Every finding on record at North Point Skilled Nursing Center

Based on observation and interview, the facility failed to store and prepare food in the kitchen under sanitary conditions to prevent food borne illnesses.Findings included:- Observation of the kitchen and food storage areas on 08/03/2026 at 10:00 AM with Dietary Staff BB (Certified Dietary Manager) revealed the following areas of concern:1.Built-in Refrigerators:A bag of cooked bacon with no label and no date.A bottle of coffee creamer was labeled with a name and no date. Dietary Staff BB reported it belonged to a staff member and should not be in the refrigerator. A bottle of sweet-and-sour sauce with no date. A bottle of soy sauce with no date.A deli sandwich with no label and no date.2. Built-in Freezer:A bag of frozen cookies with no label and no date.On 08/03/2026 at 10:15 AM, Dietary Staff BB stated she expected all the food to be labeled and dated.On 08/03/2026 at 10:37 AM, the west hallway dining room had a kitchen with a warmer table and serving area. There was a refrigerator that had a sign Kitchen Staff Only. The refrigerator had two packages of cheese with no date and no label, and the bologna in the packet was undated. The dishes on the counter were stored upright and were not covered.On 08/03/2026 at 10:52 AM, Dietary Staff BB reported that the kitchen staff serves from the west hallway kitchen area after they bring the food from the main kitchen. She reported that all the food in that kitchen should also be labeled and dated, and the plates should be stored inverted or covered.On 08/05/2025 at 04:45 PM, Administrative Staff A stated she expected all food to be labeled and dated and the dishes to be covered or stored correctly.The facility's policy Food Receiving and Storage, dated 07/2014, documented that all foods stored in the refrigerator or freezer will be covered, labeled, and dated.The facility's policy Clean Dish Storage Policy dated 01/27/2026 documented that the facility will store clean dishes in a sanitary manner that protects them from contamination and supports safe food service in accordance with applicable federal requirements and professional food-safety standards. Clean items must be stored in a clean, dry, designated area; covered or inverted when practical.

Based on observation, interviews and record review, the facility failed to ensure adequate infection control practices related to linen storage, hand hygiene, and Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) while providing care to Resident (R) 45. Findings included:- On 08/04/2026 at 07:58 AM, during an observation, the linen cart located on the south hallway lacked a covering over clean towels, washcloths, and sheets.On 08/04/2026 at 11:30 AM, during an observation, the linen cart on the south hallway lacked a covering over the clean linens.On 08/04/2026 at 08:58 AM, during the observation of Certified Nurse Aide (CNA) M and CNA N passing water and ice to the residents' rooms on the west hall, neither CNA performed hand hygiene between resident rooms five, seven, nine, 11, 12, and 15.On 08/04/2026 at 09:11 AM, during an observation of indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care for R45, CNA N and CNA M performed hand hygiene and donned gloves, but neither CNAs wore a gown.On 08/04/2026 at 01:39 PM, CNA M reported that she did not wash her hands when she provided water and ice to the residents but should have.On 08/04/2026 at 01:39 PM, CNA N and CNA M each stated that they should have worn a gown while providing urinary catheter care to R45.On 08/05/2026 at 09:13 AM, Administrative Nurse D said she expected the staff to wear a gown when providing care for residents that require EBP and expected the staff to perform hand hygiene handwashing when they provided residents with water and ice.The facility policy Enhanced Barrier Precautions, dated 01/27/2026, documented it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.The facility policy Hand Hygiene, dated 01/27/2026, documented that all staff will perform proper hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.

Based on observation, record review, and interviews, the facility failed to complete and document a post hemodialysis (a procedure where impurities or wastes are removed from the blood) assessment for Resident (R) 5.Findings included:- R5's Electronic Medical Record (EMR) included diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys).R5's 10/07/2025 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. R5 did not reject care. The MDS recorded R5 received dialysis.R5's 07/12/2026 Quarterly MDS documented no changes in status from the above assessment.The 10/13/2026 Functionally Abilities Self-Care/Mobility Care Area Assessment (CAA) documented R5 goes to dialysis two times a week with the facility providing transportation. She used a wheelchair for mobility, and at that time, her legs were weak, and she may ask for assistance with wheelchair mobility.R5's 08/03/2026 Care Plan documentation included that R5 had ESRD and was dependent upon hemodialysis. She attended dialysis on Tuesday and Saturday with a chair time of 06:00 AM. The facility provided transportation to and from dialysis. She arrived back at the facility at about 10:15 AM. She reported that she was tired afterwards and liked to go straight to her room and take a nap. R5 would be assisted back to her room by the transportation driver. Her abilities for self-care and mobility fluctuated on dialysis days, and staff monitored for increased fatigue and offered an increased level of assistance with ADLs and mobility as needed.R5's EMR recorded a Physician Orders which directed the visualization of the chest port dressing; if not in place, replace with dressing orders as needed (PRN).An order dated 07/09/2026 directed that the dressing needed to be replaced two times a day for prevention. The chest port needed to be cleansed with iodine and wiped dry with a sterile 4x4. Apply a bio-patch and then secure with sterile dressing and tape. Provide sterile technique. Change dressing to chest port for dialysis every 48 hours and PRN on day shift.Review of R5's Progress Notes lacked documentation of a post-dialysis assessment for 08/04/2026.Review of R5's Evaluation Notes lacked documentation of a post-dialysis assessment for 08/04/2026.R5's EMR lacked evidence that the resident refused the post-dialysis assessment on 08/04/2026On 08/04/2026 at 11:51 AM, R5 lay in bed. R5 stated she returned from dialysis about an hour ago, around 11:00 AM. She said she left for dialysis so early in the morning she was exhausted when she returned, and she just laid down. R5 reported that the staff rarely assessed her when she returned from dialysis. She stated staff did not come and check her port when she returned from dialysis. She reported she had a chest port for dialysis access site, and then she pulled her top to the side and exposed the chest port, which had a dry dressing intact without bleeding or drainage.On 08/05/2026 at 10:06 AM, Licensed Nurse (LN) H stated dialysis residents should have a pre- and post-dialysis assessment done, completed, and documented on the Dialysis Communication Form. The assessment should include vital signs, which the medication aide obtained, and an assessment of the dialysis port site and dressing or the dialysis fistula to ensure the resident was not having complications such as bleeding out following dialysis and/or the dressing is intact. LN H confirmed she was the nurse on duty on 08/04/2026 for R5. She stated R5 went to dialysis early in the morning; her chair time was at 06:00 AM, and R5 returned during LN H's shift the previous day. LN H stated the nurses should complete the post dialysis assessment and document the assessment on the Dialysis Communication Form. Upon request, LN H could not locate the form for 08/04/2026. She stated that after thinking about it, she did not recall seeing the communication form on the resident's return to the facility on [DATE]. LN H confirmed the post-dialysis assessment for 08/04/2026 was not available in the progress notes, evaluations, or any other location in R 5's EMR. She reported she should have documented the findings of her assessment on the Dialysis Communication Form.On 08/05/2026 at 11:16 AM, Administrative Nurse D confirmed a pre and post-assessment should be done and documented on the Dialysis Communication Form. She expected nurses to assess the residents when they return to ensure the resident has not developed any complications such as hemorrhaging following dialysis. Administrative Nurse D said the dressings should be checked to ensure they are intact to prevent contamination at the port.The 01/27/2026 facility policy titled Hemodialysis documented the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.

Based on record review, observation and interviews, the facility failed to include Resident (R) 45 or his representative in the development and planning of the resident's care plan when they failed to notify and invite them to the care plan meetings.Findings included:- R45's Electronic Medical Record (EMR) revealed diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord) and aphasia (condition with disordered or absent language function).R45's 09/10/2025 admission Minimum Data Set (MDS) documented no Brief Interview for Mental Status (BIMS) interview was completed; the resident was rarely or never understood. The staff assessment documented R45 had severely impaired cognition. The MDS documented no behavior, and he was dependent on staff for all activities of daily living (ADLs).R45's 09/11/2025 Communication Care Area Assessment (CAA) documented R45 had a potential for decline in his communication related to his diagnoses. R45 was in a car wreck when he was [AGE] years old, and it severed his spinal cord. R45 recognizes family and can at times answer yes or no questions and could at times understand what staff were asking him to do.R45's Care Plan, dated 09/17/2025, instructed staff to use communication techniques which helped R45 communicate. Staff were instructed to provide adequate time for R45 to respond and repeat as necessary. Staff were instructed not to rush him, and sometimes it would take a while for R45 to understand what was being said, and they were to face him when speaking and make eye contact with him.R45's EMR documented a care meeting was held on 02/11/2026 with R45, his guardian, and a Program of All-Inclusive Care for the Elderly (PACE is a health care program that helps people at risk for needing a nursing home stay in their own homes and communities) representative.R45's EMR lacked documentation that care plan conferences occurred with the facility staff.Observed on 08/03/2026 at 11:55 AM, R45 laid in his bed watching television; he was able to answer simple yes or no questions.On 08/03/2026 at 12:34 PM, R45's guardian reported that she had never been invited to a care plan meeting with the facility staff since R45 had been admitted to the facility on [DATE]. R45's guardian also said that she and R45 had only attended a care plan meeting with the PACE staff.On 08/05/2026 at 09:10 AM, Administrative Nurse D reported that the care plan meetings were completed by the interdisciplinary team, which included the Social Service Designee (SSD), and that person would call the family to set up a care plan meeting. Administrative Nurse D reported she was not sure if a care plan meeting occurred with just the facility and R45's guardian or with PACE.On 08/05/2026 at 01:40 PM, Administrative Nurse E reported that she expected the care plan meetings to be completed quarterly. Administrative Nurse E reported that the SSD arranged all the care plan meetings and that the care plan meetings were documented in a progress note in the residents EMR.The facility's Care Plan Conference Invitation Policy, dated 01/27/2026, documented that the facility will invite the resident, family, and chosen representatives to participate in care plan conferences and provide input into the resident's person-centered plan of care. Within one week of admission, approximately three weeks after admission. Then quarterly thereafter or as needed for significant changes or concerns.

Based on record review, observation, and interviews, the facility failed to ensure Resident (R) 39's legal representative was updated with changes to R39's treatments or medications.Findings included:- R39's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus and vascular dementia.R39's 01/27/2026 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS documented R39 had no behaviors and was dependent on staff for toileting and personal hygiene.R39's 01/28/2026 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R39 had just been admitted to hospice with the diagnosis of vascular dementia. R39 was alert to self; he had good family support, and they visited him often.R39's Care Plan, dated 07/24/2024, instructed staff to notify R39's durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) with any changes related to R39.R39's Electronic Medication Administration Record (EMAR) documented an order for fluconazole (a prescription antifungal medication used to treat and prevent various infections caused by yeast and fungi) 100 milligrams (mg) a day for 14 days, ordered on 07/30/2026.R39's 07/30/2026 Progress Note documented R39 was seen by the provider that day, and new orders were received for fluconazole 100 mg a day for 14 days. The progress note lacked documentation that R39's DPOA had been notified.Observed on 08/03/2026 at 10:50 AM, R39 laid in bed on his right side; there was a sign that reminded him to use the call light before he used the bathroom, and he had yellow mucus running out of his nose.On 08/03/2026 at 01:10 PM, R39's DPOA reported that she had not been notified of the new medication order for fluconazole. R39's DPOA reported that the facility had not always notified her of new orders.On 08/05/2026 at 08:34 AM, Licensed Nurse (LN) H reported that the nurse should have called the family or representative and updated them on any new medications or treatments that had been ordered and documented that they had been notified in the progress notes.On 08/05/2026 at 09:14 AM, Administrative Nurse D said that it was expected for the nurse to call and notify the family or representative of all new orders and document the notification in the EMR.The facility did not provide a policy for notification of changes to orders.

Based on record review, observation, and interviews, the facility failed to update the plan of care for Resident (R) 36 when the resident began using insulin and required blood sugar monitoring. Findings included:- R36's electronic medical record (EMR) documented the diagnosis of diabetes mellitus.R36's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the medication list did not indicate insulin use.R36's Annual MDS, dated [DATE], documented a BIMS score of 15 and documented that R36 received seven days of insulin.R36's Care Plan, dated 06/27/2026, lacked information that R36 had started to use insulin and required blood sugar monitoring.R36's Medication Administration Record (MAR), dated 06/28/2026, indicated insulin 100 units, inject 10 units subcutaneously (beneath the skin) at bedtime for diabetes and check blood glucose. In the morning, administer 14 units subcutaneously.R36's Progress Note, dated 07/16/2026 at 06:46 PM, documented that R36 was to have her blood sugar checked before lunch and dinner for blood sugar monitoring.On 08/05/26 at 10:22 AM, Administrative Nurse E said that R36 was a new diabetic and her care plan had not been updated to reflect it.On 08/05/26 at 12:15 PM, Administrative Nurse D said that if a resident had a new diagnosis, then the care plan should have been updated to reflect the diagnosis.The facility policy North Point Care Plan Revisions Upon Status Change, dated 01/27/2026, documented the purpose of the procedure was to provide a consistent process for reviewing and revision the care plan for those residents experiencing a status change.

Based on observation, record review, and interview, the facility failed to ensure Resident (R) 39 received assistance with activities of daily living (ADL) for nail care. Findings included:- R39's Electronic Medical Record (EMR) revealed a diagnosis of diabetes mellitus and vascular dementia.R39's 01/27/2026 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS revealed no behaviors noted, and R39 was totally dependent with toileting and personal hygiene.R39's 01/28/2026 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R39 had just been admitted to hospice with the diagnosis of vascular dementia, was alert to self, he had good family support, and they visited him often.R39's Care Plan, dated 06/10/2024, instructed the nursing staff to trim his nails as needed.Review of the facility's Bath Schedule showed R39 was scheduled for a shower on Sunday, Wednesday, and Friday morning.R39's health aide care provided from 06/03/2026 through 07/03/2026, located in the hospice chart, documented he had no care refusals.Review of R39's EMR Tasks from 07/03/2026 through 08/03/2026 documented R39 refused one shower on 07/31/2026; the EMR lacked documentation that he refused nail care.On 08/04/2026 at 08:03 AM, R39 was seated in his wheelchair in the dining room eating breakfast. R39's fingernails were long and had a brown substance under all his fingernails.On 08/04/2026 at 11:57 AM, R39 was seated in his wheelchair in the dining room eating lunch. R39's fingernails were long and had a brown substance under all his fingernails.On 08/05/2026 at 07:59 AM, R39 was seated in his wheelchair in the dining room eating breakfast, and he was wearing clean clothes. R39's fingernails were long and had a brown substance under all his fingernails.On 08/05/2026 at 08:21 AM, Certified Nurse Aide (CNA) P reported that R39 had refused his baths at times. CNA P also reported that the hospice aide would do R39's shower twice a week, and she was to be there that day. CNA P then reported that R39's nails were to have been trimmed by the nurse as he was a diabetic and the residents' fingernails should have been cleaned by the staff during the showers and as needed.On 08/05/2026 at 08:28 AM, CNA O reported she was the bath aide today and reported that R39 would receive his shower by the hospice aide this morning. CNA O reported that the nurse would cut his nails as he was a diabetic. CNA O reported that the staff would complete bath sheets on bath days even if the resident refused. CNA O reported that the resident and nurse would sign the bath sheet if the resident refused.On 08/05/2026 at 08:43 AM, Licensed Nurse (LN) G reported that she was unsure when R39 last had his fingernails trimmed and said that the staff or hospice aide were to let the nurse know when his nails required trimming; she expected the staff to provide nail cleaning on shower days or as needed. LN G reported that if a resident refused care, it should have been documented in the EMR.On 08/05 /2026 at 10:10 AM, Consultant Staff HH reported that R39 had never refused his shower. She reported that R39 had been scheduled for Wednesdays and Fridays for personal cares. Consultant Staff HH reported that she had not been allowed to trim his fingernails and that she verbally told the nurse when they needed trimmed.On 08/05/2026 at 11:35 AM, Administrative Nurse D said that it had been expected for the staff to provide nail care bath days and when needed, as residents allowed.The facility's policy Activities of Daily Living (ADLs), dated 01/27/2026, documented that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 48's feeding tube (G-tube: tube surgically placed through an artificial opening into the stomach) was monitored for placement prior to administration of medications and enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). Findings included:- R45's Electronic Medical Record (EMR) revealed diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord) and dysphagia (swallowing difficulty).R45's 09/10/2025 admission Minimum Data Set (MDS) documented no Brief Interview for Mental Status (BIMS) interview was completed; the resident was rarely or never understood. The staff assessment documented R45 had severely impaired cognition. The MDS documented R45 had no behaviors. He was dependent on staff for all activities of daily living (ADLs) except eating, as R45 had a feeding tube.R45's 09/11/2025 Feeding Tube Care Area Assessment (CAA) documented R45 received enteral feedings. It documented staff were to ensure the head of the bed was elevated while administering feedings. Nursing staff was to provide G-tube care following policy and procedure.R45's Care Plan, dated 09/17/2025, instructed staff to provide tube feeding five times a day and provide 60 milliliters (mL) of water flush before and after each feeding. R45's Care Plan, dated 08/03/2026, lacked any instructions on checking to ensure placement of the feeding tube.R45's Physician Orders directed to administer one carton of Isosource 1.5 (type of enteral feeding) five times a day. Provide a 60 mL water flush before and after each feeding for nutrition; date ordered 08/29/2025. R45's Physician Orders directed to administer free water flushes of 300 mL of water every four hours via G-tube for hydration, date ordered 06/18/2026.R45's Physician Orders dated 08/03/2026 lacked documentation to check for placement or residual of the feeding tube.On 08/04/2026 at 11:08 AM, Licensed Nurse (LN) G assisted R45 down to his room in his electric wheelchair. She reported that R45 could not move the chair himself. LN G performed hand hygiene and applied gloves and a gown. LN G connected the feeding tube to the syringe and poured 60 mL of water; then she administered his medication and rinsed the feeding tube with 60 mL of water. LN G then administered one carton of Isosource 1.5 through his feeding tube. LN G did not check placement or residual prior to administering water, Isosource, or medication.On 08/04/2026 at 11:48 AM, LN G reported she forgot to check for placement of R45s feeding tube when she administered his water and enteral feeding. She reported she normally did and had checked for residual this morning.On 08/05/2026 at 11:35 AM, Administrative Nurse D expected the nurse to check the measurement (length) of the feeding tube prior to use to check for placement. She said she believed the direction to do so was on R45's orders and did not know why LN G said she checked for residual.The facility's policy Care and Treatment of Feeding Tubes dated 01/27/2026 documented it is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. The resident's plan of care will address the use of a feeding tube, including strategies to prevent complications. Tube placement will be verified before beginning a feeding and before administering medications.

The facility reported a census of 42 residents with 15 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the care plans for two of the Residents (R)28 regarding foot pedals and R 37 regarding refusal of turning and repositioning every two hours. Findings included: - Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She required extensive assistance of one staff for locomotion on the unit with the use of her wheelchair. She had impairment on one side of her lower extremities (LE legs). The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/31/21, documented the resident required extensive assistance with wheelchair mobility due to weakness on her right side. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 10, indicating moderately impaired cognition. She required limited assistance of one staff for locomotion on the unit with the use of her wheelchair. She had impairment in functional ROM on one side of her LEs. The Activities of daily living (ADL) care plan, dated 04/13/21, instructed staff were to assist the resident to her destination with use of her wheelchair. The care plan lacked instruction on the use of foot pedals for her wheelchair. On 07/26/21 at 11:18 AM, Certified Nurse Aide Q, propelled the resident in her wheelchair to the dining room for lunch. The resident wore slippers which skimmed the floor during transport. The wheelchair lacked foot pedals. On 07/27/21 at 08:00 AM, Licensed Nurse H, propelled the resident to the dining room for breakfast. The resident wore slippers and her heels bounced up and down on the floor during transport. The wheelchair lacked foot pedals. On 07/29/21 at 12:21 PM, Administrative Nurse F stated, when a resident had foot pedals on their wheelchair, staff should include it on the care plan. On 07/29/21 at 09:57 AM, Administrative Nurse D stated, foot pedals should be included on the care plan. The facility policy for, Resident Centered Care Plan Process, updated 03/28/18, included: Staff will revise the resident's plan of care based on response to the resident's condition. The facility failed to review and revise the care plan to include wheelchair foot pedals for this dependent resident. - Review of resident (R)37's Transfer Form, dated 07/02/2021, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS), which was In progress on 07/26/21 with a look back date of 07/12/21, assessed the resident had normal cognitive function, required extensive assistance of two person for bed mobility and dressing, and was dependent of staff for transfer and toilet use. The resident had functional impairment on both sides of the lower extremities, but no impairment in her upper extremities. The resident had two unstageable pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) present upon admission. The Pressure Ulcer Care Area Assessment (CAA,) dated 07/21/21, assessed the resident admitted to the facility with suspected deep tissue injury to her bilateral (both sides) buttocks. The resident would sit for long periods of time at [CONDITION(S)] (a treatment to remove waste products from the blood.) The resident had a bariatric (oversized) bed with an air mattress and cushion in her wheelchair. The nursing staff reported the resident refused to lay down and reposition at times. The Baseline Care Plan, dated 07/21/2021, (as of 07/26/21 the comprehensive care plan was not developed) instructed staff the resident received therapy services with the goal to return home. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was in a bariatric bed and required two staff assistance with bed mobility, and to offer repositioning every two hours. Observation, on 07/27/21 at 08:36 AM, revealed the resident positioned in her bariatric bed. Administrative nurse D and Licensed Nurse (LN) G, donned gown, and gloves, and assisted the resident to turn in bed (the bed lacked positioning bars on both sides) by the resident holding onto staff's arm. Observation, on 07/28/21 at 10:07 AM revealed the resident positioned in her bed. Certified Nurse Aide (CNA) MM, and CNA NN assisted the resident to turn in bed by instructing the resident to hold her (CNA NN's) arm and pulled her onto her side. Interview, on 07/28/21 at 10:49 AM, revealed Administrative Nurse F and LN G, provided a dressing change to the resident while the resident was positioned on her side with nothing to hold onto. Administrative Nurse F confirmed the positioning bars would benefit the resident for stabilization during positioning changes but often the resident refused staff efforts for repositioning. Administrative Nurse F confirmed the resident's resistance to turn schedule was not documented on the baseline care plan. Interview, on 07/28/21 at 04:17 PM, with CNA P, revealed the resident did not like staff to offer turning opportunity every two hours, and the resident does not like to turn as she has pain. CNA P stated the positioning rail would help her with turning as she needs two staff, and one staff assists with positioning her right leg (in an immobilizer) as the resident could not move it on her own. Interview, on 07/29/21 at 10:04 AM, with Administrative Nurse D, revealed the resident was noncompliant turning and repositioning regularly. Administrative nurse D stated the resident seemed to lack motivation to actively participate with staff efforts for goals of returning home. The facility policy Resident Centered Care Plan Process, updated 03/28/18, instructed staff to revise the care plan for treatment and services based on the resident's condition and request of the resident. The facility failed to review and revise the Baseline Care Plan to include the resident's refusal of adherence to a turn and reposition schedule for this resident with pressure ulcers.

The facility reported a census of 42 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to ensure one Resident (R)37's, bed contained positioning rails to enhance the resident's turning ability and stabilization during cares. Findings included: - Review of resident (R)37's Transfer Form, dated 07/02/2021, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS), which was In progress on 07/26/21 with a look back date of 07/12/21, assessed the resident had normal cognitive function, required extensive assistance of two person for bed mobility and dressing, and was dependent of staff for transfer and toilet use. The resident had functional impairment on both sides of the lower extremities, but no impairment in her upper extremities. The resident had two unstageable pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) present upon admission. The Pressure Ulcer Care Area Assessment (CAA,) dated 07/21/21, assessed the resident admitted to the facility with suspected deep tissue injury to her bilateral (both sides) buttocks. The resident would sit for long periods of time at [CONDITION(S)] (a treatment to remove waste products from the blood.) The resident had a bariatric (oversized) bed with an air mattress and cushion in her wheelchair. The nursing staff reported the resident refused to lay down and reposition at times. The Baseline Care Plan, dated 07/21/2021, (as of 07/26/21 the comprehensive care plan was not developed) instructed staff the resident received therapy services with the goal to return home. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was in a bariatric bed and required two staff assistance with bed mobility, and to offer repositioning every two hours. Observation, on 07/27/21 at 08:36 AM, revealed the resident positioned in her bariatric bed. Administrative Nurse D and Licensed Nurse (LN) G, donned gown, and gloves, and assisted the resident to turn in bed (the bed lacked positioning bars on both sides) by the resident holding onto staff's arm. Observation, on 07/28/21 at 10:07 AM revealed the resident positioned in her bed. Certified Nurse Aide (CNA) MM, and CNA NN assisted the resident to turn in bed by instructing the resident to hold her (CNA NN's) arm and pulled her onto her side. Interview, on 07/28/21 at 10:15 AM with the resident revealed a positioning bar would be helpful to her for turning and repositioning as this would give her something solid to hold onto. Interview, on 07/28/21 at 10:49 AM, revealed Administrative Nurse F and LN G, provided a dressing change to the resident while the resident was positioned on her side with nothing to hold onto. Administrative Nurse F confirmed the positioning bars would benefit the resident for stabilization during positioning changes. Administrative Nurse F stated she would contact the bed rental company for the rails. Interview, on 07/28/21 at 04:17 PM, with CNA P, revealed the resident did not like staff to offer turning opportunity every two hours, and the resident does not like to turn as she has pain. CNA P stated the positioning rail would help her with turning as she needs two staff, and one staff assists with positioning her right leg (in an immobilizer) as the resident could not move it on her own. Interview, on 07/28/21 at 09:02 AM, with consulting therapy staff GG, revealed therapy staff working with her for bed mobility upper and lower body strengthening. Staff GG stated the resident may benefit from positioning bars. The facility policy Repositioning, dated May 2013, instructed staff to check the care plan, assignment sheet or the communication system to determine the resident's specific positioning needs including special equipment, resident level of participation and number of staff required to complete the procedure. The facility failed to ensure this resident's bed contained positioning rails to enhance and stabilize repositioning efforts.

The facility reported a census of 42 residents with 15 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide adequate assistive devices to prevent possible accidents when the facility failed to ensure staff placed foot pedals on the wheelchair of two Residents (R)6 and R 28, while being transported in the facility by staff. Findings included: - Review of the electronic medical record EMR for Resident (R)6 revealed she had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The significant change MDS, dated [DATE], documented the resident had a BIMS score of one, indicating severely impaired cognition. She required extensive assistance of one staff with locomotion on the unit with the use of her wheelchair. She had no impairment in functional ROM. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/14/21, did not trigger. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. She required supervision with locomotion on the unit with the use of her wheelchair. She had no limitation in functional range of motion (ROM). The Falls care plan, dated 04/21/21, instructed staff the resident was unaware of her safety and had weakness in her lower extremities (LE-legs). An undated addition to the care plan, instructed staff the resident would remove the foot pedals to her wheelchair in order to self- propel. Nursing staff instructed to not put foot pedals on when the resident self-propelled herself in the wheelchair. Review of the resident's EMR under the Task tab, from 06/30/21 through 07/29/21, revealed the resident required limited to total assistance of one staff for locomotion on the unit with her wheelchair. On 07/27/21 at 08:00 AM, Certified Nurse Aide (CNA) N propelled the resident in her wheelchair from her room to the dining room for breakfast. The resident wore slippers on her feet, and they skimmed the floor during transport. The wheelchair lacked foot pedals. On 07/27/21 at 11:44 AM, CNA N propelled the resident in her wheelchair from her room to the dining room for lunch. The resident wore slippers on her feet and skimmed the floor during transport. The wheelchair lacked foot pedals. On 07/27/21 at 10:04 AM, CNA M stated the resident can propel herself in the facility at times in her wheelchair by using her feet. The resident did not have foot pedals on her wheelchair due to them being a fall risk for the resident. On 07/28/21 at 10:38 AM, CNA N stated the resident had foot pedals for her wheelchair in case she was not able to hold her feet up. CNA stated she had never put the foot pedals on the resident's wheelchair for transport. CNA confirmed the resident's feet skimmed the floor during transports at times. On 07/28/21 at 02:41 PM, CNA P stated the resident did not have foot pedals for her wheelchair. On 07/28/21 at 02:11 PM, Administrative Nurse E stated, the resident should have foot pedals on her wheelchair when staff propel her. On 07/29/21 at 09:57 AM, Administrative Nurse D stated if the resident was able to hold her feet up while staff propelled her, the resident would need foot pedals. Administrative Nurse D revealed she would expect staff to use the foot pedals on the resident's wheelchair if the resident was unable to hold her feet up during transports. The facility policy, Wheelchair Positioning for Comfort and Safety, undated, included: The resident's feet should rest firmly on the wheelchair foot plates. The facility failed to place foot pedals on this resident that required extensive assistance for locomotion in her wheelchair, that created the potential for an accident hazard and injury. - Review of the Physician Order Sheet (POS), dated 07/26/21, for Resident (R)28, included diagnoses of [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (muscular weakness of one half of the body). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She required extensive assistance of one staff for locomotion on the unit with the use of her wheelchair. She had impairment on one side of her lower extremities (LE legs). The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/31/21, documented the resident required extensive assistance with wheelchair mobility due to weakness on her right side. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 10, indicating moderately impaired cognition. She required limited assistance of one staff for locomotion on the unit with the use of her wheelchair. She had impairment in functional ROM on one side of her LEs. The ADL care plan, dated 04/13/21, instructed staff were to assist the resident to her destination with use of her wheelchair. The care plan lacked instruction on the use of foot pedals for her wheelchair. Review of the resident's EMR under the Task tab, from 06/30/21 through 07/29/21, revealed the resident required independent to extensive assistance of one staff for locomotion on the unit with her wheelchair. On 07/26/21 at 11:18 AM, Certified Nurse Aide Q, propelled the resident in her wheelchair to the dining room for lunch. The resident wore slippers which skimmed the floor during transport. The wheelchair lacked foot pedals. On 07/27/21 at 08:00 AM, Licensed Nurse H, propelled the resident to the dining room for breakfast. The resident wore slippers and her heels bounced up and down on the floor during transport. The wheelchair lacked foot pedals. On 07/27/21 at 07:37 AM, Certified Nurse Aide (CNA) M stated staff do not use foot pedals on the resident's wheelchair because she will propel herself at times. On 07/28/21 at 10:38 AM, CNA N stated staff do not use foot pedals for the resident as they would be a fall hazard. On 07/28/21 at 02:47 PM, CNA O stated the resident's feet skim the floor while staff transported her in her wheelchair to the dining room. On 07/28/21 at 02:11 PM, Administrative Nurse E stated staff do not use foot pedals on the resident's wheelchair. On 07/29/21 at 09:57 AM, Administrative Nurse D stated if the resident was not able to hold her feet up while staff propelled her, the resident would need foot pedals, but Administrative Nurse D would expect staff to use foot pedals on the resident's wheelchair if the resident was unable to hold her feet up during transports. The facility policy, Wheelchair Positioning for Comfort and Safety, undated, included: The resident's feet should rest firmly on the wheelchair foot plates. The facility failed to place foot pedals on this resident, who required staff assistance with wheelchair mobility, that created the potential for an accident hazard and injury.

The facility reported a census of 42 residents with 15 selected for review, which included five residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure pressure ulcer care in a sanitary manner to prevent the spread of infection for one ,resident (R)37, of the five selected for review. Findings included: - Review of resident (R)37's Transfer Form, dated 07/02/2021, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS), which was in progress on 07/26/21 with a look back date of 07/12/21 assessed the resident had normal cognitive function, extensive assistance of two person for bed mobility and dressing and was dependent of staff for transfer and toilet use. The resident had functional impairment on both sides of lower extremities but no impairment in her upper extremities. The resident had two unstageable pressure ulcers present upon admission. The Pressure Ulcer Care Area Assessment (CAA,) dated 07/21/21, assessed the resident admitted to the facility with suspected deep tissue injury to her bilateral (both sides) buttocks. The resident sits for long periods of time at [CONDITION(S)] (a treatment to remove waste products from the blood.) The resident has a bariatric (oversized) bed with an air mattress and cushion in her wheelchair. The nursing staff reported the resident refuses to lay down and reposition at times. The Baseline Care Plan, dated 07/21/2021, (as of 07/26/21 the comprehensive care plan was not developed) instructed staff the resident received therapy services with the goal to return home. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was in a bariatric bed and required two staff assistance with bed mobility and to offer repositioning every two hours. A Physician Order, dated 07/20/2021, instructed staff to apply collagen (a substance that heals damaged tissue) powder and a super absorbent dressing daily and as needed. A Wound Culture Report, dated 07/25/2021, documented the resident's wound contained MRSA (methicillin resistant staphylococcus aureus a transmissible bacterium that is resistant to many antibiotics) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation, on 07/27/21 at 08:36 AM, revealed the resident positioned in her bariatric bed. Administrative nurse D and Licensed Nurse (LN) G, donned gown, and gloves, and assisted the resident to turn in bed (the bed lacked positioning bars on both sides) by the resident holding onto staff's arm. Administrative nurse D and Licensed Nurse (LN) G, changed the resident incontinence brief, removed gloves, then donned clean gloves, but did not perform hand hygiene. LN G removed the dressing from the resident buttocks, and sprayed gauze sponge with wound cleanser and patted the areas. The resident's buttocks contained six areas of yellow-white slough, surrounded by reddened skin with an approximate area total of eight centimeters by six centimeters. LN G removed her gloves and donned clean gloves but did not perform hand hygiene. LNG then applied the collagen powder to a dressing and applied it to the wounds and secured the dressing to the resident's skin. Interview, on 07/27/2021 at 08:50 AM, with LN G, confirmed the need for hand hygiene prior to donning clean gloves. Interview, on 07/27/21 at 08:50 AM, with Administrative Nurse D, confirmed staff should perform hand hygiene in between gloving. Administrative Nurse D stated the resident had MRSA in her buttocks wounds and felt the wounds looked better. The Infection Control Policy, dated 01/29/2021, instructed staff to perform hand hygiene immediately after removing gloves. The facility failed to ensure sanitary dressing change for this resident with MRSA infection in her pressure ulcer to prevent contamination and improve healing mechanisms.

The facility reported a census of 42 residents. Based on observation, record review, and interview, the facility failed to have a Certified Dietary Manager (CDM), as required. Findings included: - On 07/28/21 at 11:15 AM, Dietary BB stated, he was not a Certified Dietary Manager (CDM) and had not enrolled in the class. Dietary BB stated, he had been the dietary manager for approximately six months and had not gotten around to enrolling. On 07/29/21 at 11:01 AM, Administrative staff A stated, Dietary BB only enrolled in the required class on that date. The facility policy for Food Services Manager, revised 12/2008, included: The Food Services Manager was a qualified supervisor licensed by the state and was knowledgeable and trained in food procurement storage, handling, preparation, and delivery. The facility failed to have a qualified food service manager, as required.

The facility reported a census of 36 residents. Based on observation, interview, and record review, the facility failed ensure a sanitary environment for the residents and staff of this facility to prevent the possible spread of infection. Findings included: - Observation on 01/12/21 at 11:30 AM, revealed 13 residents on the Non-Covid unit. A sticky note labeled Dirty was on the door jamb to an unoccupied resident room. However, the room contained two residents' beds and their belongings. Staff placed a trash container for the unit trash and a container for soiled laundry in the residents' room. Interview, on 01/12/21 at 11:30 AM, with Certified Nurse Aide (CNA) N, revealed staff used the room as a modified Dirty utility room to place trash and dirty linen. CNA N stated the two residents who occupied this room were moved to the COVID unit, and their belongings and beds remained, but would be sanitized prior to moving them back. CNA N stated staff used an empty resident room for showers and as a Clean utility room. Observation, on 01/12/21 at 11:30 AM, revealed the Clean utility/shower room (another resident room that was not occupied and did not contain resident belongings, contained packaged food items and an uncovered clean linen cart. A wheeled cooler that contained ice and placed directly on an over bed table with a pitcher of juice. Observation, on 01/13/21 at 07:45 AM revealed an open trash can outside of the facility, by the front door, and the trash can overflowed with isolation gowns. Observation, on 01/13/21 at 03:30 PM, revealed the employee entrance through the service hall, contained debris on the floor. Dietary staff personal protective equipment (PPE) was in an open paper bag (each individual staff's PPE was labeled in separate plastic bags) stored directly on the floor, beside a trash can that overflowed with blue isolation gowns. Interview, on 01/13/21 at 03:30 PM, with dietary staff CC, revealed the bag containing staff's reusable PPE should be off the floor, away from the trash can. Observation, on 01/13/21 at 04:00 PM, on the COVID unit, revealed a soiled utility room with a biohazard (biological agent or condition that is a hazard to humans or the environment) box that overflowed with red bags (used for contaminated items) and previously worn isolation gowns. A barrel for unclean laundry and trash occupied the area by the hopper. The sink bowl and ledge contained eight fluid collecting canisters from a suction machine that contained various levels of unidentified fluid. The sink also contained mops, and buffing machine components. The clutter prevented staff from washing their hands in the sink. Interview, on 01/13/21 at 04:10 PM, with CNA O revealed she did not know who was responsible for removing the biohazard trash from the utility room and stated she did not know what was in the suction canisters or how long they had been there. CNA O stated staff could use the sink in the dining area across the hall to wash their hands . Interview, on 01/13/21 at 04:30 PM with Administrative Nurse D, revealed she did not know why the suction canisters were in the dirty utility room. Administrative Nurse D stated there was one resident who required suctioning. Administrative Nurse D stated the biohazard (including the suction canisters) should be packaged and taken to the biohazard storage unit outside of the facility for pick up. Observation, on 01/14/21 at 08:00 AM, revealed the trash can at the front door to the facility remained overflowing with isolation gowns. Interview, on 01/14/21 at 08:10 AM, with maintenance staff U, revealed housekeeping staff should empty the trash cans. The policy Suctioning the Lower Airway (Endotracheal (ET) or [MEDICAL CONDITION]), revised October 2010, instructed staff to empty and rinse the collection container if necessary or as indicated by facility protocol. The facility policy Infection Control reviewed 01/01/20, instructed staff to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This policy also instructed staff to practice appropriate use of biohazard disposal units for non-sharp items. The facility failed to ensure proper disposal of biohazard fluids from suction containers in a timely manner and packaging biohazard materials to prevent staff from touching uncontained biohazard trash. The facility failed to provide a dirty utility room staff could access with a sink for handwashing without coming in contact with biohazardous waste. The facility failed to provide a designated dirty utility area in a manner to prevent the spread of infection on the Non-COVID unit. The facility failed to ensure dietary staff stored their PPE in a sanitary area to prevent the spread of infection.

The facility reported a census of 36. Based on observation, interview, and record review, the facility failed to provide housekeeping services to ensure a safe and sanitary environment for residents and staff. Findings included: - Observation, on the West hallway revealed the following concerns: 1. The West hallway had debris on the carpets. 2. The dumpster with trash piled over the lid. 3. One resident room had a dirty overbed table. 4. One resident room had multiple white pieces of paper debris on the floor. 5. One resident room had debris under the resident's bed and in the corners of the room. 6. One resident room had a smeared hazy, white substance on the floor. On 01/12/21 at 2:00 PM, Certified Nurse Aide (CNA) N, reported she cleans when she has time. There is not a housekeeper for this hall. The nursing staff were responsible for the cleaning of the West hallway. On 01/14/21 at 1:00 PM, Administrative Nurse D confirmed nursing staff are responsible for cleaning the west hallway. The facility policy, General Cleaning and Maintenance of Resident Environment, dated 01/19, documented, the staff of this facility would provide a safe, clean, comfortable and homelike environment. Areas used by residents would be kept clean. The facility failed to provide housekeeping services to ensure a safe and sanitary environment for residents and staff.

The facility reported a census of 36 residents with seven selected for review. Based on observation, interview and record review, the facility failed to ensure accurate documentation in the medical record for gastric tube feedings for one resident (R) 4 of the seven residents reviewed, and failed to provide back -up resident information for staff unable to access the internet and electronic medical record documentation related to internet failure. Findings included: - Review of R4's Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status score (BIMS) of 11, which indicated moderate cognitive impairment. The resident received at least 51% of nutritional intake through gastric tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). The Feeding Tube Care Area Assessment (CAA), dated 03/15/20, assessed the resident received all necessary nutrition through tube feedings. The care plan, reviewed 11/28/20, instructed staff the resident had a percutaneous endoscopic gastric (PEG) tube for nutrition, and staff should check for residual stomach contents with flushes and medication administration. The resident received [MEDICATION NAME] 1.5 (a brand of nutritional tube feeding solution) continuously at 48 milliliter (ml) per hour with 150 ml water flushes every four hours. Review of the Physician Orders, dated 01/06/21, instructed staff to administer [MEDICATION NAME] 1.5 (a type of nutritional solution) 45 milliliters(ml) per hour. Review of the Medication Administration Record [REDACTED]. Observation, on 01/21/21 at 11:21AM, revealed the resident positioned on her back in bed with her head of the bed slightly elevated. The resident had a PEG tube in place in her abdomen, and a pump infused the solution. Interview, on 01/13/21 at 01:30 PM, with Licensed Nurse (LN) I revealed she admitted the resident back to the facility on [DATE], however lacked access to the computer or the availability of the electronic medical records for documentation. LN I stated the resident did have a continuous gastric feeding with a pump. LN I stated she also lacked access to point click care on 01/07/21 during her shift. Interview, on 01/14/21 at 08:15AM, with Administrative Nurse D, revealed the internet failed for the entire city on 01/06/21 and staff used their cell phones for hot spots to access the electronic medical records. Administrative Nurse D stated LNI worked on a separate unit and did not know she could not access the electronic medical record as other staff had through their hot spots. Furthermore, Administrative Nurse D did not know that the order for the gastric feeding for this resident had not been transcribed onto the MAR/TAR for administration until 01/11/21. The facility policy Power and Internet Outages for emergency documentation when there is a system failure instructed staff to use personal devices and hotspots to access the electronic medical records. Staff instructed to access the MAR/TAR backup file to use with medication administration and to use a paper MAR indicated [REDACTED]. The facility failed to ensure staff had access to resident information during internet failure and failed to ensure transcription of physician orders.

The facility reported a census of 36 residents with seven selected for sample review, including three residents sampled for indwelling catheter. Based on observation, record review, and interviews, the facility failed to ensure proper handling of the catheter drainage bag for Resident (R)6 to prevent possible urinary tract infections. Findings included: - Resident (R)6'ssigned physician orders, dated 12/30/20, documented the resident admitted on [DATE], with the following Diagnoses: [REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The care plan, reviewed on 10/23/20, for indwelling catheter use, advised the following interventions for staff: A 20 French Foley (the relative size of a Foley catheter described using French units) catheter (insertion of a catheter into the bladder to drainDid the urine into a collection bag) placed due to unstageable wounds on bilateral (both) buttocks, to reduce moisture and promote healing. Staff should provide the resident's catheter care every shift. Staff should ensure the resident's catheter secured and in a dignity bag (a covering where urine in the bag is not exposed to others for view) every shift. On 1/12/21 at 04:45 PM, the resident's catheter drainage bag lacked a dignity cover In addition, the urine collection bag touched the floor, and the resident's catheter tubing was not secured to the resident. On 01/13/21 at 03:24 PM, the resident sat in her wheelchair in the hallway with the urine drainage positioned under the wheelchair. The drainage bag lacked a dignity bag and the catheter tubing touched the floor. On 01/13/21 at 03:45 PM, Certified Nurse Aide (CNA) O, confirmed the resident's catheter bag should have a dignity bag, the tubing should not touch the floor, and the resident's tubing was not secured to the resident and the tubing should be secured. On 01/12/21 at 04:50 PM, Licensed Nurse (LN) H confirmed R6's catheter bag did not have a dignity cover, touched the floor, and the tubing should be secured to the resident to prevent possible trauma or discomfort. On 01/14/21 at 02:00 PM, Administrative Nurse D confirmed the catheter drainage bag required a dignity cover, the tubing should be secured to the resident, and the catheter tubing/bag should not touch the floor. The facility policy, dated 12/14, Incontinent Care and Catheter Care Policy and Procedure, documented the foley catheter drainage bags would be covered by a dignity bag at all times, ensure the catheter is attached to leg to reduce risk of pulling that would cause trauma or discomfort from the catheter, and to prevent catheter associated infections. The facility failed to provide this resident, with an indwelling catheter, the appropriate care and services to prevent urinary tract infections by improper placement of the catheter drainage bag, lack of a device to secure the tubing, and allowing the tubing/bag to touch the floor.

The facility reported a census of 36 residents with seven selected for review, which included five residents reviewed for activities of daily living. Based on observation, interview and record review, the facility failed to provide bathing opportunities for two residents (R)3 and R4, of the five residents reviewed for bathing. Findings included: - Review of R4's Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident was dependent on staff for bathing. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA,) dated 12/30/20 assessed the resident had left sides [MEDICAL CONDITION] and required total assistance of staff for ADLs. The Care Plan, revised 11/28/20, instructed staff the resident had left side neglect post stroke. The Kiosk (electronic care plan for Certified Nursing Staff), undated, instructed staff to provide a bath on Tuesday and Saturdays during the day shift. Review of bathing under the Task tab in the electronic medical record from 12/15/20 through 01/09/21, (the resident was out of the facility 01/02/21 through 01/06/21) revealed lack of bathing on 12/19/20, 12/22/20, 12/29/20, 01/09/21, and 01/12/21, as provided by the Kiosk preferences. Observation, on 01/12/21 at 02:08 PM, revealed Certified Nurse Aide (CNA) N, repositioned the resident. The resident lacked ability to move her left arm and left leg and she responded to yes and no questions. Interview, on 01/12/21 at 02:30 PM, with CNA N, revealed she did not know when the resident should have received her baths. Interview, on 01/12/21 at 04:26 PM, with CNA P, revealed the resident was not on the list for bathing for her shift. Interview, on 01/13/21 at 11:30 AM, with Licensed Nurse (LN) H, revealed she would expect staff to provide baths to the residents as indicated in the Kiosk (electronic care plan and documentation area for CNA's.) The facility Bathing Policy dated 01/01/20, instructed staff to provide bathing and grooming based on individual resident preferences. The facility failed to provide five bathing opportunities from 12/15/20 through 01/13/21 (the resident was out of the facility (01/02/21 through 01/06/21) as care planned. - Review of resident (R) 3's Physician order [REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident required one person assistance for bathing. The The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA,) dated 10/08/20, assessed the resident had a history of [REDACTED]. The care plan, revised 10/30/20, instructed staff the resident preferred showers on Tuesdays and Fridays, during the day. Review of Bathing in the Task tab in the electronic medical record from 12/21/20 through 01/12/21, revealed the resident requested a shower every Monday, Wednesday, and Friday and preferred the shower early in the morning. Lack of bathing opportunities noted on 01/01/21, 01/04/21 and 01/11/21. Observation, on 01/12/21 at 11:20 AM, revealed the resident dressed appropriately. The resident stated he did not receive bathes as he had requested. He stated he preferred to take a shower, and the last shower he got was on 01/08/21 at 05:00 AM. Interview, on 01/12/21 at 11:30 AM, with Certified Nurse Aide (CNA) N revealed she did not know when she should provide a bathing opportunity to the resident. CNA N stated the residents received showers in a designated room on the unit. Interview, on 01/13/21 at 11:30 AM, with Licensed Nurse (LN) H, revealed she would expect staff to provide baths to the residents as indicated in the Kiosk (electronic care plan and documentation area for CNA's.) The facility Bathing Policy dated 01/01/20, instructed staff to provide bathing and grooming based on individual resident preferences. The facility failed to provide three bathing opportunities (from 12/21/20 through 01/12/21) for this resident, who required staff assistance, as care planned.

Based on observation, interview, and record review, the facility failed to implement CMS and CDC recommended infection control practices in order to control and prevent the potential spread of COVID-19 amongst residents and staff. On 5/7/20, multiple facility staff entered the rooms of presumed-positive COVID-19 residents (R1 and R2), while failing to wear appropriate personal protective equipment (PPE), despite sufficient facility supply. Also on 5/7/20, multiple facility staff entered the rooms of residents under observation (R5, R6, and R7) while failing to wear appropriate PPE. Furthermore, on 5/7/20, a facility staff person failed to appropriately wear a face mask while in the room of two residents (R3 and R4). On 5/8/20, R1 tested positive for COVID-19. A determination was made that the facility's noncompliance with one or more requirements of participation at F880 placed all residents in the facility in immediate jeopardy. On 5/13/20 at 10:55am, the Administrator was informed of the immediate jeopardy. Findings include: - Review of CDC recommendations, dated 4/15/20, titled Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, documented: Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Residents could be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission). Testing at the end of this period could be considered to increase certainty that the resident is not infected. If an observation area has been created, residents in the facility who develop symptoms consistent with COVID-19 could be moved from their rooms to this location while undergoing evaluation. All recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn by HCP (healthcare personnel) when PPE is indicated. Review of the facility's Quarantine Hall Guidelines, undated, documented: - You do not need to wear gowns or goggles unless told otherwise by charge nurse. - You must wear your mask and gloves while providing care to these rooms. - If coming off North Hall (100 hall) to help somewhere else in facility, you must change your mask out and wash hands. You can wear same mask on North Hall and store in brown paper bag when not using or when switching to a different mask to come off North Hall, with a different brown paper bag for that mask. The Quarantine Hall Guidelines procedure failed to adhere to CDC recommendations in regards to caring for residents under observation, and for those residents presumed positive for COVID-19. On 5/7/20 at 9:10am, licensed practical nurse (LPN1), wearing a cloth facemask, indicated that R1 and R2 both received testing for COVID-19 on 5/6/20 following fevers. R1 also developed right lower lobe infiltrates (when fluid or other substances accumulate in the lower portion of the lung), and R2 developed a rash. LPN1 indicated that facility staff were expected to wear a cloth face mask and gloves when entering the rooms of R1 and R2, and only wore other PPE if providing close-contact cares, such as toileting. On 5/7/20 at 9:15am, the Director of Nursing (DON) indicated that the facility utilized the 100 hall as the observation area for new admissions and readmissions. The DON indicated that the facility had sufficient PPE and was not low. The DON indicated that full PPE was not worn by facility staff because there was a chance that in the future, the facility may run low on supplies. The DON indicated that if the facility were to begin to run low on supplies, corporate would send more. The DON indicated again that the facility had adequate PPE levels to care for any possible COVID-19 residents. The DON indicated that staff were to wear gloves and a facemask, disposable or homemade, when caring for new admissions or residents under observation. After leaving the resident's room, staff were to change their masks and dispose of gloves. The DON indicated that only residents who displayed respiratory symptoms, such as coughing, were placed on the recommended droplet precautions. The DON indicated that two residents, R1 and R2, were tested for COVID-19 on 5/6/20, but did not display any respiratory symptoms, so staff did not have to wear gowns or eye protection. The DON indicated that the facility believed both tests would come back negative. On 5/7/20 at 10:15am, the housekeeper (H1) indicated that the 100 hall was used as the isolation hall. H1 indicated that if she cleaned one of the isolation rooms, she needed to wear only gloves and a mask. H1 indicated that she was aware of two residents (R1 and R2) who were recently tested for COVID-19. H1 indicated that she would wear only a mask and gloves if cleaning the presumed-positive resident's rooms. On 5/7/20 at 10:38am, nurse aide (NA1) indicated that when he entered the room of a resident under observation, he would wear a cloth facemask and gloves. NA1 indicated that staff had their main facemask, but residents on observation had different masks in paper bags that staff must wear while they worked with that resident. NA1 indicated that if he needed to go onto the 100 hall, he would change into a different mask as well. NA1 indicated that he would only wear a gown or eye protection if he was doing close, personal cares with a resident on observation. On 5/7/20 at 10:57am, R5, a resident under observation, rang his call light. NA1 went to the entrance to the 100 hall, changed his mask, then entered R5's room. NA1 then closed the door. After a few minutes, NA1 exited R5's room. NA1 indicated that he provided stand-by assistance to R5 so that he could ambulate to his bathroom. NA1 indicated that R5 would ring his call light when he was finished in the bathroom. At 11:09am, R5 rang his call light, and NA2 responded. NA2 wore only a facemask and a pair of disposable gloves. On 5/7/20 at 11:00am, physical therapy assistant (PTA1) ambulated with R6 in her room. R6's door displayed signage documenting that she was under observation. PTA1 and R6 both wore simple cloth facemasks. PTA1 completed different physical therapy exercises with R6. On 5/7/20 at 11:28am, PTA1 indicated that new admissions to the facility were kept under observation for 14 days, and therapy staff would wear only a facemask and gloves when providing therapy exercises. On 5/7/20 at 12:30pm, R1 rang his call light. NA3 responded, walked to R1's door, changed his mask, and entered the room. R1 requested silverware for his lunch. NA3 indicated that he would be right back, left the room, changed his mask, and went to go retrieve silverware for R1. At 12:37pm, NA3 returned, changed his mask, entered R1's room, and gave him the silverware. On 5/7/20 at 12:52pm, lunch trays for the 100 hall arrived on a cart. The DON stood outside of the entry to the 100 hall, while registered nurse (RN1) began passing lunch trays. RN1 wore a simple cloth face mask and gloves. RN1 then entered five residents rooms, all under observation, while wearing only a cloth mask and gloves. RN1 also entered R2's room, who was presumed positive for COVID-19 and tested for the disease on 5/6/20. On 5/7/20 at 1:30pm, the Administrator and the DON indicated again that the facility had adequate supplies of PPE. The Administrator and DON indicated that the facility's corporate officers told them that asymptomatic residents in quarantine and asymptomatic residents who were under investigation for COVID-19 did not need full PPE, as recommended by the CDC. The Administrator and DON indicated that they were aware that residents could be positive for COVID-19, but be asymptomatic. On 5/8/20 at 2:08pm, the Administrator notified the Federal surveyor that R1 tested positive for COVID-19. - On 5/7/20 at 10:25am, the Activity Director (AD) sat with R3 and R4 in their room, talking. The AD wore a facemask, but had the mask pulled down to beneath his chin, leaving his nose and mouth completely exposed. On 5/7/20 at 10:27am, the AD indicated that he was playing a board game with the R3 and R4. The AD indicated that the appropriate way to wear a facemask was to ensure the mouth and nose were both covered. The AD indicated that his mask had slipped down, and that he had not noticed it. On 5/7/20 at 1:32pm, the Administrator and DON indicated that their expectation of staff was to wear facemasks appropriately, ensuring the mouth and nose were both covered. The IJ was removed on 5/19/20 after surveyors verified implementation of a removal plan. The scope and severity was lowered to an F.

The facility had a census of 40 residents. Based on observation and interview, the facility failed to store, prepare, distribute and serve food under sanitary conditions in one of one kitchen for all of the residents in the facility and in one of the two kitchenettes. Findings included: - The tour of the kitchen environment observation, on 11/17/19 at 10:07 AM, revealed the following areas or items of concern: The Dietary Aide, CC, revealed her hairnet did not cover the hair around her neckline as parts of her hair hung down to her shoulders. The Artic Air Freezer, contained a clear container with a green lid, labeled Chx dated 11/6/19, that did not securely seal the clear container. The food item in the container had freezer burnt appearance in nature, over the top. The Refrigerator, contained a five-pound container of Greenview Farm Cottage Cheese, with expiration date of 11/3/19, with approximately one-quarter left in the container. The Refrigerator, contained an unopened, five-pound container of Greenview Farm Cottage Cheese, with expiration date of 10/3/19. The Kitchenette, in the West Dining Room's, backsplash behind the warmer on the white trim contained a build-up of grease and grim. The Kitchenette, in the West Dining Room, contained dried liquid spilled down the cabinet and on the north wall. On 11/18/19 at 08 :10 AM, Dietary BB confirmed that the staff's hairnet should cover all the hair of the staff members that enter and work in the kitchen. She stated that their policy was first in and first out and the food items in the refrigerators were to be checked daily, every shift for the expiration dates. On 11/19/19 at 11:20 AM, Dietary BB, confirmed the above items/areas and stated that the staff had a deep cleaning schedule weekly, but the kitchenette should have been clean when visibly soiled. On 11/19/19 at 11:50 AM, Administrative Nurse D, confirmed that staff should be checking more closely for the expiration dates in the refrigerators, assure that items in the freezers are securely closed and when or if the dining rooms and kitchenettes are visibly dirty, they should be cleaned immediately. The facility policy, revised (MONTH) 2014, for Food Receiving and Storage directed staff that all foods in the freezer will be covered. The Food Preparation and Service Policy, revised (MONTH) 2014, directed dietary staff shall to wear hair restraints so that hair does not contact food. The facility failed to store, prepare, distribute and serve food under sanitary conditions in 1 of 1 kitchen for all the residents in the facility and in one of the two kitchenettes.

The facility reported a census of 44 residents with 18 selected for sample review. Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices for 3 residents of the 3 residents reviewed for accidents, including #19 with gaps in the bed rail and #53 with repeated falls. Resident #73 was placed in immediate jeopardy when the facility failed to ensure adequate supervision and assistive devices to ensure this wandering resident did not exit the facility without the staffs knowledge. Additionally, the facility failed to ensure the use of a GFCI (ground fault circuit interrupter) electrical outlet in 1 of 1 therapy rooms, with the use of a Hydrocollator (a heating unit for hot water packs) to prevent accidents for the residents of the facility. Findings included: - The facility admitted resident #73 on 7/15/14, per the ECR (electronic care record). [DIAGNOSES REDACTED]. The resident's 7/24/14 admission MDS (minimum data set) assessment, identified the resident scored 5/15 on the BIMS (brief interview for mental status) assessment, indicating severely impaired cognition, and without any behavioral or mood concerns. The 7/28/14 Care Area Assessment (care area assessment) for cognition included, the resident was only able to recall 2 of the 3 words and required cueing. The 8/5/14 care plan instructed staff the resident needed: 1. Monitoring for safety due to wandering upon admission. A wander guard (a device to alert staff when the resident approaches an alarmed exit), was currently in place to his/her right ankle for safety. 2. Staff discontinued the wander guard, per the care plan, on 9/2/14; however, the care plan lacked any further instructions on how to keep the resident safe after the wander guard removal. 3. On 9/9/14 staff placed the wander guard to the resident's right ankle and placed the resident on 30 minute visual checks for 1 week. After 1 week of 30 minute checks, change to every hour checks. 4. Staff updated the care plan on 9/15/14 to include checking placement of the wander guard every shift and checking function of the unit every day. Review of the facility elopement assessments included: 7/15/14 scoring 60, on 9/1/14 scoring 30, and on 9/9/14 scoring 65, indicating the resident at risk for elopement. The assessment identified that a score of greater than 5 indicated a risk of elopement and a score of 10 indicated a high risk of elopement. Further review of the nursing notes indicated on 8/29/14 at 9:29 AM staff documented the removal of the resident's wander guard bracelet, following an ombudsman visit, on 8/26/14. On 9/5/14 at 1:50 PM, a late entry noted a staff member on their drive into work noted the resident in the parking lot across the street from the facility. The staff member immediately turned around and picked up the resident to return him/her to the facility. Documentation further identified the resident assessment lacked identification of any injury, and the resident was unable to state the reason they left the facility grounds. The staff further documented placement of a wander guard to the resident following the resident's return to the facility. Documentation further identified the resident had a piece of paper with the door code written on the paper. Review of the investigation/reporting document dated 9/17/14, revealed administrative staff O, reported seeing the resident on the front patio smoking a cigarette, with another alert and oriented resident, about 10 minutes prior to another staff member seeing the resident across the street. Observation, on 9/25/14 at 8:45 AM identified the facility located in a commercial area, with the facility located approximately one-half a block from a frequently used street of the community. The investigation identified the resident crossed this busy street during his/her elopement. The street is identified to have 2 stop lights within less than a one mile stretch of this street, have a speed limit of 35 miles per hour, and lacked any cross walks within the area. Observation of the resident throughout the survey dates of 9/25/2014 to 9/26/14 and 9/29/14 to 9/30/14 identified the resident wandered throughout the facility, often observed in the smoking room, and occasionally observed outside in the fenced back yard of the facility, with a wander guard in place to the resident's right ankle. Direct care staff J reported, on 9/29/14 at 2:23 PM, the resident was independent with ADLs, ambulated independently throughout the facility, enjoyed staying up late at night, and was very social, although with confusion. On 9/30/14 at 9:18 AM, direct care staff M reported the resident had a wander guard upon admission to the facility, then staff removed it, and the resident left the building during the time the wander guard was not in place. On 9/30/14 at 10:46 AM administrative nursing staff F reported staff removed the resident's wander guard at the resident's request following an ombudsman visit. Following removal of the wander guard the staff discussed, with the resident, the importance of letting the staff know if the resident intended to leave the building/property. The resident reported understanding at the time of the removal; however, Staff F reported this was not documented in the clinical record. On 9/30/14 at 5:00 PM, resident advocate R, reported that upon visiting with the resident, they determined the resident's concern regarding living away from his/her friends seemed the major concern and urged the facility to advocate for the resident's desire to move closer to home. The advocate reported they did not address the issue of the wander guard placement on the resident. On 9/30/14 at 5:15 PM administrative nursing staff A reported the facility investigated the elopement and determined the resident continued the need for the wander guard and the facility changed all the door alarm codes following the resident exiting the facility unattended. On 10/1/14 at 3:45 PM licensed nursing staff N reported the resident, although confused at times, continued with immediate safety needs intact and would be safe to cross the street in front of the facility. On 10/1/14 at 3:50 PM administrative nursing staff F reported the resident's safety awareness remained intact, however, the staff continued to monitor the resident's whereabouts hourly and ensure placement and function of the wander guard to the resident's ankle. On 10/2/14 at 8:50 AM, interview with family member Q reported the resident they advised the facility on admission, in July, that the resident was not safe and needed 24 hour oversight. The family reported they discussed the removal of the wander guard bracelet with the staff and indicated they could remove the wander guard, but that the facility still needed to monitor the resident closely. The facility policy for Elopement, dated 12/13, identified all resident's entering the facility would have a Wandering/Elopement Risk Assessment completed. The policy defined elopement as a cognitively impaired resident leaving the facility without the knowledge of the staff. The facility failed to ensure adequate supervision and assistive devices to ensure this wandering resident did not exit the facility without staff's knowledge. The facility abated the immediate jeopardy, on 09/10/14 PM when the facility completed an updated elopement assessment for the resident, placed a wander guard bracelet on the resident, changed the door codes, developed and implemented a system to monitor the efficacy of the system, and developed a care plan to provide the resident with adequate supervision and assistive devices to prevent the resident from leaving the facility without staff knowledge. Furthermore, the facility changed the door codes and all residents were audited for elopement risk. Additionally, licensed nursing staff were re-educated on 10/10/14 to understand the elopement policy and procedure, department managers were also re-educated on accident/incident reporting and the system to monitor and prevent accidents, including missing residents, responding to an elopement and preventative action plan for elopement of a resident. - The facility admitted resident # 19 on 10/12/09, per the ECR (electronic care record). The resident's annual 8/12/14 MDS (minimum data set) assessment, identified the resident scored 10/15 on the BIMS (brief interview for mental status), indicating moderately impaired cognition, and needed extensive assistance of 2 staff for bed mobility and transfers, and identified the resident did not use bed rails. The 8/25/14 CAA (care area assessment) for ADLs (activities of daily living) identified, the resident needed reminders for cares and extensive assistance for ADL tasks. The resident used a repositioning bar, on the right side of the bed for assistance in repositioning. The resident's 9/8/14 care plan instructed staff the resident able to reposition him/herself at times, but needed extensive assistance of 2 staff for bed mobility, with the resident's bed placed against the wall for easier access and a repositioning bar in place to the right side of the bed. On 9/25/14 at 2:43 PM, observation identified the resident rested in the bed, with a transfer bar, located at the head of the bed, with an inside opening, measuring 10 by 11 inches. On 9/25/14 at 3:15 PM, administrative nursing staff A indicated the rail on the residents personal bed, failed to meet the facility guidelines for safety. On 9/29/14 at 11:29 AM, observation identified the transfer bar, now wrapped with a material to prevent entrapment, in the large opening, which remained in place at the head of the bed. On 9/29/14 at 2:30 PM, observation identified the wrapped side rail now pushed away from the edge of the bed, which created a gap, between the mattress and the transfer bar, of approximately 6 inches. Administrative nursing staff A reported on 9/29/14 at 4:10 PM, the resident's loose transfer rail with a gap between the mattress and the rail, needed removed. Maintenance staff B, reported on 9/29/14 at 5:05 PM, the staff monitored and checked all transfer bars and side rails monthly, for safety. The staff member reported they overlooked the resident's personal transfer rail, due to the rail being on the resident's personal bed and it not permanently attached to the bed. The facility policy for Physical Restraints, dated 10/12, instructed that side rails are assessed monthly to determine continual compliance with FDA and facility guidelines. The FDA (food and drug administration) dimensional limit recommendations for spacing, dated 9/2010, included no more than a 4 and 3/4 inches gap within the rail and 4 and 3/4 inches gap between the rail and the mattress. The facility failed to ensure this dependent resident's environment remained free of accident hazards, with the use of a bed rail, with large openings and gaps between the mattress and bed rail, which created the potential for entrapment of the resident. - The facility admitted resident #53 on 10/2/13, per the ECR (electronic care record). An 8/22/14 quarterly MDS (minimum data set) assessment identified the resident scored 4/15 on the BIMS (brief interview for mental status) assessment, indicating severely impaired cognition, and needed supervision of 1 staff to set-up help only for bed mobility and transfers, supervision with walking, and independent with personal hygiene. The assessment identified the resident with falls since the prior assessment with minor injury. Review of the Fall Risk Assessments included; on 8/9/14 a score of 17 and on 9/21/14 a score of 14. The assessment indicated a score of 16 or greater represented a high risk for falls. A 9/12/14 care plan instructed staff regarding accidents: 1. The resident assessed at a very high risk for falls. 2. Anti-rollback brakes on the wheelchair for safety. 3. Fall mat at bedside. 4. Bed positioned against the wall for easier access. 5. Keep the bed in the lowest position when the resident is in it. 6. Make sure the call light is within reach at all times, although the resident does not use it routinely. Bright tape has been placed on it to remind the resident to use the call light. 7. Shoes and/or non-skid footwear when out of bed. 8. Likes bedroom door left open when the resident is in bed. 9. Visual cues have been placed on the walker to remind the resident to use the walker. 10. A wheelchair is available to the resident and he/she is able to propel it independently. The resident also walks using a roller walker, and needed only supervision with occasional limited assistance when walking. Review of the ECR indicated the resident experienced falls on 8/9/14 and on 9/21/14 while performing ADL's independently. Observations of the resident on 9/25/2014 at 3:01 PM, on 9/29/14 at 11:00 AM, on 2/29/14 at 2:10 PM and on 11/30/14 at 11:00 AM, identified the resident seated in a wheelchair without the planned anti-rollback brakes. On 9/30/14 at 11:00 AM, observation and interview with maintenance staff B, reported the staff installed anti-rollback brakes to the resident's wheelchair, and to their knowledge the anti-rollbacks remained in place. However, after viewing the resident's wheelchair, staff B confirmed the absence of the special brakes. Staff B felt the staff had placed the wrong wheelchair to the resident's room, following wheelchair washing. The staff reported they were unaware how long the resident had been in the wrong chair. On 9/30/2014 at 11:17 AM, administrative nursing staff K, reported not being aware the resident's anti-rollback brakes were discontinued and would check into the concern. At 12:30 PM, staff K reported the resident frequently chair shops in the hall way for different chairs, and at some point obtained a chair that did not have anti-rollback brakes on it. The staff lacked knowledge of how long ago this occurred. The facility failed to ensure this resident, at risk for falls, received assistive devices to prevent further falls. - On 9/30/14 at 10:30 AM, environmental tour of the facility revealed, the therapy room contained a Hydrocollator not plugged into a GFCI (ground fault circuit interrupter). Maintenance staff B reported, at that time, surprise the unit was not plugged into a GFCI, because the area had recently been remodeled. The facility failed to maintain a safe environment for the residents of the facility, free from environmental hazards, when this hydrocollator failed guarding from electrical shock by the use of a GFCI plug. The scope and severity of the deficiency remains at an E.