Every finding on record at Oakridge of Plattsburg

Based on observation and interview, the facility failed to provide a clean and home like environment for three sampled residents (Resident #4, #14 and #27), when the facility did not ensure window curtains were in good repair and air conditioning units were clean in resident rooms and failed to ensure bathrooms in resident rooms were in good repair. This affected three of 14 sampled residents (Resident #4, #14 and #27). The facility census was 55. The facility did not provide the requested policy on environment.1. Observation of the Resident #4's room on 03/04/2026 at 02:31 P.M., showed:-The vents of air conditioner were covered in dust and dirt;-The air conditioner was on and blowing cold are and dust into the room;-The bathroom door is stuck shut and was hard to open;-The bathroom door had a strip of missing paint on the top of the door;-The window curtains were torn and frayed.Observation of the resident's room on 03/05/2026 at 09:07 A.M., showed:-The vents of air conditioner were covered in dust and dirt;-The air conditioner was on and blowing cold are and dust into the room;-The bathroom door is stuck shut and was hard to open;-The bathroom door had a strip of missing paint on the top of the door;-The window curtains were torn and frayed.During an interview on 03/05/26 at 9:18 A.M. the resident said:-He/She expected her room to be comfortable and homelike-He/She would not have torn and frayed curtains in the home he/she used to live in;-He/She expected bathroom to be in good repair and the door should not stick shut;-The air conditioner should be clean and not blowing out dust. 2. Observation of Resident #14's room on 3/04/2026 at 02:30 P.M., showed:-The bottom of the doorway to the bathroom was missing a 2 inch chunk of wood;-The bottom of the door to the bathroom was had multiple black scraped areas that were missing paint;-The door to the resident's room had multiple scraped areas that were missing paint;-A 1 inch chunk of wood is missing by the door latch the resident's room;-The window curtains are torn and the lining is shredded;-The vents on the air conditioner were covered in dirt and dust;-The air conditioner was on blowing cool air and dust into the resident's room.Observation of the resident's room on 3/05/2026 at 10:03 A.M., showed:-The bottom of the doorway to the bathroom was missing a 2 inch chunk of wood;-The bottom of the door to the bathroom was had multiple black scraped areas that were missing paint;-The door to the resident's room had multiple scraped areas that were missing paint;-A 1 inch chunk of wood is missing by the door latch the resident's room;-The window curtains are torn and the lining is shredded;-The vents on the air conditioner were covered in dirt and dust;-The air conditioner was on blowing cool air and dust into the resident's room.During an interview on 3/5/26 at 10:12 A.M. the resident said:-He/She expected his/room to be clean and in good repair;-He/She did not know who was responsible for the repairs of the room;-He/She expected the air conditioner to be clean and dust free. 3. Observation of the Resident #27's room on 03/04/2026 at 02:31 P.M., showed:-The vents of air conditioner were covered in dust and dirt;-The air conditioner was on and blowing cold are and dust into the room;-The window curtains were torn and frayed.Observation of the resident's room on 03/05/2026 at 09:07 A.M., showed:-The vents of air conditioner were covered in dust and dirt;-The air conditioner was on and blowing cold are and dust into the room;-The bathroom door is stuck shut and was hard to open;-The bathroom door had a strip of missing paint on the top of the door;-The window curtains were torn and frayed.During an interview on 03/05/26 at 9:18 A.M. the resident said:-He/She expected her room to be comfortable and homelike-The air conditioner should be clean and not blowing out dust. During an interview on 03/06/26 at 11:24 A.M. the Housekeeping Supervisor said:-She was in charge of ensuring the window curtains were in good condition;-She and the Maintenance Supervisor were in charge of cleaning the air conditioner vents;-The resident rooms should be clean and home like;-Window curtains should be in good repair and not torn or frayed.During an interview on 03/06/26 at 11:44 A.M. the Maintenance Supervisor said:-She was in charge ensuring the resident rooms were in good repair;-She is in charge of cleaning the air conditioning vents in the residents' rooms;-She is in charge of repairs to the bathrooms;-Bathroom doors in the residents' room should not stick and be hard to open;-Resident rooms should be in clean, in good repair and home like.During an interview on 03/06/26 at 12:58 P.M. the Maintenance Supervisor said:-He expected all resident to be provided a clean and home like environment;-He expected the curtains in the resident rooms to be clean and in good repair;-He expected the bathroom door to open easily and be in good repair;-He expected there to be a regular scheduled cleaning of the air conditioner in resident rooms.

Based on observation, interview and record review, the facility failed to provide adequate Activities of Daily Living (ADL) cares for dependent residents when the facility allowed a resident to remain in his/her wheelchair for over four hours without repositioning the resident, toileting the resident, providing oral care after meals or offering the resident a drink; affecting one resident (Resident #29). And when the facility failed to ensure proper perineal care was provided to one resident when a staff member used a disposable cleansing wipe multiple times to clean bowel movement off of a resident (Resident #25). The facility census was 54.Review of the facility's ADL Policy dated 01/31/2024, showed that the facility is to assist the resident in achieving maximum function. 1.Review of Resident #29's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff) dated 02/20/2026, showed:-Resident dependent on staff for eating, toileting, and all ADL's;-Always incontinent of bowel and bladder;-Diagnoses included: kidney disease, seizures and dysphagia (difficulty swallowing). Review of Resident Care Plan dated, 2/20/2026, showed:-He/She was at risk for dehydration;-Staff to offer fluids to encourage drinking during cares;-He/She was at risk for skin breakdown related to incontinence and impaired mobility;-He/She required extensive assistance with all ADLs. Continuous observation of the resident on 03/05/2026 from 8:34A.M. through 1:00P.M., showed:-He/She was in the wheelchair during the entire observation period.-At 9:15A.M., the resident was moved from the TV room to the activity room by nursing staff without repositioning, toileting, or providing oral care after meal;-At 10:55A.M., he/she was pushed from activity room to dining room by nursing staff;-At 11:43A.M., after being fed lunch, resident was pushed by staff back to the TV room;-At 12:43P.M., resident was pushed in wheelchair to resident's room by the nursing staff;-At 12:50 P.M. he/she was transferred to bed via Hoyer lift by two Certified Nurses Aids (CNA), CNA A, staff changed his/her incontinence brief, repositioned resident in bed, lowered bed, placed fall mats, clipped call light to blanket across resident's chest and left room;-There was no drink offered to resident or oral care provided. During an interview on 03/06/2026 at 12:20P.M., CNA A said:-Incontinent residents should be checked for incontinence every two hours;-Dependent residents should be offered something to drink at least every two hours;-Oral care should be provided to dependent residents after each meal;-A resident should not remain in a wheelchair without repositioning for over four hours;-Dependent residents should be repositioned and offered a drink every 2 hours;-Oral care needs to be provided to dependent residents every shift;-Poor oral care and dysphagia can lead to resident harm;-A resident should not remain in a wheelchair without repositioning for over four hours. 2.Review of the facilities Perineal Care- Male policy, dated 2/1/24, showed:- Use a clean wet wipe to clean the scrotum;- Use a clean wet wipe to clean other areas of the leg;- Wash anal area with a new wet wipe. Review of the facilities Perineal Care- Female policy, dated 2/1/24, showed:- Gently open all inner skin folds and wash inner area from front to back;- With a new wet wipe, wash the outer skin folds from front to back;- With a new wet wipe, wash inner legs and outer peri area;- With a new wet wipe, wash the anal area. Review of Resident #25's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 1/2/26, showed:- The resident was cognitively intact;- The resident had an indwelling urinary catheter (a flexible tube inserted through the urethra into the bladder to drain urine into a collection bag);- The resident had diagnosis of retention of urine, urinary tract infection, and constipation. Review of Resident #25's care plan, dated 1/13/26, showed:- The resident had an indwelling urinary catheter (a thin tube inserted into the bladder through the urethral meatus to drain urine):- The resident was dependent on staff for catheter care and bowel incontinent care. Observation on 03/05/2026 at 9:07 A.M. showed:- Certified Nursing Assistant (CNA) B performed perineal care on the resident;- CNA B used a disposable cleansing wipe to clean the left side of the residents perineum, then folded the cleansing wipe and used it again to clean the right side of the resident's perineum;- CNA B used a disposable cleansing wipe to clean bowel movement off of the resident, then folded the cleansing wipe and used it again to clean the resident's right gluteal fold;- CNA B used a disposable cleansing wipe to clean bowel movement off of the resident, then folded the cleansing wipe and used it again to clean bowel movement off of the resident;- CNA B used a disposable cleansing wipe to clean bowel movement off of the resident, then folded the cleansing wipe and used it again to clean bowel movement off of the resident. During an Interview on 03/05/2026 at 9:30 A.M. CNA B said: Disposable cleansing wipes can be folded up to three times when providing perineal care to a resident. During an Interview on 03/06/2026 at 11:19 A.M. Certified Medication Technician (CMT) B said: Disposable cleansing wipes should only be used one time while providing perineal care to resident's. During an Interview on 03/06/2026 at 11:20 A.M. CNA C said: Disposable cleansing wipes should not be used more than once when providing perineal care to resident's. During an Interview on 03/06/2026 at 1:40 P.M. the Infection Control Nurse said: Disposable cleansing wipes should only be used once when providing perineal care to a resident. During an Interview on 03/06/2026 at 12:15 P.M. Licensed Practical Nurse A said: Disposable cleansing wipes should only be used once when providing perineal care to a resident. During an Interview on 03/06/2026 at 12:29 P.M. the Director of Nursing said: Disposable cleansing wipes should only be used once when providing perineal care to a resident.

Based on observation, interview, and record review the facility failed to ensure residents with an indwelling catheter received the appropriate care and services to prevent urinary tract infections to the extent possible when the facility failed to ensure proper catheter care was provided for two (Resident #25 and Resident #8) of the 14 sampled residents. The facility census was 55. Review of the facilities Catheter, Emptying Urinary Drainage Bag policy, dated 1/31/24, showed:- Place a paper towel beneath the drainage bag;- Position the measuring container under the drainage bag;- Remove the drainage tube from it's holder;- Open the drainage and let urine flow into the measuring container;- After the drainage bag has emptied, close the drain;- Wipe the drain with an alcohol sponge or swab;- Replace the drain back into it's holder. Review of the facilities Enhanced Barrier Precautions policy, dated 3/5/26, showed:- Enhanced barrier precautions will be implemented for resident's who have wounds or indwelling medical devices;- Staff must wear a gown and gloves during high-contact care activities including: dressing or bathing, transferring, toileting assistance, and wound care. 1. Review of Resident #25's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 1/2/26, showed:- The resident was cognitively intact;- The resident had an indwelling urinary catheter (a flexible tube inserted through the urethra into the bladder to drain urine into a collection bag);- The resident had diagnosis of retention of urine, urinary tract infection, and constipation. Review of the resident's care plan, dated 1/13/26, showed:- The resident required use of enhanced barrier precautions (EBP, staff are required to wear a surgical gown and gloves while providing direct care to residents with wounds and/or indwelling medical devices) due to indwelling urinary catheter;- The resident was dependent on staff for catheter care and bowel incontinent care. Review of the physician order, dated 2/9/26, showed an order for Augmentin (an antibiotic used to treat urinary tract infections) 875-125mg twice a day from 2/9/26 to 2/16/26. Observation on 03/05/2026 at 9:07 A.M. showed:- Certified Nursing Assistant (CNA) B entered the resident's room to empty the resident's catheter drainage bag;- CNA B did not put a gown on;- CNA B used a graduate (a container used to measure volume of liquid) as a container to drain the urine in from the resident's catheter drainage bag;- CNA B set the graduate on the floor without using a barrier between the floor and the graduate such as a paper towel;- CNA B drained the urine from the catheter drainage bag and secured the catheter drainage tube into the catheter drainage tube holder without cleaning the tube with an alcohol sponge or swab. During an Interview on 03/05/2026 at 9:30 A.M. CNA B said:- He/she should have worn EBP when emptying the resident's catheter drainage bag;- He/she should have put a paper towel on the floor to act as a barrier between the graduate and the floor when emptying the resident's catheter drainage bag;- He/she was not sure if the catheter drainage tube should have been cleaned after emptying the catheter bag. During an Interview on 03/06/2026 at 11:19 AM Certified Medication Technician B said:- EBP should be worn when providing direct care to residents with a catheter;- A barrier should be placed on the floor between the graduate and the floor when emptying a urinary catheter drainage bag;- Catheter drainage tubing should be cleaned off with an alcohol wipe after emptying the catheter drainage bag. During an Interview on 03/06/2026 at 11:20 A.M. CNA C said: - EBP should be worn when emptying a catheter drainage bag;- A barrier should be placed on the floor between the graduate and the floor when emptying a urinary catheter drainage bag;- Catheter drainage tubing should be cleaned off with an alcohol wipe after emptying the catheter drainage bag. During an Interview on 03/06/2026 at 11:40 P.M. the Infection Control Nurse said:- A barrier should be placed on the floor between the graduate and the floor when emptying a urinary catheter drainage bag;- EBP should be worn when providing direct care to residents with a urinary catheter;- Catheter drainage tubing should be cleaned off with an alcohol wipe after emptying the catheter drainage bag. During an Interview on 03/06/2026 at 12:15 P.M. Licensed Practical Nurse A said:- EBP should be worn when providing direct care to residents with a catheter;- Catheter drainage tubing should be cleaned with an alcohol wipe after emptying the catheter drainage bag. During an Interview on 03/06/2026 at 12:29 P.M. the Director of Nursing said:- EBP should be worn when providing direct care to residents with a catheter;- A barrier should be placed on the floor, such as a paper towel, between the graduate and the floor when emptying a catheter drainage bag;- Catheter drainage tubing should be cleaned with an alcohol wipe after emptying the catheter drainage bag. 2. Review of Resident #8's admission MDS dated [DATE], showed:-Mild cognitive impairment;-Moderate assist from staff required for transfers and toileting;-Diagnoses included: seizure disorder, high blood pressure and urinary tract infection. Review of the care plan dated 02/02/2026, showed:-Staff to manage all care associated with urinary catheter;-Do not allow tubing or any part of the drainage system to touch the floor;-He/She required Enhanced Barrier Precautions;-He/She was at risk for Urinary Tract infection (UTI) related to chronic suprapubic catheter (SPC) and history of UTI. Review of resident's nursing progress notes dated 01/29/2026, showed:-LPN A spoke with resident's urology clinical staff and they stated that resident was to be seen monthly in the clinic for exchange of suprapubic catheter (SPC) and the resident had not been seen since October 2025;-The urology office did not want the facility exchanging the suprapubic catheter due to previous complications and infections. Review of resident's Electronic Medical Record (EMR) from August of 2025 through February of 2026 showed the resident was hospitalized on [DATE], 10/02/2025, 11/14/2025, 12/23/2025, 01/23/2026, and 02/25/2026 with diagnoses of UTI and urosepsis (a life-threatening inflammatory response to a severe UTI). Observation on 03/03/2026 at 11:58A.M. showed the resident being pushed into dining room, he/she had foley tubing coming from right pant leg, with tubing clipped near his/her right knee, forming a large dependent loop before connecting to dependent drainage bag; blocking gravity drainage, allowing urine to pool in tubing. During an interview on 03/06/2026 at 12:20P.M., CNA A said:-There should not be a dependent loop in catheter tubing, this can cause bacteria to grow and travel up tubing back into the bladder;-Tubing should not touch or drag along ground to help prevent infection;-Catheter care is performed daily and as needed by nursing staff. During an interview on 03/06/2026 at 10:45A.M., LPN A said:-Catheter care provided by staff daily and as needed by CNAs or any nursing staff;-Resident's catheter tubing should not touch the floor;-Tubing should be free from obstructions, not have a dependent loop, and collection bag should be in a dignity bag (a device used to keep urine collection bags out of sight). During an interview on 03/06/2026 at 11:40A.M., the DON said:-Catheter care should be provided each shift and as needed by nursing staff;- Catheter tubing should not touch ground or drag along floor;- There should be no dependent loop in tubing.

Based on observation, interview and record review, the facility failed to ensure medication error rate was less than five percent for two sampled residents (Resident #29 and Resident #30) out of 26 opportunities, when staff administered a rectal suppository without lubricant, withheld a prescribed medication, and additionally when staff documented a medication was administered when it was withheld; causing a 12% medication error rate. The facility census was 54.Review of the facility's Medication Administration Policy dated April 2019, showed:-Medications are administered in a safe and timely manner;-Medications are administered in accordance with prescriber orders;-If a dosage is believed to be inappropriate or excessive, the person administering the medication will contact the prescriber or facility's medical director to discuss concerns. Review of the National Library of Medicine website, dated 2021, showed the administration of a rectal suppository should be completed by use of a gloved index finger, placing the lubricated suppository into the rectum for ease of placement. 1.Review of Resident #29's Physician Order Sheet (POS) dated 03/05/2026, showed Bisacodyl suppository 10mg, one suppository rectally on Mondays and Thursdays weekly for constipation. Observation and interview on 03/05/2026 at 12:50P.M., showed Certified Medication Technician (CMT) A administered a suppository in resident's rectum. The resident moaned and moved away from CMT A as he/she was administering the suppository. CMT A said she should have used lubricant prior to inserting the suppository. During an interview on 03/06/2026 at 11:40A.M., the Director of Nursing (DON) said that lubrication is necessary for suppository administration. 2.Review of Resident #30's POS dated 03/05/2026, showed:-Administer Amlodipine (a medication used for the treatment of high blood pressure) 2.5mg by mouth daily;-Hold Amlodipine if blood pressure is less than 90/60;-Administer Med Pass nutritional supplement (a physician prescribed nutritional supplement) 120cc twice daily. Review of the resident's Medication Administration Record dated 03/05/2026, showed:- Med Pass nutritional supplement documented as administered by CMT B with morning medications;- Resident's blood pressure was 135/73 and pulse was 52;-CMT B held Amlodipine 2.5 mg on 03/05/2026 and documented the reason as resident's pulse was under 60. During an observation on 03/06/2026 at 8:49A.M.,-CMT B did not administer Med Pass nutritional supplement to the resident but should have.-He/she was given water to take with medications;-He/she drank all water provided. During an interview on 03/06/2026 at 12:20P.M., CMT B said:-All medications that are withheld should be documented as held;-He/she is not allowed to hold a medication without a physician order;-He/she does not notify nurse when he/she holds medications per ordered parameters. During an interview on 03/06/2026 at 10:45A.M., LPN A said:-CMTs should notify the nurse for the resident when medications are withheld;-He/She is responsible for contacting prescriber for additional parameters needed on medications. During an interview on 03/06/2026 at 11:40P.M., the DON stated:-Medication should have been administered to Resident #30 as the resident's blood pressure was within parameters;-CMTs are not allowed to hold a medication without an order from the physician.

Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates, for 10 sampled residents (Residents #1, #3, #6, #8, #29, #33, #48, #52, #53, and #56) when the facility had six opened multi-use medications that were not labeled with the open date, six opened multi-use medications with open date over 28 days prior to observation date and one large, opened, undated syringe of topical medication without a medication or resident label. The facility census was 54. Review of the facility's Medication Storage policy dated 02/01/2024, showed:-No discontinued, outdated or deteriorated drugs may be retained for use;-All outdated or discontinued drugs must be returned to the issuing Pharmacy to be destroyed in accordance with established guidelines;-Medications must be stored in the container in which they were received;-No instruction on dating medications or biologicals when opening. Observation of medication cart for 300/400 hall on 03/03/2026 at 10:15A.M., showed:-Resident #1 had a large, personal bottle of Fiber lax opened on 09/22/2025, this should have been disposed on 10/20/2025;-Resident #3's Novolog insulin pen open with no open date;-Resident #6's artificial tears opened 09/05/2025, this should have been disposed on 10/03/2025;-Resident #8's artificial tears opened 11/2025, this should have been disposed on 11/29/2025;-Resident #29's artificial tears open with no open date;-Resident #33's open artificial tears, open Flonase nasal spray and open viscous lidocaine with no open dates;-Resident #48's open Flonase nasal spray with no open date;-Resident #52's artificial tears opened 03/01/2025, this should have been disposed on 03/29/2025;-Resident #53's artificial tears opened 01/28/2026, this should have been disposed on 02/25/2026;-Resident #56's open artificial tears with no open date. During an interview on 03/03/2026 at 10:30A.M., CMT B stated:-Multi-use medications are to be labeled with the date the medication was opened;-There is no scheduled cleaning or clearing out of medication carts; -He/she disposes of expired medications as he/she comes across them by throwing medications such as eye drops into the trash and there is a waste bin in the medication room for pills. During an interview on 03/06/2026 at 11:40A.M, the DON stated:-Multi-use medications should be dated when initially opened;-Expired and outdated medications should not be on medication cart or administered to residents;-Eye drops are good for use for 90 days after opening.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when the facility failed to ensure staff wore enhanced barrier precautions (EBP surgical gown and gloves) while providing direct care to residents with wounds and/or indwelling medical devices for two residents, (Resident #9 and Resident #25) and when the staff failed to use an alcohol wipe to clean a insulin bottle and allow an the injection site to dry for (Resident #3), and additionally when the facility failed to ensure all staff members had tuberculin skin testing (TB), a test performed to determine if a person has been exposed to tuberculosis, performed before beginning employment this had the potential to affect all residents in the facility. The facility census was 55. Review of the facilities Enhanced Barrier Precautions policy, dated 3/5/26, showed:- Enhanced barrier precautions will be implemented for resident's who have wounds or indwelling medical devices;- Staff must wear a gown and gloves during high-contact care activities including: dressing or bathing, transferring, toileting assistance, and wound care. Review of facility policy, Tuberculosis (TB) Screening – Residents and Staff, revised 3/5/26, showed: - All employees must complete TB screening prior to employment including a TB skin test. - TB screening and testing results will be documented in the employee health file. Review of the facility's Insulin Administration Policy dated 2/1/2024, showed:-Wipe top of vial with alcohol wipe;-Cleanse injection site with alcohol;-Allow skin to dry. 1. Review of Resident #9's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 1/29/26, showed:- The resident was not cognitively intact;- The resident was dependent on staff for completing activities of daily living;- The resident had diagnoses of non-Alzheimer's dementia (a progressive brain disorder that affects personality, movement, and memory), anxiety, and depression. Review of the resident's care plan, dated 3/4/26, showed:- The resident required the use of EBP related to wounds;- The resident was at risk for pressure ulcers related to impaired mobility and incontinence; - The resident was not able to verbally communicate his/her needs. Observation on 03/04/2026 at 2:48 P.M. showed:- Certified Nursing Assistant (CNA) D and CNA E performed perineal care on the resident;- CNA D and CNA E did not put on a gown when providing perineal care for the resident;- No sign outside of the resident's door indicating the need for EBP. During an Interview on 03/04/2026 at 2:55 P.M. CNA D said:- The resident does not require EBP anymore;- The resident used to required EBP when he/she was receiving medication through an IV;- He/she knows when to wear EBP when there was a sign outside of the resident's room indicating that EBP is required. During an Interview on 03/06/2026 at 11:19 A.M. Certified Medication Technician (CMT) B said:- EBP should be worn when providing direct care for resident's with open wounds;- Signs indicating the need for EBP are posted outside of the resident's doors. During an Interview on 03/06/2026 at 11:20 A.M. CNA C said:- EBP should be worn when providing direct care for resident's that had wounds;- Signage is posted outside of the resident's door if they require the use of EBP. During an Interview on 03/06/2026 at 11:40 P.M. the Infection Control Nurse said:- EBP should be worn when providing direct care for resident's that had wounds;- She forgot to post the sign outside of the resident's room indication that EBP needed to be worn. During an Interview on 03/06/2026 at 12:15 P.M. Licensed Practical Nurse A said:- EBP should be worn when providing direct care for resident's that had wounds;- Signs were posted outside of the resident's rooms that require EBP and gowns and gloves were kept near the resident's rooms for staff to utilize. 2. Review of Resident #25's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 1/2/26, showed:- The resident was cognitively intact;- The resident had an indwelling urinary catheter (a flexible tube inserted through the urethra into the bladder to drain urine into a collection bag);- The resident had diagnosis of retention of urine, urinary tract infection, and constipation. Review of the resident's care plan, dated 1/13/26, showed:- The resident required use of enhanced barrier precautions (EBP, staff are required to wear a surgical gown and gloves while providing direct care to residents with wounds and/or indwelling medical devices) due to indwelling urinary catheter;- The resident was dependent on staff for catheter care and bowel incontinent care. Review of the resident's prescription order, dated 2/9/26, showed the resident had an order for Augmentin (an antibiotic used to treat urinary tract infections) 875-125mg twice a day from 2/9/26 to 2/16/26. Observation on 03/05/2026 at 9:07 A.M. showed:- Certified Nursing Assistant (CNA) B entered the resident's room to empty the resident's catheter drainage bag;- CNA B did not put a gown on;- CNA B used a graduate (a container used to measure volume of liquid) as a container to drain the urine in from the resident's catheter drainage bag;- CNA B set the graduate on the floor without using a barrier between the floor and the graduate such as a paper towel;- CNA B drained the urine from the catheter drainage bag and secured the catheter drainage tube into the catheter drainage tube holder without cleaning the tube with an alcohol sponge or swab. During an Interview on 03/05/2026 at 9:30 A.M. CNA B said:- He/she should have worn EBP when emptying the resident's catheter drainage bag;- He/she should have put a paper towel on the floor to act as a barrier between the graduate and the floor when emptying the resident's catheter drainage bag;- He/she was not sure if the catheter drainage tube should have been cleaned after emptying the catheter bag. During an Interview on 03/06/2026 at 11:19 AM Certified Medication Technician B said:- EBP should be worn when providing direct care to resident's with catheters;- Barrier should be placed on the floor between the graduate and the floor when emptying a urinary catheter drainage bag;- Catheter drainage tubing should be cleaned off with an alcohol wipe after emptying the catheter drainage bag. During an Interview on 03/06/2026 at 11:20 A.M. CNA C said: - EBP should be worn when emptying a catheter drainage bag;- A barrier should be placed on the floor between the graduate and the floor when emptying a urinary catheter drainage bag;- Catheter drainage tubing should be cleaned off with an alcohol wipe after emptying the catheter drainage bag. During an Interview on 03/06/2026 at 11:40 P.M. the Infection Control Nurse said:- A barrier should be placed on the floor between the graduate and the floor when emptying a urinary catheter drainage bag;- EBP should be worn when providing direct care to resident's with a urinary catheter;- Catheter drainage tubing should be cleaned off with an alcohol wipe after emptying the catheter drainage bag. During an Interview on 03/06/2026 at 12:15 P.M. Licensed Practical Nurse A said:- EBP should be worn when providing direct care to resident's with a catheter;- Catheter drainage tubing should be cleaned with an alcohol wipe after emptying the catheter drainage bag. During and Interview on 03/06/2026 at 12:29 P.M. the Director of Nursing said:- EBP should be worn when providing direct care to resident's with a catheter;- A barrier should be placed on the floor, such as a paper towel, between the graduate and the floor when emptying a catheter drainage bag;- Catheter drainage tubing should be cleaned with an alcohol wipe after emptying the catheter drainage bag. 3.Review of Resident #3's Comprehensive MDS assessment dated [DATE], showed:-No cognitive impairment;-Indwelling catheter;-Dependent on staff for personal and toileting hygiene;-Diagnoses of wound infection, urinary tract infection, and diabetes. Review of the care plan dated 03/02/2026, showed:-Stage three wounds to right and left buttocks;-Resident at risk for complications related to diabetes mellitus;-Required enhanced barrier precautions (EBP) related to catheter and wounds. Observation of insulin administration on 03/06/2026 at 8:20A.M., showed CMT A:-Entered the resident's room, washed his/her hands and applied gloves, touched computer, mouse, several drawer handles on medication cart;-Wiped rubber seal of multi-use insulin pen with alcohol wipe;-Turned insulin pen dose knob to two units and engaged pen, causing droplets of insulin to expel onto rubber seal;-Applied disposable, single-use needle to insulin pen;-Wiped resident's left upper arm with alcohol pad;-Fanned resident's arm with his/her hand;-Administered insulin, disposed of needle;-Removed gloves;-Capped insulin pen, placed back into medication cart. During an interview on 03/06/2026 at 8:25A.M., CMT A said:-He/She was not sure if wiping rubber seal was correct procedure;-He/She should not have fanned arm after cleansing. During an interview on 3/06/2026 at 11:40A.M., the DON said:-Each time an insulin pen is used, rubber seal should be cleaned with an alcohol wipe;-A needle needs to applied prior to priming insulin pen;-Should not fan skin with hand after cleansing skin with alcohol pad;-Insulin administration requires staff to wear gown and gloves with resident's that require EBP. 4.Review of employee health files, showed:- LPN (A) had a date of hire of 3/3/25, had his/her first step TB test administered on 8/18/25 which was read on 8/20/25 and was negative (5 months and 17 days after his/her date of hire);- Dietary Aide (A) had a date of hire of 5/28/25, had his/her first step TB test administered on 8/11/25 which was read on 8/13/25 and was negative (2 months and 14 days after his/her date of hire); During an interview on 3/5/26 at 10:10 A.M., the HR director said she schedules the initial test for new hires to get the process going and she and the Director of Nursing (DON) manage the program to get the second test done. The facility policy requires new hires to have their first TB test completed before coming into contact with residents. The first week is orientation for new hires which takes place before they interact with residents. During an interview on 3/5/25 at 11:25 A.M., the DON said TB tests are required for all employees prior to starting employment at the facility.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility managed funds for 5 residents. The facility census was 54.Review of facility policy, Resident Trust Fund Account Management, revised 3/5/26, showed: - The facility will maintain accurate accounting, protect resident funds from misappropriation, and ensure residents maintain control over their personal finances.- Resident funds will be maintained separate from facility operating funds. The total balance of resident ledgers must equal the resident trust account bank balance. Record review of the facility maintained attempted reconciliation forms, for the period 2/1/25 - 1/31/26, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. The amount of $8,559.84 was carried forward each month.During an interview on 3/5/26, at 9:30 A.M., the Business Office Manager said the $8,559.84 was carried as far back as 12 years and it has always been that way since she took the position and she just kept balancing knowing there was an extra amount in the account. During an interview on 3/5/26 at 1:15 P.M., the Administrator said he expects that the resident trust account is reconciled monthly to those (5) residents who actively have funds in this account.

Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe dining environment for one resident (Resident #1) who sustained burns to the fingers on the right hand, when left un-attended during meal service and was witnessed by Resident #2. This affected one out of four residents sampled. The facility census was 52.On 10/14/25, the Administrator was notified of the past noncompliance which occurred on 10/7/25. On 10/7/25, facility administration was notified of the incident, an investigation immediately began, and corrective action were implemented to include a new policy for meal service for residents who require assistance, and staff training regarding meal service that included staff education that supervision and assistance must be provided to residents when served. The non-compliance was corrected 10/7/25.Review of the facility's Accident and Incident Policy, revised 2017 showed all accident or incident involving residents on the premises will be investigated and reported to the administrator. The nurse supervisor or charge nurse will initiate and document the investigation of the incident with immediate corrective action put into place. All responsible persons will be notified and updated.Review of the facility's Providing Dining Assistance Policy, revised on 10/7/25 showed staff are to assist any resident that cannot feed themselves safely.Review of an all-staff in-service dated 10/7/25 showed the following: Residents that require assistance during meals will not be served until a nursing staff member is present and directly observing/assisting with meal intake. Staff are remined to observe residents who attempt to feed themselves to avoid risk of injury from hot food. Included in this training is educational information about food temperature requirements and also how quickly an injury can happen from handling hot foods. 1. Review of Resident #1's care plan dated, 10/13/25, showed the resident had difficulty expressing needs related to impaired cognition. The resident required staff assistance for all activities of daily living, including being fed at meals by nursing staff.Review of resident's physician order report dated 9/29/25-10/14/25 showed the resident was admitted with a diagnosis of Parkinson's, disorders of peripheral nervous system, and diabetes.Review of the facility's investigation report dated 10/7/25, regarding the resident's burns to fingers on the right hand showed the resident was left unattended at the dining room table with a plate of hot food at breakfast. The resident attempted to feed self with his/her hands and sustained burns resulting in grape-like fluid filled blister to the fingers on the resident's hands. During an observation on 10/14/25 at 11:25 A.M., Resident #1 sat at the dining room table with his/her spouse. The residents' fingers on the right hand were bandaged except the right thumb and right forefinger. During an observation on 10/14/25 at 11:35 A.M., staff placed the resident's plate in front of him/her, which included lasagna, California blend vegetables (green beans, cauliflower, and carrots) and garlic bread. The resident's spouse was assisting the resident to eat. During an interview on 10/14/25 at 12:06 P.M., LPN C said, the resident required nursing assistance when eating and required encouragement at meals. Lids provided for the drinks to reduce spillage, and food was normally not that hot and staff would normally stir the food before starting to assist the resident to eat. Since the resident was burned, CMTs and a CNA are now required to be in the dining room before the passing of any meal trays. During an interview on 10/14/25 at 12:16 P.M., the dietary host said, on the day the resident received the burns, nursing staff were still bringing residents into the dining room while the resident's tray was in front of him/her. The Resident had biscuits and gravy, scrambled eggs, cream of wheat and juice. The dietary host said, she saw the resident's eggs had been touched and there was food on the resident's right hand. The resident's spouse was not there that day to feed the resident. There was no one feeding the resident breakfast. She does not feed residents but observed the resident this day with food on his/her hands. During an interview on 10/11/25 at 12:28 P.M., LPN B said, on 10/7/25 he/she was working in the dining room and was called over to the residents table by CMT A, to assess burns on the resident's right hand. CMT A observed the resident's fingers to be blistered. CMT A then notified RN A to come and look at the resident's hand and fingers, then the physician was also notified. During an interview and observation on 10/14/25 at 12:59 P.M., LPN A provided wound care to the resident's right hand and fingers. He/she observed a blister on the resident's little finger on the right hand and the blister measured at 2cm (centimeter) x 2.5cm and was yellow fluid filled with no drainage. He/she observed a blister measuring 3cm x 4cm with yellow fluid filled blister with no drainage to the ring finger. He/she observed a blister measuring, 1cm x 1cm with intact with fluid and no drainage on the resident's middle finger. Treatment to areas included application of skin prep applied to each finger, let dry, apply gauze and Coban (self- adherent elastic wrap) to each finger. The resident was unaware of treatment being provided. LPN A said since the incident, there now had to be a CNA, CMT or a nurse in the dining room before residents are served food and that any residents who required assistance to eat are to be served last so that staff can sit with the residents and assist them. Resident #1 required supervision due to tremors and needed extensive help with feeding. During an interview on 10/14/25 at 2:43 P.M., CNA A said He/she was in the dining room that day and went to assist the resident and noticed the burns on residents' fingers and notified LPN A. During an interview on 10/14/25 at 3:18 P.M., RN A said she did not notice blisters on the resident's right hand that morning during a skin assessment. Since the resident sustained a burn in the dining room, residents who require assistance with eating will now be fed last and only when staff are in the dining room to assist. Residents who need assistance should not be left alone with their meal tray. Resident #2's MDS (Minimum Data Set) a federally mandated assessment completed by facility staff dated 10/06/25 showed the resident to be cognitively intact and had a diagnosis of Parkinson's and respiratory problems. During an interview and observation on 10/14/25 at 3:05 P.M., Resident #2 said: He/she was sitting at table with resident #1 on 10/07/25, during breakfast and observed Resident #1 pick up the scrambled eggs off the plated with his/her fingers to eat and no staff were assisting the resident. Then, Resident #1 had blisters appear on fingers to right hand. Resident #2, who normally only eats in the dining room for breakfast and lunch, said Resident #1's spouse is usually there to feed the resident but not that morning. During an interview on 10/14/25 at 4:22 P.M. the DON said she was notified of the incident immediately contacted the facility NP regarding the burns to the residents' fingers on the right hand. It was reported by the DON that the resident did have eggs and food particles visibly present on his/her fingers on the right hand. During an interview on 10/14/25 at 4:22 P.M., the Administrator said he was aware of the residents burns to right hand fingers and that the resident should not have been left alone with hot food and no one there to monitor. An in-service had been provided to all staff and corrective measures put in place. Intake 2637826Intake 2637323

Based on observation and interviews the facility failed to provide a comfortable and homelike environment for all residents when they did not ensure cobwebs were cleaned from the dining room as well as the common area near the facility entrance, and failed to match the paint when repairing drywall in the dining room, or to ensure ceiling trim in the dining room was secure around attic access in the dining room. Additionally, the facility failed to maintain resident safety when they did not ensure a handrail was secure, and failed to provide a homelike environment when they did not fix or replace dining room chairs that are had tearing in the fabric. The facility census was 55. The facility did not provide a policy for regarding maintaining the facility. 1. Observation of the diningroom on 11/18/24 at 10:59 showed: -Dining room chairs vinyl was peeling off and fabric was torn. -Cobwebs near ceiling next to large upper window in dining room. -Wood trim strip around attic access panel in dining room was pulling away from the celiing with nails exposed. 2. Observation of the diningroom on 11/21/24 at 09:11 AM showed: -Cobwebs on the ceiling by the top of the TV in dining room. 3. Observation on the 100 hallway on 11/21/24 at 09:26 AM showed: -Handrail outside room [ROOM NUMBER] is loose. 4. Observation on 11/21/24 at 09:53 AM showed: -Cobwebs near ceiling in common area across from the nurse's station. -Dark water spots about 12 inches x 4 inches near light fixture in common area by main entrance and a large stain on ceiling near vent by main entrance. During an interview on 11/21/24 at 09:42 AM, housekeeping supervisor said twice a week housekeeping does deep cleaning tasks. Deep cleaning in common areas happens once every other week. High dusting to get cobwebs in common areas happens every other day. During an Interview on 11/21/24 at 12:52 PM, the administrator said that he would expect furnishings to be in good repair and free from peeling material and tears. He also stated that said there should not be accumulated cobwebs, and the facility should be clean at all times and housekeeping is responsible for ensuring all areas are clean. During an interview on 11/21/24 09:48 AM, the maintenance supervisor stated that they are looking into getting the dining chairs reupholstered and that there is no schedule for painting walls, however does attempt to get to painting needs as they are seen.

Based on observation, interview, and record review, the facility staff failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, complete morning hygiene cares, offer fluids, or toilet dependent residents. These failures affected three of the 14 sampled residents (Residents #4, #34and #44). The facility census was 55. Review of the facility's policy for peri care - female, revised 2/1/24, showed, in part: - Purpose: To provide comfort for the resident and to prevent infection. - (7.) Expose peri area, separate inner labia and gently wash from front to back. - (8.) With new wipe, gently open all inner skin folds and wash inner area from front to back. - (9.) With new wet wipe, wash the outer skin fold from front to back. - (10.) With new wet wipe, wash inner legs and outer peri area. - (16.) Offer resident fluids. 1. Review of Resident #4's care plan (a detailed written document created by the facility that outlines the specific needs of a resident, with the goal of maintaining their quality of life in the facility) revised 4/16/2024 showed, in part: - Needs assistance with most ADLs - Requires one person to assist with toilet transfers, toilet hygiene, pericare/incontinence cares and wears briefs for dignity. - Requires one person to assist with transfers. - Is at risk for skin breakdown. - Staff are to keep clean and dry as much as possible, minimize skin exposure to moisture. - Resident #4 is cognitively intact and able to verbalize needs to staff. - Resident #4 is hard of hearing and does not wear his/her hearing aids. During an observation and interview on 11/20/2024 at 7:14 A.M. showed: - CNA C, NA A, and NA B entered Resident #4's room to provide peri care/incontinence care, provide morning cares, and transfer the resident to his/her wheelchair for breakfast. - Resident #4 kept his/her legs tightly closed throughout peri care. - CNA C and NA A failed to expose or clean the peri area throughout peri care. With the resident on his/her back, CNA C, assisted by NA A, wiped the lower portion of Resident #4's pubic area (the lower part of the abdomen just above the external genital organs). After each wipe, staff then pushed the used wet wipes between Resident #4's tightly closed legs into the used brief beneath the resident. - CNA C and NA A failed to expose or clean labial/vaginal folds throughout peri care. With the resident on his/her back, CNA C, assisted by NA A, wiped the outermost portion of the labia (the fleshy folds that surround the opening of the vagina) as they pushed clean wet wipes between Resident #4's tightly closed legs but never cleaned between skin folds or opened Resident #4's legs to allow access to provide complete care. - NA A failed to remove his/her used gloves and complete hand hygiene after assisting to provide peri care to Resident #4. NA A continued Resident #4's morning cares wearing the same gloves he/she wore during peri care. - NA A and NA B failed to change Resident #4's shirt while dressing him/her, leaving the resident to wear the same shirt he/she wore the previous day and had slept in. - NA B failed to provide oral care to Resident #4 or to set up supplies for Resident #4 to complete oral care for himself/herself. NA B rinsed Resident #4's dentures with water and assisted Resident #4 to put them in. - CNA C, NA A, and NA B failed to wash Resident #4's face, to set up supplies for Resident #4 to complete this morning care for himself/herself, or to ask the resident if this is a care he/she would like completed. - During an interview with CNA C and NA B, both staff members reported that they had been trained to open inner perineal folds and clean this area. Neither staff member was aware that washing the resident's face was part of morning cares reporting that night shift handles that. NA B reported that he/she didn't think dentures needed to be brushed because they had been soaking overnight. 2. Review of Resident #34's care plan, revised 6/20/2024, showed, in part: - Requires assistance with most ADLs. - One person to assist with dressing/undressing, and mobility. - Urinary incontinence and require assist with toileting, and incontinent brief changing. - One person to assist with incontinence cares/pericares. - Not able to communicate needs. - Allow sufficient uninterrupted rest periods. - At risk for pressure ulcers R/T decreased mobility. Observation on 11/20/24 from 5:56 A.M. until 12:21 P.M showed the following interactions with the resident: - Resident #34 was seated in his/her broda chair (a specialized wheelchair) next to his/her bed, dressed in the same clothes as the day before at 5:56 A.M. - At 7:45 A.M. Resident #34 was moved to the dining room for breakfast. Resident #34 was still wearing yesterday's clothes and had not been repositioned since this surveyor first observed the resident at 5:56 A.M. - At 9:00 A.M. Resident #34 was observed sleeping in his/her broda chair in the T.V. room. Resident #34 was still in the same position and wearing the same clothes with no indication that he/she had been repositioned or toileted since this surveyor's first observation of the resident that day. - At 9:52 A.M. Resident #34 was moved from the T.V. room to the activity room for bible study. The resident remained in the same position and wearing yesterday's clothes. No indication that Resident #34 had been repositioned, toileted, or allowed to rest in bed was observed. - At 10:54 A.M. Resident #34 was moved from the activity room back to the dining room for lunch. Resident #34 remained within this surveyor's line of sight for the entirety of his/her time in the activity room. No observation of staff repositioning, toileting, or ADL care. - At 11:51 A.M. Resident #34 was observed being fed by the activities director in the dining room. - At 12:21 P.M. Resident #34 was taken to his/her room. Nursing staff transferred the resident into bed, and did not change the resident into clean clothes. - Resident #34 was not interviewable, however the average person would expect to have clean clothes, positioning changes, and hygiene needs met. During an interview on 11/20/24 at 12:42 P.M., NA B said: - Residents that require a lot of help from staff are usually gotten up by the night shift and are already up when he/she arrives at work in the morning. - He/she thinks staff is supposed to check and reposition residents every 2 hours, but he/she thinks that might depend on the resident. During an interview on 11/20/24 at 12:46 P.M., NA A said: - Residents should be turned and repositioned every 2 hours and that toileting residents should also happen every 2 hours or as needed. During an interview on 11/21/24 at 12:52 P.M., the DON said: - Residents are gotten up by staff at a time that is based on each resident's routines and preferences. - If a resident is up a 5:55 A.M., that resident should be repositioned after breakfast. - It is unacceptable for a resident to be up from 5:55 A.M. to 12:21 P.M. without being repositioned. During an interview on 12/2/24 at 10:35 A.M. the DON said: - During morning cares, everything should be addressed, peri care, washing face and hands, and brushing teeth. - A resident's dentures should be brushed every morning, regardless of how long they had been soaking. - Staff is expected to change resident's clothing according to their personal preference. Non-verbal residents or resident who are not able to make their needs known should have their clothes changed daily. - It is expected that staff anticipate the needs of non-verbal residents or residents who cannot make their needs known, and act on them accordingly. 31102 3. Review of Resident #44's Quarterly MDS, dated [DATE] showed: - Long term and short term memory problems; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included dementia (inability to thing), senile degeneration of the brain (a progressive decline in cognitive function that occurs with age). Review of the resident's care plan, revised 9/13/24 showed: - The resident needed assistance with all activities and and daily cares. Required the assistance of one staff for showering, with repositioning in bed, dressing and to propel him/her in the Broda chair (a type of reclining geri chair). The resident required the assistance of two staff for incontinent care and to assist with transfers using the mechanical lift. Observation on 11/20/24 showed: - At 5:55 A.M., the resident was already dressed and up in his/her Broda chair; - At 7:45 A.M., staff propelled the resident to the dining room for breakfast and the resident's eyes were closed; - At 8:45 A.M., staff propelled the resident from the dining room to the front lobby area by the nurse's station and his/her eyes were closed; - At 8:54 A.M., staff propelled the resident to the TV room; - At 9:42 A.M., the resident remained in the the TV room in the Broda chair; - At 9:46 A.M., staff propelled the resident to the large activity room; - At 10:54 A.M., staff propelled the resident from the large activity room directly to the dining room for lunch. Staff did not offer to toilet the resident or offer him/her any fluids since breakfast and he/she has not been repositioned in the Broda chair; - At 11:41 A.M., staff sat down to assist the resident to eat; - At 11:58 A.M., staff propelled the resident from the dining room to the front lobby area by the nurse's station; - At 12:21 P.M., Nurse Aide (NA) A and NA B propelled the resident to his/her room and used the mechanical lift and transferred the resident from the Broda chair to his/her bed and provided incontinent care in the following manner; - NA A and NA B turned the resident side to side in bed and removed the lift pad and pulled the resident's pants down and unfastened the incontinent brief with a strong odor of urine noted; - NA A used the same area of the wipe and wiped down one side of the groin, across the pubic area and down the other side of the groin; - NA A used a new wipe and wiped once down the middle perineal folds; - NA A and NA B turned the resident onto his/her side; - NA A wiped three times from front to back with fecal material on each wipe; - NA A used the same area of the wipe and wiped up both sides of the buttocks, removed gloves, washed hands, applied new gloves and applied house barrier to the resident's red buttocks; - NA A and NA B placed a clean incontinent brief under the resident and fastened it. During an interview on 11/20/24 at 12:42 P.M., NA B said: - The night shift got the resident up this morning; - The resident was normally up when the day shift arrived to work; - The resident had not been toileted or laid down since he/she came to work this morning; - With one of the residents, they have to be checked every two hours but he/she thought it would depend on the resident on how often they were checked; - He/she had started in August and was in-serviced on peri care. During an interview on 11/20/24 at 12:46 P.M., NA A said: - The residents should be turned and repositioned every two hours and toileted as needed or at least every one or two hours; - The resident should have turned and repositioned every two hours; - He/she should have separated and cleaned all areas of the skin where urine or feces had touched; - He/she should not have used the same area of the wipe to clean different areas of the skin. During an interview on 12/2/24 at 11:16 A.M., the DON said:- If a resident is up at 5:55 A.M., then staff should reposition and toilet them after breakfast; - It is not acceptable for a resident to be up from 5:55 A.M. until 12:21 P.M., before they are repositioned or toileted; - Staff should not use the same area of the wipe to clean different areas of the skin; - Staff should separate and clean all the skin folds. Review of the facility's shower schedule showed: - Resident #44 was scheduled to have a shower on Wednesday evening; - The resident was listed under Hospice (end of life care) on Friday evenings. Review of the resident's shower sheets shower sheets for August, 2024 showed: - The resident had two showers out of nine opportunities, 8/17 and 8/14. Review of the resident's shower sheets shower sheets for September 2024 showed: - The resident had four showers out of eight opportunities , 9/4, 9/11, 9/18, and 9/25. Review of the resident's shower sheets shower sheets for October 2024 showed: - The resident had four showers out of eight opportunities, 10/2, 10/9, 10/16 and 10/23. Review of the resident's shower sheets shower sheets for November 2024 showed: - The resident had one shower out of six opportunities, 11/6. Observation on 11/20/24 at 12:21 P.M., showed the resident's hair was dull and the resident had a strong odor of urine. During an interview on 11/20/24 at 12:46 P.M., NA A said: - They have two shower aides on days, the aides do the showers on evening shift; - On Friday evening, they have a shower aide come in to do the showers; - All of the residents should get two showers a week if that's what they want; - If a resident refused their shower, the staff would try to get it made up at some point. During an interview on 12/2/24 at 11:16 A.M., the DON said: - She would expect the residents to get a shower twice a week unless their care plan had something differently.

Based on observations, interviews, and record review, the facility failed to ensure residents' safety and independence by pushing residents in their wheelchairs who are able to propel themselves for four of the fourteen sampled residents (residents #17, #10, #39, and #19). The facility census was 55. Review of the Accidents and Incidents policy did not show any details regarding footrest safety. 1. Review of Resident #17's Quarterly MDS (minimum data set), a federally mandated assessment tool completed by facility staff, dated, 9/19/24, showed: -Resident has severely impaired cognition. -Resident is able to wheel themselves in a wheelchair for 150 feet without assistance from helper. -Diagnoses included traumatic brain dysfunction, high blood pressure, anxiety, and depression. Observation on 11/18/24 at 11:29 A.M. showed: -Out of convenience, to move wheelchair traffic out of the hall more quickly. CNA A pushed resident #17 in her/his wheelchair out of dining room without footrests, The resident was instructed to hold feet up while being pushed down the hall, which poses a safety risk, and aides in promoting decline in resident's mobility. 2. Review of Resident #10's Quarterly MDS dated [DATE], showed: -Resident is cognitively intact. -Diagnoses included diabetes, osteoporosis, dementia, and depression. -Resident is able to independently walk 150 feet. -Resident uses a manual wheelchair. Observation on 11/19/24 04:03 P.M. showed: -Out of convenience to move wheelchair traffic out of the hall more quickly,CNA B pushed resident #10 in his/her wheelchair to his/her room without footrests. Resident was instructed to hold feet up while being pushed down the hall, which poses a safety risk, and aides in promoting decline in resident's mobility. which poses a safety risk, and aides in promoting decline in resident's mobility. 3. Review of Resident #39's Quarterly MDS dated [DATE] showed: -Resident has moderately impaired cognition. -Diagnoses included diabetes. -Resident requires partial/moderate assistance to wheel themselves 150 feet. Observation on 11/18/24 at 3:53 P.M. showed: -Out of convenience to move wheelchair traffic out of the hall more quickly, the kitchen manager pushed resident #39 in his/her wheelchair into dining room without putting footrests down Resident was instructed to hold feet up while being pushed down the hall, which poses a safety risk, and aides in promoting decline in resident's mobility. 4. Review of Resident #19's Annual MDS dated , 8/29/24, showed: -Resident is cognitively intact. -Diagnoses include stroke, high blood pressure, paralysis on one side of the body, and seizure disorder. -Resident is able to wheel themselves in a wheelchair for 150 feet without assistance from helper. Observation 11/19/24 at 3:30 P.M. showed: -Out of convenience to move wheelchair traffic out of the hall more quickly, the Activities director pushed resident #19's wheelchair out of the dining room without footrests, Resident was instructed to hold feet up while being pushed down the hall, which poses a safety risk, and aides in promoting decline in resident's mobility Residents #17, #10, #39, and #19 were not interviewable, however a reasonable person would want to propel their self if possible or have a foot rest to protect their feet. During an interview on 11/21/24 at 10:00 A.M., CNA A said there are foot pedals accessible for residents that need them. She said it is standard practice to push a resident without foot pedals if the resident can lift their feet because they don't want the resident to get hurt. During an interview on 11/20/24 at 4:11 P.M., LPN A, said that nursing staff will recommend footrests if a resident's feet are dragging. He/She said there needs to be footrests if a resident is not able to propel themselves but believes it to be ok for staff to push a resident without footrests if they are able to lift their feet up. He/She stated that it is probably a gray area because residents could get hurt. During an interview on 11/21/24 at 12:52 P.M., the DON said residents in wheelchairs should not be pushed by staff if their wheelchair does not have footrests.

Based on observation, record review, and interviews, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, failed to review the risk and benefits with the resident or the resident's representative (Resident #5, #45) , failed to obtain informed consent prior to installation (Resident #5 and #45), failed to ensure the bed's dimensions were appropriate for the resident's size and weight (Resident #5 and #45), failed to obtain a physician's order prior to installation of side rails (Resident #5), and failed to complete quarterly safety assessments for residents (Resident #5, #45), and failed to care plan side rails (Resident #5). This included four of 14 residents sampled (Residents #5, #45, #17, and #42). The facility census was 55. Review of facility policy, bed assist bar usage, revised 4/24/24, showed: -Policy to prevent entrapment and other safety hazards associated with bed assist bar use. -Facility leadership will be responsible for completing individual assist bar evaluation on a regular basis; -Providing employees appropriate information, education, training pertaining to general risks and benefits of assist bar use; -Education pertaining to resident-specific risks and care needs associated with bed assist bar use; -Upon admission, readmission or change of conditions residents will be screened to determine level of independence with bed mobility, bed comfort level, if bed meets manufacturers recommendations and specifications pertaining to resident height and weight, and assess the need for special equipment and accessories (assist bars); -Assess the resident to identify appropriate alternative prior to installing assist bars; -Assess the resident for risk of entrapment from assist bar(s) prior to installation; -Facility will document ongoing need for the use of an assist bar; -Review the risks and benefits with resident and resident representative; -Obtain informed consent; -Obtain physician order for medical symptom assessed for need for assist bar use; -Resident care plan will include use of assist bar(s) as assessed); -When installing or maintaining assist bar(s), the maintenance department staff will follow the manufacturer's recommendations and specifications, or provide another bed or appropriate alternative in accordance with individual bed inspections. -Maintenance department will conduct regular annual inspection of all bed frames, mattresses, and quarterly on assist bar(s) as part of a regular maintenance program to identify areas of possible entrapment; 1. Review of admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/22/24, showed: -He/She admitted to facility on 8/12/24; -He/She was cognitively intact; -He/She had clear speech, clear comprehension, and ability to understand others; -He/She had no impairment to upper or lower extremities; -He/She was dependent on a wheelchair; -He/She was independent with mobility, dressing toileting, and personal hygiene; -Diagnoses included diabetes (too much sugar in the blood), heart failure, and high blood pressure. Review of physician's orders, dated 11/18/24, showed no orders for the use of side rail or assist bars. Review of care plan, dated 9/4/24, did not address use of side rails or assist bars. During an interview on 11/18/24 at 2:36 P.M., resident said he/she had side rail so he/she could hold onto it to help position self in bed and assist self when he/she stood up out of his/her bed. Observation on 11/18/24 at 2:36 P.M. showed resident had a u shaped cane rail on right side of bed. Review of electronic medical record showed: -He/She did not have consent for side rails; -He/She did not have side rail assessment; A request for the bed and assist rail maintenance inspection form for the resident was requested and not provided. During an interview on 11/21/24 at 10:08 A.M., MDS Coordinator said: -He/She did not have a side rail assessment completed on the resident; -He/She did not have a physician's ordes for side rails for the resident; -He/She was unsure if resident's side rails were care planned. 2. Review of Resident #45's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and clear comprehension of others; -He/She had impairment of one side of lower extremities; -He/She was dependent on a wheelchair; -He/She required partial to moderate assistance with lying to sitting on side of bed, chair to bed transfers, sit to stand transfers, toilet transfers, and upper body dressing; -He/She required substantial to maximal assistance with lower body dressing, bathing, and applying footwear; -Diagnoses included amputation of left leg below the knee, diabetes, high blood pressure. Review of physician's orders, dated 11/19/24, showed: -Start dated 4/23/24, may use positioning bars for bed mobility and transfers; -Start date 8/13/24, non weight bearing to left leg. Review of care plan, revised 9/4/24, showed: -Resident expressed a desire to use positioning bars to serve as an enabler to promote independence; -He/She had consented to use positioning bars; -Orders per primary care provider, may use positioning bars for bed mobility and transfers; -Positive and negative aspects of positioning bar use have been discussed with resident and/or family and are aware of risks involved with use of positioning bars; -Review of positioning bar use every quarter with significant status change. Remove bars if no longer appropriate; -Resident needed assist with some activities of daily living due to left below knee amputation. During an interview on 11/18/24 at 3:20 P.M., Resident said: -He/She used side rails to pull self up; -The side rails had been on bed ever since he/she had the bed. Observation showed on 11/18/24 at 3:20 P.M. that resident had a u-shaped cane rail on both sides of his/her bed. Review of side rails assessment showed: -9/19/24 he/she was assessed for side rails to use to assist with transfers and bed mobility; -6/20/24 he/she was assessed for side rails to use to assist with transfers and bed mobility. Review of bed and assist rail maintenance inspection form showed: -Bed assessment frequency-If assist bar(s), initally when installed, quarterly, and/or when bed frame, mattress, or other accessories replaced -The Inspection form dated 6/5/24, showed there was no gaps of 4 and 3/4 inches inside the rail, under the rail, between the rail and the matress, or 2 and 3/8 inches between the rail and the headboard or footboard while resident was in his/her bed; -The facility provided no other completed quarterly assessments. 51166 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed: -Resident was rarely/never understood. -Resident had a memory problem. -Resident's cognitive skills for daily decision making was moderately impaired. -Resident required partial/moderate assistance to move from lying to sitting on side of bed. -Resident required partial/moderate assistance to move from sitting to lying on back in bed. -Resident's diagnoses included traumatic brain dysfunction, heart disease, high blood pressure, and depression. Observation on 11/21/24 at 11:07 A.M., showed resident has a U-shaped cane rails on both sides of the bed. Review of care plan, dated 4/25/24, showed: -Family had expressed a desire for me to use positioning bars to serve as an enabler to promote independence. -Family had consented for me to use positioning bars. -Order per my PCP, may use positioning bars for bed mobility and transfers -Positive and negative aspects of positioning bar use have been discussed with resident and/or family and are aware of risks involved with use of positioning bars -Review of positioning bar use every quarter and with significant status change. Remove bars if no longer appropriate. Review of physician orders, dated 4/23/24, showed the reisdent may use positioning bars for mobility and transfers. Review of Bed Rail Safety Assessment, dated 5/20/24, showed the resident was assessed for bed rails. Review of Side Rail Use Assessment Form, dated 4/24/24, showed a recommendation for side rails on both sides of the bed to help with independence. A quarterly bedrail assessment was requested and not provided. During an interview on 11/21/24 at 09:59 A.M., NA A said the U-shaped rails are used to assist the resident in turning in bed or to get out of bed or to grab to position while receiving cares. During an interview on 11/20/24 04:11 PM LPN A said the U-shaped rails are for mobility. 4. Review of Resident #42's Quarterly MDS, dated [DATE], showed: -Resident had severe cognitive imparment. -Resident had no imparment in upper or lower extremity functional range of motion. -Resident was able to roll from left to right independently. -Resident required no assistance to move from lying to sitting on side of bed. -Resident required no assistance to move from sitting to lying on back in bed. -Resident's diagnoses included traumatic brain dysfunction, high blood pressure, and Alzheimer's disease. Observation on 11/21/24 at 11:07 A.M., showed resident has a U-shaped cane rail on left side of the bed. Review of care plan, dated 4/25/24, showed: -Family had consented to use positioning bars. -Order per PCP, may use positioning bars for bed mobility and transfers -Positive and negative aspects of positioning bar use have been discussed with resident and/or family and are aware of risks involved with use of positioning bars -Review of positioning bar use every quarter and with significant status change. Remove bars if no longer appropriate Review of Bed Rail Safety Assessment, dated 5/24/24, showed the resident was assessed for bed rails. Review of Side Rail Use Assessment Form, dated 4/24/24, showed the recommendation for side rails on the left side of the bed to help with independence. Review of care plan, dated 4/25/24, showed: -Family has expressed a desire to use left positioning bar to serve as an enabler to promote independence. -Family has consented to use positioning bar. -Order per my PCP, may use positioning bar for bed mobility and transfers. -Positive and negative aspects of positioning bar use have been discussed with resident and/or family and are aware of risks involved with use of positioning bar. -Review of positioning bar use every quarter and with significant status change. Remove bar if no longer appropriate Start Date 04/25/2024 Review of physician's orders, dated 4/23/24, showed the resdient may use positioning bars for bed mobility and transfer. A request for quarterly bedrail assessment was made but not provided. During an interview on 11/21/24 at 10:53 A.M., the resident said the U-shaped rail is really handy. He/she uses it to get up. During an interview on 11/20/24 at 8:15 A.M, Director of Nursing (DON) said: -Facility did complete side rail assessments on residents; -Sometimes residents move in and side rails are already installed on the bed they move into; -Facility must obtain physician's orders prior to installing side rails; -Side rails should be care planned; -Maintenance staff has a guide for entrapment measurements; -Facility switched from side rails to only using u-shaped cane bars and did not view the cane rails as same risk for entrapment; -The Minimum Data Set (MDS) Nurse completed side rail assessments on residents. During an interview on 11/20/24 at 2:39 P.M., Maintenance said: -Facility only used mobility bars (u-shaped cane rails); -Nurse or therapy department will notify him/her to put the side rails on the bed; -He/She completed measurements with the mattresses and side rails using a guide called bed and assist rail maintenance inspection form and bed rail safety assessment; -He/She completed the entrapment assessment with the bed rail safety assessment when resident first comes into facility and with the change of mattress; -He/She did not measure entrapment zones on a monthly basis; -He/She completed a safety assessment monthly to ensure side rails had not come undone; -Does not measure on a monthly basis; -Does do safety assessments; -Side rails will not come out if undone, all have give, there is a deal underneath the clips that go into the side of the bed, will not let you release bars. During an interview on 11/20/24 at 3:05 P.M., Licensed Practical Nurse A said: -Side rails are assessed upon admission of new residents; -He/She would ask resident or family if the side rails were something they preferred or would aide them in getting around and in and out of their bed; -If resident wanted side rails he/she would get a hold of maintenance; -If resident had side rails on their bed they should have a physician's order; -He/She would request a physician's order for the side rail; -MDS coordinator completed quarterly side rail assessments for residents; -Side rails should be included in resident's care plan. During an interview on 11/21/24 at 10:08 A.M., MDS Coordinator said: -Side rails are not already installed on resident's bed; -Side rails are installed when and if a resident requested them; -Facility completed assessments to determine if side rails were appropriate for the resident; -Assessments were done quarterly; -A physician's order for the side rails must be obtained from the physician; -Maintenance or housekeeping would install the side rails; -He/She obtained consents by calling the resident's representative or discussing with resident if they were their own person and obtain consent; -Consent was included under the side rail assessment form; -The initial side rail assessment would show the consent signature of resident or their representative; -Maintenance staff is responsible for measuring dimensions and areas of entrapment; -He/She assumed entrapment zones were measured quarterly but did not know for sure; -A physician's order was required prior to installing side rails; -He/She expected side rails to be care planned; -He/She was responsible for writing care plans. During an interview on 11/21/24 at 12:52 P.M., Administrator said: -Verbal or written consent must be obtained for installation of side rails; -Side rail consents were documented on initial side rail assessment form but were not updated with quarterly assessments; -Entrapment assessments should be completed be completed upon initial installation and quarterly; -He/She expected a physician's order prior to installation of side rails.

Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent (%). Staff made 6 medication errors out of 31 opportunities for error, which resulted in an error rate of 19.35%. This affected 4 of the 14 sampled residents, (Residents #5, #29, #49, and #50). The facility census was 55. Review of the facility's policy for preparation and administration of oral medications, revised 2/1/24 showed, in part: To ensure the resident receives prescribed medications as ordered by Doctor utilizing the most current nursing practice. Review and verify medication administration records/medication cards with Doctor's order according to facility policy. Check medication record/card and remove the container of medication from the bin. LIQUIDS - Shake liquid (unless medication is not to be shaken) holding label to palm and pour into calibrated cup at eye level. Check the medication record/card and label again. Physician Order to be followed completely. This includes completing medication as ordered. Review of the facility's policy for administration of eye medications, revised 1/31/2024 showed, in part: - POLICY: To ensure resident receives the prescribed medication as ordered by the Doctor utilizing the most current acceptable nursing practice. - (2.) Check the treatment record with the medication label. - (11.) Do not let the dropper tip touch the eye, eyelid, or finger. - (15.) Read label of medication again. 1. Review of Resident #29's Physician order sheet (POS), dated 10/20/2024 - 11/20/2024 showed: - Start date: 10/17/2019 - Artificial Tears (polyvin alc) (polyvinyl alcohol) [OTC] drops; 1.4%; amt: 2 drops each eye; ophthalmic (eye) Three Times A Day; AM 06:00 - 10:00, MD 13:00 - 16:00, PM 19:00 - 22:00. Review of the Resident #29's medication administration record (MAR), dated 11/01/2024 - 11/20/2024 showed: - Artificial Tears (polyvin alc) (polyvinyl alcohol) [OTC] drops; 1.4%; Amount to Administer: 2 drops each eye; ophthalmic (eye) - Documentation shows it was administered three times per day for the past 19 days; Observation and interview on 11/20/24 at 6:06 A.M., showed: - LPN C administered eye drops that were labeled with a different resident's patient sticker. LPN C retrieved a box of artificial tears from the med cart. The box had Resident #29's name written in black marker across the front. The patient sticker on the bottom of the box was labeled with the name of a different resident. LPN C used the bottle of artificial tears from the mislabeled box for administration. - LPN C failed to keep the tip of the applicator bottle from touching the resident's eye lashes during administration. - LPN C reported during interview that the facility regularly has in-service and education related to medications and medication administration. - LPN C stated she was unaware that the sticker on the bottom of the box had another resident's name on it. During an interview with the Director of Nursing (DON) on 11/21/24 at 12:52 P.M. the DON said: - the tip of the eye dropper should not touch the eyelid or eye lashes when administering eye drops. 2. Review of Resident #50's Physician order sheet (POS), dated 10/19/2024 - 11/19/2024 showed: - Start date: 01/22/2024 - House Supplement 120 mL BID for weight loss, advanced age Twice a day; AM 06:00 - 10:00, PM 15:00 - 18:00 Review of Resident #50's medication administration record (MAR), dated 11/01/2024 - 11/19/2024 showed: - House Supplement 120 mL BID d/t weight loss, advanced age. - Documentation shows it was administered twice per day for the past 19 days. Observation and interview on 11/20/24 at 6:24 A.M., showed: - LPN C failed to follow the provider's orders when he/she administered an unknown dose of House Supplement. LPN C retrieved the bottle of House Supplement from the med cart and proceeded to fill a small plastic cup without measuring it and administered the liquid to Resident #50. - LPN C said, that he/she was unaware of how many milliliters (mL) the cup held. During an interview with the DON on 12/2/24 at 10:45 A.M., the DON said: - When preparing liquid medications, staff are expected to measure the liquid in a measuring cup at eye level. - That all liquid medications should be measured before administration. - To his/her knowledge there is no liquid medication used in the facility that would not need to be measured before administration. 31102 3. Review of Resident #49's POS dated November, 2024 showed an order start date for 2/29/24 for Olopatadine drops 0.1 % one drop daily in each affected eye for dry eyes. Review of the resident's MAR dated November, 2024 showed an order for Olopatadine drops 0.1 % one drop daily in each affected eye for dry eyes. Observation on 11/20/24 at 6:45 A.M., showed: - CMT A placed one drop in the resident's left eye and the tip of the eye dropper touched the resident's eye lid and eye lashes and applied lacrimal pressure for 13 seconds; - CMT A placed one drop in the resident's right eye and the tip of the eye dropper touched the resident's eye lid and eye lashes and applied lacrimal pressure for 14 seconds. During an interview on 11/21/24 at 10:21 A.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lid or eye lashes; - Should apply lacrimal pressure for five to ten seconds. During an interview on 11/21/24 at 12:52 P.M., the DON said: - The tip of the eye dropper should not touch the resident's eye lid or eye lashes; - Staff should apply lacrimal pressure for one minute. 4. Review of the facility's policy for nasal medication administration revised 2/1/24, showed, in part: - To ensure resident receives nasal medication per physician's orders according to approved procedures; - Position resident: sitting up for nasal sprays; - Give the resident a tissue and instruct to blow nose to clear nasal passage; - Instruct resident to use finger to close nostril opposite of nostril receiving medication; - Administer the dosage: insert spray nozzle gently into nose and spray; - Wipe away excess medication with tissue; - Instruct resident not to blow nose for a few minutes. Review of the package leaflet for Flonase nasal spray, revised March 2016, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. Review of Resident #5's POS dated November, 2024 showed: - Start date: 11/11/24 - Fluticasone (Flonase) propionate spray, 50 micrograms (mgs.) two sprays in both nostrils daily for chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the residents's MAR, dated November, 2024 showed: - Fluticasone (Flonase) propionate spray, 50 mgs., two sprays in both nostrils daily for COPD. Observation on 11/20/24 at 7:16 A.M., showed: - CMT A did not shake the Flonase bottle; - CMT A did not have the resident blow his/her nose; - CMT A administered two sprays in the resident's right nostril and gave two sprays in the left nostril and did not occlude either side of the nostril. During an interview on 11/21/24 at 10:21 A.M., CMT A said: - He/she should follow the manufacturer's guidelines for administration of Flonase. During an interview on 11/21/24 at 12:52 P.M., the DON said;- She would expect the staff to follow the manufacturer's guidelines for the administration of Flonase.

Based on observation, record review, and interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to utilize proper thawing techniques, failed to ensure garbage cans were kept covered when not in use, failed to properly sanitize all food preparation surfaces in kitchen, failed to store dishes in an inverted position, failed to implement proper hand washing techniques, and failed to ensure proper storage and labeling of foods. The facility census was 55. 47195 1. Review of facility policy, waste disposal, dated April 2011, showed: -All waste must be placed in lined garbage and trash cans and kept covered when not in use. Observation on 11/18/24 9:07 A.M., showed there was no lids on two large trash cans, one in dishwashing area and one towards back of kitchen. Observation on 11/20/24 at 9:21 A.M. showed no lids were on the trash cans in the kitchen. During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -Trash cans in the kitchen should have lids on them at all times. During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -Trash cans in kitchen should have lid. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -Trash cans in kitchen should have lids on them. During an interview on 11/21/24 at 9:00 A.M., Dietary Aide A said: -Trash cans in kitchen should be covered; -The trash cans in the kitchen were not covered. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -He/She expected trash cans in kitchen to be covered at all times unless they are being used. During an interview on 11/21/24 at 12:52 P.M., Administrator said: -He/She expected trash cans in the kitchen to be covered. 2. Review of facility policy, hand washing and glove use dining services, posted 9/5/11, showed: -All residents and staff should be free from contamination by improper hand washing and glove use. -Wash hands after every activity such as eating, drinking, using the restroom, touching a resident or wheelchair, picking up trash, taking out the trash, touching face or hair, bussing tables; -Wash hands before and after glove use; -Wash hands following the instructions located at every hand sink. Review of facility policy, untitled, revised 7/22/14, showed: -Use proper hand washing techniques often and when necessary (hand washing should be done after any activity, such as eating, drinking, using the restroom, smoking, cleaning, touching anything contaminated, and before and after glove use) Review of facility policy, dishwashing, dated April 2011, showed: -Sanitize hands properly before pulling racks from the clean side of the dish machine; -Allow items to thoroughly dry before unloading racks or storing items. During a continuous observation on 11/20/24 from 9:21 A.M.-11:35 A.M., showed: -9:29 A.M., [NAME] B washed his/her hands and then turned faucet off with his/her paper towel, and continued to use same paper towel to dry his/her hands; -9:36 A.M. [NAME] B went from dirty dishes of dishwasher to clean side of dishwasher. He/She removed items from clean side of dishwasher without washing his/her hands; -9:45 A.M., Dietary Aide B washed his/her hands and used bare hands to shut off water faucet handles. He/She then dried hands with paper towel; -10:10 A.M., Dietary Aide B washed his/her hands and used bare hands to turn off faucet handles; -10:23 A.M., Dietary Aide B washed his/her hands and used bare hands to turn off faucet handles; -10:51 A.M., [NAME] B washed his/her hands, used paper towel to turn off faucet, then used same paper towel to dry his/her hands; -11:09 A.M., Dietary Aide B washed his/her hands and used bare hands to turn off faucet handles. Review of facility policy, dishwashing, dated April 2011, showed: -Sanitize hands properly before pulling racks from the clean side of the dish machine. During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -He/She must wash hands any time changing tasks, entering kitchen, and any time he/she contaminates his/her hands; -It was not sanitary to wash his/her hands and then use his/her bare hands to shut off faucet; -It was not sanitary to wash his/her hands, turn off faucet handles with paper towel, and then use same paper towel to dry his/her hands. -He/She should wash hands after loading dirty dishes into dishwasher and before taking clean dishes out of dishwasher. During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -He/She expected frequent hand washing with anytime changing tasks, leave kitchen and returning to kitchen; -It was not sanitary for staff to wash hands and turn faucet off with bare hands; -He/She expected staff to use a different paper towel to shut off faucet after washing hands and should not use same paper towel to dry his/her hands; -He/She expected staff to wash hands between loading dirty dishes and removing items from clean side of dishwasher. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -He/She had to wash hands if went to bathroom, took out trash, wipe off carts, touch his/her face, brush his/her hands, or when entered kitchen; -It was not sanitary for him/her to shut off faucet handles with bare hands after washing his/her hands; -It was not sanitary for him/her to shut off faucet handles with paper towel and use same paper towel to dry his/her hands. -He/She did not know if he/she should wash his/her hands before removing clean dishes from dishwasher During an interview on 11/21/24 at 9:00 A.M., Dietary Aide A said: -He/She should wash hands by running water for 20 seconds, putting on soap, rubbing nails and stuff, rinsing hands off, pull paper towels down, turn off water with paper towel; -It was not sanitary to use his/her bare hand to shut off water faucet; -It was not sanitary to use paper towel to shut off water faucet and then use same paper towel to dry his/her hands. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -He/She expected staff to wash their hands between going to bathroom, smoking, when in and out of the kitchen; -He/She expected staff to turn off faucet handles after washing their hands with a towel; -He/She expected staff to wash their hands before going to clean side of dishwasher and putting dishes away. During an interview on 11/21/24 at 12:52 P.M., Administrator said: -He/She expected dietary staff to wash hands frequently; -He/She expected staff to wash hands and turn faucet off with a paper towel; -He/She did not expect staff to turn off faucet handles with bare hands or use the same paper towel to turn off faucet handles and then dry their hands with same paper towel but expected them to use new paper towel. 3. Review of facilitys food policy, untitled, revised 8/26/11, showed: -Leftovers will be stored and discarded properly; -Put leftovers in appropriate containers; -Label, date, and initial the containers; -Place containers in cooler or freezer. -Max storage for leftovers is 7 days for canned fruits, vegetables, etc. and 3 days for foods prepared with mayor or cooked meats. Review of facility policy, receiving and storage of food, dated April 2011, showed: -Keep all foods in clean, undamaged wrappers or packages; Observation on 11/18/24 at 8:57 A.M. of the walk in cooler in kitchen showed: -Opened, unsealed, and undated bag of soft shell tortillas; -Opened and undated 5 lb shredded Monterey jack cheese; -Opened and undated 5 lb pimento spread; -Three sections of opened and undated American cheese wrapped in clear plastic wrap; -Opened and undated bag of hard boiled eggs; -Opened and undated dough; Observation on 11/18/24 at 9:03 A.M. of dry storage showed: -Undated and opened 5lb egg noodles; -Undated and unsealed 10 oz bag of spaghetti noodles; -Undated bag of mini marshmallows; Observation on 11/18/24 at 9:07 A.M. of spice rack showed: -Outdated 16 oz ground clove, dated 10/11/22 -Opened and undated 16oz chives; -Opened and undated garlic powder had no date; -Opened and undated Italian seasoning; -Opened and undated lemon pepper 20oz; -Opened and undated basil leaves 20 oz; -Opened and undated celery salt 20 oz; -Opened and outdated dill weed, dated 1/10/22; -Opened and outdated rubbed sage 60z dated 10/11/22; -Opened and undated Hungarian paprika 18oz; -Opened and undated 20 oz onion powder; -Opened and undated beef flavor soup base 16 oz; -Opened and undated chicken flavor soup base 16 oz; -Opened and undated iodized table salt 26 oz; -Opened and undated season salt 16 oz; -Opened and undated corn starch 16oz; -Opened and undated cinnamon, 16 oz; -Opened and undated nutmeg 16oz; -Opened and outdated ground ginger 14oz dated 1/17/22. Observation on 11/18/24 at 9:12 A.M. of food preparation table: -Opened and undated sliced white bread; During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -Food should be dated when opened with date opened and three days following; -Spices should be dated; -Spices could be maintained thirty days to one year after opening; -Spices should be thrown out after one year During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -He/She expected a date and label on anything left over from being cooked or that was taken out of a can; -Leftovers could be kept for three days; -He/She expected condiments such as salad dressing to have a written opened date and a disposal date one month after that open date; -Spices should be dated when opened; -Spices should be disposed one year after opened date; -He/She expected staff to dispose of spices after 1 year. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -He/She dated food items when he/she opened them; -Bags should be sealed; -Spices should have a date on them; -He/She did not know how long spices could be maintained in kitchen from date they were opened. During an interview on 11/21/24 at 9:00 A.M., Dietary Aide A said: -He/She dated food items when they were opened; -Items stored in fridge or freezer should be sealed; -Spices should be dated when they were opened. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -He/She expected spices to have dates written on the bottle after they were opened; -Spices could be kept for 1 year after they were opened; -Food items that are opened should have a date on them; -Food items should not be exposed to air; -Everything store should be sealed. During an interview on 11/21/24 at 12:52 P.M., Administrator said: -He/She expected food in kitchen to be dated when opened; -He/She expected opened food to be stored in sealed containers; -He/She expected spices dated 2022 to be discarded. 4. Facility did not provide a policy on storage of dishware. Observation on 11/18/24 at 9:01 A.M. showed bowls and plates are stored upright. Observation on 11/18/24 at 9:18 A.M. showed 17 metal bake pans were stored upright, three bowls sat on top of microwave not in use stored upright; Observation on 11/20/24 at 9:21 A.M. showed plates and bowls were stored face up on counter. Bowls located on top of the microwave were stored up right. Observation on 11/20/24 at 11:08 A.M. showed under the steam table shelf had plastic containers, bowls, with lids were all stored upright. During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -Bowls, plates, cups, pans, pitchers should be stored inverted; During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -Anything that could be stored inverted should be including plates, bowls, pitchers, and bakeware. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -They always stored plates, dishes, bowls upright in the kitchen. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -He/She expected plates when stored at the end of the day to be covered with a blanket and stored up right; -Items that have contact with food should be covered or stored upside down; -Pitchers and bowls should be stored inverted if they were not covered. 5. Facility did not provide a policy on proper unthawaing techniques. Observation on 11/18/24 at 8:57 A.M. of the walk in cooler showed a 5 lb roll of hamburger was unthawing on top of a cardboard box on the bottom shelf; During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -Meat should be unthawed in fridge prior to when need it; -Hamburger should not be unthawing on top of card board box; During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -He/She expected meat to be unthawed overnight in the refrigerator in a separate container. -Meat could be unthawed under running water below 70 degrees in a pinch, but he/she preferred meat be unthawed in advance. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -Meat should be unthawed in refrigerator or during cooking process; 6. During a continuous observation on 11/20/24 from 9:21 A.M.-11:35 A.M., showed: -9:21 A.M., towels and Dawn dish soap out on counter, [NAME] B used a wash cloth to wipe off food prep surfaces that was not in sanitizer water. -9:24 A.M., [NAME] B tested sanitizer water showed appropriate parts per million (PPM), stated he/she set up the sanitizer water when he/she came into shift that morning; -9:40 A.M., Dietary Aide A used a green towel that was in a gray pale bucket next to dawn dish soap to wipe off 3 tiered cart. During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: Surfaces in kitchen should be sanitized with water we make from our sanitizer out of the machine or 409. During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -He/She expected kitchen surfaces to be sanitized with sanitizer solution. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -He/She sometimes used dish soap to wash off surfaces in the kitchen; -He/She at times would use dish soap and sanitizer on kitchen surfaces in the kitchen; -He/She did not always use both dish soap and sanitizer and sometimes only sanitized surfaces with dish soap. During an interview on 11/21/24 at 9:00 A.M., Dietary Aide A said: -He/She was using soapy dish water in gray container to wash off kitchen carts; -He/She did not use sanitizer on the 3 tiered carts; -He/She would use towels to dry off coffee cups and silverware; -He/She used dish soap to sanitize surfaces in the kitchen; -He/She also used sanitizer that comes from dishwasher to sanitize surfaces in the kitchen. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -Kitchen prep surfaces should be scrubbed with dish detergent, then expected staff to use 409; -He/She expected sanitizer to be used on food prep surface areas; -Towels were not supposed to be used to dry things and should only be used for carts and stuff; -He/She expected dish soap and sanitizer to be used on carts; During an interview on 11/21/24 at 12:52 P.M., Administrator said: -He/She expected surfaces in kitchen to be cleaned with sanitizer solution and then allowed to dry.

Based on observation, interview and record review, the facility failed to follow acceptable infection control practices to reduce the development and spread of infections for three of the 14 sampled residents (Resident #18, #24, and #53), and failed to ensure the urinary catheter drainage bag for Resident #53 did not touch contaminated surfaces. The facility additionally failed to place residents with wounds (Resident #18 and Resident #24) and with urinary catheters (Resident #18 and #53) on enhanced barrier precautions (EBP). The facility census was 55. Review of the facility's Enhanced Barrier Precautions policy, dated August 2022, showed: - EPBs are utilized to prevent the spread multi drug resistant organisms (MDRO) to residents; - EPBs employ targeted gown and glove use during high resident care activities when contact precautions do not otherwise apply; - Gloves and gowns are applied prior to performing the high contact resident care activity; - Examples of high contact resident care activities that require the use of gown and gloves are; - Catheter care or use; - Wound care; - EPBs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling device; -Signs are posted on the door or on the wall outside the resident's room indicating the type of precautions and personal protective equipment (PPE) required. Review of the facility's Catheter Emptying, Urinary Drainage Bag, revised 1/31/24, showed: -Keep the drainage bag and tubing off the floor at all times to prevent contamination. 1. Review of Resident #53's Admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/30/24, showed: -No cognitive impairment; -Substantial assistance with showers; -Partial assistance with toileting; -The resident has indwelling urinary catheter; -Frequently incontinent of bowel; -Diagnoses included, kidney failure, and thyroid dysfunction. Review of the resident's care plan dated 11/1/24, showed: -The resident requires the assistance of one staff for Activities of Daily Living (ADLs); -The resident has an indwelling urinary catheter; - Do not allow tubing or any part of the drainage system to touch the floor. Observation on 11/21/24, at 9:36 A.M., showed: -There was a yellow gown for PPE hanging on the back of the resident's door; -Certified Nurses Aide (CNA) D washed his/her hands and applied gloves; -CNA D removed the residents brief; -CNA D lowered catheter drainage bag to the floor by the catheter tubing; -The resident's catheter drainage bag came in contact with the floor; -CNA D drained the urine from the top of the catheter tubing into the drainage bag and hung it on the bed; -CNA D removed the drainage bag from the bed and drained the urine out of the catheter tubing again; -The drainage the bag came in contact with the floor again and with top of the trash can beside the resident's bed; -CNA D failed to keep the catheter drainage bag off the floor; -CNA D failed to keep the catheter drainage bag from touching the trash can; -CNA D did not apply the yellow isolation gown hanging on the back of the resident's door before starting cares on the resident; -No signs were posted on the door or on the wall outside the resident's room indicating the resident was on EBP. During an interview on 11/21/24 at 9:48 A.M., CNA D said: -The catheter drainage bag or tubing should not touch the floor; -The catheter drainage bag or tubing should not touch the trash can; -He/she was not aware that the resident was on EBP. During an interview on 11/21/24 at 9:57 A.M., Registered Nurse (RN) A said: -The catheter drainage bag or tubing should not touch the floor; -The catheter drainage bag or tubing should not touch the trash can; -If a resident has a catheter they should be on EBP; -The resident should have a sign on the door or the wall indicating EBP should be used; -The yellow gown on the back of the residents door is used for EBP. During an interview on 11/21/24 at 12:52 P.M., the Director of Nursing (DON) said: -He/she expects the staff to use EBP when the resident has a catheter or a wound; -He/she expects staff to keep catheter drainage bags from touching the floor or other contaminated surfaces. 31102 2. Review of Resident #18's Admission MDS, dated [DATE] showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing and transfers; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel - Diagnoses included anxiety, multiple sclerosis (a disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve and spinal cord, called the myelin sheath), and neuromuscular dysfunction of the bladder (a condition that occurs when the nerves, spinal cord, or brain that control bladder function are damaged). Review of the resident's care plan, revised 11/8/24 showed: - The resident required enhanced barrier precautions related to Suprapubic catheter (a catheter which enters the bladder through the lower abdomen); - Clean hands before entering and when leaving the room; - Do not wear the same gown and gloves for the care of more than one person; - Wear gloves and a gown for the following high-contact resident care activities: dressing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, central line, urinary catheter, feeding tube, tracheostomy (an artificial opening into the wind pipe to aid breathing) and wound care. Review of the resident's physician order sheet (POS) dated November 2024 showed: - Start date: 7/17/24 - Catheter change as needed related to non-function; - Start date: 11/18/24 - Cleanse wound with normal saline, pat dry. Apply skin prep to area where foam dressing will be applied, apply saline moistened prisma (a sterile, freeze-dried wound dressing that's used to help manage wounds and promote healing) to ulcer base and cover with hydrofera blue (a moist antibacterial foam dressing used to treat a variety of wounds) over ulcer and secure with 3 x 3 quadrilobe allevyn foam dressing (a hydrocellular foam dressing with a quadrilobe shape and wide border that's designed to conform to the body's contours) to the area. Change daily every two days or when 3/4 saturated with drainage. Observation on 11/20/24 at 10:36 A.M., showed: - There was a sign outside the resident's room which indicated staff should use enhanced barrier precautions; - There were two reusable gowns hanging on the back of the resident's door; - The resident's drainage bag hung on the side of the resident's bed and did not have a dignity cover over it; - The resident declined to have the surveyor observe catheter care; - Licensed Practical Nurse (LPN) A and LPN B entered the resident's room, washed their hands and applied gloves; - LPN A and LPN B did not apply any gown during the wound care process; - LPN B provided wound care to the resident's right gluteal fold ( the horizontal crease that separates the upper thigh from the buttocks), covered the resident with a blanket and placed the resident's call light in reach; - LPN A and LPN B removed gloves, washed hands and left the room. During an interview on 11/20/24 at 11:03 A.M., LPN B said: - He/she should have worn the gown on the back of the resident's door for EBP; - The drainage bag should have a dignity cover over it. 51626 3. Review of Resident #24's undated care plan showed: - Resident required Enhanced Barrier Precautions (EBP) related to urinary catheter and wounds. - Staff is expected to wear gloves and gown for the following high-contact resident care activities: Dressing, Bathing/showering, transfering, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care: central line, urinary catheter, feeding tube, tracheostomy; wound care. - Resident was admitted to the facility with stage III pressure ulcers (wounds caused by prolonged pressure on the skin) to his/her back and coccyx (the small, triangular bone at the base of the spine). - Staff is expected to keep linens clean and dry. - Requires help with all ADLs. Review of Physician orders for October 2024., showed: - Wound Care start date: 10/04/2024 Cleanse wounds with wound cleanser, dry. Apply lidocaine 5%/bupivocaine 2%/metronidazole 20% (pixie dust), calcium alginate, and super absorbant dressings to sacral and spinal wounds daily. An observation on 11/18/24 at 2:18 P.M. showed: - Multiple dime-sized dried blood droplets on the Resident's sheet. - A fist-sized blood stain on the bottom sheet under the resident. During an observation and interview on 11/19/24 at 10:08 A.M., showed: - LPN A and LPN D entered Resident's room for wound care. - Staff failed to apply gowns prior to care. - Blood stained top sheet and draw sheet remained untouched on Resident #24's bed. -There was no EHB signage on the door or outside the resident's room. - Two washable EBP gowns were hung on the back of Resident #24's door for staff use. - LPN D said that a resident with a catheter and wounds would require EBP. - LPN D said that they both should have donned gowns prior to wound care. During an interview on 11/21/24 at 12:52 P.M., the DON said staff are expected to wear gowns and gloves during wound care for all residents requiring EBP.

Based on record review and interview, the facility failed to keep residents' money separated from the facility's operating account. This effected eight additionally sampled residents (Resident #37, #156, #157, #158, #159, #160, #161, and #162). The facility census was 110. Review of the facility policy titled Guidelines for Maintaining the Resident Trust Fund Account, dated [DATE], showed the following: - This facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf. - A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf; - The facility will deposit all funds of the resident in an interest-bearing account that is separate from any of the facility operating accounts and all interest will be credited monthly to the resident fund account with a separate accounting for each resident's share; - Written receipts will be issued for cash received. 1. Review of the facility's aging report (a report used to determine if the facility has residents' funds in the operating account) showed the following residents had money in the facility's operating account: - Resident #37- $1190.88; - Resident #156- $860.06; - Resident #157- $3411.46; - Resident #158- $176.35; - Resident #159- $1899.91; - Resident #160- $140.18; - Resident #161- $4197.40; - Resident #162- $5566.25. During an interview on [DATE] at 1:48 P.M., the Business Office Manager said: - Resident #37's family member keeps paying the room and board amount monthly and she keeps telling him/her not to; - Resident #156 expired in 2018. She has tried to get ahold of family, but she had not been able to make contact; - Resident #157 discharged in 2019. She did not realize the resident had money in the aging report; - Resident #158 discharged in 2020. She could send the money to family; - Resident #159 expired in 2018. She could contact the family; - Resident #160 discharged in 2018. She did not know there was money in the operating account. - She had spoken with Resident #161's family and they wanted the money transferred to the other family member in the facility. She would call them. - She was told by Resident #162's family the money was going to be donated, but will contact family to issue a check to them; - She knew resident funds should not be in the operating account. She ran the report every so often, but it had gotten away from her.

Based on record review and interview, the facility failed to maintain a surety bond sufficient to cover any loss or theft to residents' money held in the facility's Resident Trust Fund (RTF) account which had the potential to affect all eight residents who had money held in their RTF account. The facility census was 53. The facility did not have a policy for surety bonds. 1. Review of the facility's RTF documents showed there were currently eight residents with open RTF accounts in the facility. Review of the facility's approved surety bond, approved on 6/3/1996, showed an approved amount of $10,000.00. Review of the RTF worksheet on 1/12/23, showed: - The average monthly balance for the facility's interest bearing account of $11,923.42; - The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $18,000. During an interview on 4/5/23 at 1:48 P.M., the Business Office Manager said she did not realize the bond amount was not sufficient. She would talk to the Administrator about increasing the amount.

Based on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; and for residents with a mental disorder or related disabilities, the mailing, electronic mail (email) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy for Mentally III Individuals Act. This affected three of 14 sampled residents (Resident #7, #8 and #11). The facility census was 53. Review of the facility's policy for discharge/transfer of resident, revised 2/7/23, showed, in part: - The purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Explain the discharge guidelines and reason to resident and give copy of transfer and discharge notice as required. Include representative; - If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible; - Explain and give copy of bed hold form to the resident and/or representative; - Complete transfer form, copy any portion of the medical record necessary for care of resident; - Send original of transfer form and portions of medical record that was copied with the resident; - Notify Business office/Administration of discharge. 1. Review of Resident #8's annual Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/1/23, showed: - Modified independence with communication; - Required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use; - Upper and lower extremity impaired on one side; - Diagnoses included stroke, hemiparesis (muscle weakness on one side of the body) and anxiety. Review of the resident's progress notes, dated 3/6/23 at 7:51 A.M., showed: - The resident had a wet cough and labored breathing and agreed to go to the local hospital via ambulance. Review of the resident's transfer or discharge notice, dated 3/6/23, showed: - The resident was transferred due to labored breathing and a wet cough;- It did not contain the addresses, emails or telephone numbers for the Appeals Unit or the Ombudsman's office. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed: - The resident had short term and long term memory problems; - Required extensive assistance of two staff for transfers, and dressing; - Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Alzheimer's disease. Review of the resident's progress notes dated 3/3/23, showed: - The resident was transferred to the local hospital due to labored breathing and low oxygen saturation (amount of oxygen in the blood). Review of the resident's transfer/discharge notice dated 3/3/23 showed;- The resident was transferred due to labored breathing and low oxygen saturation; - It did not contain the addresses, emails or telephone numbers for the Appeals Unit or the Ombudsman's office. 3. Review of Resident #7's quarterly MDS dated [DATE] showed: - A Brief Interview for Mental Status (BIMS) score of 5, indicating moderate cognitive impairment. - Diagnoses included: Muscle weakness and heart failure. - He/she required the assistance of one staff to reposition him/her while in bed, transfer and use the toilet. Review of the resident's record showed he/she was hospitalized on [DATE] due to low blood pressure and the resident became unresponsive. He/she returned to the facility on [DATE] with hospice services. The facility staff did not document they provided the resident with the hospital transfer documents. 4. During an interview on 4/6/23 at 9:37 A.M., Registered Nurse (RN) said: - When he/she sent a resident to the hospital, the paperwork included the face sheet, physician's order sheet (POS), Out of Hospital Do Not Resuscitate (OHDNR, informs emergency personnel or staff what to do if your heart stops beating or you stop breathing), labs if indicated and recent vital signs. During an interview on 4/7/23 at 2:58 P.M., the Director of Nursing (DON) said: - She thought there was new criteria; - She knew their current form needed to have additional criteria. 44993

Based on observation, interview and record review, the facility staff failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of 14 sampled residents (Residents #28, #29, and #36). The facility census was 53. Review of the perineal care of the female resident policy, dated 2/7/23, showed: - The purpose of perineal care was to provide comfort for the resident and prevent an infection. - The staff was supposed to separate the inner perineal folds and wipe from front to back with a clean wipe. - Wipe from front to back the outer skin folds with a clean wipe. - With a new wet wipe clean the inner thighs. 1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 2/22/23, showed: - Brief Interview for Mental Status (BIMS) score of 0, indicating a severe cognitive deficit. - Diagnoses included: Dementia (a disease of the brain that causes memory loss and impaired reasoning) and muscle weakness; - He/she required the assistance of two staff to reposition while in bed, transfer, personal hygiene, and to get dressed. - He/she was incontinent of bowel and bladder. Review of the resident ADL care plan, dated 6/20/22, showed: - He/she required the staff to provide perineal care for him/her after each incontinent episode. Observation on 4/6/23 at 9:57 A.M., showed Certified Nurses Aide (CNA) C and CNA D: - Entered the resident's room to lay the resident down in bed and provide perineal care. - CNAs C and D used the mechanical lift and laid the resident in bed. - CNA D removed the resident's pants and wet brief. - CNA C cleaned the outer skin folds of the resident with one swipe down each side of the resident's perineal area. He/she used a clean wipe with each swipe. - CNA C did not spread the resident's inner perineal folds and clean the area. During an interview on 4/7/23 at 10:36 A.M., CNA C said: - He/she was trained to separate the inner skin folds to provide perineal care. - He/she did not separate the inner skin folds when he/she provided perineal care to Resident #28. 31102 2. Review of Resident #29's quarterly MDS, dated [DATE], showed: - Short- and long-term memory problems; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and toilet use; - Always incontinent of bowel and bladder; - Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions). Review of the resident's care plan, revised 3/28/23, showed;- The resident had urinary incontinence and dependent with incontinent care; - Provide assistance of two staff with incontinence care. Observation on 4/6/23 at 8:45 A.M., showed: - CNA C wiped down one side of the groin and with the same area of the wipe, wiped down the groin again; - CNA C did not separate and clean all the perineal folds; - CNA C and CNA E turned the resident on his/her side; - CNA C used a new wipe and wiped the buttocks twice with the same area of the wipe. He/she used a new wipe and wiped front to back, folded the same wipe and wiped again from front to back; - CNA C and CNA E turned the resident to the other side; - CNA C used a new wipe and used the same area of the wipe and wiped up and down the buttocks; - CNA E removed the wet paper pad and placed a clean one under the resident. During an interview on 4/7/23 at 10:36 A.M., CNA C said: - He/she should not use the same area of the wipe to clean different areas of the skin; - He/she should not fold the wipe; - He/she should have separated and cleaned all areas of the skin where urine has touched. 3. Review of Resident #36's care plan, revised 2/3/23, showed: - The resident had left sided weakness related to a stroke and required assistance with most activities of daily living (ADLs); - The resident was unable to tell staff when he/she needed to use the bathroom and wore incontinent briefs for dignity; - Required the assistance of two staff with incontinent care. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and toilet use; - Upper and lower extremity impaired on one side; - Always incontinent of bowel and bladder; - Diagnoses included stroke and hemiparesis (muscle weakness on one side of the body) and anxiety. Observation on 4/4/23 at 1:33 P.M., showed: - CNA A and CNA B used the mechanical lift and transferred the resident from his/her wheelchair to the bed; - CNA A and CNA B turned the resident from side to side to remove the lift sling and pulled the resident's pants down; - CNA A unfastened the soiled incontinent brief and turned the resident on his/her side; - CNA B wiped the rectal area three time with fecal material on each new wipe; - CNA B wipe front to back three more times with a new wipe each time; - CNA B removed the soiled and wet incontinent brief; - CNA B used a new wipe and wiped from front to back, folded the wipe and wiped one side of the resident's buttocks, folded the same wipe and wiped the other side of the buttocks; - CNA A placed a clean incontinent brief under the resident and turned him/her on their back; - CNA A used the same area of the wipe and wiped each side of the resident's inner legs and each side of his/her groin; - CNA A did not separate and clean all areas of the skin folds. During an interview on 4/7/23 at 9:37 A.M., CNA A said: - Should not fold the wipes with perineal care; it should be one swipe, one swipe; - He/she should have separated and cleaned all the skin folds where urine or feces had touched; - He/she should not have used the same area of the wipe to clean different areas of the skin. During an interview on 4/7/23 at 10:32 A.M., CNA B said;- He/she thought it was alright to fold the wipes with perineal care; - He/she should make sure to separate and clean all the skin folds where urine or feces has touched; - He/she should not use the same area of the wipe to clean different areas of the skin. 4. During an interview on 4/7/23 at 2:58 P.M., the Director of Nursing (DON) said: - She would not expect staff to use the same area of the wipe to clean different areas of the skin; - Staff should not fold the wipe with perineal care; - Staff should wipe from the inner to outer skin folds and should make sure they separate and clean all areas of the skin where urine or fecal material has touched.

Based on observation, interview, and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM or to prevent further decrease in ROM. This affected four (Resident #2, #7, #8, and #19) of 14 sampled residents. The facility census was 53. Review of the restorative nursing policy, dated 2/7/23, showed: - The purpose policy was to identify residents that would benefit from restorative nursing services and to maintain the current level of independence. - The therapist will meet with the restorative aide once the resident's skilled therapy has been completed. - The charge nurse will be responsible to obtain an order for restorative services. - The restorative aide will be responsible for documentation of the restorative services provided. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 1/11/23, showed: - He/she had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. - He/she required two staff to help the resident reposition while in bed, transfer and use the toilet. - He/she had an impairment to left side of the upper and lower body. - Diagnoses included: Weakness, hemiplegia (paralysis of one side of the body), and abnormal mobility. Review of the resident's April 2023 physician's order sheet (POS) showed: - 4/4/23 Apply splint to the resident's left hand, on at all times and off only for hygiene. Review of the resident's activities of daily living (ADL) care plan, dated 9/11/20, showed: - He/she required the assistance of one staff to get dressed. - He/she required the assistance of two staff to use the toilet and transfer. - He/she had left-sided body weakness. - His/her hand splint was not addressed. Observation and interview on 4/4/23 at 9:02 A.M., showed and the resident said: - He/she had a stoke in 1999, and has had trouble with his/her left upper and lower extremity weakness. - His/her left hand with fingers curling in to the palm of his her hand. - He/she was not wearing a splint. Observation on 4/4/23 at 11:16 A.M., showed: - He/she had a hand splint on his/her left hand that straightened his/her fingers. During an interview on 4/7/23 at 8:53 A.M., the resident said: - He/she would like to participate in a restorative program to strengthen the his/her hand and straighten his/her fingers. - He/she was afraid if the staff did not work with his/her hand, his/her fingers would curl tighter and he/she would lose even more function of his/her hand. During an interview on 4/7/23 at 9:10 A.M., Certified Nurse Aide (CNA) A said: - He/she ran the Restorative Therapy program in the facility until November of 2022. - He/she stepped down from the Restorative Therapy program and began working on the floor as a CNA because he/she was assigned to work on the floor and he/she was not able to complete his/her Restorative Therapy duties. - There was not a current Restorative Therapy program at the facility. 2. Review of Resident #7's quarterly MDS, dated [DATE], showed: - He/she had a BIMS score of 5, indicating moderate cognitive impairment. - Diagnoses included: Muscle weakness and heart failure. - He/she required the assistance of one staff to reposition him/her while in bed, transfer and use the toilet. Review of the POS, dated April 2023, showed an order to complete hand hygiene twice daily to the right hand due to a contracture. Review of the resident's limited ROM care plan, dated 3/13/23, showed: - He/she had limited ROM to his/her right hand. - He/she had a hand splint for his/her right hand. - He/she often refused to wear the splint and often took it off. Observation on 4/4/23 at 10:48 A.M., showed: - The resident's right hand was closed in a tight fist with his/her fingers digging into his/her palm. - He/she was not wearing a splint. Observation on 4/7/23 at 12:10 P.M., showed the resident had his/her hand splint applied to his/her right hand. The resident did not appear to be in distress. The splint did not fit properly and was not flush against his/her palm. 31102 3. Review of Resident #8's annual MDS, dated [DATE], showed: - Modified independence with cognitive skills; - Required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use; - Upper and lower extremity impaired on one side; - Diagnoses included stroke, anxiety and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 3/22/23, showed: - It did not address restorative therapy. Review of the resident's POS dated April 2023 showed:- Start date: 3/12/23 - restorative care program: perform seated exercises, bilateral lower extremities (BLE) as tolerated for 15 minute sessions, once a day on Monday, Tuesday, Wednesday, Thursday and Friday. Observation of the resident at various times from 4/4/23 through 4/7/23, showed the resident in a wheelchair and had limited range of motion on one side of her body. Review of the resident's medical record showed no RA documentation to indicate staff had completed the RA program with the resident. 4. Review of Resident #29's quarterly MDS, dated [DATE], showed; - Short and long term memory problems; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and toilet use; - Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions). Review of the resident's care plan, revised 3/28/23, showed: - The resident had limited range of motion to left leg and both arms related to contractures and right leg is amputated above the knee; - The care plan did not address any restorative therapy. Observations at various times from 4/4/23 through 4/7/23 showed: - The resident lay in bed with no wash cloths in his/her hands. Review of the resident's medical record showed no documentation regarding the resident's contractures, RA services or passive ROM. 5. During a telephone interview on 4/7/23 at 10:36 A.M., CNA C said: - As far as he/she knew, they did not have anyone doing RA at this time. During an interview on 4/7/23 at 9:37 A.M. the Physical Therapy Director said: - Once the resident completed his/her skilled therapy days, the therapy department develops a Restorative Therapy program for the resident. - The facility staff were then expected to carry out the prescribed program. - The facility had staffing problems and do not currently have a Restorative Therapy program. - The therapy department educated the staff how to apply hand splints to Residents #2 and #7. During an interview on 4/7/23 at 2:59 P.M. the Director of Nursing said: - The facility did not have an active Restorative Therapy program. - The program dissolved in November of 2022 due to staffing. - The facility staff were not providing Restorative Therapy services to the residents. - The nurses and therapy were to educate the staff how to apply hand splints to Resident #2 and #7.

Based on observation, interview, and record review, the facility failed to provide supervision and protective over sight for one sampled resident (Resident #1), when he/she was found with an acute comminuted displaced fracture (a bone broken in 2 places, caused by severe trauma) of his/her left humerus (left upper arm bone). The facility census was 57. The facility did not provide a policy in regards to preventing accidents or providing supervision and protective over sight. Review of the facility's policy regarding Transfers with Mechanical Lift, dated 8/24/2018, showed: -Policy: To make sure that each resident receives adequate supervision and assistance devices to prevent accidents. Any resident unable to bear own weight will use the Mechanical Lift. -Procedures: Secure the assistance of another Aide. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/8/2022, showed: -Rarely understood, rarely understands others, and has unclear speech -Unable to complete a Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients, due to advanced dementia. -Total dependence on staff for all activities of daily living, including dressing, bathing, transfers, hygiene, and eating. -Always incontinent of bowel and bladder. -Diagnoses of Alzheimer's Disease, dementia without behaviors, anxiety Review of Resident #1's care plan, dated 6/15/2022, showed: -The resident requires the use of a mechanical lift for transfers, using two staff members. -Two staff members are required for all cares. The resident is dependent on staff for cares, including dressing, bathing, transferring, personal hygiene and feeding him/herself. Review of the medical records from a local hospital, dated 7/15/2022, showed: -The resident arrived at the emergency roiagnom on [DATE] at 3:41 P.M. -The emergency room assessment noted significant swelling with deformity over the left upper arm consistent with likely humerus fracture. There is a large area of ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) as well. Patient withdraws to painful stimuli (a thing or event that evokes a specific functional reaction in an organ or tissue) in that arm. -The emergency room physician's progress note said will likely need and open reduction and internal fixation (ORIF), a type of surgery used to stabilize and heal a broken bone. The trauma orthopedist (a doctor who specializes in the branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the skeleton) is being consulted. -The Diagnostic Radiology report, dated 6/30/2022 at 4:47 P.M., noted that there was an acute comminuted displaced fracture (a bone broken in two placed caused by severe trauma) involving the proximal(a part of the body that is closer to the center of the body than another part) diaphysis (the shaft of the bone) of the left humerus. -The resident was discharged back to the facility on [DATE]. Review of the resident's progress notes showed: -6/29/2022 at 9:03 P.M. Resident observed, no acute respiratory issues observed, no cough noted. -6/30/2022 at 2:44 A.M. No behaviors noted at this point in shift. -6/30/2022 at 6:20 A.M. Certified Nursing Assistant (CNA) called this writer to patient room. Patient's left shoulder/clavicle/humerus area appeared slightly swollen, no bruising to these areas at this time, (older blue/purple bruising noted to left forearm). Patient grimaces/moans out when range of motion (ROM) is attempted. Patient left in bed at this time. Called the on call physician twice, but was transferred to voice mail. Message left for on call to call back. 6/30/2022 at 12:32 P.M. Family Nurse Practitioner (FNP) was in the facility to see the resident. New order noted for left shoulder x-ray. Mobile x-ray provider called. 6/30/2022 at 14:30 P.M. Mobile x-ray provider here for x-ray at this time. Registered Nurse (RN)noted a visible fracture, spoke with R. [NAME] FNP and received order for humerus x-ray and to send the resident to hospital for evaluation and treatment. Left message for Durable Power of Attorney (DPOA) and Family Member A at this time. 6/30/2022 at 2:37 P.M. Family Member A notified and stated that he/she wants the resident to go to a local hospital. 6/30/2022 at 2:50 P.M. Emergency Medical Services (EMS) called to transport resident to the local hospital emergency room for evaluation and treatment. 6/30/2022 at 3:00 P.M. Resident left facility with EMS. Report called to the nurse in the emergency room . 6/30/2022 at 8:45 P.M. Nurse spoke with Registered Nurse (RN) with the local hospital emergency room , who stated the resident is being admitted for a urinary tract infection ([CONDITION(S)]) and a spiral fracture of the humerus. Resident will see the orthopedist tomorrow and they will decide whether the resident is a candidate for surgery. 72/2022 at 11:41 A.M. Received report from nurse with local hospital. The resident is on the way back via ambulance. The nurse thinks the family is still deciding about whether or not to have the surgery since the resident may not survive the surgery. The resident is coming back with an immobilizer and may take it off for showers. The resident hasn't appeared to be in much pain and have been giving him/her Tylenol since he/she has a [MEDICATION(S)] patch (a patch placed on the skin, providing medication for severe pain). 7/2/2022 at 12:20 P.M. The resident arrived by ambulance. Transferred to his/her bed. Calm until turned to put brief on. Staff will feed the resident in bed. Immobilizer in place on left upper arm. 7/2/2022 at 12:48 P.M. Physician gave order for [MEDICATION(S)] (medication used to treat pain) 100 mg/ml (20 mg/ml): 0.5 ml every 2-4 hours as need for cares. Family has requested hospice evaluation and possible admission. 7/5/2022 at 10:56 A.M. Resident's spouse stated the family has decided not to do surgery and would like a local hospice provider to evaluate the resident. 7/5/2022 at 6:30 P.M. Received order to admit the resident to a local hospice provider. During an interview on 7/5/2022 at 5:10 P.M., Family Member A said: -He/she accompanied the resident in the emergency roiagnom on [DATE]. -He/she met with the trauma surgeon while the resident was in the hospital and the trauma surgeon informed the resident's family that the resident would require surgery to repair the fracture of the left humerus and did not feel the resident would survive the surgery due to his/her current health. -The resident returned to the facility and is in the process of being admitted to hospice. -When the facility called Family Member A on 6/30/2022, he/she was informed the resident just had some swelling. -The resident also had bruising to his/her right arm and shoulder area. Observation of Resident #1 on 7/6/2022 at 11:30 A.M., showed: -The resident was laying in bed in his/her room, on his/her back, with the covers pulled up to mid-chest. -The resident was wearing an immobilizer on the upper left arm. -The resident was making incoherent sounds and his/her eyes were open. During an interview on 7/6/2022 at 11:44 A.M., Certified Nursing Assistant (CNA) A said: -He/she works the 2 P.M. to 10:00 P.M. shift, and overnight shifts. -He/she bounces around and has worked on all halls. -He/she has worked on the 100 hall and has worked with Resident #1 -He/she worked with the resident on the evening of 6/29/2022 -At approximately 5:30 P.M., he/she assisted the resident to bed using a mechanical lift (a lift typically utilizing hydraulic power, electric power or battery power, used for patients who require assistance to move one place to another). When in the bed, he/she rolled the resident from side to side to place a clean bed pad and to change the resident's brief. He/she then changed the resident into night close. This included lifting the residents arm to change the shirt. No bruising or swelling was noted at this time. - He/she then conducted a bed check at 9:00 P.M. This including checking the resident's brief. The resident did not need the brief changed at that time. No bruising or swelling was noted at this time. The resident displayed no signs of pain during cares, such as moaning or flinching. - He/she conducted the above cares alone. - He/she is aware there should be two staff members when using a mechanical lift with a resident. - He/she is also aware that the Resident requires two staff members for all cares. -The resident does not move on his/her own. -He/she denies anything out of the ordinary occurred during the transfer or during cares that may have caused injury to the resident. - He/she has received training and in-services regarding transferring and providing care to the resident when transferring, dressing, or changing the resident. During an interview on 7/6/2022 at 12:39 P.M., Licensed Practical Nurse (LPN) A, said: -He/she worked the night shift, 6/29/2022 into 6/30/2022, 6:00 P.M. to 6:00 A.M. -Between 3:30 A.M. and 4:00 A.M., CNA E asked him/her to come to the resident's room. -The resident's left upper arm/shoulder had some swelling. The resident did not want staff to touch his/her left arm, and would grimace and moan when range of motion was attempted. -He/she instructed CNA's to leave the resident in bed and he/she would call the physician. -He/she attempted two times to call the on-call physician, but the answering service sent him/her to voicemail each time. -He/she had to then pass medication and did not have time to attempt to call the on-call physician again when she left at 7:15 A.M. -He/she did inform the on-coming day shift charge nurse of the swelling to the resident's left arm/shoulder. -He/she knew the nurse practitioner was scheduled to do rounds sometime on 6/30/2022 and asked the day charge nurse to speak with the nurse practitioner regarding the swelling in the resident's left side. During an interview on 7/6/2022 at 12:48 P.M., CNA B said: -He/she works the day shift, 6:00 A.M. to 2:00 P.M., arriving to the facility about 5:30 A.M. to prepare for the shift. -On the morning of 6/30/2022, at the beginning of the shift, Resident #1 was still in bed, which was unusual. -He/she asked the charge nurse why the resident was still in bed, but the charge nurse did not give an answer, instructing him/her to continue getting other residents up for the day. -He/she and CNA C returned to the resident's room after getting the other resident's on the hall up. When he/she began removing the resident's night gown, he/she noticed the resident's left shoulder and upper chest were puffy but there was no bruising. -He/she took the resident's breakfast to the room and fed the resident while he/she was sitting up in bed. The resident did not display any signs of pain, such as grimacing, at this time. -He/she checked on the resident again after lunch. The left shoulder of the resident's shirt had slipped down, and he/she noticed discoloration/bruising to the resident's left shoulder. He/she notified the charge nurse and the Director of Nursing (DON). -The Nurse Practitioner was called to the room to assess the resident. -Two staff members should be used when transferring a resident with a mechanical lift. -Resident #1 requires assistance of two staff for all cares. -Staff should never attempt to transfer a resident with a mechanical lift alone, or provide cares alone to a person who requires the help of two staff. During an interview on 7/6/2022 at 1:20 P.M., CNA C said: -He/she worked the day shift, 6 A.M. to 2 P.M. on 6/30/2022. -Usually night shift has gotten Resident #1 up for the day before the day shift comes in. However, when he/she came on shift, the resident was still in bed. -The charge nurse didn't tell them why the resident was still in bed and told the staff to get the other residents on the hall up for the day. -When CNA B and CNA C returned to the resident's room to assist him/her up, the resident arm was not in her gown and the left shoulder was visible. CNA C observed some swelling to the left shoulder area. -When he/she went to assist the resident after lunch, bruising was observed to the resident's left shoulder. -The charge nurse, DON and nurse practitioner all assessed the resident. -The resident does not move on his/her own. -The resident requires the assistance of two staff members for all cares. There is a care card on the back of the resident' door which tells the staff how many staff are needed. -Two staff people should be used every time a mechanical lift is needed to transfer a resident. During an interview on 7/6/2022 at 1:43 P.M., the Nurse Practitioner said: -He/she was unaware of the swelling/discoloration to the resident's shoulder/upper arm prior to arriving at the facility. He/she was scheduled to conduct rounds at the facility on 6/30/2022. -He/she ordered an x-ray to the shoulder/upper arm. That x-ray showed a fracture to the left humerus. He/she then ordered for the resident to be send to the hospital for evaluation. During an interview on 7/6/2022 at 2:00 P.M., the DON said: -When using a mechanical lift to transfer a resident, two staff persons should be used each time. -Resident #1 requires the assistance from two staff members for all cares. The DON expects the required number of staff to be used each time. -There is a care card on the back of each resident's door that informs staff of the residents care needs, including how many staff are needed during cares. During an interview on 7/6/2022 at 2:51 P.M., the Physician said: -He/she does now know how the resident received this injury. -He/she expects to be notified when a resident has a suspected injury. During an interview on 7/6/2022 at 3:13 P.M., CNA E said: -He/she works the night shift, 10:00 P.M. to 6:00 A.M. -He/she worked the night of 6/29/2022 into 6/30/2022. -He/she conducted a bed check on Resident #1 at 3:00 A.M The resident needed to have his/her brief changed. -He/she rolled the resident from side to side to change the brief, put a clean bed pad down, and to change the resident into a clean gown. -When he/she was putting the clean gown on the resident, he/she noted swelling to the resident's left shoulder/upper chest area. He/she noted the resident's left arm was also limp. -He/she informed the charge nurse of the swelling to the resident's shoulder. -He/she conducted these cares alone. -He/she is aware that Resident #1 requires two staff members to provide care, but there are less staff on night shift. \ -He/she conducted these cares alone. -He/she is unaware of what the resident's care care or care plan says in regards to the resident's care needs. MO 3 MO 1 MO 9

Based on interviews and record review the facility failed to obtain pain medications in a timely manner to assure they were able to meet the resident's needs. Staff ran out of resident's scheduled pain medication and failed to notify the physician when the medication was not available, and staff failed to utilize the resident's PRN (as needed) pain medication to control pain for one of 13 sampled residents (Resident #7). The facility census was 52. Review of the facility's medication policy dated March 2012, showed medications are given to benefit a resident's health as ordered by the physician. 1. Review of the Resident # 7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/31/17, showed: -Moderate cognitive impairment; -Extensive assist of two staff for bed mobility, dressing, transfers, and personal hygiene; -Always incontinent of urine and frequently incontinent of bowel; -At risk of developing pressure ulcer (PU); -Five unstageable (Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough ( necrotic/avascular tissue) or escar (thick, leathery, frequently black or brown in color, dead tissue) PU's; -Pain frequency almost constantly; -[DIAGNOSES REDACTED]. Review of the resident's Physicians Orders Sheet (POS), dated 8/26/17 thru 9/26/17, showed: -[MEDICATION NAME] 10 milligrams (mg) orally twice daily; -[MEDICATION NAME] 5 mg 1-2 tabs orally every 6 hours as needed for pain; -[MEDICATION NAME] concentrate 100 mg 5 Milliliters (ml) give 0.25ml-1.0 ml every hour as needed for pain. Review of resident's care plan, with a start date 9/18/17, showed: -PU Deep Tissue Injury (DTI) left heel; -Arterial ulcer left medical foot; -PU DTI coccyx; -PU DTI right superior ankle; -Unstageable PU right lateral ankle; -PU DTI right heel. -Provide treatment for [REDACTED].>-No care plan and or interventions for chronic pain. Review of the Weekly Skin/ Wound report from WC, dated 9/19/17 showed: -Wound # 12 PU /Coccyx, Length (L) 5.00 centimeter (cm), x Width (W) 9.00 CM, Depth (D) 1.50 cm, Odor none, Wound Status improved; -Wound # 11 Arterial left foot medial L 2.70 cm W 1.50 cm x D 0.10 cm. -Wound #10 PU/ Suspected DTI left heel L 5.00 cm x W 5.00 cm x D 0.10 cm; -Wound #8 PU/ Suspected DTI right superior ankle, L 10.50 cm x W 6.50C x D 0.10 cm; -Wound # 9 PU/ Suspected DTI right heel, L 1.50 cm x W 2.50CM, D 0.10 cm; -Wound # 6 PU/Unstageable ankle right lateral, L 2.50 cm x W 2.50 cm, Depth (D) 0.10 cm; During an interview on 9/25/17, at 12:25P.M., the resident said: -He/she was in constant pain and was unable to get out of bed; -He/she had a sore on my bottom that hurts real bad. Review of the facility's 24 hour report sheet dated, 9/25/17 showed: -No [MEDICATION NAME]; -Faxed pharmacy used PRN [MEDICATION NAME]; Review of Electronic Medication Administration Record (EMAR) from 9/22 /17 thru 9/26/17 showed: -[MEDICATION NAME] 10 mg extended release every 12 hours Schedule II orally one tablet twice daily; -9/22/17 at 9:00 P.M., medication not administered item unavailable; -9/23/17 at 7:52 A.M., medication not administered item unavailable; -9/23/17 at 10:04 P.M., medication not administered item unavailable; -9/24/17 at 8:00 A.M., medication not administered item unavailable; -9/24/17 at 9:50 P.M., medication not administered item unavailable; -9/25/17 at 9:12 A.M., medication not administered item unavailable; -9/25/17 at 9:27 P.M., medication not administered item unavailable; -9/26/17 at 8:05 A.M., medication not administered item unavailable; Observation on 9/26/17, at 9:45 A.M., showed the resident laying in bed on his/her back. Certified Nurse Aide (CNA) B and Licensed Practical Nurse (LPN) A informed the resident that they plan to provide wound care for his/her PU's; -Prior to LPN A starting to provide wound care the resident verbalized to both staff that he/she was in pain; -This surveyor asked him/her to rate the pain on a numeric scale and the resident rated pain at 8; -CNA B removes the blankets from the resident's lower extremities only as the resident's reports being cold; -As CNA B lifted the resident's right leg upwards the resident said, ouch that hurts; -LPN A started to cleanse the unstageable PU to the resident's right leg with gauze and the resident loudly said, ouch and was frowning and was biting his/her lip; -CNA B asked the resident's if he/she was ok the resident said, it hurts; -The resident's had his her hands clenched as he/she held onto the blanket; -LPN A continued with cleansing the PU's to the resident's right ankle and heel; -The resident's repeatedly said, oh, oh, it hurts as CNA B is holding his/her leg and LPN A applies the dressings to the PU's; - At 10:03 A.M., CNA B was holding the resident's left leg about 30 degrees off the bed as LPN A cleansed and applied dressings to the resident's left heel as the resident said, oh,oh; - At 10:07 A.M., CNA B removed the blanket from the resident's upper body and the resident said, my bottom hurts; -CNA B rolled the resident's onto his/her right side as the resident's said oh, oh, oh and had facial grimacing; -LPN A provided incontinent care; -LPN A then removed the outer dressing from the resident's coccyx as the resident said, that hurts; -CNA B informs the resident that they are almost finished with the dressing changes; -LPN A used his/her thumb and index finger to remove a foreign object from the center of the PU, and the resident's said, ouch, oh, oh,oh; - At 10:20 A.M., showed the resident's laying on his/her right side as LPN A applied the dressing to the resident's coccyx the resident's breathing pattern changed and he/she gasps and loudly said, ouch, it hurts, oh, oh LPN A replied sorry I know it is not very comfortable; -CNA B again informs the resident's we are almost done; -At 10:22 A.M., LPN A applied moisture barrier to the resident's buttock, the resident said, oh, oh -At 10:25 A.M., both staff covered the resident's up with several blankets as he/she reports being cold; -At no time did LPN A ask the resident if he/she wanted to wait to continue with the dressing changes; -At no time did LPN A advise the resident's that he/she was going to administer additional pain medication. During an interview on 9/26/17, at 10:45 A.M., LPN A said: -He/she was informed earlier today prior to the dressing change that the resident's scheduled [MEDICATION NAME] 10 mg was not administered because the medication was not available; -It did not cross his/her mind to stop the dressing change and administer pain medication to the resident, he/she had PRN pain medication available; -Dressing changes are very painful for the resident and he/she should have medicated the resident before the dressing change. During an interview on 9/26/17, at 11:10 A.M., Certified Medication Technician (CMT) A said: -He/she did not administer the resident's [MEDICATION NAME] 10 mg this morning because the medication was not available; -The resident had been out of the medication for several days; -He/she informed LPN A that the medication was not available and had not been administered on 9/26/17. During an interview on 9/26/17, at 1:45 P.M., Registered Nurse (RN) A said: -He/she was the case manager for Hospice and the resident was receiving hospice services; -On 9/22/17 he/she was informed that the Oxtcontin 10 mg had been reordered; -On 9/23/17 he/she was in the building and staff did not inform him/her that Resident #7 did not have any [MEDICATION NAME] and/or had missed any scheduled doses; -The resident has PRN pain medication that staff can administer; -Facility staff should have informed hospice staff that the resident's did not have his/her scheduled pain medication. Review of the resident's nurses' notes dated, 9/26/17 at 3:10 P.M., showed: -Physician notified that the resident's had been without the scheduled [MEDICATION NAME] 10 mg pain medication since 9/22/17. -Pharmacy confirms the medication will be delivered tonight and the delay was due to needing a prescription for the medication; During an interview on 9/27/17, at 8:30 A.M., the resident's physician said: -It was unacceptable for the resident to have not had his/her scheduled pain mediation for the last 5 days; -He/she was aware that dressing changes were very painful for the resident; -The resident's would benefit from being medicated prior to the dressing changes due to increased pain; -He/she planned to contact the facility with a new order instructing staff to administer pain medication prior to dressing changes; -He/she was informed on 9/26/17 that the resident's had not received his/her scheduled [MEDICATION NAME] 10 mg since 9/22/17; -The facility, hospice, and the physician work together to provide care for the resident's and communication is essential to ensure the resident's needs are being met. Observation on 9/27/17, at 10:05 A.M., showed LPN A asking the resident to rate his/her pain and informing the resident that he/she planned to administer pain medication before he/she started wound care. Observation on 9/27/17, at 11:00 A.M., showed LPN A and the Director of Nurses (DON) providing wound care to the resident's coccyx: -LPN A asked the resident again to rate his/her pain and LPN A reported the resident appeared to be comfortable; - The resident did not display behaviors to indicate signs of pain such as facial grimacing, lip biting, and clenching of fists. During an interview on 9/27/17, at 11:30 A.M., LPN A said: -The resident had his/her scheduled [MEDICATION NAME] 10 mg at 8:00 A.M., -The resident now has an order to administer pain medication before dressing changes; -He/she administered [MEDICATION NAME] concentrate 100 mg /5 ML, 0.5 ml's at 10:15 A.M., Review of the resident's nurses' notes dated, 9/28/17 showed: -New orders received and noted to schedule [MEDICATION NAME] IR 10 mg before dressing changes; During interviews on 9/26/17, at 1:00 P.M., and on 9/28/17, at 11:45 P.M., the Director of Nursing (DON) said: -She was unaware that the resident had not had his/her scheduled pain medication for the last 5 days; -It is unacceptable for the resident to not have his/her scheduled pain medication for 5 days; -Nursing staff should of used a PRN pain medication on 9/26/17 before the dressing change and she would of expected nursing staff to stop and medicate the resident when the resident continued to have objective and subjective signs of pain, then wound care should of been completed after the pain medication had time to work; -The resident had PRN pain medication that can be administered and she reviewed the EMAR and the resident did receive some PRN doses of pain medication within the last 5 days; -The pharmacy did not refill the medication because they needed a prescription from the resident's physician; -Nursing staff should of notified the resident's physician, hospice, and her that the medication was not available; -The resident has chronic pain and would benefit from pain medication being administered before dressing changes and the resident now has an order to medicate before dressing changes. -The resident should have a care plan for pain.