) [OTC] aerosol, spray; 0.65%; 1 spray; nasal [four times a day] QID to nose for 1 month.Review of R12's Medication Administration Record (MAR) for February 2026 revealed, from 02/21/26-02/23/26, R12 was not administered Afrin and Saline Spray due to Drug/Item Unavailable. Awaiting arrival from pharmacy. Further review also revealed from 02/22/26- 02/25/26 R12's aspirin was on hold due to frequent nosebleeds. During an interview on 03/05/26 at 5:40 PM, RN1 stated, We have an emergency kit box located on [NAME] and Palmetto Wings. On February 23, the nasal spray was not available on the medication cart or the emergency kit box. It was waiting to come from the pharmacy.During an interview on 03/05/26 at 6:24 PM, Register Nurse (RN)1 revealed, The pharmacy knew that the medication wasn't there. The order was put in over the weekend, and they don't deliver on the weekends. The medication was available Monday.During an interview on 03/05/26 at 7:19 PM, the Unit Manager (UM)1 revealed, If a medication is on order, but unavailable, it is documented as unavailable on the MAR and waiting to come from pharmacy. If we get it in the system before 5, we usually get it the same night. My expectations are to give pharmacy a call if medications are not available, but I don't know what the policy is here.During an interview on 03/05/26 at 7:40 PM, the Director of Nursing (DON) revealed, if a medication is on order, but unavailable, it is expected to call the pharmacy to see when the medications will be available. If the medication is on back order, let the facility know when the medications are available. If it's a significant medication, sometimes the Nurse Practitioner (NP) will order the medication within 2 - 3 days.

Based on observation, interview, record review, and review of facility policies, the facility failed to ensure the environment remained free from potential accident hazards for 4 of 5 residents, related to medications at bedside. Specifically, the facility failed to ensure the environment for Resident (R)33, R389, R38, and R69, was free of medication that was required to be properly monitored and stored, to prevent accidental hazards. Findings include: Review of the facility policy, revised 01/01/2019, titled, Medication Storage in the Facility policy states, Medications and biologicals are stored safely, securely and properly manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under Procedures, B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication are permitted to access medication. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the facility policy, revised 01/01/2019, titled, Preparation and General Guidelines: Self-Administration of Medications policy revealed under procedures, A. If the resident desires to self-administer medications, an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry our responsibility. E. Beside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, resident who self-administer. Review of R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease late onset, emphysema, left anterior fascicular block, right bundle-branch block, atherosclerosis of aorta, hypertension, Hypothyroidism, Alzheimer's disease, major depressive disorder, recurrent, mild, generalized anxiety disorder, and adult failure to thrive. Review of R33's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R33 has no cognitive impairment. Section E revealed R33 has no rejection of care behavior exhibited. Section GG revealed R33 requires no assistance with activities of daily life, notes that R33 is independent to feed self. Review of R33's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R33's Physician Orders revealed an active order for, 9AM administration of Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mg 1 tablet listed for nursing medication administration. Nurse signed off for administration on 10/15/24. No evidence of active orders for self-administration. Review of R33's Care Plan, last revised on 08/05/24, revealed R33's medication and treatment orders are considered part of the active care plan. Goal: R33 will not have any negative outcomes from medications and treatments. Approach administer medications and treatments as ordered. Cognition/Communication Deficits related to dementia with fluctuating cognition and inability to always stay on topic. BCRS (Brief Cognitive Rating Scale) score of 21/35 and GDS (Global Deterioration Scale) score of 4.2/7 indicating a moderate cognitive impairment per ST assessment on 09/08/23. Review of R389's Face Sheet revealed R389 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease with late onset, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, atrial fibrillation, hypothyroidism, peripheral vascular disease, polyosteoarthritis and contracture. Review of R389's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R389 has intact cognition. Further review of the MDS revealed R389 has no rejection of care behavior exhibited and is dependent to maximal assist of care. R389, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R389's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R389's Physician Orders did not reveal an order for topical medication Nystatin Powder. Review of R389's Care Plan, last revised on 08/08/24, reveals R389's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach administer medication and treatments as ordered. Review of R38's Face Sheet revealed R38 was admitted to the facility on [DATE], with diagnoses including but not limited to: Bipolar Disorder, anxiety disorder, insomnia, hypothyroidism, radiculopathy cervical region, polyneuropathy, polyosteoarthritis, and atherosclerotic heart disease. Review of R38's Quarterly MDS with an ARD of 09/30/24, revealed a BIMS score of 14 out of 15, indicating R38 has intact cognition. Section E revealed R38 has no rejection of care behavior exhibited. Section GG revealed R38 is dependent to maximal assist of care. R38, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R38's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R38's Physician Order did not reveal an order for Nervive Roll on cream. Review of R38's Care Plan, with a revision date of 10/13/24, revealed R38's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach: administer medication and treatments as ordered. Problem: Cognitive loss/dementia, goal is R38 will communicate simple needs for 90 days until next review and update. Approach is to offer cues and reminders as needed. Remind R38 of surroundings only if it calms patient and visit for conversation stimulation. R38's problem of behavioral symptoms by observed occasional declination of medications and care. Diagnosis of bipolar disorder, these behaviors fluctuate related to diagnosis extremely pleasant at times and just as quickly she is accusatory and yelling. Review of R69's Face Sheet revealed R69 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified visual loss right eye. Review of R69's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R69's Physician Orders revealed an active order for, Wixela Inhub (Fluticasone propion-salmeterol) blister with device 250-50 mcg/dose, amount one puff inhalation twice a day listed for nursing medication administration. Review of R69's Care Plan reveals R69's identified problem is cognitive loss/dementia. Cognition fluctuate, requires assistance with decision making. Requires cues and reminders for safety. Brief Cognitive Rating Scale, BCRS of 26/35 and GDS (Global Deterioration Scale) score of 5.2/7 indicating moderately severe cognitive impairment per speech therapy assessment on 12/13/23. Resident continues with liberal unassisted ambulation about facility; cognitive deficits with dx; risk harm from his peers related to occasional socially intrusive during his interactions as he strolls and some peer's inability to interpret his interactions; episodes of agitation and verbal aggression occur as well related to his deficits edited on 09/10/24. Review of R69's Quarterly MDS with an ARD of 09/03/24, revealed a BIMS score of 10 out of 15, indicating R69 has moderate cognitive impairment. Section E revealed R69 has no rejection of care behavior exhibited. Section GG revealed R69 is independent in activities of daily life and feeding self. During an observation and interview on 10/15/24 at 10:51 AM, of R33's room, a medication cup with several pills where on the bedside table in front of R33. There were no staff present and R33's roommate was in a wheelchair leaving the restroom. During introductions, R33 quickly took the medications in the cup without the nurse present. R33 stated, she does not know the medicine she takes but takes what the nurse places on the table in the cup for her to take. R33 revealed that staff occasionally leave her medicines in her room for her to take by herself because she is able. During an observation and interview on 10/15/24 at 10:54 AM, Licensed Practical Nurse (LPN)2 signed off administration of R33's 9:00 AM medications, which included: Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mb 1 tablet. LPN2 stated R33 can give herself the medication unattended because she is independent, and she knows her medications. LPN2 further stated, R33 is sometimes given her medications like this and has not had any issues in the past. LPN2 confirmed that R33 does not have an order to self-administer medications and acknowledged the facility policy for self-administration. During an observation on 10/15/24 at 12:41 PM, of R38's room, revealed a Nervive roll on 2.5oz 8/2025 Lot 4092Y5 and IcyHot Max Lidocaine lot 24B401 02/2026, was located on the bedside table in front of R38. Furthermore, there was one unopened box of Nervive 7/2025 Lot 4030Y5 box medication cream 3.0oz on the bookshelf. During an observation and interview on 10/16/24 at 10:36 AM, the Director of Nursing (DON) verified the Nystatin powder lot421209 3/31/2026, on R389's dresser. The DON stated that treatment medications should be secured on the cart unless it is peri care and lotion. If there is a prescription, there should be a bedside order. During an observation on 10/16/24 at 10:53 AM, of R69's room, revealed an inhalation medication on the tall dresser next to the television. The inhalar was left opened and unattended. Further review of the inhaler revealed, Fluticasone Propionate and Salmeterol 250mcg/50mcg 60 blisters with lot number AC2029A expiration date of MAR2026, 43 puffs left. No open date and no use by date on the medication. During an interview on 10/16/24 at 10:56 AM, Licensed Practical Nurse (LPN)2 verified the medication on the dresser in R69's room and stated that another LPN forgot it earlier after administration of medication due to cleaning R69's room. LPN2 further stated she watched R69 take medication and receive breathing treatment at 8:08 AM that morning. LPN2 than closed the medication and secured medication back in in cart. During an interview on 10/16/24 at 04:02 PM the (ADON) Assistant Director of Nursing/Infection Control revealed that she was not aware of the items being in the room and ADON was following up with R38 and seen the medication at bedside. ADON took the Nervive roll that was on the bedside table and three bottles of the Nervive R38 had in the bedside drawer. ADON reported that she educated the resident and left with the items. Expectations are for staff to follow policy and if items are coming from family educate the resident and let them know why they cannot have at bedside. We are to keep in the medication cart and regulate it for R38 and keep it locked up for patient safety. Expectation for self-administration is that we do have a protocol to follow to determine if they are competent to do to self-administer. During an interview on 10/16/24 at 04:15 PM the ADON revealed the expectation to follow policy that medication should be administered at bedside and watched. The ADON stated, we can assess their competency level to see if they can self-administer but there is a protocol. I do not know the specifics because i have not heard of it being done often and i have been here three years. R33 has not been assessed for self-administration. We train the nurses on medication administration and documentation annually and frequently at nurse's meetings probably 3 to 4 times a year. During an interview on 10/17/24 at 11:31 AM, the Administrator revealed that every patient is within eyesight of nurse and at bedside when taking medications. The Administrator stated, If the patient is able to self-administer the patient needs to be assessed and care planned appropriately. I am aware of two patients in this facility that is approved for self-administration. During an interview on 10/17/24 at 11:39 AM, the Administrator revealed that administration medications should be locked and if not the patient need to be cleared to self-administer. The barrier cream for peri-care is allowed but anything that is coming from the pharmacy should be properly assessed and screened for self-administration. Daily rounding by leadership is done to ensure there is not an incident or hazard and to assist staff. If there is an issue we are to address, educate. The way that we address family are at different intervals at admission and it states what they can and cannot provide. We explain to the family that we oversee care and if anything is needed, we can provide. We also address as it is an issue, we address it seasonally (especially Christmas), resident council, and at care plans.

Based on observation, interview, record review, and review of facility policies, the facility failed to ensure the environment remained free from potential accident hazards for 4 of 5 residents, related to medications at bedside. Specifically, the facility failed to ensure the environment for Resident (R)33, R389, R38, and R69, was free of medication that was required to be properly monitored and stored, to prevent accidental hazards. Findings include: Review of the facility policy, revised 01/01/2019, titled, Medication Storage in the Facility policy states, Medications and biologicals are stored safely, securely and properly manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under Procedures, B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication are permitted to access medication. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the facility policy, revised 01/01/2019, titled, Preparation and General Guidelines: Self-Administration of Medications policy revealed under procedures, A. If the resident desires to self-administer medications, an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry our responsibility. E. Beside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, resident who self-administer. Review of R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease late onset, emphysema, left anterior fascicular block, right bundle-branch block, atherosclerosis of aorta, hypertension, Hypothyroidism, Alzheimer's disease, major depressive disorder, recurrent, mild, generalized anxiety disorder, and adult failure to thrive. Review of R33's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R33 has no cognitive impairment. Section E revealed R33 has no rejection of care behavior exhibited. Section GG revealed R33 requires no assistance with activities of daily life, notes that R33 is independent to feed self. Review of R33's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R33's Physician Orders revealed an active order for, 9AM administration of Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mg 1 tablet listed for nursing medication administration. Nurse signed off for administration on 10/15/24. No evidence of active orders for self-administration. Review of R33's Care Plan, last revised on 08/05/24, revealed R33's medication and treatment orders are considered part of the active care plan. Goal: R33 will not have any negative outcomes from medications and treatments. Approach administer medications and treatments as ordered. Cognition/Communication Deficits related to dementia with fluctuating cognition and inability to always stay on topic. BCRS (Brief Cognitive Rating Scale) score of 21/35 and GDS (Global Deterioration Scale) score of 4.2/7 indicating a moderate cognitive impairment per ST assessment on 09/08/23. Review of R389's Face Sheet revealed R389 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease with late onset, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, atrial fibrillation, hypothyroidism, peripheral vascular disease, polyosteoarthritis and contracture. Review of R389's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R389 has intact cognition. Further review of the MDS revealed R389 has no rejection of care behavior exhibited and is dependent to maximal assist of care. R389, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R389's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R389's Physician Orders did not reveal an order for topical medication Nystatin Powder. Review of R389's Care Plan, last revised on 08/08/24, reveals R389's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach administer medication and treatments as ordered. Review of R38's Face Sheet revealed R38 was admitted to the facility on [DATE], with diagnoses including but not limited to: Bipolar Disorder, anxiety disorder, insomnia, hypothyroidism, radiculopathy cervical region, polyneuropathy, polyosteoarthritis, and atherosclerotic heart disease. Review of R38's Quarterly MDS with an ARD of 09/30/24, revealed a BIMS score of 14 out of 15, indicating R38 has intact cognition. Section E revealed R38 has no rejection of care behavior exhibited. Section GG revealed R38 is dependent to maximal assist of care. R38, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R38's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R38's Physician Order did not reveal an order for Nervive Roll on cream. Review of R38's Care Plan, with a revision date of 10/13/24, revealed R38's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach: administer medication and treatments as ordered. Problem: Cognitive loss/dementia, goal is R38 will communicate simple needs for 90 days until next review and update. Approach is to offer cues and reminders as needed. Remind R38 of surroundings only if it calms patient and visit for conversation stimulation. R38's problem of behavioral symptoms by observed occasional declination of medications and care. Diagnosis of bipolar disorder, these behaviors fluctuate related to diagnosis extremely pleasant at times and just as quickly she is accusatory and yelling. Review of R69's Face Sheet revealed R69 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified visual loss right eye. Review of R69's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R69's Physician Orders revealed an active order for, Wixela Inhub (Fluticasone propion-salmeterol) blister with device 250-50 mcg/dose, amount one puff inhalation twice a day listed for nursing medication administration. Review of R69's Care Plan reveals R69's identified problem is cognitive loss/dementia. Cognition fluctuate, requires assistance with decision making. Requires cues and reminders for safety. Brief Cognitive Rating Scale, BCRS of 26/35 and GDS (Global Deterioration Scale) score of 5.2/7 indicating moderately severe cognitive impairment per speech therapy assessment on 12/13/23. Resident continues with liberal unassisted ambulation about facility; cognitive deficits with dx; risk harm from his peers related to occasional socially intrusive during his interactions as he strolls and some peer's inability to interpret his interactions; episodes of agitation and verbal aggression occur as well related to his deficits edited on 09/10/24. Review of R69's Quarterly MDS with an ARD of 09/03/24, revealed a BIMS score of 10 out of 15, indicating R69 has moderate cognitive impairment. Section E revealed R69 has no rejection of care behavior exhibited. Section GG revealed R69 is independent in activities of daily life and feeding self. During an observation and interview on 10/15/24 at 10:51 AM, of R33's room, a medication cup with several pills where on the bedside table in front of R33. There were no staff present and R33's roommate was in a wheelchair leaving the restroom. During introductions, R33 quickly took the medications in the cup without the nurse present. R33 stated, she does not know the medicine she takes but takes what the nurse places on the table in the cup for her to take. R33 revealed that staff occasionally leave her medicines in her room for her to take by herself because she is able. During an observation and interview on 10/15/24 at 10:54 AM, Licensed Practical Nurse (LPN)2 signed off administration of R33's 9:00 AM medications, which included: Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mb 1 tablet. LPN2 stated R33 can give herself the medication unattended because she is independent, and she knows her medications. LPN2 further stated, R33 is sometimes given her medications like this and has not had any issues in the past. LPN2 confirmed that R33 does not have an order to self-administer medications and acknowledged the facility policy for self-administration. During an observation on 10/15/24 at 12:41 PM, of R38's room, revealed a Nervive roll on 2.5oz 8/2025 Lot 4092Y5 and IcyHot Max Lidocaine lot 24B401 02/2026, was located on the bedside table in front of R38. Furthermore, there was one unopened box of Nervive 7/2025 Lot 4030Y5 box medication cream 3.0oz on the bookshelf. During an observation and interview on 10/16/24 at 10:36 AM, the Director of Nursing (DON) verified the Nystatin powder lot421209 3/31/2026, on R389's dresser. The DON stated that treatment medications should be secured on the cart unless it is peri care and lotion. If there is a prescription, there should be a bedside order. During an observation on 10/16/24 at 10:53 AM, of R69's room, revealed an inhalation medication on the tall dresser next to the television. The inhalar was left opened and unattended. Further review of the inhaler revealed, Fluticasone Propionate and Salmeterol 250mcg/50mcg 60 blisters with lot number AC2029A expiration date of MAR2026, 43 puffs left. No open date and no use by date on the medication. During an interview on 10/16/24 at 10:56 AM, Licensed Practical Nurse (LPN)2 verified the medication on the dresser in R69's room and stated that another LPN forgot it earlier after administration of medication due to cleaning R69's room. LPN2 further stated she watched R69 take medication and receive breathing treatment at 8:08 AM that morning. LPN2 than closed the medication and secured medication back in in cart. During an interview on 10/16/24 at 04:02 PM the (ADON) Assistant Director of Nursing/Infection Control revealed that she was not aware of the items being in the room and ADON was following up with R38 and seen the medication at bedside. ADON took the Nervive roll that was on the bedside table and three bottles of the Nervive R38 had in the bedside drawer. ADON reported that she educated the resident and left with the items. Expectations are for staff to follow policy and if items are coming from family educate the resident and let them know why they cannot have at bedside. We are to keep in the medication cart and regulate it for R38 and keep it locked up for patient safety. Expectation for self-administration is that we do have a protocol to follow to determine if they are competent to do to self-administer. During an interview on 10/16/24 at 04:15 PM the ADON revealed the expectation to follow policy that medication should be administered at bedside and watched. The ADON stated, we can assess their competency level to see if they can self-administer but there is a protocol. I do not know the specifics because i have not heard of it being done often and i have been here three years. R33 has not been assessed for self-administration. We train the nurses on medication administration and documentation annually and frequently at nurse's meetings probably 3 to 4 times a year. During an interview on 10/17/24 at 11:31 AM, the Administrator revealed that every patient is within eyesight of nurse and at bedside when taking medications. The Administrator stated, If the patient is able to self-administer the patient needs to be assessed and care planned appropriately. I am aware of two patients in this facility that is approved for self-administration. During an interview on 10/17/24 at 11:39 AM, the Administrator revealed that administration medications should be locked and if not the patient need to be cleared to self-administer. The barrier cream for peri-care is allowed but anything that is coming from the pharmacy should be properly assessed and screened for self-administration. Daily rounding by leadership is done to ensure there is not an incident or hazard and to assist staff. If there is an issue we are to address, educate. The way that we address family are at different intervals at admission and it states what they can and cannot provide. We explain to the family that we oversee care and if anything is needed, we can provide. We also address as it is an issue, we address it seasonally (especially Christmas), resident council, and at care plans. Based on observation, interview, record review, and review of facility policies, the facility failed to ensure the environment remained free from potential accident hazards for 4 of 5 residents, related to medications at bedside. Specifically, the facility failed to ensure the environment for Resident (R)33, R389, R38, and R69, was free of medication that was required to be properly monitored and stored, to prevent accidental hazards. Findings include: Review of the facility policy, revised 01/01/2019, titled, Medication Storage in the Facility policy states, Medications and biologicals are stored safely, securely and properly manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under Procedures, B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication are permitted to access medication. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the facility policy, revised 01/01/2019, titled, Preparation and General Guidelines: Self-Administration of Medications policy revealed under procedures, A. If the resident desires to self-administer medications, an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry our responsibility. E. Beside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, resident who self-administer. Review of R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease late onset, emphysema, left anterior fascicular block, right bundle-branch block, atherosclerosis of aorta, hypertension, Hypothyroidism, Alzheimer's disease, major depressive disorder, recurrent, mild, generalized anxiety disorder, and adult failure to thrive. Review of R33's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R33 has no cognitive impairment. Section E revealed R33 has no rejection of care behavior exhibited. Section GG revealed R33 requires no assistance with activities of daily life, notes that R33 is independent to feed self. Review of R33's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R33's Physician Orders revealed an active order for, 9AM administration of Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mg 1 tablet listed for nursing medication administration. Nurse signed off for administration on 10/15/24. No evidence of active orders for self-administration. Review of R33's Care Plan, last revised on 08/05/24, revealed R33's medication and treatment orders are considered part of the active care plan. Goal: R33 will not have any negative outcomes from medications and treatments. Approach administer medications and treatments as ordered. Cognition/Communication Deficits related to dementia with fluctuating cognition and inability to always stay on topic. BCRS (Brief Cognitive Rating Scale) score of 21/35 and GDS (Global Deterioration Scale) score of 4.2/7 indicating a moderate cognitive impairment per ST assessment on 09/08/23. Review of R389's Face Sheet revealed R389 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease with late onset, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, atrial fibrillation, hypothyroidism, peripheral vascular disease, polyosteoarthritis and contracture. Review of R389's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R389 has intact cognition. Further review of the MDS revealed R389 has no rejection of care behavior exhibited and is dependent to maximal assist of care. R389, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R389's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R389's Physician Orders did not reveal an order for topical medication Nystatin Powder. Review of R389's Care Plan, last revised on 08/08/24, reveals R389's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach administer medication and treatments as ordered. Review of R38's Face Sheet revealed R38 was admitted to the facility on [DATE], with diagnoses including but not limited to: Bipolar Disorder, anxiety disorder, insomnia, hypothyroidism, radiculopathy cervical region, polyneuropathy, polyosteoarthritis, and atherosclerotic heart disease. Review of R38's Quarterly MDS with an ARD of 09/30/24, revealed a BIMS score of 14 out of 15, indicating R38 has intact cognition. Section E revealed R38 has no rejection of care behavior exhibited. Section GG revealed R38 is dependent to maximal assist of care. R38, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R38's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R38's Physician Order did not reveal an order for Nervive Roll on cream. Review of R38's Care Plan, with a revision date of 10/13/24, revealed R38's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach: administer medication and treatments as ordered. Problem: Cognitive loss/dementia, goal is R38 will communicate simple needs for 90 days until next review and update. Approach is to offer cues and reminders as needed. Remind R38 of surroundings only if it calms patient and visit for conversation stimulation. R38's problem of behavioral symptoms by observed occasional declination of medications and care. Diagnosis of bipolar disorder, these behaviors fluctuate related to diagnosis extremely pleasant at times and just as quickly she is accusatory and yelling. Review of R69's Face Sheet revealed R69 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified visual loss right eye. Review of R69's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R69's Physician Orders revealed an active order for, Wixela Inhub (Fluticasone propion-salmeterol) blister with device 250-50 mcg/dose, amount one puff inhalation twice a day listed for nursing medication administration. Review of R69's Care Plan reveals R69's identified problem is cognitive loss/dementia. Cognition fluctuate, requires assistance with decision making. Requires cues and reminders for safety. Brief Cognitive Rating Scale, BCRS of 26/35 and GDS (Global Deterioration Scale) score of 5.2/7 indicating moderately severe cognitive impairment per speech therapy assessment on 12/13/23. Resident continues with liberal unassisted ambulation about facility; cognitive deficits with dx; risk harm from his peers related to occasional socially intrusive during his interactions as he strolls and some peer's inability to interpret his interactions; episodes of agitation and verbal aggression occur as well related to his deficits edited on 09/10/24. Review of R69's Quarterly MDS with an ARD of 09/03/24, revealed a BIMS score of 10 out of 15, indicating R69 has moderate cognitive impairment. Section E revealed R69 has no rejection of care behavior exhibited. Section GG revealed R69 is independent in activities of daily life and feeding self. During an observation and interview on 10/15/24 at 10:51 AM, of R33's room, a medication cup with several pills where on the bedside table in front of R33. There were no staff present and R33's roommate was in a wheelchair leaving the restroom. During introductions, R33 quickly took the medications in the cup without the nurse present. R33 stated, she does not know the medicine she takes but takes what the nurse places on the table in the cup for her to take. R33 revealed that staff occasionally leave her medicines in her room for her to take by herself because she is able. During an observation and interview on 10/15/24 at 10:54 AM, Licensed Practical Nurse (LPN)2 signed off administration of R33's 9:00 AM medications, which included: Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mb 1 tablet. LPN2 stated R33 can give herself the medication unattended because she is independent, and she knows her medications. LPN2 further stated, R33 is sometimes given her medications like this and has not had any issues in the past. LPN2 confirmed that R33 does not have an order to self-administer medications and acknowledged the facility policy for self-administration. During an observation on 10/15/24 at 12:41 PM, of R38's room, revealed a Nervive roll on 2.5oz 8/2025 Lot 4092Y5 and IcyHot Max Lidocaine lot 24B401 02/2026, was located on the bedside table in front of R38. Furthermore, there was one unopened box of Nervive 7/2025 Lot 4030Y5 box medication cream 3.0oz on the bookshelf. During an observation and interview on 10/16/24 at 10:36 AM, the Director of Nursing (DON) verified the Nystatin powder lot421209 3/31/2026, on R389's dresser. The DON stated that treatment medications should be secured on the cart unless it is peri care and lotion. If there is a prescription, there should be a bedside order. During an observation on 10/16/24 at 10:53 AM, of R69's room, revealed an inhalation medication on the tall dresser next to the television. The inhalar was left opened and unattended. Further review of the inhaler revealed, Fluticasone Propionate and Salmeterol 250mcg/50mcg 60 blisters with lot number AC2029A expiration date of MAR2026, 43 puffs left. No open date and no use by date on the medication. During an interview on 10/16/24 at 10:56 AM, Licensed Practical Nurse (LPN)2 verified the medication on the dresser in R69's room and stated that another LPN forgot it earlier after administration of medication due to cleaning R69's room. LPN2 further stated she watched R69 take medication and receive breathing treatment at 8:08 AM that morning. LPN2 than closed the medication and secured medication back in in cart. During an interview on 10/16/24 at 04:02 PM the (ADON) Assistant Director of Nursing/Infection Control revealed that she was not aware of the items being in the room and ADON was following up with R38 and seen the medication at bedside. ADON took the Nervive roll that was on the bedside table and three bottles of the Nervive R38 had in the bedside drawer. ADON reported that she educated the resident and left with the items. Expectations are for staff to follow policy and if items are coming from family educate the resident and let them know why they cannot have at bedside. We are to keep in the medication cart and regulate it for R38 and keep it locked up for patient safety. Expectation for self-administration is that we do have a protocol to follow to determine if they are competent to do to self-administer. During an interview on 10/16/24 at 04:15 PM the ADON revealed the expectation to follow policy that medication should be administered at bedside and watched. The ADON stated, we can assess their competency level to see if they can self-administer but there is a protocol. I do not know the specifics because i have not heard of it being done often and i have been here three years. R33 has not been assessed for self-administration. We train the nurses on medication administration and documentation annually and frequently at nurse's meetings probably 3 to 4 times a year. During an interview on 10/17/24 at 11:31 AM, the Administrator revealed that every patient is within eyesight of nurse and at bedside when taking medications. The Administrator stated, If the patient is able to self-administer the patient needs to be assessed and care planned appropriately. I am aware of two patients in this facility that is approved for self-administration. During an interview on 10/17/24 at 11:39 AM, the Administrator revealed that administration medications should be locked and if not the patient need to be cleared to self-administer. The barrier cream for peri-care is allowed but anything that is coming from the pharmacy should be properly assessed and screened for self-administration. Daily rounding by leadership is done to ensure there is not an incident or hazard and to assist staff. If there is an issue we are to address, educate. The way that we address family are at different intervals at admission and it states what they can and cannot provide. We explain to the family that we oversee care and if anything is needed, we can provide. We also address as it is an issue, we address it seasonally (especially Christmas), resident council, and at care plans.

Based on the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, observations and interviews, the facility failed to ensure Resident (R)95 was free from significant medication errors. Specifically, ertapenem reconstituted solution 1 gram infused with 100mL of normal saline intravenous (IV) in a safe manner and in accordance with professional standards of medication administration via peripherally inserted central catheter (PICC or PICC line). The findings include: Review of the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, states under the Policy Statement, To administer medications in a safe and effective manner. An observation on 10/17/2024 at 1:08 PM revealed ertapenem intravenous administration for R95. Licensed Practical Nurse (LPN)1 failed to ensure R95 safely received antibiotic therapy via PICC line by improperly managing the IV line once primed to reduce the risk of contamination before going to the patient. The primed uncapped IV line was placed on a blue chux and then the outside of an alcohol packet, then administered to the R95. LPN1 when accessing PICC line failed to scrub/wipe top of access for a minimum of 15 seconds. Task completed less than 10sceonds and uncapped IV line was placed within access. LPN1 started infusion. During an interview on 10/17/24 at 01:46 PM the Director of Nursing revealed that skills training is done once a year. This training included PICC lines and IV infusions. The expectation is that staff follow protocol and follow infection control guidelines during medication administration. The last class was in November 2023 and that was the skill fair. Since this morning, we have started retaining the licensed practical nurses regarding the PICC and working with R95. We have another skills fair that is in November 2024. During an interview on 10/17/24 at 02:09 PM, LPN1 revealed that she does not remember her last PICC Training. LPN1 revealed that she was expected to use a clean technique when accessing a PICC line. She admitted to taking the uncapped primed IV line, placing on the blue pad, and once alerted placed the uncapped IV line on an alcohol pack. LPN1 revealed that she was expected to discard of the IV line and start over prior to administering to R95. Review of Competency Standard Skills Checklist for PICC lines with LPN name, signature, and not dated with DON name, signature, and date of 11/21/23.

Based on review of facility policy, record review, observation and interview the facility failed to provide 1 of 4 residents (R95) and 1 of 34 medication opportunities given by 4 nurses, medication administration without possibility of cross contamination. Specifically, ertapenem reconstituted solution 1 gram infused with 100mL of normal saline intravenous in accordance with infection control and prevention standards of medication administration via peripherally inserted central catheter (PICC or PICC line). Findings include: Review of the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, states under the Policy Statement, To administer medications in a safe and effective manner. Review of the facility policy titled, PICC and Midline Catheter Flushing, states under general guideline, 3. Consult state Nurse Practice Act for RN/LPN scope of practice and function. Review of Competency standard skills checklist PICC lines with DON name, signature, and date of 11/ 21/23. LPN1 name and signature present without a date. Checklist revealed flushing the PICC line, administer infusion, changing the PICC line, and changing the PICC adapter instructions that have been checked off by LPN1 except for changing the PICC line. Under flushing the PICC line, Scrub the top of the adapter of the PICC with alcohol swab for minimum 15 seconds with a juicing action. Under Administer Infusion, 3. Thoroughly friction swab access site with alcohol for 15 seconds. Review of R95's face sheet revealed R95 was admitted to the facility on [DATE] with diagnoses including, but not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region, Escherichia coli, extended spectrum beta lactamase, proteus, enterococcus as the cause of disease and presence of cardiac or vascular implant and graft, PICC line. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R95 had a Brief Interview of Mental Status (BIMS) score of 2, suggesting R95 is severely cognitively impaired. It further revealed R95 does not exhibit behavior of rejection of care. Review of R95's physician orders revealed R95 has an ongoing ertapenem reconstituted solution 1 gram infused with 100mL of normal saline intravenous for one hour vis PICC line every 24 hours start date 09/18/2024 to end date 10/18/2024. An observation on 10/17/2024 at 1:08 PM revealed ertapenem intravenous administration for R95. Licensed Practical Nurse (LPN)1 failed to ensure R95 safely received antibiotic therapy via PICC line by improperly managing the intravenous (IV) line once primed to reduce the risk of contamination before going to the patient. The primed uncapped IV line was placed on a blue chux and then the outside of an alcohol packet, then administered to the R95. LPN1 when accessing PICC line failed to scrub/wipe top of access for a minimum of 15 seconds. Task completed less than 10sceonds and uncapped IV line was placed within access. LPN1 started infusion. During an interview on 10/17/24 at 1:46 PM, the Director of Nursing revealed that skills training is done once a year. She stated, this training included PICC lines and IV infusions. The expectation is that staff follow protocol and follow infection control guidelines during medication administration. The last class was in November 2023 and that was the skills fair. Since this morning, we have started retaining the licensed practical nurses regarding the PICC and working with R95. We have another skills fair that is in November 2024. During an interview on 10/17/24 at 1:51 PM, the Assistant Director of Nursing/Infection Preventionist revealed that the staff are expected to follow procedures for sterile and clean technique per policy when it is warranted. During an interview on 10/17/24 at 2:09 PM, LPN1 revealed that she does not remember her last PICC Training. She revealed that she was expected to use a clean technique with accessing a PICC line. LPN1 confirmed taking the uncapped primed IV line, placing on the blue pad, and once alerted placed the uncapped IV line on an alcohol pack. LPN1 revealed that she was expected to discard of IV line and start over prior to administering to R95.

Based on observation, interview, record review, and policy review, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure the nebulizer machines mask for Resident (R)69 and R389 were clean, labelled, and bagged when not in use. Findings include: Review of the policy titled Jet Nebulizer Treatment revised 09/07 reveals under procedure,10. When treatment is completed remove the nbulizer to the sink area, empty any remaining medication, rinse with water, and return setup to bag. Note change nebulizer setups weekly, date and initial equipment. Review of Review of Resident 69's face sheet revealed that resident was current admitted to the facility on [DATE] with the diagnoses listed but not limited to dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified visual loss right eye. Review of Resident 389's face sheet revealed that resident was current admitted to the facility on [DATE] with the diagnoses listed but not limited to Alzheimer's Disease with late onset, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, atrial fibrillation, hypothyroidism, peripheral vascular disease, polyosteoarthritis and contracture. Review of R69's Physician Orders revealed orders for Budesonide Suspension for nebulization 0.5mg/2mL give twice a day. Review of R69's care plan revealed that R69 identified problem is Respiratory, at risk for complications related to Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, personal history of nicotine dependence, and shortness of breath. Approach administer nebulizer, inhaler as indicated. Review of R69's Minimum Data Set (MDS) quarterly review dated 09/03/2024 revealed a Brief Interview for Mental Status (BIMS) score is 10 out of 15, R 69 has moderate cognitive impairment. Section E revealed R63 has no rejection of care behavior exhibited. Section GG revealed R69 is independent in activities of daily life and feeding self. Review of R389's Physician Orders revealed orders for Albuterol Sulfate Solution for nebulization 2.5mg/3mL (0.083%) one nebulizer three times a day. Review of R389's care plan revealed that R389 is not care planned for breathing treatments scheduled or PRN. Last revised care plan with start date 09/16/2024 problem listed acute bronchitis with approaches medications and lab per orders, resident will complete antibiotics on 09/18/2024. Observe for increased signs and symptoms of infection, and vital signs as needed. Review of R389's annual MDS dated [DATE] revealed a BIMS score is 13 out of 15, R389 has intact cognition. Section E revealed R389 has no rejection of care behavior exhibited. Section GG revealed R389 is dependent to maximal assist of care. R389, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. During an observation and interview of R69 on 10/15/24 at 01:27 PM resident was fully dressed ambulatory in room. The face mask with connected tubing to the jet nebulizer machine was not dated, not in a bag, and located on the right side of the nightstand near floor. R69 revealed having a breathing treatment that morning. During an observation of R389's room on 10/15/24 at 12:15 PM, there was a face mask with connected tubing to the jet nebulizer machine not dated, not in a bag, located on the floor between the bed and nightstand. During an observation of R389's room on 10/16/24 at 10:29 AM, there was a face mask with connected tubing to the jet nebulizer machine not dated, not in a bag, located on the floor between the bed and nightstand. During an observation and interview on 10/16/24 at 10:39 AM, the Director of Nursing (DON) witnessed R389's jet nebulizer's face mask on the floor and revealed that the respiratory equipment is expected to be in a bag and dated. She stated, I am sure staff has had in-service on respiratory care and infection control. DON immediately discarded mask. DON revealed that respiratory therapy is in charge of weekly changes of respiratory equipment. The nurses are in charge of daily care. During an interview on 10/16/24 at 10:56 AM, Licensed Practical Nurse (LPN)2 revealed that she gave the jet nebulizer treatment and the inhaler that morning at 8:08 AM. She revealed that after treatment, she rinsed R69's face mask but, she left it across the bed. LPN2 was aware of the policy when it is not in use it is to be stored in a plastic bag to keep the dust and keep it clean. The bags are labeled treatments. During an interview on 10/16/24 at 03:52 PM, the DON revealed that staff are trained on respiratory equipment on hire and as needed for trends. The equipment or mask is expected to be rinsed after usage, set on a paper towel to dry and placed in a dated bag. The DON stated, It is expected to be changed weekly. It is my expectation that nurses are following policy as it pertains to medication administration and respiratory care. During an interview on 10/16/24 at 04:37 PM, the Assistant Director of Nursing revealed the policy for the nebulizer are expected to be followed. The nebulizer mask are to be rinsed out and bagged. The plan of correction we will reeducate staff on the proper storage of the respiratory equipment. During an interview on 10/17/24 at 11:50 AM the Administrator revealed an expectation is that the nebulizer is stored in a bag and labeled. It is expected to be rinsed, dried, dated, and packed in place. We must assure that it is being done by rounding and addressing that it is being done.

Based on review of Center for Medicare and Medicaid Services (CMS) QSO-20-38-NH Revised, and policy review, interviews, and record reviews, the facility failed to perform COVID-19 testing immediately for all staff and residents regardless of vaccination status when an outbreak was identified and failed to retest every three to seven days until no additional cases were identified for 14 days. The facility failed to perform thorough contact tracing when staff tested positive for COVID-19 to determine residents and staff with higher exposure which added to the noncompliance with staff and resident testing in an outbreak. This noncompliance resulted in 17 residents (Resident (R) 18, R56, R69, R78, R83, R110, R120, R154, R155, R255, R258, R259, R260, R261, R262, R263, and R264) and 17 staff members contracting COVID-19 and increased likelihood for additional serious infections and potential hospitalization s and death due to transmission of COVID-19 between staff members and residents. Findings include: Review of the facility's policy titled Covid-19- Infection Control Manual Volume 1 Updated February 2022 .3. Determining the time period when the patient, visitor, or HCP (healthcare care personnel) with confirmed [CONDITION(S)]-CoV-2 infection could have been infectious: a. For individuals with confirmed COVID-19 who developed symptoms, consider the exposure window to be 2 days before symptom onset through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions. b. For individuals with confirmed [CONDITION(S)]-CoV-2 infection who never developed symptoms, determining the infectious period can be challenging. In these situations, collecting information about when the asymptomatic individual with [CONDITION(S)]-CoV-2 infection may have been exposed could help inform the period when they were infectious. i. If the date of exposure cannot be determined, although the infectious period could be longer, it is reasonable to use a starting point of 2 days prior to the positive test through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions for contact tracing Review of QSO-20-38-NH, REVISED 03/10/2022, stated Newly identified COVID19 positive staff or resident in a facility that can identify close contacts: Test all staff, regardless of vaccination status, that had a higher-risk exposure with a COVID-19 positive individual. Test all residents, regardless of vaccination status, that had close contact with a COVID-19 positive individual. Newly identified COVID19 positive staff or resident in a facility that is unable to identify close contacts: test all staff, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred (e.g., unit, floor, or other specific area(s) of the facility). Test all residents, regardless of vaccination status, facility-wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility). Testing of Staff and Residents During an Outbreak Investigation A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g., facility-wide) testing. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. During an interview on 08/29/22 at 9:16 AM during the entrance conference, the Administrator stated there were no active COVID-19 cases in the building and that the facility was not in outbreak status. Review of the facility's COVID-19 testing logs provided by the Infection Preventionist (IP) revealed 17 residents tested positive for COVID-19 since July 1, 2022, which constituted an outbreak. The following residents tested positive for COVID-19: 1. Review of R18's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed she was readmitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R18's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/13/22 with symptoms starting on 07/13/22. Symptoms included cough and congestion. Review of R18's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/13/22 and was experiencing cough and congestion. 2. Review of R56's Face Sheet located in the EMR under the Face Sheet tab revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R56's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/01/22 with a fever starting on 07/01/22. Review of R56's Progress Notes located in the EMR under the Progress Notes tab indicated the resident had an elevated temperature, along with positive COVID-19 test. 3. Review of R69's Face Sheet, located in the EMR under the Face Sheet tab revealed he was readmitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R69's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/11/22 with recent exposure and symptoms including cough and runny nose. Review of R69's Progress Notes located in the EMR under the Progress Notes tab indicated on 07/18/22 the resident was on isolation precautions related to positive COVID-19 test. On 07/13/22 the resident was noted to have difficulty breathing while lying flat. 4. Review of R78's Face Sheet, located in the EMR under the Face Sheet tab revealed she was readmitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R78's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/31/22 and was symptomatic. Symptoms started on 07/29/22 which included cough and fatigue. The resident was sent to the hospital on 08/07/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R78's Progress Notes located in the EMR under the Progress Notes tab indicated the resident complained of having a cough and not feeling well on 07/29/22. COVID-19 test was negative on 07/29/22. On 07/31/22 COVID-19 test repeated with positive results. The resident was experiencing loose stools and productive cough. 5. Review of R85's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was readmitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R85's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/01/22 with no symptoms reported but had been recently exposed. Review of R85's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/01/22 with no symptoms reported. 6. Review of R110's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R110's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/08/22 with no symptoms reported but had been recently exposed. Review of R110's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/08/22, chest x-ray results indicated right lower lobe infiltrates, and was experiencing a dry, non-productive cough, and poor appetite. 7. Review of R120's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R120's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/01/22 with no symptoms reported but had been recently exposed. Review of R120's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/01/22 with symptoms including headache. 8. Review of R154's Face Sheet located in the EMR under the Face Sheet tab, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R154's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/01/22, was symptomatic and had recently been exposed. Symptoms included cough and fatigue. Review of R154's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/01/22 and was experiencing cough. 9. Review of R155's Face Sheet located in the EMR under the Face Sheet tab revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R155's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/04/22 with no symptoms reported but had been recently exposed. Review of R155's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/04/22 per dietician's notes. Nursing note dated 08/05/22 indicated orders were received to discharge the resident home with no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 10. Review of R255's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was readmitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R255's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/08/22 with symptoms starting on 07/08/22. Symptoms included congestion and headache. Review of R255's Progress Notes located in the EMR under the Progress Notes tab indicated the resident had episodes of coughing on 07/10/22, then on 07/11/22 R255 noted to be on isolation precautions related to COVID-19. 11. Review of R258's Face Sheet, located in the EMR under the Face Sheet tab revealed he was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R258's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/04/22 with symptoms starting on 07/04/22. Symptoms included fever and cough. The resident went to the hospital on 07/04/22 and did not return. Review of R258's Progress Notes located in the EMR under the Progress Notes tab indicated the resident complained of difficulty breathing while lying flat on 07/02/22. On 07/04/22 the resident complained of coughing, had a fever, and that he felt like he had the flu. Rapid COVID-19 test was positive and the resident was placed on isolation precautions. The resident was transferred to the emergency department for evaluation and treatment. 12. Review of R259's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R259's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/08/22 with symptoms starting on 07/08/22. Symptoms included congestion. Review of R259's Progress Notes located in the EMR under the Progress Notes tab did not document COVID-19 status until 07/13/22, stating resident resting no acute respiratory symptoms noted r/t [related to] COVID-19 . 13. Review of R260's Face Sheet, located in the EMR under the Face Sheet tab, revealed he was readmitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R260's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/09/22 with symptoms starting on 07/08/22. Symptoms included fever. Review of R260's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested negative for COVID-19 on 07/08/22 but noted with 101.4 temperature. On 07/11/22 resident diagnosed with pneumonia. On 07/13/22 progress note indicated positive COVID-19 test results. 14. Review of R261's Face Sheet, located in the EMR under the Face Sheet tab revealed he was readmitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R261's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/09/22 with symptoms starting on 07/08/22. Symptoms included cough. Review of R261's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/09/22. Symptoms included intermittent coughing. 15. Review of R262's Face Sheet, located in the EMR under the Face Sheet tab revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R262's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/11/22 with recent exposure and symptoms including coughing and runny nose. Review of R262's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/11/22 and had generalized pain. 16. Review of R263's Face Sheet, located in the EMR under the Face Sheet tab revealed he was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R263's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/14/22 with symptoms starting on 07/14/22. Symptoms included coughing. Review of R263's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/14/22 and was experiencing loose stools on 07/18/22. 17. Review of R264's Face Sheet, located in the EMR under the Face Sheet tab, revealed he was readmitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R264's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/15/22 with recent exposure and symptoms included not feeling well. Review of R264's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/11/22, no symptoms noted. Review of the facility's COVID-19 testing logs provided by the Infection Preventionist (IP) revealed 17 staff tested positive for COVID-19 since July 1, 2022, which constituted an outbreak. The following staff members tested positive for COVID-19: 13.Review of Certified Nursing Assistant (CNA)s COVID-19 testing log indicated CNA13 tested positive for COVID-19 with an antigen covid test on 07/01/22. Symptoms started on 06/30/22 which included chills and body aches. The staff member had cared for a resident on 06/27/22 that later tested positive for COVID-19. 2. On 07/04/22, Registered Nurse (RN)1 tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/03/22 which included chills and fatigue. 3. On 07/05/22, the Assistant Director of Nursing (ADON) tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/04/22 which included sore throat. 4. On 07/07/22, Licensed Practical Nurse (LPN)2 tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/06/22 which included chills and body aches. 5. On 07/08/22, CNA2 tested positive for COVID-19 with an antigen covid test. Symptoms included sinus drainage and sore throat. 6. On 07/08/22, LPN9 tested positive for COVID-19 with an antigen covid test. Symptoms included sore throat. 7. On 07/08/22, CNA3 tested positive for COVID-19 with PCR covid test. Unspecified symptoms started on 07/03/22. 8. On 07/11/22, the Assistant Administrator(AA) tested positive for COVID-19 with antigen covid test. Symptoms included cough, runny nose, and headaches. 9. On 07/14/22, Certified Occupational Therapy Assistant (COTA) 1 tested positive for COVID-19 with antigen covid test. Symptoms included sore throat, cough, and congestion. 10. On 07/18/22, Former MDS (Minimum Data Set) nurse tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/17/22 included congestion. 11. On 07/26/22, Physical Therapist (PT)1 tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/25/22 included sore throat. 12. On 07/28/22, Food Services Supervisor tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/27/22 which included cough and sore throat. 13. On 08/11/22, LPN1 tested positive for COVID-19 with an antigen covid test. Symptoms started on 08/08/22 which included fever, chills, and sore throat. 14. On 08/11/22, the Receptionist/Cosmetologist tested positive for COVID-19 with PCR test. Staff member reported no symptoms. 15. On 08/11/22, Dietary Partner (DP1)tested positive for COVID-19 with an antigen covid test. Symptoms included headaches and body aches. 16. On 08/24/22, Housekeeper 1 (HSK1) tested positive for COVID-19 with an antigen covid test after working at the facility 7:00 AM-2:21 PM. Symptoms included runny nose and diarrhea. 17. On 08/26/22, Housekeeper 2 (HSK2) tested positive for COVID-19 with an antigen covid test. The last day worked was 08/23/22. Symptoms included congestion and cough. Review of the testing logs confirmed only routine testing for staff was completed for those staff members that were not vaccinated or were partially vaccinated despite the facility being in an outbreak. Further review of the testing logs confirmed staff and residents were tested when symptomatic but not as the result of outbreak testing. During an interview on 08/29/22 at 7:15 PM with the IP stated she performed Contact Tracing which only included interviewing of the two positive staff members, HSK1 and HSK2. During an interview with the IP, with the Administrator and survey team present on 08/29/22 at 7:18 PM, the IP stated she interviewed Housekeeper 1 on 08/24/22 and the staff member stated she was not in contact with any residents or staff longer than 15 minutes or within 6-foot distance. HSK1 had worked her shift on an unknown part of the facility and contact tracing was not done to determine which residents or staff were in contact with the positive staff member. During an interview on 08/29/22 at 7:18 PM with the IP and the Administrator present, the IP stated she interviewed Housekeeper 2 on 08/26/22 and the staff member told her they were not in contact with any residents or staff longer than 15 minutes or within 6-foot distance. Only the two staff members that tested positive (HSK1, HSK2) were tested due to her determining there was no high-risk exposure, so she didn't do full contact tracing. The IP stated she had not contacted the supervisor to determine exactly where the staff worked for their shifts. No additional staff members or residents were tested due to not being in proximity for more than 15 minutes per staff interviews with HSK1 and HSK2. During an interview on 08/30/22 at 3:20 PM, the IP stated on 08/11/22 she had an interview with the Cosmetologist/Receptionist who stated she was in contact with three residents and contact tracing was done. For Dietary Partner (DP)1 on 8/15/22 contact tracing was not done due to no exposure to residents or other staff for more than 15 minutes. During an interview on 08/30/22 at 3:41 PM, the Environmental Services Manager (ESM), stated HSK2 worked on 8/22/22 and 8/23/22 in the laundry room. On 8/24/22-8/25/22 HSK2 was off work. On 08/26/22 he called and said he was feeling funny, they tested him in the back parking lot, rapid test results were positive, and he has not returned back to work as of 08/30/22. Regarding HSK1 who tested positive on 8/24/22. HSK1 did the PCR test on 8/22/22 (worked Magnolia wing), test came back negative on 8/23/22 (worked Magnolia wing 100 hall, resident rooms, and administrative office), then she was still feeling bad on 8/24/22 midway through the shift, she was tested with a rapid COVID-19 test, and it came back positive. She returned to work 08/30/22 with negative results test. HSK1 always cleans resident rooms on the Magnolia Unit and cleans the administrative offices at entrance of the facility. During an interview on 08/31/22 at 8:51 AM the Administrator stated the facility was doing broad based COVID-19 testing that included certain units that they felt may have been exposed, but not all staff and residents were tested as per guidance from CMS QSO-20-38-NH Revised states for outbreak testing. The facility only performed COVID-19 testing on residents and staff that may have been potentially exposed to COVID-19.

Based on review of the facility's policy, record review, observations, and staff interviews, the facility failed to check for placement of a gastrostomy (g)-tube prior to administering medications for 1 resident (Resident (R) 38) of 5 residents reviewed during medication administration. Findings include: Review of the facility's undated Feeding/Enteral Tube Medication Administration Procedure read, in pertinent part, Check tube placement by aspirating gastric contents (prior to water flush and medication administration). Review of R38's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab revealed R38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R38'sPhysician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R38'sG-Tube Care Plan, most recently dated 06/27/22 and found in the EMR under the Care Plan tab, read, in pertinent part, Problem: Risk for aspiration pneumonia secondary to tube feeding, poor cognition, and inability to always manage her secretions. Approaches included: Check PEG (g-tube) for placement prior to use per policy. Licensed Practical Nurse (LPN)4 was observed administering R38's medication via her g-tube on 08/30/22 at 12:06 PM. LPN 4 did not check the placement of R38's g-tube prior to flushing the tube with water and administering the [MEDICATION(S)]. During an interview with LPN4 on 08/30/22 at 12:13 PM, she indicated R38's continuous feeding had been discontinued at 10:00 AM that morning and would be restarted at about 1:00 PM that day. LPN4 acknowledged she did not check R38's g-tube placement prior to administering the water flush or medication and stated her Unit Manager (Registered Nurse (RN)2 told her the facility policy had changed and g-tube placement no longer needed to be checked prior to administering anything through a g-tube. During an interview with RN2 on 08/30/22 at 12:18 PM, she verified her understanding was g-tube placement did not need to be checked prior to administering medication through the tube. RN2 stated, That policy changed more than two years ago. During an interview on 09/01/22 at 1:18 PM, the Director of Nursing (DON) verified her expectation was g-tube placement to be checked prior to the administration of fluid, medication, and nutrition and that the policy had not changed concerning checking placement.

Based on review of the facility policy, record review, and staff interviews, the facility failed to ensure the appropriate use of side rails for 2 Residents (R), R7 and R38 of 4 residents reviewed for accidents. Findings include: The facility's side rail policies were requested on 09/01/22 at 10:34 AM and were not received prior to facility exit. In an interview conducted with the Director of Nursing (DON) at the time of the request, she indicated side rails were addressed for each resident specifically as part of each resident's individualized plan of care. 1. Review of R38's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab, revealed R38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R38's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/22/22 indicated R38 was dependent upon two or more staff for all mobility, including mobility within her bed and transfers in and out of her bed. Review of R38's Physician Order Report, dated 08/01/22 through 09/01/22 and found in the EMR under the Orders tab, indicated no orders for the use of side rails. R38's comprehensive care plan, most recently dated 06/27/22 and found in the EMR under the Care Plan tab, was reviewed and indicated no care plan had been developed for R38's use of side rails. Review of R38's Siderails Utilization Assessment, dated 09/01/22 and found in the EMR under the Observations tab, indicated R38 was not appropriate for the use of side rails. R38 was observed lying in her bed, awake and nonverbal, on 08/29/22 at 4:28 PM, 08/31/22 at 9:52 AM, 12:00 PM, and 2:47 PM, and on 09/01/22 at 8:44 AM. R38 was able to make nonsensical vocal noises at times during the observations, but did not appear to be able to move any part of her body on her own. Bilateral 1/4 side rails were observed to be in the raised position on the resident's bed during each of the observations. During an interview with Certified Nursing Assistant (CNA)5 and CNA6 together on 09/01/22 at 8:49 AM, both staff members indicated they were familiar with R38, and both stated R38 required total care/assist with movement in her bed. Both staff members stated R38 was not able to use her side rails to assist with movement. CNA 6 stated, She [R38] is not able to use them [the side rails] at all. During an interview with Unit Manager Registered Nurse (RN)2 on 09/01/22 at 8:58 AM, she confirmed R38 required total assistance from staff to move in her bed. RN2 stated, She [R38] does not use any intentional movement to help reposition herself. During a follow-up interview with RN2 on 09/01/22 at 9:32 AM, she stated, She [R38] does not need the [side] rails. R38 was observed with RN2. RN2 acknowledged the bilateral side rails on R38's bed and RN2 stated she would contact maintenance to remove the rails from the bed. 2. Review of R7's undated Resident Face Sheet, found in the EMR under the Face Sheet tab revealed R38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R7's significant change MDS with an ARD of 08/22/22 indicated R7 was dependent upon two or more staff for all mobility, including mobility within her bed and transfers in and out of her bed. Review of R7's Physician Order Report, dated 08/01/22 through 09/01/22 and found in the EMR under the Orders tab, indicated no orders for the use of side rails. R7's Activities of Daily Living Care Plan, most recently dated 06/03/22 and found in the EMR under the Care Plan tab, was reviewed and read, in pertinent part, Problem: Continues with extensive to essentially total care per staff re [related to] her history of [CONDITION(S)] [stroke]. Approaches included: 2 (1/4) grab bars to assist with turning and positioning. Review of R7's Siderails Utilization Assessment, dated 08/11/22 and found in the EMR under the Observations tab, indicated R7 was unable to utilize the side rails as an enabler for mobility and indicated the use of the rails was not requested by the resident. The assessment, however, indicated the use of bilateral 1/4 side rails on the upper right and upper left portion of the resident's bed. R7 was observed lying in her bed on 08/30/22 at 1:51 PM and 1:57 PM, and on 08/31/22 at 12:08 PM and 2:54 PM. Two 1/4 rails were observed to be in the raised position during each of the observations. During an interview with Unit Manager (UM) Licensed Practical Nurse (LPN)3 on 08/30/22 at 1:57 PM, R7 was observed lying in her bed with both side rails in the raised position. LPN3 acknowledged the rails on R7's bed and stated, [R7] does not move at all independently. She is completely dependent [on staff to move in her bed.] During a follow-up interview with LPN3 on 09/01/22 at 9:11 AM, she confirmed R7 was totally dependent upon staff for movement from side to side. LPN3 stated, At one time she [R7] was able to hold on to the bar [side rail] to move from side to side. Now she's not able to use them [the side rails] due to a recent change in condition. LPN3 stated R7 no longer needed the rails on her bed. During an interview with the Director of Nursing (DON) on 09/01/22 at 9:36 AM, she stated side rails were typically used by residents for turning and repositioning in bed. The DON stated if a resident was not able to assist with repositioning in bed the side rails were not needed and should be removed from the resident's bed.

Based on policy review and interview, the facility failed to ensure that 2 of 8 staff (Certified Nursing Assistant (CNA)7 and CNA8) reviewed for COVID-19 vaccination status were fully vaccinated. This failure increases the risk of transmission of COVID-19 to residents and other staff members. Findings include: Review of the facility's policy titled Human Resources Policies and Procedures CMS Emergency Regulation- Mandatory COVID-19 Vaccine, revised 03/18/22, stated Our company requires all employees to receive the COVID-19 vaccine .If you are hired, the company will require you to prove that you have received the COVID-19 vaccine or have a valid medical or religious reason not to be vaccinated .New hires will be subject to the same requirements as current staff and must have received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the center/agency and/or its patients .The employer shall require and maintain documentation for each eligible individual (including new hires) proof of current vaccination against COVID-19 or the individual's completed COVID-19 Vaccination Declination Form (with vaccine exemption documentation with required exemption approval, as appropriate), and a system to track the vaccination status of all personnel (such as the CDC staff vaccination tracking tool available on the NHSN website). Review of facility document titled, Employee Listing, dated 08/31/22, provided by the facility indicated CNA7 was hired on 07/20/22 and CNA8 was hired on 06/29/22. Review of facility's untitled document provided by the Administrator on 09/01/22 included a line listing for staff including any/all doses of COVID-19 immunizations. CNA7 received an initial Moderna COVID-19 immunization on 01/25/22 with no additional doses documented. CNA8 received an initial Pfizer COVID-19 immunization on 06/10/22 with no additional doses documented. During an interview on 09/01/22 at 3:53 PM, the Infection Preventionist (IP) stated staff are considered fully vaccinated for COVID-19 if they have received the single-dose of Johnson & Johnson vaccine, or both doses of the two-dose Moderna or Pfizer vaccinations. The IP stated that if any staff are unvaccinated for COVID-19 they should have a medical or religious exemption in their employee file. The IP confirmed that CNA7 had received an initial dose of Moderna COVID-19 on 01/25/22 and had not received the second dose. Additionally, the IP stated the process for ensuring that staff are up to date on COVID-19 immunizations included notification of the nursing manager that specific staff members were due for the second dose of the immunization or boosters per CDC guidelines. During an interview on 09/01/22 at 4:31 PM, IP stated she spoke with CNA7 who told her that she was interested in getting an exemption for the remaining COVID-19 immunizations. During an interview on 09/01/22 at 4:32 PM, the IP confirmed CNA8 had received an initial dose of Pfizer COVID-19 on 06/10/22 and had not received the second dose.

Based on observation, interview, and review of facility policy and procedure, the facility failed to ensure that the barrier for the Covid-19 unit was intact without any holes from the non Covid-19 section of the unit and Personal Protective Equipment (PPE) was appropriately doffed prior to leaving from the Covid-19 unit of the building and entering the Non-Covid-19 units of the facility for 1 of 3 units observed. Findings include: Review of undated facility policy titled, Procedure for Partners Working the Covid Unit stated, Partners working the Covid unit enter at the designated entry point for the unit .Once on the unit do not leave the unit or enter any other part of the center .At the end of the shift discard all PPE upon exiting the unit at the exterior door, perform hand hygiene. Exit the building thorough the designated Covid unit entry/exit. 1. During an observation between the Covid-19 barrier and the Magnolia unit on 09/23/21 at 12:00 PM revealed, two areas of the Covid-19 barrier wall and the Magnolia unit with cup-size holes in the plastic lining near the lower section of the barrier. Surveyor able to observe the floor area on the other side of the barrier. An interview with the Administrator on 09/23/21 at 4:10 PM revealed, Maintenance is responsible for keeping it taunt and fixed. Black areas of tape on the wall is just from wear and tear. Everyone is responsible for making sure it's secure. 2. During an observation between the Covid-19 barrier and the Magnolia unit on 09/23/21 at 12:24 PM revealed, Health Information Management 1 exited the Covid-19 unit through a zippered section in the barrier by the nurses station without removing PPE and/or washing hands post exit. HIM 1 went directly into a residents room on the Magnolia unit who did not have a mask donned while sitting in a wheelchair. The resident was taken to the dining room area by a Certified Nursing Assistant (CNA) with four other residents eating without mask donned and two other CNA's assisting the residents. An interview with HIM 1 on 09/23/21 at 12:26 PM stated, I place names on the doors in the Covid unit. I didn't go around any patients, I just put the names on the doors. I wasn't doing anything with the resident in the room. I just remove my lab coat and place it in the laundry bin when I finish with it. An interview with Infection Preventionist 1 stated, The staff is to enter the Covid unit from the outside of the building. Any staff who may have to go to the unit should go from clean to dirty and then exit from the Covid unit and not re-enter the building.

Based on observations, record reviews, interviews, and review of facility policy, it was determined for one (1) of 47 sampled residents (Resident #61) that the facility failed to ensure the resident's environment remained as free of accident hazards as possible. The facility also failed to ensure the resident received adequate supervision and assistance to prevent accidents. The facility failed to ensure Resident #61's safety by not ensuring this cognitively impaired resident, who had a history of wandering and multiple falls, was properly supervised to keep the resident safe. The facility's failure to supervise Resident #61 resulted in harm to the resident when s/he fell while unattended outside in the Courtyard and sustained fractures to his/her third (3rd) and fourth (4th) Metacarpals (fingers) of the left hand. Findings Include: Review of the facility policy entitled Falls Safety, dated/revised September 8, 2020 revealed Purpose: To assess residents for risk of falls and initiate appropriate interventions. Procedure: When admitted to the facility, complete Falls Risk Assessment. When a fall occurs assess resident status. Assess position of the resident immediately after the fall. Notify Medical Doctor (MD) and responsible party of fall. Review situation regarding the fall and initiate the appropriate intervention(s) as necessary. Falls Check List: Falls event completed in the Matrix-care including vitals and notification. Asked, Patient what they were trying to do, at the time of the fall and document Family Representative, MD/NP notified and documented in progress notes Fall documentation seventy-two (72) hour initiated in Matrix-Care (Located in routine orders) Progress note: 72-hour fall charting for each entry unit it is completed. Statement from Partners. Discuss with Partners Interventions and Prevention. Report given to next nurse. Place in Nurse Manager box after completion. Review of the clinical record revealed Resident #61 was admitted into the facility on [DATE]. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 6/21/21, to have diagnoses of Falls, History of wandering that occurred daily, Unsteady gait of mobility, Moderately impaired vision, Moderately impaired hearing, Alzheimer's disease, Dementia with behavioral disturbance, Essential (primary) hypertension, [CONDITION(S)], Circadian rhythm sleep disorder, Overactive bladder, and Cognitive Communication Deficit. Under Section G of the MDS, the Resident was assessed as requiring supervision for Activities of Daily Living (ADL's) to include walk in corridor, locomotion on and off the unit. Resident #61 had a Brief Interview for Mental Status (BIMS) score of two (2) which indicated severely impaired cognition. The MDS revealed Resident #61 did not participate in skilled therapies or special treatments. Review of the Care Plan dated, 7/24/2020, revealed Resident #61 had fall injury risks related to his/her cognitive deficits and a tendency to ambulate without regard to fatigue; use of cardiac and psychoactive medications; 6/17/21 fell in Courtyard, his/her most recent fall risk assessment score dated 7/22/21 was 15 indicating the resident was at high risk of falling. ADL function/limited to extensive assist related to his/her diagnoses of cognitive deficits, pleasantly confused; not always able to follow tasks through to completion; he/she risk for overall decline in current abilities relates to cognitive deficits. Resident had diagnoses of Dementia and Alzheimer's Disease. Confusion and forgetfulness were noted daily. Resident#61 benefited from verbal cues and reminders-especially for safety. Goals for R#61 included: Resident will continue to have risk for falls with injury addressed and minimized with staff assessing for changes in his/her function and mobility over the next 90 days. Will continue to have ADL needs met with staff assistance with ADL completion over the next 90 days. Resident will not injure self, secondary to impaired decision making. Approaches included: increase rounding by all staff; resident to be encouraged to remain on the unit in populated areas as tolerated; occupy resident with meaningful distractions, medication review as needed for changes in his/her mobility or function; increased falls. Ensure resident is wearing appropriate footwear. Note vision impaired secondary to [CONDITION(S)]. Non-skid footwear while up, anticipate needs resident has un-steady gait and will not always call for assist due to cognitive impairment. Intervene as indicated. Call light in reach, bed in lowest position. Wander-guard-check every shift, expiration 1/2022. Monitor for exit seeking behaviors, wandering into unsafe areas, and entering other resident rooms un-invited. Review of the facility's John Hopkins Fall Risk Assessments Tools dated, 1/18/21, indicated that Resident #61 had a total fall risk score of 30 indicating the resident was at high or very high risk of falling. The assessment dated [DATE] noted Resident #61 had a total fall risk score of 12, indicating moderate risk of falling. The assessment dated [DATE] noted Resident #61 had a total fall risk score of 19, indicating the resident had a high or very high risk of falling. The facility provided a hand-written Fall Risk Assessment completed on 8/13/21 by the Nurse Manager revealing that on 6/17/21, the day of fall in the Courtyard, Resident #61 had a total fall risk score of 12, which indicated a moderate risk for falls. On 7/9/21, Resident #61 had a total fall risk score of 13, which indicated high or very high risk of falling. On 7/22/21, Resident #61 had a total score of 15, which indicated Resident #61 had a high or very high risk of falling. Review of the Facility's Walking assessment dated [DATE] revealed, shoes appropriate plus fit. Slippers are slip-on; Resident #61 can slip off the side or back of slippers. Slippers were given to the Nurse Manager. Recommended Resident wear shoes only. Resident does not follow instructions due to cognition, but able to rise to standing after loss of balance. Review of the facility's Post Investigation Root Cause Analysis Reports dated 10/27/2020 at 7:33 p.m. revealed Resident #61 had a fall with left wrist fracture and laceration to left eyebrow. The resident was in the bathroom being given a shower and fell on to the Certified Nursing Assistant (CNA) performing the shower. On 11/12/2020 at 11:15 p.m., Resident #61 walked backwards with his/her walker and fell on to buttocks. On 11/28/2020 at 9:13 p.m., Resident #61 entered another resident's room, other resident attempted to turn resident's walker with their walker and Resident #61 fell . On 6/17/21 at 3:30 p.m. Resident #61 was ambulating self in Courtyard and fell (between the 300 and 400 hall) receiving an abrasion to the right knee. Resident #61 resides on 100 unit. This fall investigation failed to complete the factors contributing to falls section on the report. On 7/9/21 a t11:15 a.m., Resident #61 ran up the hallway, bruising noted to face. This fall investigation failed to complete the factors contributing to the falls section. On 7/22/21 at 3:32 p.m., Resident #61 was ambulating on another unit, bruising to face and hand; factor that contributed to fall was footwear. The facility failed to provide a falls investigation report for a fall on 11/9/2020 at 6:59 p.m. Resident #61 was noted to have a fall and blood on his/her scalp. Review of the Facility's Progress Notes revealed: 10/27/2020 9:43 a.m. Resident #61 transferred to Hospital via stretcher related to fall. fell while getting dressed in bathroom, fall witnessed. Certified Nursing Assistant (CNA) informed that resident had fallen hitting his/her left side of face on the floor. Laceration to left eyebrow noted, dressing applied complained of pain in left wrist, vitals within normal limits. Neuro-checks started with no abnormalities noted at this time. Unit manager and Medical Doctor (MD) notified. Resident Representative called with no answer, waiting on return call. 11/09/2020 6:59 p.m. Resident #61 noted walking in the hallway with blood in the scalp. Asked the resident what happened, and he/she was unable to tell me. Resident #61 states no pain, scalp was cleaned with soap and water dressed and [MEDICATION(S)] topical ointment. Will continue to monitor change in level of consciousness (LOC). Resident to be sent to emergency room for evaluation and treatment if positive for change in LOC. (The facility did not provide an incident or investigation report for this fall.) 6/17/21 3:53 p.m. Resident #61 noted to be ambulating in Courtyard beside hall of another wing when fall occurred. Fall was witnessed by staff member (who was walking down the hall looking out the window between the units). Resident noted to get up on his/her own and continue walking. Staff member accompanied resident to his/her bedroom. Resident assessed and noted to have small topical abrasion on right knee from fall measuring (half) 0.5 centimeters (CM) diameter. No other injuries noted, area cleansed, and bandage applied. Resident does not complain of pain on Range of Motion, breathing even and unlabored, Resident Representative notified and voiced understanding. Will continue to monitor. 6/25/21 2:32 p.m. X-ray results received Resident #61 had fractures to the third (3rd) and fourth (4th) metacarpals with demineralization noted. Previous fracture also noted to left extremity. Results given to Nurse Practitioner (NP) and Medical Doctor (MD). Writer received the new order for [MEDICATION(S)] and Resident #61 an Orthopedic consult. Resident Representative made aware expressed wishes for the resident not to be sent to emergency room at this time. Will continue to monitor and assess for pain. 7/14/21 at 0:05 a.m. Upon chart review Resident #61 noted to have multiple falls over the previous months. Root cause identified as resident ambulating self frequently about the facility and holding on to objects within reach while doing so such as handrails, walls, and miscellaneous objects, redirection attempted on multiple occasions without success. Resident #61 still set to follow up with Orthopedics on 7/21/21. Resident having no on-going pain or difficulty related to previous fracture, able to feed self and aid in Activities of Daily Living (ADL's) care, continues to ambulate holding on to handrails without difficulty. Fall interventions in place such as low bed while occupied, non-skid footwear, increased monitoring while ambulating, medication review by pharmacy/Medical Doctor as indicated, Physical Therapy evaluation as indicated. Resident Representative (RP) and MD in agreement that benefit of continued independent mobility outweighs fall risk currently. 7/22/21 10:36 p.m. Unit manager called by another unit to notify them that Resident #61 had fallen on their unit and this nurse was notified, upon assessment Resident #61 noted to have hit his/her face and had a bruise to the right eye lid measuring one (1) [NAME]-meter (cm) by one-and-a-half (1.5) cm and a bruise to the top of right hand measuring one-and-a-half (1.5) cm in diameter. No open areas were noted, no other injuries found. Neuro-checks were initiated as per protocol. MD and RP notified. Resident #61 encouraged to sit down with no success and continues to ambulate around the facility. Staff continues to monitor, re-direct and assist to prevent any future incidents. 7/23/2021 03:15 p.m. Nurse Practitioner (NP) saw Resident #61 today related to previous fall, new orders written to x-ray right eye and right knee. Tylenol 500 milli-grams (mg) given by mouth every eight (8) hours. RP made aware. The facility did not provide any in-services related to supervision of Resident #61, furthermore the facility could not provide proof of hourly rounding for Resident #61. Several observations on 8/10/2021 -8/11/2021 from 9:30 a.m. until 2 p.m. revealed Resident #61 up ambulating on unit with another resident holding hands, had on white tennis shoes and brace to left hand and wrist, bruise to right side of face. Observation on 8/10/21 at 12:20 p.m. revealed Resident #61 in dining area eating lunch, staff holding hand assisting him/her to the lunch table. Had on white tennis shoes, brace to left hand and wrist, bruise to right side of face. Observation of the Resident #61 on 8/11/21 at 2:14 p.m. revealed R#61 sitting in day area with other residents watching television (tv), noted to have on white tennis shoes, bruise to right side of face, blue brace on left hand and wrist, and white Wander Guard to right lower ankle. Observation on 8/12/21 at 9:00 a.m. revealed Resident #61 asleep in bed. Bed in low position. Brace to left wrist and hand. Observation on 8/13/21 at 11:00 a.m. revealed Resident #61 asleep in bed, bed in low position and brace to left hand and wrist. An interview was conducted on 8/11/21 at 1:36 p.m. with the Director of Nursing (DON) while observing the Courtyard where Resident #61 fell . The DON revealed the resident was outside alone and no other staff or residents were out in the Courtyard. Resident #61 was observed on the ground in the grass close to the brushes by the dietician (who was walking in the hallway and looked out the window). The DON stated, s/he would expect Resident #61 to be supervised but is faster than us at times. An interview conducted on 8/11/21 at 2:16 p.m. with License Practical (LPN) Charge Nurse #4 revealed Resident #61 was alert and oriented to person ambulates about the unit, around the facility, and at times will go into the Courtyard. On the day of the fall 6/17/21 he/she was on a different unit on the other side of the building. It is my understanding s/he was outside trying to attend to a flower and fell in the bushes, Resident #61 had on pink slip on slippers with no back to them, I'm not sure how long s/he was off the unit; it is everyone's responsibility to supervise the resident even while off the unit it is a collaborative effort by all in the facility. Usually, I will get a call from other units that Resident #61 is over there on their unit. An interview was conducted on 8/11/21 at 2:41 p.m. with Certified Nursing Assistant CNA # 5 revealed that Resident #61 eats breakfast in his/her room and gets up around nine (9) or 10 a.m. The resident will ambulate around the unit and sometimes on other units. CNA#5 stated everyone in the building was responsible for supervising the resident on and off the unit, Resident #61 had been wearing pink house shoes for some time because his/her other shoes were too small. CNA #5 stated s/he recently asked the family to bring in a new pair of tennis shoes for the resident. CNA#5 stated I was on vacation the day Resident #61 fell in the Courtyard. Further interview on 8/12/21 at 10:50 a.m. with CNA #5 revealed I did work on 6/17/21 and got off around 3:15 p.m. but wasn't here when he/she fell . I took Resident #61 to the bathroom a little bit before 3:00 p.m., and that was the last time I seen the resident he/she was sitting in the day area watching tv before I left for the day. CNA #5 stated because of the fall with fracture and Resident #61 wandering around, we round every hour, if I don't see Resident #61, I start to look for him/her. The resident's room is so close to the exit door to the other units, I may not see him/her exit the unit if I'm busy. An interview was conducted with the Family of Resident #61 on 8/11/21 at 3:00 p.m. which revealed the family was notified of the falls but were not sure when because the residents' Son-in-Law may take two (2) weeks to call the facility back. The Family of Resident #61's stated his/her daughter and Son-in-Law were reclusive and stayed home and were not active in the resident's care. They did not visit. The Family of Resident #61 revealed pre-Covid-19 s/he would visit often; but had not been in the facility for a while due to personal issues. The family member stated s/he thought the facility was a nice place, but after some visits, was not happy with Resident #61's care. An interview was conducted on 8/12/21 at 9:18 a.m. with Dietician #7 revealed, I was walking down the hallway between 300 and 400 halls (not sure of the time) looked out the window and seen[sic] Resident #61 in the Courtyard leaning over looking at the flowers, s/he was alone, I did not see other resident's or staff, I noticed the resident was falling went to get the (DON) and then outside to help, Resident #61 got up and started walking towards us; did not complain of pain. I let the DON assess the resident then left. The resident fell in the grassy area but was probably standing on the sidewalk. Supervision for all Residents are[sic] our responsibility, we allowed them to walk around the entire facility even Dementia patients. Resident #61 resided on the100 hall at the time of the fall. An interview conducted on 8/12/21 at 9:37 a.m. with Unit Manager #3 revealed after Resident #61's fall, one of the nurses met the DON in the hallway to bring the resident back to Unit 100. At the time of the fall, I did not know how long Resident #61 was off the unit, and not sure if there was anyone out there with the Resident. The CNA's complete rounding and notice if a resident is off the unit, then we all look for them; with Resident #61's history of falls, it was expected that he/she be supervised more. We are increasing hourly rounding to make sure the Resident has tennis shoes or non-skid socks on. My definition for supervision is to ensure staff check on the resident hourly and if he/she is not on the unit they are expected to go find the resident. An interview conducted on 8/12/21 at 10:30 a.m. with the Administrator revealed, we have weekly fall meetings and if there is a fall in the building I'm notified right away. I was told the Dietician observed Resident #61 in the Courtyard fall, the resident got up on his/her own, at the time of the fall they did not identify any injury. Supervision depends on the Resident even Dementia residents, every person in the building has a responsibility to re-direct the resident and ensure they are safe. The Residents have the right to ambulate around the facility, I don't know if there was anyone out there during the fall, more frequent checks is/means keeping the Resident in a more populated area to be observed. The CNA assigned to the Resident and Nurse are responsible for checking on the Resident and if they are busy every partner in the building is responsible for supervision. If I'm a CNA I'm going to do my rounds and if I don't see the resident, I would ask anyone if they had seen him/her, than take a walk off the unit to look for them. The expectation is that the CNA would do that, the fall in the Courtyard was between shifts. The Administrator stated, other than putting Resident #61 in a Broda chair or chemically restraining him/her that is the only option other than sending the resident out of the facility to meet his/her needs. An interview conducted on 8/12/21 at 3:00 p.m. with Certified Nursing Assistant (CNA) #6 revealed, at 2:40 p.m. Resident #61 was laying down in his/her room, I started doing my vitals on the other resident's, I had no idea Resident #61 had left the unit, I noticed he/she was gone off the unit around 3:20 p.m., I started looking for the resident then checked the dining room, after that I met the DON coming from the 300 and 400 halls with Resident #61. The DON stated Resident #61 had fell so I took the resident back to the unit, there were no other Nurses or CNA's with me, Resident #61 had on black slippers, our training for Dementia residents is to check on them every 30 minutes to an hour. Supervision for all residents is the CNA's responsibility and I don't recall the other falls Resident #61 had on second shift. An interview on 8/13/21 at 9:23 a.m. with the Family of Resident #61 revealed he/she had been taking care of Resident #61's daughter who has short term memory loss for the last nine (9) years. We received a call yesterday 8/12/21 from the Social Services Director to come in and speak with you guys about the falls, Resident #61 has been here for a year, I believe he/she had three (3) incidents, one which caused a broken wrist, most recent injury three (3) weeks ago, we were told he/she had fallen, we discussed the option of going to the hospital, but we did not want to cause him/her any stress, so we decided to have the x-rays done in the facility. The resident was admitted during COVID-19, so we have not had much in-house observation due to that. This morning the facility added a note that he/she had on house slippers, they did not contact us about getting him/her shoes, most of the shoes upon admission were inappropriate we never had a face-to-face meeting upon admission, we were told the facility would ensure that Resident #61 would be supervised and monitored. The Administrator and Social Worker informed us today that is it essential to let him/her walk around the facility to maintain independence; the Administrator stated to us that putting the resident in a wheelchair would be the only other option, they ask us how we felt, I told them closing the wing or using mechanical doors would be an option to keep Resident #61 from roaming off the unit into other areas and the Courtyard to stay safe. The facility failed to adequately supervise Resident #61 to prevent injury from a fall in the Courtyard, furthermore there were discrepancies from staff during the interviews as to how long Resident #61 was off the unit. Several of the fall investigations were not completed to include Factors Contributing to the falls. The facility did not provide a fall investigation for the fall on 11/9/2020 that included the scalp injury and failed to ensure that proper footwear was provided for Resident #61 until the last fall on 7/22/21.

Based on observations, record reviews, interviews, and review of facility policy, it was determined for one (1) of 47 sampled residents (Resident #61) that the facility failed to ensure the resident's environment remained as free of accident hazards as possible. The facility also failed to ensure the resident received adequate supervision and assistance to prevent accidents. The facility failed to ensure Resident #61's safety by not ensuring this cognitively impaired resident, who had a history of wandering and multiple falls, was properly supervised to keep the resident safe. The facility's failure to supervise Resident #61 resulted in harm to the resident when s/he fell while unattended outside in the Courtyard and sustained fractures to his/her third (3rd) and fourth (4th) Metacarpals (fingers) of the left hand. Findings Include: Review of the facility policy entitled Falls Safety, dated/revised September 8, 2020 revealed Purpose: To assess residents for risk of falls and initiate appropriate interventions. Procedure: When admitted to the facility, complete Falls Risk Assessment. When a fall occurs assess resident status. Assess position of the resident immediately after the fall. Notify Medical Doctor (MD) and responsible party of fall. Review situation regarding the fall and initiate the appropriate intervention(s) as necessary. Falls Check List: Falls event completed in the Matrix-care including vitals and notification. Asked, Patient what they were trying to do, at the time of the fall and document Family Representative, MD/NP notified and documented in progress notes Fall documentation seventy-two (72) hour initiated in Matrix-Care (Located in routine orders) Progress note: 72-hour fall charting for each entry unit it is completed. Statement from Partners. Discuss with Partners Interventions and Prevention. Report given to next nurse. Place in Nurse Manager box after completion. Review of the clinical record revealed Resident #61 was admitted into the facility on 7/24/2020. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 6/21/21, to have diagnoses of Falls, History of wandering that occurred daily, Unsteady gait of mobility, Moderately impaired vision, Moderately impaired hearing, Alzheimer's disease, Dementia with behavioral disturbance, Essential (primary) hypertension, Hyperlipidemia, Circadian rhythm sleep disorder, Overactive bladder, and Cognitive Communication Deficit. Under Section G of the MDS, the Resident was assessed as requiring supervision for Activities of Daily Living (ADL's) to include walk in corridor, locomotion on and off the unit. Resident #61 had a Brief Interview for Mental Status (BIMS) score of two (2) which indicated severely impaired cognition. The MDS revealed Resident #61 did not participate in skilled therapies or special treatments. Review of the Care Plan dated, 7/24/2020, revealed Resident #61 had fall injury risks related to his/her cognitive deficits and a tendency to ambulate without regard to fatigue; use of cardiac and psychoactive medications; 6/17/21 fell in Courtyard, his/her most recent fall risk assessment score dated 7/22/21 was 15 indicating the resident was at high risk of falling. ADL function/limited to extensive assist related to his/her diagnoses of cognitive deficits, pleasantly confused; not always able to follow tasks through to completion; he/she risk for overall decline in current abilities relates to cognitive deficits. Resident had diagnoses of Dementia and Alzheimer's Disease. Confusion and forgetfulness were noted daily. Resident#61 benefited from verbal cues and reminders-especially for safety. Goals for R#61 included: Resident will continue to have risk for falls with injury addressed and minimized with staff assessing for changes in his/her function and mobility over the next 90 days. Will continue to have ADL needs met with staff assistance with ADL completion over the next 90 days. Resident will not injure self, secondary to impaired decision making. Approaches included: increase rounding by all staff; resident to be encouraged to remain on the unit in populated areas as tolerated; occupy resident with meaningful distractions, medication review as needed for changes in his/her mobility or function; increased falls. Ensure resident is wearing appropriate footwear. Note vision impaired secondary to Macular Degeneration. Non-skid footwear while up, anticipate needs resident has un-steady gait and will not always call for assist due to cognitive impairment. Intervene as indicated. Call light in reach, bed in lowest position. Wander-guard-check every shift, expiration 1/2022. Monitor for exit seeking behaviors, wandering into unsafe areas, and entering other resident rooms un-invited. Review of the facility's John Hopkins Fall Risk Assessments Tools dated, 1/18/21, indicated that Resident #61 had a total fall risk score of 30 indicating the resident was at high or very high risk of falling. The assessment dated [DATE] noted Resident #61 had a total fall risk score of 12, indicating moderate risk of falling. The assessment dated [DATE] noted Resident #61 had a total fall risk score of 19, indicating the resident had a high or very high risk of falling. The facility provided a hand-written Fall Risk Assessment completed on 8/13/21 by the Nurse Manager revealing that on 6/17/21, the day of fall in the Courtyard, Resident #61 had a total fall risk score of 12, which indicated a moderate risk for falls. On 7/9/21, Resident #61 had a total fall risk score of 13, which indicated high or very high risk of falling. On 7/22/21, Resident #61 had a total score of 15, which indicated Resident #61 had a high or very high risk of falling. Review of the Facility's Walking Assessment dated 7/29/21 revealed, shoes appropriate plus fit. Slippers are slip-on; Resident #61 can slip off the side or back of slippers. Slippers were given to the Nurse Manager. Recommended Resident wear shoes only. Resident does not follow instructions due to cognition, but able to rise to standing after loss of balance. Review of the facility's Post Investigation Root Cause Analysis Reports dated 10/27/2020 at 7:33 p.m. revealed Resident #61 had a fall with left wrist fracture and laceration to left eyebrow. The resident was in the bathroom being given a shower and fell onto the Certified Nursing Assistant (CNA) performing the shower. On 11/12/2020 at 11:15 p.m., Resident #61 walked backwards with his/her walker and fell onto buttocks. On 11/28/2020 at 9:13 p.m., Resident #61 entered another resident's room, other resident attempted to turn resident's walker with their walker and Resident #61 fell. On 6/17/21 at 3:30 p.m. Resident #61 was ambulating self in Courtyard and fell (between the 300 and 400 hall) receiving an abrasion to the right knee. Resident #61 resides on 100 unit. This fall investigation failed to complete the factors contributing to falls section on the report. On 7/9/21 a t11:15 a.m., Resident #61 ran up the hallway, bruising noted to face. This fall investigation failed to complete the factors contributing to the falls section. On 7/22/21 at 3:32 p.m., Resident #61 was ambulating on another unit, bruising to face and hand; factor that contributed to fall was footwear. The facility failed to provide a falls investigation report for a fall on 11/9/2020 at 6:59 p.m. Resident #61 was noted to have a fall and blood on his/her scalp. Review of the Facility's Progress Notes revealed: 10/27/2020 9:43 a.m. Resident #61 transferred to Hospital via stretcher related to fall. Fell while getting dressed in bathroom, fall witnessed. Certified Nursing Assistant (CNA) informed that resident had fallen hitting his/her left side of face on the floor. Laceration to left eyebrow noted, dressing applied complained of pain in left wrist, vitals within normal limits. Neuro-checks started with no abnormalities noted at this time. Unit manager and Medical Doctor (MD) notified. Resident Representative called with no answer, waiting on return call. 11/09/2020 6:59 p.m. Resident #61 noted walking in the hallway with blood in the scalp. Asked the resident what happened, and he/she was unable to tell me. Resident #61 states no pain, scalp was cleaned with soap and water dressed and Bactroban topical ointment. Will continue to monitor change in level of consciousness (LOC). Resident to be sent to emergency room for evaluation and treatment if positive for change in LOC. (The facility did not provide an incident or investigation report for this fall.) 6/17/21 3:53 p.m. Resident #61 noted to be ambulating in Courtyard beside hall of another wing when fall occurred. Fall was witnessed by staff member (who was walking down the hall looking out the window between the units). Resident noted to get up on his/her own and continue walking. Staff member accompanied resident to his/her bedroom. Resident assessed and noted to have small topical abrasion on right knee from fall measuring (half) 0.5 centimeters (CM) diameter. No other injuries noted, area cleansed, and bandage applied. Resident does not complain of pain on Range of Motion, breathing even and unlabored, Resident Representative notified and voiced understanding. Will continue to monitor. 6/25/21 2:32 p.m. X-ray results received Resident #61 had fractures to the third (3rd) and fourth (4th) metacarpals with demineralization noted. Previous fracture also noted to left extremity. Results given to Nurse Practitioner (NP) and Medical Doctor (MD). Writer received the new order for Tramadol and Resident #61 an Orthopedic consult. Resident Representative made aware expressed wishes for the resident not to be sent to emergency room at this time. Will continue to monitor and assess for pain. 7/14/21 at 0:05 a.m. Upon chart review Resident #61 noted to have multiple falls over the previous months. Root cause identified as resident ambulating self frequently about the facility and holding on to objects within reach while doing so such as handrails, walls, and miscellaneous objects, redirection attempted on multiple occasions without success. Resident #61 still set to follow up with Orthopedics on 7/21/21. Resident having no on-going pain or difficulty related to previous fracture, able to feed self and aid in Activities of Daily Living (ADL's) care, continues to ambulate holding on to handrails without difficulty. Fall interventions in place such as low bed while occupied, non-skid footwear, increased monitoring while ambulating, medication review by pharmacy/Medical Doctor as indicated, Physical Therapy evaluation as indicated. Resident Representative (RP) and MD in agreement that benefit of continued independent mobility outweighs fall risk currently. 7/22/21 10:36 p.m. Unit manager called by another unit to notify them that Resident #61 had fallen on their unit and this nurse was notified, upon assessment Resident #61 noted to have hit his/her face and had a bruise to the right eye lid measuring one (1) [NAME]-meter (cm) by one-and-a-half (1.5) cm and a bruise to the top of right hand measuring one-and-a-half (1.5) cm in diameter. No open areas were noted, no other injuries found. Neuro-checks were initiated as per protocol. MD and RP notified. Resident #61 encouraged to sit down with no success and continues to ambulate around the facility. Staff continues to monitor, re-direct and assist to prevent any future incidents. 7/23/2021 03:15 p.m. Nurse Practitioner (NP) saw Resident #61 today related to previous fall, new orders written to x-ray right eye and right knee. Tylenol 500 milli-grams (mg) given by mouth every eight (8) hours. RP made aware. The facility did not provide any in-services related to supervision of Resident #61, furthermore the facility could not provide proof of hourly rounding for Resident #61. Several observations on 8/10/2021 -8/11/2021 from 9:30 a.m. until 2 p.m. revealed Resident #61 up ambulating on unit with another resident holding hands, had on white tennis shoes and brace to left hand and wrist, bruise to right side of face. Observation on 8/10/21 at 12:20 p.m. revealed Resident #61 in dining area eating lunch, staff holding hand assisting him/her to the lunch table. Had on white tennis shoes, brace to left hand and wrist, bruise to right side of face. Observation of the Resident #61 on 8/11/21 at 2:14 p.m. revealed R#61 sitting in day area with other residents watching television (tv), noted to have on white tennis shoes, bruise to right side of face, blue brace on left hand and wrist, and white Wander Guard to right lower ankle. Observation on 8/12/21 at 9:00 a.m. revealed Resident #61 asleep in bed. Bed in low position. Brace to left wrist and hand. Observation on 8/13/21 at 11:00 a.m. revealed Resident #61 asleep in bed, bed in low position and brace to left hand and wrist. An interview was conducted on 8/11/21 at 1:36 p.m. with the Director of Nursing (DON) while observing the Courtyard where Resident #61 fell. The DON revealed the resident was outside alone and no other staff or residents were out in the Courtyard. Resident #61 was observed on the ground in the grass close to the brushes by the dietician (who was walking in the hallway and looked out the window). The DON stated, s/he would expect Resident #61 to be supervised but is faster than us at times. An interview conducted on 8/11/21 at 2:16 p.m. with License Practical (LPN) Charge Nurse #4 revealed Resident #61 was alert and oriented to person ambulates about the unit, around the facility, and at times will go into the Courtyard. On the day of the fall 6/17/21 he/she was on a different unit on the other side of the building. It is my understanding s/he was outside trying to attend to a flower and fell in the bushes, Resident #61 had on pink slip on slippers with no back to them, I'm not sure how long s/he was off the unit; it is everyone's responsibility to supervise the resident even while off the unit it is a collaborative effort by all in the facility. Usually, I will get a call from other units that Resident #61 is over there on their unit. An interview was conducted on 8/11/21 at 2:41 p.m. with Certified Nursing Assistant CNA # 5 revealed that Resident #61 eats breakfast in his/her room and gets up around nine (9) or 10 a.m. The resident will ambulate around the unit and sometimes on other units. CNA#5 stated everyone in the building was responsible for supervising the resident on and off the unit, Resident #61 had been wearing pink house shoes for some time because his/her other shoes were too small. CNA #5 stated s/he recently asked the family to bring in a new pair of tennis shoes for the resident. CNA#5 stated I was on vacation the day Resident #61 fell in the Courtyard. Further interview on 8/12/21 at 10:50 a.m. with CNA #5 revealed I did work on 6/17/21 and got off around 3:15 p.m. but wasn't here when he/she fell. I took Resident #61 to the bathroom a little bit before 3:00 p.m., and that was the last time I seen the resident he/she was sitting in the day area watching tv before I left for the day. CNA #5 stated because of the fall with fracture and Resident #61 wandering around, we round every hour, if I don't see Resident #61, I start to look for him/her. The resident's room is so close to the exit door to the other units, I may not see him/her exit the unit if I'm busy. An interview was conducted with the Family of Resident #61 on 8/11/21 at 3:00 p.m. which revealed the family was notified of the falls but were not sure when because the residents' Son-in-Law may take two (2) weeks to call the facility back. The Family of Resident #61's stated his/her daughter and Son-in-Law were reclusive and stayed home and were not active in the resident's care. They did not visit. The Family of Resident #61 revealed pre-Covid-19 s/he would visit often; but had not been in the facility for a while due to personal issues. The family member stated s/he thought the facility was a nice place, but after some visits, was not happy with Resident #61's care. An interview was conducted on 8/12/21 at 9:18 a.m. with Dietician #7 revealed, I was walking down the hallway between 300 and 400 halls (not sure of the time) looked out the window and seen[sic] Resident #61 in the Courtyard leaning over looking at the flowers, s/he was alone, I did not see other resident's or staff, I noticed the resident was falling went to get the (DON) and then outside to help, Resident #61 got up and started walking towards us; did not complain of pain. I let the DON assess the resident then left. The resident fell in the grassy area but was probably standing on the sidewalk. Supervision for all Residents are[sic] our responsibility, we allowed them to walk around the entire facility even Dementia patients. Resident #61 resided on the100 hall at the time of the fall. An interview conducted on 8/12/21 at 9:37 a.m. with Unit Manager #3 revealed after Resident #61's fall, one of the nurses met the DON in the hallway to bring the resident back to Unit 100. At the time of the fall, I did not know how long Resident #61 was off the unit, and not sure if there was anyone out there with the Resident. The CNA's complete rounding and notice if a resident is off the unit, then we all look for them; with Resident #61's history of falls, it was expected that he/she be supervised more. We are increasing hourly rounding to make sure the Resident has tennis shoes or non-skid socks on. My definition for supervision is to ensure staff check on the resident hourly and if he/she is not on the unit they are expected to go find the resident. An interview conducted on 8/12/21 at 10:30 a.m. with the Administrator revealed, we have weekly fall meetings and if there is a fall in the building I'm notified right away. I was told the Dietician observed Resident #61 in the Courtyard fall, the resident got up on his/her own, at the time of the fall they did not identify any injury. Supervision depends on the Resident even Dementia residents, every person in the building has a responsibility to re-direct the resident and ensure they are safe. The Residents have the right to ambulate around the facility, I don't know if there was anyone out there during the fall, more frequent checks is/means keeping the Resident in a more populated area to be observed. The CNA assigned to the Resident and Nurse are responsible for checking on the Resident and if they are busy every partner in the building is responsible for supervision. If I'm a CNA I'm going to do my rounds and if I don't see the resident, I would ask anyone if they had seen him/her, than take a walk off the unit to look for them. The expectation is that the CNA would do that, the fall in the Courtyard was between shifts. The Administrator stated, other than putting Resident #61 in a Broda chair or chemically restraining him/her that is the only option other than sending the resident out of the facility to meet his/her needs. An interview conducted on 8/12/21 at 3:00 p.m. with Certified Nursing Assistant (CNA) #6 revealed, at 2:40 p.m. Resident #61 was laying down in his/her room, I started doing my vitals on the other resident's, I had no idea Resident #61 had left the unit, I noticed he/she was gone off the unit around 3:20 p.m., I started looking for the resident then checked the dining room, after that I met the DON coming from the 300 and 400 halls with Resident #61. The DON stated Resident #61 had fell so I took the resident back to the unit, there were no other Nurses or CNA's with me, Resident #61 had on black slippers, our training for Dementia residents is to check on them every 30 minutes to an hour. Supervision for all residents is the CNA's responsibility and I don't recall the other falls Resident #61 had on second shift. An interview on 8/13/21 at 9:23 a.m. with the Family of Resident #61 revealed he/she had been taking care of Resident #61's daughter who has short term memory loss for the last nine (9) years. We received a call yesterday 8/12/21 from the Social Services Director to come in and speak with you guys about the falls, Resident #61 has been here for a year, I believe he/she had three (3) incidents, one which caused a broken wrist, most recent injury three (3) weeks ago, we were told he/she had fallen, we discussed the option of going to the hospital, but we did not want to cause him/her any stress, so we decided to have the x-rays done in the facility. The resident was admitted during COVID-19, so we have not had much in-house observation due to that. This morning the facility added a note that he/she had on house slippers, they did not contact us about getting him/her shoes, most of the shoes upon admission were inappropriate we never had a face-to-face meeting upon admission, we were told the facility would ensure that Resident #61 would be supervised and monitored. The Administrator and Social Worker informed us today that is it essential to let him/her walk around the facility to maintain independence; the Administrator stated to us that putting the resident in a wheelchair would be the only other option, they ask us how we felt, I told them closing the wing or using mechanical doors would be an option to keep Resident #61 from roaming off the unit into other areas and the Courtyard to stay safe. The facility failed to adequately supervise Resident #61 to prevent injury from a fall in the Courtyard, furthermore there were discrepancies from staff during the interviews as to how long Resident #61 was off the unit. Several of the fall investigations were not completed to include Factors Contributing to the falls. The facility did not provide a fall investigation for the fall on 11/9/2020 that included the scalp injury and failed to ensure that proper footwear was provided for Resident #61 until the last fall on 7/22/21.

Based on observation, record review, interview and review of the facility's Pressure Ulcer Skills Check, and review of the facility's policy, Pain Management, the facility failed to treat complaints of pain during wound care for Resident #49, 1 of 3 residents reviewed for pain management. The findings included: The facility admitted Resident #49 on 10/10/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During wound care observation on 06/26/19 at approximately 12:00 PM, Resident #49 complained of pain and requested to be put back on her/his back. LPN (Licensed Practical Nurse) #1 offered the resident pain medication to which the resident didn't respond but continued to complain of pain, stating s/he was hurting all over. The LPN continued the treatment and RN (Registered Nurse) #1 told Resident #49 they would be done in just a few minutes. When LPN #1 applied Sure Prep to the wound, the resident became louder with her/his complaints of pain. The LPN asked the resident if s/he wanted something for pain and the resident responded maybe. The LPN continued the treatment and applied a transparent dressing, asking the resident if s/he wanted pain medication as the resident continued to complain of pain. The Resident stated probably. During an interview on 06/26/19 at approximately 03:44 PM, LPN #1 stated I probably should have stopped and given (the resident) something then. The LPN further stated that Resident #49 complained of pain whenever s/he was touched and stated it was hard to tell if s/he was really in pain or not. On 06/27/19 at 09:52 AM, review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Pressure Ulcer Skills Check revealed PAIN is assessed and treated prior to procedure. Review of the facility's policy entitled Pain Management revealed 6. If pain has been identified A. Non-medication interventions i.e. (for example) repositioning, massage. B. Administer prescribed/pain medication if prescribed. C. Contact Physician if needed. At 09:56 AM, review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview the facility failed to ensure the resident was free from abuse and neglect. Resident #2 was resisting care and Certified Nursing Assistant (CNA) #1 held the resident's wrists instead of following the care plan and facility policy to approach at a later time and to provide goods and services necessary to avoid physical harm. Resident #2 sustained bruising to both wrists and right side of face along cheekbone during incontinent care. 1 of 2 residents reviewed for abuse. The findings included: Resident #2 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During the days of survey Resident #2 was not in the facility. The surveyor was informed that the Resident was with family and that the family did not want to be interviewed. Record review of facility reportable dated 5/22/19 revealed that on 5/22/19 at 9:00 AM Resident #2's daughter/son asked the nurse what happened to cause bruising under her/his mother's/father's eye. A CNA indicated s/he did not notice it on AM rounds. Nurse was not aware of any falls or incident involving patient. Right side of face along cheekbone discolored area (purple with some slight swelling along cheekbone) about 1 inch in length. Patient noted to have discoloration 2 small areas on left wrist/forearm and right wrist with reddened area. Review of the facility interview with CNA #1 revealed [S/he] reports that [name of CNA] asked for assistance changing [name of resident] at 5:30 am [s/he] stated the patient had a BM (bowel movement) while in bed and it was going everywhere. During this change they did wake the patient up to change [her/him]. [S/he] said [name of resident] was very combative, and [s/he] demonstrated how [s/he] was holding [her/his] wrists and hands during care. (Demonstrated after [s/he] was swinging crossed the patient's hands in fists across [her/his] chest and the employee held [her/him] around [her/his] wrists and hands with patients' hands being positioned new [her/his] face. [S/he] said [s/he] was waiving [her/his] arms and trying to kick and hit during care . Review of CNA #1's written statement revealed @ (at) 5:15 am I was asked to assist with [name of resident] again and this time [s/he] was very combative trying to bite, kick, hit. [S/he] was covered in poop it was running we had to change [her/him] I held [her/his] arm's so [s/he wouldn't hit me while [name of CNA] clean [her/his] bottom then we turned [her/him] over [name of CNA] had [her/his] arm's while I put the diaper/padding on (helping out). Review of the facility interview with CNA #2 revealed [S/he was real difficult to change the last time. [S/he] was real combative [name of CNA] held [her/him] while I cleaned [her/him] up. It was a mess and hard to clean because [s/he] was kicking and pinching, pushing our arms and swinging. I was on the side of the bed by the door, and we rolled [her/him] toward [ name of can] so that I could get the dirty pad off the bed, and finish cleaning [her/him] up. [S/he] was real close to the edge of the bed because of how [s/he] was kicking and stuff. [name of CNA was still holding [her/his] hands and arms so that I could finish up. Review of a written statement by CNA #2 dated 5/22/19 revealed To whom it may concern I [name of CNA], went in room [room number] at 5:15 am to change [her/him] [s/he] had a BM. Me and the other CNA changed [her/him] [s/he] was fight us. While I was in the bathroom to set a washcloth to clens (sic) [her/him] up. The CNA hold [her/his] arm to keep from get hit. Review of Resident #2's output bowel movement record revealed that on 5/22/19 at 9:47 am bowel movement was documented as none. On 5/21/19 at 11:31 PM bowel movement was documented as Large. Review on 6/27/19 of Resident #2's nursing notes dated 5/20/19 through 5/21/19 revealed no documentation of bruising. Review on 6/27/19 of Resident #2's nursing notes dated 5/22/19 revealed Resident has some discoloration noted to [her/his] right side of face and wrist/forearms. Nurse Practitioner notified and gave orders for X rays per [name of x-ray service]. [Daughter/son] here and aware. [Name of Doctor] made aware. Review on 6/27/19 of Resident #2's nursing notes dated 5/23/19 revealed Discoloration continue to resident right side, wrist, and forearms C/O (complains of) no pain or discomfort. Will continue to monitor. On 06/25/2019 at approximately 3:49 pm during an interview with the Agency Nurse Practitioner s/he stated that on the morning of 05/22/2019 s/he observed Resident #2 with face and wrist/forearm discoloration. During an interview on 06/26/2019 at approximately 10:29 am the Director of Nursing (DON) stated that s/he was told about the incident and did look at the resident. The DON stated that there was bruising under the right eye and bruising on both wrists. S/he stated that s/he called CNA #1 and CNA #2 and got statements from them. The DON stated that they explained BM was everywhere and they turned the resident on her/his right side while holding the resident's wrists to stop [her/him] from hitting the staff that were trying to clean [her/him]. The DON stated that both staff members stated that they just wanted to be clean the resident. During an interview on 06/26/2019 at11:05am the Administrator stated, They panicked and wanted to clean [her/him] up. During an interview on 06/26/2019 at approximately 3:40pm, CNA #1 stated CNA #2 asked me for help to clean-up Resident #2. The resident was lying in BM--It was seeping out of [her/his] pull-up and leaked onto the floor. While CNA #1 was trying to clean [her/him] up the resident was moving [her/his] legs and arms and was trying to hit us. I moved [her/him] on [her/his] right side were [her/his] right arm was free to move. I held [her/his] left arm by the elbow. Then I moved [her/him] to the left side [her/his] left arm was free to move. I held [her/his] left arm by the elbow. Also, [her/his] right face was against the grab bar. At no time did we back away from the resident to see if [s/he] would calm down because I did not want [her/him] to get into the BM. Review of Resident #2 care plan dated 9/17/18 revealed a problem area cognition approaches included If resistant to care, reproach at a later time if able. Review of the facility policy titled Patient Protection and Response Policy for Allegation/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation revealed under definition of policy Abuse, Neglect, Misappropriation of Property and Exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in this center. The patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restrain not required to treat the patient's medical symptoms. Further review revealed under Definitions neglect: the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Based on observation, record review, and interview, the facility failed to provide treatments to pressure ulcers on the bilateral heels for Resident #105, 1 of 3 residents reviewed for pressure ulcers. In addition, the wounds on Resident #105's heels, initially documented as pressure ulcers, were currently being assessed as vascular wounds without physician documentation that the wounds were vascular and not pressure related. Furthermore, 5 other wounds observed on Resident #105 were not assessed and no treatment was provided. The findings included: The facility admitted Resident #105 on 05/11/19 with [DIAGNOSES REDACTED]. During an interview on 06/25/19 at 11:06 AM, Resident #105 reported that s/he had wounds on his/her bilateral heels and that the dressings were not being' changed like they're supposed to be. On 06/25/19, review of Resident #105's physician orders [REDACTED]. Clean the right heel with normal saline and apply Santyl then cover with wet to dry, wrap with Kerlix and change daily. On 06/25/19 at 11:07 AM, review of Resident #105's Wound Management documentation revealed wound type venous ulcer, location right heel, date/time identified 6/7/19 01:18 PM, Present on Admission Yes, Created date/time 06/07/2019 01:19 PM. Further review revealed wound type venous ulcer, location left heel, date/time identified 6/7/2019 01:17 PM, Present on Admission Yes, Created date/time 06/07/2019 01:17 PM. Wound management observation history indicate the wounds on the bilateral heels were venous ulcers but review of the [DIAGNOSES REDACTED]. Review of Resident #105's care plan revealed a problem dated 05/31/2019 Resident is at risk for pressure ulcers R/T (related to) decreased mobility, R(ight) hip fx (fracture), hx (history) of falls, [DIAGNOSES REDACTED], [MEDICAL CONDITION] with use of Foley, presence of vascular ulcers to his R(ight) foot, bilat(eral) heels, frequent incontinence of bowel. On 06/26/19, review of the TAR (Treatment Administration Record) for (MONTH) 2019 revealed no treatments were provided to the left and right heel in the month of (MONTH) 2019. A treatment for [REDACTED].**specify site*** change every 3 days and PRN (as needed) when soiled or dislodged was noted with a start date of 05/13/19 and was listed twice on the treatment administration record. No treatment was signed off as completed during the month and there was no indication the treatment had been discontinued during the month. No other treatments were documented for 05/11 through 05/31/19 to the left or right heel. Further review of the (MONTH) 2019 TAR revealed a treatment for [REDACTED]. No treatments were documented for 06/01 through 06/12/19 to the left or right heel. During the wound care observation on 06/26/19, wounds were also noted on the top of the left great toe, the top of the left foot, the left plantar, and on the right foot, on the top of the foot, and the right plantar. No treatment was provided to any of these areas during the wound care observation. Review of the wound documentation for Resident #105 revealed there were no assessments or measurements of the wounds to the left great toe, the top of the left foot and the left plantar, the top of the right foot, or the right plantar. During an interview on 06/27/19 at 09:15 AM, RN (Registered Nurse) #1 confirmed that the treatment sheet indicated no treatment was provided to the heels until 06/13/19. The RN further stated s/he was going to verify that there were no discontinued treatments that didn't appear on the treatment sheets provided by the facility from the EHR (electronic health record). During an interview on 06/27/19 10:29 AM, RN #1 confirmed that Resident #105 received no treatment to the left or right heel from admission on 05/11/19 until 06/13/19 and stated the orders for the Polymem were supposed to be on the bilateral heels.

Based on observation, record review, and interview, the facility failed to provide treatment to wounds for Resident #224, 1 of 1 resident reviewed for non-pressure skin conditions. The findings included: The facility admitted Resident #224 on 05/30/19 with [DIAGNOSES REDACTED]. Observations on 06/24/19 revealed Resident #224's left arm had a transparent dressing and noted to have dark blood under it. The right arm had a geri-sleeve over it and blood had seeped through the sleeve. Upon closer inspection on 06/25/19, the areas were observed to be bruises/dried blood blisters. At that time, the resident's family was at the bedside and stated the areas were a result of surgery done approximately 05/24/19 and were related to the anticoagulant the resident received in the hospital. One family member asked why the resident's geri-sleeve wasn't on and reported that it had been dried to the wound the evening before when it was removed. On 06/25/19, review of Resident #244's Admission MDS (Minimal Data Set) assessment dated [DATE] revealed Skin Conditions question M1200 G. Application of nonsurgical dressings was not checked. Review of the physician orders [REDACTED]. Review of Resident #244's care plan on 06/25/19 revealed no care plan related to the impaired skin integrity. Further review on 06/26/19 revealed a problem with a start date of 06/25/19 that the Resident has SCAR TISSUE ON BOTH ELBOWS (abrasions, bruises, etc.) R/T _USE OF ELIQUIS. The approach listed was Avoid shearing resident's skin during positioning, transferring, and turning. No other interventions were listed. On 06/26/19 at 10:36 AM, review of the Treatment Administration Record revealed no treatment had been provided to the areas on the resident's upper extremity's until after a copy of the treatment record was requested by the surveyor on 06/25/19. The treatment was completed at 11:42 PM on 06/25/19. During an interview on 06/26/19 at 11:44 AM, the Director of Nursing (DON) would neither confirm nor deny the lack of treatment to the wounds on Resident #224s upper extremities, stating I'll have to check.

Based on record review and interview, the facility failed to ensure coordination of care for Resident #159, a [MEDICAL TREATMENT] patient, as evidenced by multiple communication documents related to care in the [MEDICAL TREATMENT] center not in the medical record nor the facility for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #159 on 8/19/2016 with [DIAGNOSES REDACTED]. Review on 6/27/2019 at approximately 10:51 AM of the medical record for Resident #159 revealed no communication with the [MEDICAL TREATMENT] center to coordinate care on 3/9/2019, 3/28/2019, 3/30/2019. 4/16/2019, 4/18/2019, 4/23/2019, 4/27/2019 and 5/2/2019. Further review on 6/27/2019 at approximately 10:51 AM of the medical record for Resident #159 additionally revealed no communication with the [MEDICAL TREATMENT] center to coordinate care on 5/4/2019, 5/7/2019, 5/11/2019, 5/21/2019, 6/1/2019, 6/13/2019 and 6/13/2019. During an interview on 6/27/2019 at approximately 12:40 PM with Registered Nurse #1 s/he confirmed the missing communication sheets from the [MEDICAL TREATMENT] center.

Based on observations, interview and review of the facility policy titled, Patient Rights, the facility failed to provide dignity to residents during the lunch meal service on the Magnolia Hall/100 Unit as evidenced by, staff knocking on resident room doors and entering without waiting for permission to enter. Staff walking in rooms with lunch trays without knocking and placing clothing protectors without first asking if the residents would like to have one applied during 2 of 2 dining observations of the lunch meal. The findings included: Observations on 6/24/2019 at approximately 12:15 PM and 6/25/2019 at approximately 12:25 PM during the lunch meal service on the 100 Unit/Magnolia Hall revealed staff knocking on resident room doors, and not waiting for permission to enter and entering with a lunch meal tray. Staff applying clothing protectors without first asking if the residents would like to have one applied. Additional observations on 6/24/2019 at approximately 12:15 PM and 6/25/2019 at approximately 12:25 PM during the lunch meal service on the 100 Unit/Magnolia Hall revealed staff entering rooms with lunch trays and not knocking before entering. And staff entering rooms after knocking but not waiting for permission to enter. During an interview on 6/25/2019 at approximately 12:40 PM with Certified Nursing Assistant #3, he/she stated that staff should wait for permission to enter after knocking and should always knock before entering a resident's room, we should ask if the resident would like to have a clothing protector and not just put it on them. Review on 6/27/2019 at approximately 5:05 PM of the facility policy titled, Resident Rights, states, The rights of patients are codified in both federal and state statutes with the intent of further protecting each patient's civil, religious, and human rights while the resident in a health care center. The Guarantee of rights that depends on the actions of PARTNERS are requirements for personnel: The first bullet under the requirement states, The right to respect and dignity are requirements of partners.