Every finding on record at Orchard Grove Health Campus

Based on observation, interview, and record review, the facility failed to ensure proper food safety and equipment storage within the food service area, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include: On 07/07/2026 during an initial observation of the kitchen with Dietary Manager (DM) G between 9:00 AM-9:45 AM, the following items were observed: In the reach-in cooler, there were 2 opened gallons of whole milk, with a manufacturer's best-by date of 7/6, but with a handwritten sticker noting a use-by date of 7/12. In addition, there were 2 unopened gallons of whole milk with a manufacturer's use-by date of 7/6. When queried on 07/07/2026 at 9:15 AM, DM G confirmed the milk should have been discarded after the manufacturer's use-by date. The ice scoop holder mounted on the side of the ice machine was observed with standing water and black debris at the bottom of the container. The tip of the ice scooper was resting in the standing water. There were no drainage holes at the bottom of the ice scoop holder. When queried on 07/07/2026 at 9:20 AM, DM G confirmed the ice scoop holder was in need of cleaning. In the 2-compartment sink, there were 2 whole turkey breasts, still wrapped in the original packaging, and submerged in standing water. In the other compartment of the sink, there was a 12-quart container with cod filets submerged in water. The internal temperature of the cod was measured to be 60 degrees Fahrenheit. When queried on 07/07/2026 at 9:40 AM, Dietary Staff H stated that they had just pulled the cod (from the freezer) but was unable to explain why the internal temperature was at 60 degrees Fahrenheit. DM G confirmed the turkey, and cod were not thawed properly. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, .(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf According to the 2022 FDA Food Code section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food; According to the 2022 FDA Food Code section 3-501.13 Thawing, Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5 C (41 F) or less Pf; or (B) Completely submerged under running water: (1) At a water temperature of 21 C (70 F) or below Pf, (2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5 C (41 F) Pf, or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5 C (41 F), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking Pf, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5 C (41 F) Pf;

Based on observation, interview, and record review, the facility failed to revise the care plan for three residents (R4, R62, R63) of three reviewed for timeliness of person-centered care plans. Findings include:R4 A review of the medical record revealed that R4 admitted into the facility on 5/14/2026 with the following medical diagnoses, Spinal Stenosis and Osteomyelitis of vertebra, lumbar region. Further review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment of 13/15, indicating an intact cognition. R4 also required staff assistance with bed mobility and transfers. A review of a progress note dated 7/6/2026 documented the following, Residents rash on [their] back has improved since removing (name of medical device used to promote healing in complex wounds by applying controlled suction to the wound area). Further review of the current care plan noted the following, Problem: Resident has a surgical incision to lumbar with (name of medical device). Start Date: 5/15/2026. On 7/7/2026 at 10:00 AM, an interview was conducted with R4. R4 reported they were allergic to the material used to apply the (name of medical device) and it caused a bad rash on their back reporting the (name of medical device) had been off for about a month. On 7/09/2026 at 12:29 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who reported the (name of medical device) care plan should have been revised since it no longer applies. On 7/09/2026 at 1:53 PM an interview was conducted with MDS nurse F who confirmed creating a wound care plan has been recently reassigned to them saying, they have not gone through all the wound care plans yet, but the care plan should have been revised once the (name of medical device) was removed (on 7/6/26). R62 A review of the Electronic Medical Record (EMR) revealed R62 was originally admitted on [DATE] with diagnosis of Dementia, Cerebrovascular disease, and Dysphagia. Review of the most recent Minimum Data Assessment (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 06/15 which indicated impaired cognition and required supervision with activities of daily living. A care plan was initiated on 10/3/25 and revised on 5/22/26 documented, Resident is at risk for adverse consequences related to adverse consequences receiving antianxiety medication: anxiety.' Review of R62's EMR revealed there was no physician's order for any antianxiety medication. An interview with the Director of Social Work (DSW) on 7/9/26 at 1:30 PM, they confirmed the resident is not on any antianxiety medications. The DSW revealed care plans should be updated and/or revised due to specific changes and as needed per care plan policy. R63 On 7/07/2026 at 10:00 AM, R63's room was observed to have a sign on the door which indicated R63 was on contact isolation precautions (isolation requiring protective equipment) but was not observed in the room at that time. The resident was later observed that day in the dining room sitting at a table. R63 was continued to be observed outside of their room throughout the day on 7/7, 7/8, and 7/9/26. Further review of R63's medical record revealed, R63 was admitted to the facility on [DATE] with diagnosis of Bacteremia (bacteria in the blood stream). A review of R63's physician's history note revealed, 07/03/2026 12:21 PM. Comprehensive History and Physical Chief complaint: Debility. Bacteremia . with past medical history of diabetes and CAD (coronary artery disease) was hospitalized times weakness and fall. Patient was diagnosed with ESBL (Extended-Spectrum Beta-Lactamase), E. coli -UTI (Urinary Tract Infection) and bacteremia . An isolation care plan had an intervention for R63 to stay in their room for meals due to being on contact isolation precautions for an infection. On 7/8/26 at 1:04 PM, the Infection Control Nurse and Assistant Director of Nursing (ADON) were interviewed about R63's infection and care planned interventions. The two nurses confirmed R63's infection did not require them to remain in their room for meals and said the care plan was the standard care plan with interventions for residents on isolation. On 7/09/2026 at 1:53 PM, Minimum Data Set Assessment (MDS) Nurse F was asked about revisions of care plans. MDS nurse F explained they are in charge of completing and resolving care plans and R63's updated would have occurred when they complete the next comprehensive MDS assessment. A review of the policy titled, Comprehensive Care Plan Guideline noted that the facility's care plan purpose was to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. The comprehensive care plan should be reviewed no less than quarterly and revised to reflect changes in the resident's condition as they occur.

This citation pertains to Complaint #2587468Based on interview and record review the facility failed to ensure a resident with a known fall risk received necessary interventions to prevent falls, ensure the resident was properly lifted off the ground following the fall and transferred timely to the hospital following the fall for one (R701) of two residents reviewed for falls, resulting in R701 being transferred to the hospital and treated for a nondisplaced oblique fracture, pain and dehydration.Findings include:A complaint was filed with the State Agency (SA) that alleged on or about 7/23/25, R701 who was admitted to the facility following a fall at home that resulted in a fracture to the right hip leading to hip replacement, fell again at the facility and sustained a fracture to the right hip. The Complainant noted R701 suffered from dementia and never should have been left unattended and needed to be transferred immediately to the hospital.An EMS (emergency medical services) run sheet was reviewed and documented the following: R701.Date: 7/24/25.time: 10:58 AM.Chief Complaint: Injury to hip.Mechanism of injury: Blunt.Trauma.History: Dementia.Pelvis: Pain.Hip: Pain.Narrative: Arrived to find patient lying in bed.Patient has a history of dementia.Nursing home staff said that patient had a fall at 10 PM last night. Nursing home staff said the patient fell onto their right hip and then back onto their head on the right side of their head.Nursing home staff said the patient is in the facility for rehab due to right hip surgery.Patient was 10 out of 10 . moved to hospital without incident.Hospital Records: 7/24/25. (R701) experienced a fall at the rehabilitation facility with conflicting reports about the circumstances.(R701) is in significant pain with concern for potential injury to their right hip, which had previously undergone a full replacement.Dehydration: they appeared dehydrated. (R701) is experiencing nausea, which is atypical for them.X-ray.nondisplaced oblique fracture at proximal femoral shaft adjacent to distal end of femoral hardware stem.Orthopedics Consult Note (7/24/25) .R701 admitted after a ground level fall. (R701) broke their hip last week and was treated with a THA (Total Hip Arthroplasty- a surgical procedure to replace a damaged hip joint with an artificial implant) and overall was doing very well until fall.They state they fell and landed directly onto their hip.they were found to have a right periprosthetic (break in the bone near a total hip replacement, often caused by trauma and a common reason for reoperation after hip replacement therapy).A review of R701's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: fracture of unspecified part of neck of right femur, presence of artificial hip joint, unspecified fall, Alzheimer's disease, Dementia and pain in right hip.Continued review of R701's clinical record revealed, in part, the following:7/21/25: Wound Care Note: R701 admitted on [DATE] with RIGHT ANTERIOR TOTAL HIP ARTHOPLASTY.Surgical date 7/17/25. Surgical site has 22 staples.7/21/25 (2:56 PM): Physician Progress Note: R701 with.dementia was hospitalized with fall, right hip fracture requiring right hip total arthroplasty.patient is confused, unable to provide me any history.Psychiatric: Not agitate.Care Plan: Problem (7/21/25) Resident demonstrates significant cognitive deficits.BIMS(brief interview for mental status) score of 1 (significantly impaired cognition).Problem (7/21/25).Falls: resident is at risk for falling r/t (due to) impaired mobility.Dx (diagnosis): fall w/right femoral neck fracture (hip) s/p (status post) THA (Total Hip Arthroplasty) 7/17/25.Dementia. 7/23/25 (10:49 AM): Resident First Meeting Minutes:.Conference Type: Admission.Resident attended meeting.Resident Representative attended meeting.Resident has.surgical wounds.Safety:.Current interventions effective to mitigate continued risk of falling or injury prevention.Mood behavior: No altered moods are present.No behaviors are present.Does the resident receive a psychotropic medication? No.Resident is anticipated to be discharged to another facility, to the community.7/23/25 (2:51 PM): Verbal order to give Alprazolam (Xanax).25 mg (milligram) one time now for anxiety. Resident having outbursts throughout shift, periods of refusing care, self-transferring out of wheelchair multiple times.Behavior Analysis Report: No Behaviors Occurred.7/20/25 (10:41 PM), 7/21/25 (6:39AM, 10:44 AM, 6:30 PM), 7/22/25 (1 AM, 10:28 AM), 7/23/25 (3:37 AM, 3:43 AM, 10:32 AM, 9:45 PM), 7/24/25 (3:41 AM, 11:02 AM). *It should be noted that anything marked Interventions/Intervention Effective was marked NA (not applicable).7/23/25 (9:28 PM) Medication Administration History: .Alprazolam (Xanax).Time 9:38 PM.PRN (as needed) reason: Behavior Issue.PRN Follow up (blank). Medication administered by Nurse A.7/23/25 (9:38 PM) Medication Administration History: .Oxycodone 5 mg.Time 9:38 PM.PRN reason: Pain.PRN Follow up (blank). Medication administered by Nurse A. *It should be noted that the last PRN pain (Oxycodone 5 mg) was given to R701 on 7/21/25.7/23/25 (10:30 PM): Resident observed on floor lying on their back in 100 hall near nurse's station. Resident is confused and unable to recall event leading to the incident.Vital signs assessed.noted skin tear to right elbow. Resident transferred to wheelchair with assistance of writer plus three CRCA's (certified nursing assistants) via (name of mechanical) lift. Resident was grimacing and guarding the right lower extremity per staff resident has resisted care and has been anxious during dayshift. Resident then transferred to their bed and given.meds and PRN (as needed) oxycodone. *It should be noted that this note was written by Licensed Practical Nurse (LPN) A and noted as recorded as a late entry on 7/24/25 at 6:36 AM.7/23/25 (11:24AM) Physician Progress Note: .Pt (R701) is at Facility. Patient had a fall yesterday and was found on the floor.7/24/25 (11:55 AM) Progress Note: Patient was observed being in a lot of pain grimacing, crying and guarding right hip side.unable to accomplish the morning care or reposition the resident.pt (patient) c/o nausea and refused breakfast. transferred to hospital.Event Report: Creator: Nurse A: Event date: 7/23/25.Date recorded: 7/23/25 11:20 PM.Event Details: Date/Time of incident: 7/23/25: 9:20 PM.Type of Incident: Fall.Location: Hallway.Was incident witnessed: No.Did the resident require an ER evaluation (left blank).What was resident doing prior to fall: .Ambulating without assistance.Does resident exhibit any of the following as a change in mental status or new onset: Anxiety.Confusion.What was adaptive equipment used at the time of fall.Wheelchair.Physical status at time of fall (left blank).Was safety equipment in place and functioning at time of fall? None ordered.Indicate if any of the following factors are present: Cognitive or memory impairment.Difficulty understanding and following directions.Requires assistance to transfer.What time was the resident last seen (left blank).Who last saw the resident (left blank).Name of person who found resident (left blank).Was a head to toe assessment completed (left blank).Problem Category (7/21/25): Transfer 2 PA toilet transfers.1 PA all other transfers.Statement of Witness Form: Name of Interviewee: Nurse A.Date of Interview: 7/24/25.Date of incident /situation: Upon coming in for my shift at 7 pm the resident.was in the dining room.at about 7:45/8 PM.brought them to tables by 200 hall (*resident resided on the 200 hall unit).At about 9:15 PM, Nurse B came to the 200 hall to let me know that R701.had fallen near 100 hall.they were laying on the floor with no s/s (signs) verbal or nonverbal in regard to pain.we let the resident we were going to assist them back to their chair they started yelling we tried to describe how and they continued to yell. Upon asking about their yelling the staff (*no staff members named) stated this is something that they often do, since admission.Resident was (mechanically lifted) to their chair and then to the bed, the yelling did not stop until they were in bed. *The form was typed and not signed or dated by Nurse A.An attempt to contact Nurse A was made on 8/20/25 at approximately 12:39 PM and a voice message was left. No return call was made prior to the end of the survey. Statement of Witness Form: Name of Interviewee: Nurse B.Date of Interview: 7/24/25.At about 9/10 PM was the first time I saw R701 and they were sitting near the 100 hall desk in their chair.I saw them moving around in the wheelchair in the 100 hall common area and I took a second to reposition her to be more comfortable.I then assisted her in her chair to a more visible spot in the common area and to be seen from the med cart.As I started walking back to the med cart to pass meds I heard a noise behind me and turned to see R701 laying on the floor on her right side.went and got Nurse A and tell her what happened.obtained vitals and prepared to get them in the mechanical lift to transfer the resident to the chair.Once the resident heard about the mechanical lift they started yelling and continued to yell until in bed. The same yelling is something that the resident does with care and did not sound worse.When I got report the next morning and assessed resident at about 7:45 AM R701 was resting in bed on their back, no s/s (signs/symptoms) of pain. I was asked to go back to room once they were sitting up eating breakfast because they started to moan, rub the right hip and wouldn't let me touch it. I immediately let Physician C know and he came and assessed them. *The form was typed and not signed or dated by Nurse B.On 8/20/25 at approximately 12:43 PM, a phone interview was conducted with Nurse B. Nurse B reported being employed by the facility for about one year and generally works 12-hour shifts (both day/night). Nurse B was asked about R701's fall that occurred on 7/23/25. Nurse B noted that in the evening between 9/10 PM they noticed R701 sitting alone near the 100-hall trying to lift themself out of their chair. They made attempts to have them sit more comfortably and moved them closer to the TV area so that they could attempt to keep on eye on them. As they started walking to their med cart they heard a loud noise. They then went back to see R701 on the floor. Nurse B stated they went to find other staff and decided the only way to get the resident off the floor was to use a mechanical lift. Nurse B further noted that as they were lifting the resident with the mechanical lift they were crying in pain. Nurse B noted that they did not call either the physician or the resident's family. Nurse B stated they left the facility around 11 PM and came back to the facility the next day (7/24/25) at approximately 7 AM. Later in the morning R701 was in a lot of pain and was sent out to the hospital. On 8/20/25 at approximately 2:15 PM, an interview was conducted with Physical Therapy Director (PTD) D. PTD D was asked if they were familiar with R701 and subsequent fall at the facility. PTD D noted that they recalled R701 was admitted to the facility for rehabilitation following a fall with a fracture requiring surgery. PTD D was then asked as to their opinion on transferring a resident like R701 with a know history of falls resulting in a fracture and THA implant, should have been transferred via a mechanical lift into a wheelchair and then to their bed. PTD D reported that the mechanical lift transfer would not be the preferable way to transfer a resident like R701 and noted a flat lift (generally used by EMS) might have been more appropriate.On 8/20/25 at approximately 2:40 PM an interview was conducted with the Director of Nursing (DON). The DON was asked about the fall/incident that occurred on 7/23/25 involving R701. The DON reported they were not at the facility the night the incident occurred but started an investigation on 7/24/25. The DON was queried as to R701's fall interventions as they were admitted to the facility following a fall with injury. The DON reported the resident was a fairly new admit to the facility and had minimum interventions in the care plan. The DON stated that it was their understanding that following dinner R701 was placed at a table near the nurse's station on the 200 hall. They did not have an exact time of when the resident was placed there and noted there were no cameras on the floor that would confirm timing. The DON then noted at some point in the evening R701 moved themselves from the table to the 100 hall and was found by Nurse B trying to get out of their chair and moved to a different area by the TV. Following the move by Nurse B, the resident had an unobserved fall. The DON was asked about the transfer of R701 following the fall as notes by Nurse A describe the resident as grimacing and grabbing their right lower extremity. The DON stated that staff believed yelling was their baseline did not believe resident was in pain. As such, staff took vitals and utilized a mechanical lift to get them up in their wheelchair and then into bed. The DON was asked was asked why at 9:38 PM it was noted R701 was given both Xanax and Oxycodone . The DON was not able to provide an answer as to whether the PRN medications were given prior to or after the fall and the reason for administering the medication. Subsequent information provided by the Administrator noted the medication was given following the fall indicating PRN Xanax is used for sundowning symptoms and yelling after the resident was laid in their bed. As for the PRN Oxycodone, no specific details as to why pain medication was given were noted.

This citation pertains to Intake number MI00152757. Based on observation, interview, and record review, the facility failed to ensure residents were treated in a dignified manner for two (R293 and R143) out of two residents reviewed for dignity/respect. Findings include: A Facility Reported Incident (FRI) was submitted to the State Agency (SA) that alleged that a CNA (certified nursing assistant) would not listen to the resident's (R293) request to wear certain clothing and then started yelling loudly at the resident. A review of R293 clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: syncope and collapse (temporary loss of consciousness), epilepsy and history of pulmonary embolism. A BIMS (Brief Interview for Mental Status) evaluation noted the resident had a BIMS score of 13/15 (cognitively intact). On 5/5/25 at approximately 9:39 AM, R293 was observed sitting in a wheelchair in their room. The resident was alert and able to answer questions asked about the care provided in the facility. R293 reported that everything was going well, however, noted that an incident occurred a few weeks ago with a staff member. R293 suggested reading through their paperwork as they did not want to talk about it again. R293's roommate (R3) reported they heard the CNA yelling very loudly at the resident. A request was made for any Investigation/Accident (IA) reports pertaining to R293. A review of an IA documents with a start date of 4/26/25 revealed, in part, the following: .Conclusion: .from the interviews we have learned that the resident has some individual preferences that have since been updated .The resident did not like the approach from the aide. The resident did not like the fact that she (hereinafter CNA 'F) was communicating very loudly to her in a way that made her feel uncomfortable. We have substantiated that customer service should have been better .Statement of Witness Form: Name of Interviewee (R293) .Date of Interview: 4/26/25: I asked to get dressed last night. The aide (CNA F) came in .I told her that I wanted my [NAME] (camisole) on before my shirt. The aide kept trying to put on the shirt before the [NAME]. I told her to stop .The aide was yelling loudly and said, :don't you want to go to bed? She was very loud. It scared me. We were both standing up at the time, the aide pushed away the clothes towards me and left the room Statement of Witness Form: Name of Interviewee (R3) .Date of interview: 4/26/25 .Incident/Situation: Last night the aide that came into our room to help my roommate (R293) was yelling at her. I've never heard someone yell like that in all the times I've been here . *It should be noted that R3 had a BIMS score of 15/15 (cognitively intact cognition). CNA F's personnel file was reviewed and documented, in part: Personnel Action Form .Name: CNA F .termination date: 4/30/25 .Termination Action Reason: Unsatisfactory Performance .staff member was suspended pending an investigation, after investigation findings staff members employment was terminated . On 5/6/25 at approximately 10:18 AM, an interview was conducted with the Administrator/Abuse Coordinator regarding the incident involving R293. The Administrator reported that CNA F was terminated following the incident involving R293. They noted that CNA F had received sensitivity training in the past following other concerns and based on what occurred between CNA F and R293 on 4/25/25 the facility decided to terminate them. 34851 R143 On 5/05/25 at 11:51 AM, R143 was asked about the care at the facility. R143 explained at times the staff, Forget we are human. R143 explained this morning the staff came into their room and started pulling clothes out of the closet, throwing them on the bed, and didn't asked what I wanted to wear. On 5/06/25 at 9:53 AM, R143 was observed in their room and did not report any other incidents. A review of R143's medical record revealed, R143 was admitted to the facility on [DATE] with diagnosis of infection. R143's assessment noted, R143 with an intact cognition. The above concern was mentioned to the Nursing Home Administrator (NHA), the NHA reported she would look into the incident. A request was made for the facility's policy pertaining to dignity/respect. No policy was provided before the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure oxygen (02) was administered per the physician's order for one (R294) of one resident reviewed for respiratory/oxygen care. Findings include: On 5/5/25 at approximately 10:50 AM, R294 was observed lying in bed. The resident was alert but unable to answer any questions asked. An oxygen concentrator was observed approximately three feet from the resident's bed. The concentrator was running at 2L (liter), however, the oxygen nasal canula tubing was wrapped around the concentrator and not inserted in the resident's nose. At approximately 11:00 AM and 11:10 AM, the resident was again observed without any 02 inserted in their nose. The DON was approached and asked if the resident received continuous oxygen. The DON was not certain as to their order and noted would review the residents record. A review of R294's clinical record revealed the resident was initially admitted to the facility with diagnoses that included: malignant cancer of the prostate, metabolic encephalopathy and stroke. The resident's Minimum Data Set (MDS) noted the resident was severely cognitively impaired and required oxygen therapy. Continued review of R294's clinical record noted the following: General Order (4/17/25): .Start Date: 4/17/25 .End Date: Open Ended .Order Description: Order Set 02 @ 2L per nasal canula continuous . Medication Administration Order (MAR) : Order .Order set 02-Assess/Observe for s/s (signs/symptoms) of SOB (shortness of breath) while lying flat .Order Set 02 @ 2 L per nasal canula continuous . *It should be noted that by 11:36 AM on 5/5/25 there was no indication that the above orders were noted as completed for 5/5/25. On 5/6/25 at 10:21 AM, an interview was conducted with the DON and the Administrator. The DON was queried as to the facility policy/protocol regarding physician orders for the use of oxygen. The DON reported that all orders should be followed, including those regarding oxygen. With respect to R294, the DON noted there was an order for the resident to remain on 2L of oxygen continuously ( 24 hours per day) and nursing staff should have ensured it was in place. The DON noted that the resident was a Hospice resident and was scheduled for discharge with the continuous O2 order. The facility was asked to provide a copy of their policy pertaining to oxygen treatment. The facility reported that they did not have a policy.

Based on observation, interview, and record review, the facility failed to maintain infection control practices of multi-use equipment between resident use for two residents (R14, and R16) of two reviewed for infection control practices. Findings include: On 3/26/2024 at 9:30 AM, Nurse C was observed to take R14's blood pressure. When the task was completed the device was not cleaned. When queried whether the device should be cleaned, Nurse D replied after each use. Nurse C did not then clean the device before moving on to the next resident. On 3/27/2024 at 11:30 AM, Nurse B took R16's blood pressure. Upon leaving the room, Nurse E did not clean the blood pressure device. When queried about when the blood pressure device should be cleaned and with what, Nurse E stated after each resident with germicidal wipes. On 3/27/2024 at 1:30 PM, an interview with the Infection Preventionist, Nurse D revealed that the expectation for cleaning multi-resident use equipment is that it is cleaned after each use, between residents. On 3/28/2024 at 11:30 AM, an interview with the Director of Nursing (DON) revealed that their expectation for cleaning multi-resident use equipment is that it is cleaned after each use, between residents. On 3/28/2024, a review of the policy Standard Precautions stated, properly clean and disinfect or sterilize reusable equipment before use on another resident.

Based on interview and record review, the facility failed to monitor and justify the administration of an antibiotic for one resident (R6) of three residents reviewed for unnecessary medications. Findings include: A review of R6's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Unspecified open wound, right lower leg, subsequent encounter, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes Mellitus. Further review revealed that the resident was cognitively intact and require supervision to limited assistance with Activities of Daily Living. Further review of the medical record revealed that the resident had been prescribed the following on 12/28/23, Vancomycin (antibiotic) 50 mg/mL (milligrams/milliliters); Amount to Administer: 2.5 ml/ 125mg; Oral twice a day for recurrent C-Diff (Clostridium difficile, a bacterium that causes infection in the colon-large intestine which can lead to symptoms ranging from diarrhea to severe damage to the colon). Further review of R6's medical record revealed Medication Administration Records for December 2023, January 2024, February 2024, March 2024, and April 2024 indicating that the resident had received the antibiotic as ordered. Further review of the medical record revealed the following progress notes: 12/15/2023 5:33PM Per resident he has had chronic CDIFF since 2019 and has been on vancomycin oral antibiotic throughout that time period, with small periodic breaks of treatment. Upon admission to the hospital for his surgery, they reviewed his conditions and medications and vancomycin was discontinued. Upon admission to the facility the vancomycin had been ordered to be discontinued in the hospital paperwork. informed resident of this information, he stated that he understood and would follow up with [facility physician] on his recommendations. 12/18/2023 12:52PM Encounter Date: December 18, 2023 Complaints history and physical Chief complaint: Right leg pain, recurrent C. difficile colitis Enterocolitis due to C. difficile, recurrent . Patient with recurrent C. difficile colitis, according to patient has been on vancomycin 125 mg twice daily at home and wants to restart it Patient had 3 loose stools last night, denies any nausea/vomiting or abdominal Pain . Further review of the medical record did not reveal any coordination of care of communication with the resident's primary care physician regarding recurrent C-Diff. A review of the facility's Infection Tracking-ATB (antibiotic) Surveillance Log for December 2023 revealed the following: R6's admitted followed by the type of infection which was Chronic C-Diff prior to hospitalization . Symptom present: Diarrhea. Antibiotic: Vanco (Vancomycin). Start date: 12/19/23. End date 12/28/23. Diagnostic test: N/A (not applicable). Transmission Based Precaution (TBP): N (no). Further review of the Infection Tracking-ATB Surveillance Logs for January 2024, February 2024, and March 2024 revealed that R6 was not listed on the log as being prescribed an antibiotic, or being monitored for an infection. Further review of the medical record revealed no documentation of the antibiotic being reviewed for appropriateness following the physician order on 12/28/23. In addition, there was no reassessment of the antibiotic or labs completed to assess the antibiotic as appropriate. On 4/3/24 at 1:45pm, the Infection Control Preventionist (ICP) D was asked about R6's Vancomycin order, specifically the duration and monitoring of the antibiotic. ICP D explained that the resident reported using it prior to admission for recurrent C-Diff, and Physician E reordered it for the resident. Regarding the monitoring of the medication for adverse consequences, ICP D explained that they monitor for loose stools, and the physician orders what to look for regarding signs and symptoms. In addition, the pharmacist completes reviews and provides recommendations. On 4/4/24 at 10:17 AM, the Director of Nursing (DON) was asked about R6's Vancomycin order, specifically the duration and monitoring of the antibiotic. The DON explained that she would want to inquire as to why the resident was still on the medication due to adverse effects, and that there should always be monitoring of signs and symptoms of the medication. On 4/4/24 at 11:33 AM, an interview was completed with Physician E in which he explained that the medication was prescribed for recurrent C-Diff. Regarding coordination of care with the resident's primary care physician, he explained that this usually occurs during discharge and if there are concerns. No other information was provided regarding the duration/monitoring of the antibiotic specific to R6. A review of the facility's Antibiotic Stewardship Guideline revealed the following, .1. Review infections and monitor antibiotic usage pattern. New orders for antibiotics usage will be reviewed during the campus Clinical Care Meeting on regular business days .3. Monitor antibiotic resistance patters (MRSA, VRE, EXBL. CRE, etc.) and Clostridium difficile infections. 4. Report on number of antibiotics prescribed (e.g., days of therapy), per prescribed, and the number of residents treated each month . A review of the Center for Disease Control and Prevention (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes dated 2015, documented in part . Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use . CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Antibiotics are among the most frequently prescribed medication in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics . studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic -resistant organisms . Infection prevention coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria . during the evaluation and management of treated infections and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms. When infection prevention coordinators have training, dedicated time, and resources to collect and analyze infection surveillance data, this information can be used to monitor and support antibiotic stewardship .

Based on observation, interview, and record review, the facility failed to ensure food items dated and discarded when expired, failed to store raw potentially hazardous food items appropriately, and failed to maintain a ceiling vent cover in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On [DATE] between 7:20 AM-7:50 AM, the following items were observed: In the walk-in cooler, there was a container of mousse with a use-by date of ,d+[DATE]. In addition, there was raw ground beef stored on an open shelving unit directly above a pan of raw fish. In the True reach-in cooler, there was an opened half gallon of lemonade with a hand written use by date of ,d+[DATE] and a manufacturer's use by date of ,d+[DATE], an opened undated gallon container of golden Italian salad dressing, and an opened gallon container of thousand island salad dressing with a use by date of ,d+[DATE]. According to the 2017 FDA Food Code section ,d+[DATE].17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. The ceiling vent covers located above the ice machine were observed to be coated with dust. According to the 2017 FDA Food Code section ,d+[DATE].14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. In the Bulldog Cafe refrigerator, there was an opened bottle of raspberry vinaigrette dressing dated [DATE], and a tray of peanut butter and jelly sandwiches with a use by date of ,d+[DATE]. On [DATE] at approximately 1:30 pm, Director of Food Services D was queried about the undated and expired food items, but provided no explanation.

Based on observation, interview, and record review, the facility failed to assess for self-medication administration prior to leaving medications in room, for one sampled resident (R27) reviewed for self-medication administration, resulting in medications left in the resident's room. Findings Include: On 03/20/23 at 9:12 AM, two inhalers were observed on R27's over bed table. R27 was asked if they kept these inhalers in their room and R27 stated, No. The Nurse will come back and get them. On 3/20/23 at 10:27 AM, the two inhalers remained at R27's bedside on the table. R27 stated, I am done with them. The Nurse or staff was not observed on the unit. The inhalers labels revealed, Albuterol sulfate and Fluticasone propionate aerosol. A review of R27's orders noted, Albuterol sulfate aerosol inhaler; 90 mcg (Microgram)/actuation; amt (amount): 2 puffs; inhalation. Frequency: Once A Day. 7:00 - 11:00 AM. Fluticasone propionate aerosol inhaler; 44 mcg actuation; amt: 2 puffs; inhalation. Twice A Day 7:00 AM - 11:00 AM. On 3/20/23 at 2:37 PM, the two inhalers were no longer on the over bed table. On 3/20/23 at 2:48 PM, Registered Nurse (RN A) was asked about the medications that were observed at R27's bedside, and if R27 was able to self-administer. RN A stated, Yes. [R27] is able. RN A, was asked if R27 had an assessment completed for self-administration and stated, I am not sure, I would have to look for that. During this interview a request was made for R27's assessment for self-administration of medication. On 3/21/23 at 12:21 PM, the facility provided a document titled, Self-Administration Of Medication for R27 with a date and time stamp of 3/20/23 at 2:55 PM. On 3/21/23 at 1:19 PM, the Director of Nursing (DON) was asked about the process for medications and determination of self-administration. The DON explained that she did the assessment with [RN A] as an education. The DON was asked if it's ok for R27's medication to be left in the room before assessment. The DON explained that the medication should have been taken out of the room when the Nurse left. A review of the facility's titled Guidelines for Self-Administration of Medications dated 12/31/22, noted, Policy Guidelines for Self-Administration of Medications. Purpose: To ensure the safe administration of medication for residents who request to self-medicate or when self-medication is a part of their plan of care. Procedures: 1. Resident requesting to self-medicate or has self-medication as a part of their plan of care shall be assessed using the observation Trilogy-Self Administration of Medication within the electronic health record . 3. The medication will be kept in a locked drawer in the residents' room. The resident will maintain the key, as well as a key will be maintained by the licensed nurse .

Based on interview and record review the facility failed to provide adequate supervision for two sampled resident (R33 and R143) of eight residents reviewed for accidents, resulting in the resident sustaining a fall. Findings include: On 3/20/23 at 9:18 AM, R33 was observed asleep with a low bed and with fall mats on the floor. A review of R33's medical record revealed a nurses note, 3/09/2023 12:32 PM, Writer called to salon . whom had been notified by [Salon Staff C], the beautician. [Salon Staff C] reported that she had been assisting resident into salon chair and resident started to fall. [Salon Staff C] assisted resident to the floor and called for help. [Salon Staff C] reported that resident did not hit [R33] head. ROM (range of motion) completed and WNL (within normal limits), no c/o (complaints of) pain, VSS (vital signs stable), no injury noted at this time. Resident assisted up into w/c (wheelchair) . Writer spoke with . and notified of fall and plan to only have clinical staff complete transfers. A review of R33 incident and accident report noted, Event date 3/9/23 10:49 AM. Description: Fall event. Event details: Location of fall Other describe - Salon staff transferring resident . Safety equipment in place and function at time of incident? None ordered . Fall Risk Re-Assessment: (checked) Resident has cognitive or memory impairment that effects safety and judgement? (checked) Resident requires use of an assistive device and /or often forgets to use device? . New Interventions-Immediate measures taken (checked) Other, describe- Salon staff instructed to get clinical staff for transfers. Additional Information: Witnessed fall, no trauma to head. Neurochecks not warranted. Fall Prevention intervention: Salon lady (Staff C) instructed to ask nursing staff to assist with transfer from wheelchair to salon chair . On 3/21/23 at 1:36 PM, Salon Staff C was asked about the incident and stated, [R33] normally transfers [themselves] and that day when [R33] got up [R33] wanted to sit back down. So I had to hold [R33] when [R33] went to sit down to the floor. I saw a staff person walk by and I flagged them down and they helped [R33] get up. That was the first time that happened. On 3/21/23 at 1:42 PM, during an observation of the facility's salon noted, dryers with and without seats attached and two salon chairs for styling. A review of R33's medical record revealed, R33 was admitted to the facility on [DATE] with diagnosis of Acute Respiratory disease. A review of R33's Minimum Data Set (MDS) assessment dated [DATE] revealed, Transfer/Self-Performance 3 (extensive assistance) and Transfer/Support 3 (two+) staff. On 3/21/23 at 1:40 PM, Licensed Practical Nurse (LPN B), was asked about the incident report and stated, I'm not sure how that happened. Maybe they thought [R33] was with it or something. LPN B was asked how the salon staff knows who needs assistance with a transfer. LPN B stated, It's on the back of the wheelchair, but I am not sure if they (salon staff) know it's there or if they use it. LPN B was asked if a resident needed to transfer to a salon chair, how does that happen. LPN B stated, The floor staff would help. On 3/21/23 at 1:50 PM, a Salon Staff C was asked how they know if a resident is able to transfer alone or if they need assistance. Salon Staff C stated, I am new, and I just ask the residents. I am getting to know them. Resident #143 (R143) On 3/21/23 at 1:52 PM, Salon Staff C was observed to wheel R143 down the hall into the salon. Once in the salon, Salon Staff C was observed to push R143 to the salon chair. R143 attempted to get out of the wheelchair, Salon Staff C was observed to adjust the wheelchair closer to the salon chair. After the final adjustment with the wheelchair R143 was observed to stand and move into the salon chair. The chair appeared to be unlocked and moved during the transfer. During the observation there were no other staff present during the event. On 3/21/23 at 2:45 PM, Salon Staff C was asked about R143's transfer and stated, I saw that [R143] could do it when [R143] was in the room. Salon Staff C was asked if the floor staff told her that R143 could transfer themself. Salon Staff C stated, No. Salon Staff C was asked if staff came into the salon with residents to assist with transfers and stated, No, only when I ask, they will help. A review of R143's medical record revealed, R143 was admitted to the facility on [DATE], with diagnoses of Osteoporosis and Surgical incision to right hip. A review of R143's therapy evaluation noted, Therapy Update: Resident: R143. Physical Therapy. Bed Mobility: 1 person assist. Transfers: 1 person assist. Ambulation: Unable. Occupational Therapy: Feeding: Independent. Grooming/Hygiene: Set Up. Upper Body self care: 1 person assist. Lower Body self care: 1 person assist. Toileting: 1 person assist . Comments: 1 person pivot transfer .Date: 3/21/23. A review of R143's care plan noted, Problem Start Date 3/21/23. Category: Falls. Resident is at risk for falling R/T (related to): hx (history) of falls, impaired mobility, PAD (Peripheral Arterial Disease) with left AKA (above knee amputation), right THA (Total hip arthroplasty) . Goal: Resident will remain free of falls with major injury. Created 3/21/23. Approach: Staff to assist resident with transfers as needed. Discipline: Nursing, Occupational Therapy, Physical Therapy. On 3/22/23 at 11:24 AM, the Director of Nursing (DON) was explained the observation with R143 and Staff C and was asked the facility's expectation and stated that she will look into it. On 3/22/23 at 12:06 PM, the DON explained that education will be completed for Salon Staff C to make sure they know to not transfer without staff. A policy titled, Resident Transfers dated 3/21/23 noted, Overview: To ensure the safety of residents and staff when performing mobility/transfer tasks. 1. Upon admission the admitting nurse and/or therapy department shall determine the type of transfer device, amount of assistance required to assist with safe mobility based on assessments in the areas of: a. cognition-ability to follow simple instruction. B. weight bearing status-full, partial, toe touch, non-weight. C. Resident's weight. D. Upper and lower body strength. E. trunk stability. F. skin condition. G. Mobility status-supervision, limited, extensive, dependent .

Based on observation, interview, and record review, the facility failed to ensure handwashing by dietary staff, failed to maintain ceiling ventilation covers in a sanitary manner, failed to hold wiping cloths in a chemical sanitizer solution, failed to store food items 6 inches above the floor, and failed to store potentially hazardous cold food items at 41 degrees Fahrenheit or below, resulting in the increased potential for cross contamination and foodborne illness. These deficient practices had the potential to affect all residents that consume food from the kitchen. Findings include: On 3/8/22 between 8:30 AM-9:00 AM, during an initial tour of the kitchen with Morning Cook Q, the following items were observed: Upon initial entry into the kitchen, Morning Cook Q was observed near the steam table, talking on a cellular phone. Staff Q finished her phone call, and then went back to preparing breakfast food items, without first performing hand washing. On 3/8/22 at approximately 11:45 AM during lunch meal service, Morning Cook Q was observed preparing food items for the steam table with gloved hands. Morning Cook Q removed some plastic wrap from a pan, lifted the lid of the garbage can with her gloved hand to throw away the trash, and then returned to the steam table to resume lunch service. Morning Cook Q did not change her gloves or wash her hands after handling the trash can lid. According to the 2013 FDA Food Code section 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: .(E) After handling soiled equipment or utensils; .(I) After engaging in other activities that contaminate the hands. The 2 ceiling vent covers located above the ice machine, were coated with a thick layer of dust. According to the 2013 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. On the soiled side of the dish machine, the caulking along edge where the drainboard and the wall meet, was black and was completely gone in some spots. According to the 2013 FDA Food Code section 4-402.11 Fixed Equipment, Spacing or Sealing, (A) EQUIPMENT that is fixed because it is not EASILY MOVABLE shall be installed so that it is: .(3) SEALED to adjoining EQUIPMENT or walls, if the EQUIPMENT is exposed to spillage or seepage. A red sanitizer bucket, filled with solution and containing a wiping cloth, was observed on a shelf near the oven/food prep area. The solution was tested with a quaternary ammonia test strip, and no sanitizer was detected. Morning Cook Q was queried and stated, In the morning, I do a mixture of soap and sanitizer, because just the sanitizer alone doesn't clean the grease that well. According to the 2013 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; There was cottage cheese cups, yogurt cups and fruit cups stored on a cart in front of the steam table. The cold food items were in a pan, which was nesting inside another pan that contained ice. The temperature of the cottage cheese cup was 61 degrees Fahrenheit, and the cup of watermelon chunks was 59 degrees Fahrenheit. According to the 2013 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: (1) At 57ºC (135ºF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54ºC (130ºF) or above; or (2) At 5ºC (41ºF) or less. In the dry storage room, there was a box of fried crispy onions, a box of egg noodles, and 2 boxes of fruit juice which were stored directly on the floor. Morning Cook Q was queried as to when the facility had received stock, and stated that they had received the stock yesterday. According to the 2013 FDA Food Code section 3-305.11 Food Storage, (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on observation, interview and record review, the facility failed to ensure call light buttons were easily accessible for one sampled Resident (R38) and one non-sampled Resident (R17) of four observed for call light placement, resulting in the potential for unmet care needs and or care needs not being met timely. Findings include: R38 On 03/08/22 at 2:19 PM, R38 reported that their call light was not always in reach. R38 was seated in a specialized wheelchair slightly forward of the foot of their bed watching TV. The call light was observed to hang over the headboard and not in reach of R38. R38 reported facility staff usually brought them back to their room. R38 reported the need for assistance to move around when in the chair. At 2:31 PM and 4:19 PM, R38 was observed positioned as previously observed. The call light was over the headboard and not in reach. On 03/09/22 at 12:37 PM, Staff I returned R38 to their room after lunch. R38 was seated in a specialized wheelchair slightly forward of the foot of their bed. R38 was watching TV. The call light was observed on the bed. This was a pad style call light. The bed height was between the elbow and the shoulder of R38 and about an arms length away. The chair back was reclined, but R38 sat more upright. R38 reported it would be better if the call light was closer in case they needed something or had an emergency. R38 was observed to have a softer voice. At 12:50 PM R38 remained as before. At 12:55 PM, a rehab staff member walked down to R38's room, went in and came right back out. At 1:14 PM R38 was as observed before up in the chair bedside, and the call light not in reach. R17 On 03/08/22 at 10:05 AM, R17 was observed to be in bed and appeared asleep. The call button was observed to hang down below the frame of the bed. The call button was outside the assist bar and more perpendicular to the floor. At 11:46 AM and at 1:20 PM, R17 was observed to be in bed as before, with the same call button placement. On 03/09/22 at 1:41 PM, the Therapy Manager reported R38 to have intermittent confusion but generally alert and oriented. It was further reported R38 was able to elevate their arms to 100 degrees (90 degrees equals arms extended straight out) and was on service for strengthening and range of motion. The Therapy Manager was asked where the call light should be for R38 and reported it should be clipped somewhere between the chest and the pants (waist). The Manager further noted that R38 was limited in and dependent for, bed and wheelchair mobility and daily activities. The Manager was also asked about R17 and reported R17 was a max assist to dependant for most activities of daily living. On 03/09/22 at 4:18 PM, the Director of Nursing/Director of Health Services (DON) was interviewed and asked about positioning for the call button. The DON reported the call button should be in reach for all residents regardless of their ability to use it and when staff enter the room of the resident a head to toe check should be done for proper positioning and call light location. The DON further noted that resident checks were done at least every two hours while the resident is in their room. The DON was asked about staffing for the units and reported they try to have a nurse and a aide on each hall during the day and afternoon and two nurse and two aides at night. A review of the facility record for R38 revealed, R38 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for extensive assistance of one or two persons for bed mobility, eating, dressing and personal hygiene. The Therapy Screen dated 01/10/22 documented spastic movements for all extremities upon initiation. A review of the facility record for R17 revealed, R17 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Guidelines for Answering Call Lights revised 05/11/16 revealed, Purpose: To respond to the resident's request and needs .2. Ensure call light is plugged in securely to the outlet and in reach of the resident .

Based on observation, interview, and record review, the facility failed to implement a nutrition care plan intervention for one sampled Resident (R33) of six reviewed for nutrition, resulting in the resident failing to be encouraged and/or assisted as needed during meals and experiencing weight loss. Findings include: On 3/8/21 at 1:23 PM, an observation was made of R33's lunch being uneaten other than the fruit cup. R33 was interviewed regarding their lunch and stated, I'm working on it. No facility staff was observed to be present in R33's hallway where their room was located. On 3/9/22 at 12:53 PM, 1:47 PM, 1:57 PM, and 2:03 PM, observations were made of R33's lunch sitting in front of them uneaten. R33 was interviewed about their lunch and their full plate of food, and stated, I'm not that hungry. No facility staff was observed to be present in R33's hallway. On 3/10/22 at 9:59 AM, an observation was made of R33's breakfast plate on their bedside table. The plate was observed to be covered and the food underneath was untouched. R33 was observed to be sleeping. On 3/10/22 at 10:41 AM, Nurse K was interviewed regarding R33's observed lack of food consumption. Nurse K stated, [Resident] requires encouragement to eat. Nurse K indicated that it was the assigned Certified Resident Care Aide's (CRCA) task to do that. On 3/10/22, at 10:46 AM, CRCA E was interviewed regarding R33's observed lack of food consumption and indicated that [Resident] required encouragement to eat. CRCA E stated, I wish we could get [Resident] to go to the assisted dinning room, but ever since they had COVID, they won't get out of bed. CRCA was asked if they encouraged and assisted R33 with eating as needed. CRCA E indicated that they were encouraging [Resident] to eat when they were able too. CRCA E was asked if they documented their attempts to encourage R33 to eat. CRCA E stated, No I document how much food [Resident] has eaten. On 3/10/22 at 11:00 AM, a thirty day look back of R33's vitals in their Electronic Medical Record (EMR) revealed that over the past thirty days R33 had lost 8.6 pounds. Further review of R33's EMR revealed that R33 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's most recent minimum data set assessment (MDS) dated [DATE] indicated that R33 had a severely impaired cognition and required setup assistance for meals. A comparison MDS was reviewed for R33 which was dated 11/8/21. That MDS indicated that R33 required one person assistance during meals. On 3/10/22 at 11:30 AM, R33's nutrition care plan was reviewed and revealed the following, Problem: Resident has significant weight loss occurring. Resident had h/o (History of) COVID-19 in October 2021, Pneumonia which was treated with abx (antibiotics) and developed thrush which led to oral pain and decreased intakes. start date: 12/13/2021 Last reviewed: 03/10/2022. Goals: No further unwarranted significant weight loss will occur. Target date: 05/24/2022 (Long term goal). Approaches: Approach: Offer encouragement and assistance with eating PRN (As needed). On 3/10/22 at 2:30 PM, Registered dietician (RD) L was interviewed regarding R33's weight loss and their nutrition care plan and interventions. RD L indicated that staff should be encouraging and assisting the resident with eating as needed per the care plan intervention. On 3/10/22 at 3:00 PM, the Director of nursing (DON) was interviewed regarding R33's weight loss and their expectations for staff involving R33's nutrition care plan implementation. The DON indicated that staff should be following the interventions listed on the care plan. On 3/10/22 at 3:30 PM, a facility policy titled, Comprehensive Care Plan Guideline Revised Date: 05/22/2018 stated, Purpose: To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. 1. b. Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident.

Based on observation, interview and record review the facility failed to ensure residents were repositioned timely for two sampled Residents (R16 and R38) of three reviewed for positioning, resulting in the potential for skin impairments and resident discomfort. Findings include: R16 On 03/08/22 at 9:58 AM, R16 was observed to be in bed on their right side facing to the right. R16 did not reply to queries. R16 appeared thin and frail. On 03/08/22 01:22 PM, R16 was observed post lunch siting in a recliner/geri chair, a tray table placed in front of them, with their head down asleep in the recliner, and a stuffed duck was in their lap. A sippy styled cup of pink liquid was on the tray table in front of resident. On 03/08/22 at 4:12 PM, R16 was observed to be seated in recliner/geri chair next to their bed. A stuffed duck was in their lap, the drink had been removed from the tray table, and the call light was pinned to the blanket on the bed, to the left of the resident. On 03/09/22 at 8:22 AM, R16 was observed to be seated hunched over in a recliner/geri chair. R16 wore an orange long sleeve top. R16's head was down, a stuffed duck was in the crease of the left elbow and the call light was clipped to the left pillow. On 03/09/22 at 10:10 AM, two staff (wearing black tops and khaki pants) were observed to enter and then exit the room of R16, after spending around 15 seconds in the room. R16 was observed in the same position as at 8:22 AM after they left. On 03/09/22 at 11:52 AM, Nurse M removed R16 from their room. R16 was seated in the recliner/geri chair with their eyes now open. A blanket was placed over their lap along with the stuffed duck and R16 was placed in the restorative dining area for lunch. On 03/09/22 at 12:59 PM, R16 was observed to be in their room seated in a recliner/geri chair, with their head down and hunched down. The blanket was over their legs and the duck at their left side against a pillow placed on the edge. On 03/09/22 at 1:02 PM, R16 staff placed R16 into the bed. The aide commented that R16 had been up in the recliner since breakfast. The skin on their buttocks was observed at this time with Nurse M. A kidney shaped area of redness with a darker purple red color in the middle was observed on the medial area of the left buttock. The area of redness began along the gluteal cleft. The area did not appear to blanch (turn white) when pressed by Nurse M. A smaller area to the right ischial area was also observed and did not blanch. Nurse M reported it was new that the areas did not blanch. At 1:16 PM, R16 was observed placed onto their left side in the bed. On 03/09/22 at 2:34 PM, R16 was observed to be in bed and faced left as before. At 4:33 PM, R16 remained faced toward the left as before and repeatedly said, I don't know. On 03/10/22 at 9:44 AM, R16 was observed to be in bed on their left side. At 10:24 AM, the buttocks area was viewed and the area of redness to the left buttock had diminished but was still discolored (pink) as compared to the rest of the buttock. A review of the record for R16 revealed, R16 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing care plan identified a decline in health status and weight loss. A nurse note dated 03/09/21 at 2:26 PM documented Reddened un-blanchable area noted to coccyx and right buttock . A note by the Director of Nursing dated 03/09/22 at 6:01 PM documented, .Resident had been identified to be at high risk for pressure ulcer since 12/20/16 due to advanced age and impaired mobility requiring 2 (person assist) PA for transfers and bed mobility . R38 On 03/08/22 at 2:19 PM, R38 was observed in their room seated in a specialty wheelchair (BRODA) toward the foot of their bed facing the TV. R38 reported they had returned from being out with family. R38 was dressed and had shoes on. It was observed that R38 had a lift sling placed under the legs and behind their back. At 2:31 PM and 4:19 PM R38 remained in the same position. At 4:50 PM, R38 was observed seated in the BRODA chair in the restorative dining area. The sling was observed to be as at 2:19 PM. On 03/09/22 at 10:02 AM, 10:55 AM, R38 was observed dressed and seated in the BRODA chair in the common area. The lift sling was under the resident. At 10:59 AM, Nurse M took R38 to their room for a medication administration and then R38 was taken back to the common area. On 03/09/22 at 12:37 PM, R38 was returned to their room and placed at the foot of their bed facing the TV. At 12:50 PM R38 continued to be seated in the chair. At 12:55 PM, a therapy staff person was observed to enter and shortly exited R38's room. At 1:14 PM R38 was observed in their room seated in the BRODA chair as before. At 2:36 PM R38 was observed to be in bed. The head of the bed was up around 45 degrees. At 4:40 PM, R38 appeared asleep and in a similar position as at 2:36 PM. A review of the facility record for R38 revealed, R38 was admitted into the facility 03/10/19. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for extensive assistance of one or two persons for bed mobility, eating, dressing and personal hygiene. The Therapy Screen dated 01/10/22 documented spastic movements for all extremities upon initiation. On 03/09/22 at 1:31 PM, the therapy history for R16 was reviewed with the Therapy Manager. It was reported that R16 was dependent for care for all activities of daily living which included bed and chair mobility. The Therapy Screen dated 02/07/22 documented nursing reported R16 had a decline and found R16 did not initiate voluntary movement or baseline for the lower extremities, shoulders and elbows. On 03/09/22 at 1:41 PM, the Therapy Manager reported R38 to have intermittent confusion but was generally alert and oriented. It was further reported R38 was able to elevate their arms to 100 degrees (90 degrees would be angle with arms extended straight out) and was on service for strengthening and range of motion. The Therapy Manager was asked about the sling placement for R38 and indicated it would be better to remove the sling from the chair after transfer to decrease the chance of skin impairment. The Manager further noted that R38 was limited in and dependent for, bed and wheelchair mobility and daily activities. On 03/09/22 at 4:18 PM, the Director of Nursing DON/Director of Health Service (DHS) was asked about positioning for residents in their room and reported checks were to be done at least every two hours for proper positioning and residents repositioned as needed every two hours. A review of the policy titled, Guidelines for General Wound and Skin Care dated 05/23/18 revealed, Purpose: To provide measures that will promote and maintain good skin integrity .2. Turn/reposition residents who are immobile according to their care plan requirements .

The facility failed to monitor meal assistance administration, provide meal assistance and encourage meal consumption for one sampled Resident (R33) of six residents reviewed for nutrition, resulting in decreased nutritional food intake and significant weight loss. Findings include: On 3/8/21 at 1:23 PM, an observation was made of R33's lunch being uneaten other than the fruit cup. R33 was interviewed regarding their lunch and stated, I'm working on it. No facility staff was observed to be present in R33's hallway where their room was located. On 3/9/22 at 12:53 PM, 1:47 PM, 1:57 PM, and 2:03 PM, observations were made of R33's lunch sitting in front of them uneaten. R33 was interviewed about their lunch and their full plate of food, and stated, I'm not that hungry. No facility staff was observed to be present in R33's hallway. On 3/10/22 at 9:59 AM, an observation was made of R33's breakfast plate on their bedside table. The plate was observed to be covered and the food underneath was untouched. R33 was observed to be sleeping. On 3/10/22 at 10:41 AM, Nurse K was interviewed regarding R33's observed lack of food consumption. Nurse K stated, [Resident] requires encouragement to eat. Nurse K indicated that it was the assigned Certified Resident Care Aide's (CRCA) task to do that. On 3/10/22, at 10:46 AM, CRCA E was interviewed regarding R33's observed lack of food consumption and indicated that [Resident] required encouragement to eat. CRCA E stated, I wish we could get [Resident] to go to the assisted dinning room, but ever since they had COVID, they won't get out of bed. On 3/10/22 at 11:00 AM, a thirty day look back of R33's vitals in their electronic medical record (EMR) revealed that over the past thirty days R33 had lost 8.6 pounds (7.5 %). Further review of R33's EMR revealed that R33 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's most recent Minimum Data Set assessment (MDS) dated [DATE] indicated that R33 had a severely impaired cognition and required setup assistance for meals. A comparison MDS was reviewed for R33 which was dated 11/8/21. That MDS indicated that R33 required one person assistance during meals. On 3/10/22 at 11:30 AM, R33's nutrition care plan was reviewed and revealed the following, Problem: Resident has significant weight loss occurring. Resident had h/o (History of) COVID-19 in October 2021, Pneumonia which was treated with abx (antibiotics) and developed thrush which lead to oral pain and decreased intakes. start date: 12/13/2021 Last reviewed: 03/10/2022. Goals: No further unwarranted significant weight loss will occur. Target date: 05/24/2022 (Long term goal). Approaches: Approach: Offer encouragement and assistance with eating PRN (As needed). On 3/10/22 at 2:30 PM, Registered dietician (RD) L was interviewed regarding R33's weight loss and interventions provided to R33. RD L indicated that staff should be encouraging and assisting the resident with eating as needed. On 3/10/22 at 3:00 PM the Director of nursing (DON) was interviewed regarding R33's weight loss and their expectations for staff involving R33's nutrition care plan implementation. The DON indicated that staff should be following the interventions listed on the care plan. On 3/10/22 at 3:15 PM, a facility policy titled, Guidelines for Weight Tracking Revised 05/22/2018 was reviewed and did not address the concerns reported in this citation.

Based on interview and record review the facility failed to provide documentation of nurse and Certified Nursing Assistant (CNA) skills/competency completion for four of four aides reviewed, resulting the potential for clinical skill level deficiencies to be unidentified. Findings include: On 03/08/22 at 2:05 PM, incontinence care was observed on two female residents. The first resident was observed with Certified Resident Care Associate (CRCA/CNA) E and Medication Technician (MT) O. MT O was observed to wipe the left then right groin area and then the vaginal area with the same cloth. Stool was then also cleaned up. Gloves were not observed to be changed when the cleaning was done prior to positioning the resident in the bed. The next observation involved CRCA E, MT O and MT N. The staff used three different cloths in the same fashion. Gloves were not changed to reposition the resident in the bed. On 03/08/22 at 3:54 PM, annual/regular skill competency/evaluation and 12 hours of training, were requested for CRCA O, CRCA H, CRCA G and CRCA P from the Administrator. However the requested skills competencies were not provided prior to survey exit. The skill competency checks for Nurse B, C and D were also requested at this time, but were not provided prior to survey exit. On 03/09/22 at 11:55 AM, during a dining observation CRCA I was observed to be seated between two residents. CRCA I was observed to feed the two residents with the same hand without hand hygiene between each alternated bite provided. CRCA I provided 4-5 bites to the residents in an alternate fashion, then switched to using different hands for each resident. CRCA I reported they had caught themselves and switched to using different hands. On 03/10/22 at 12:30 PM, the competency for CRCA O, CRCA H, CRCA G and CRCA P and Nurses B, C and D were requested from the Assistant Director of Nursing (ADON). The ADON reported they had been at the facility about a month and they were working on updating the competencies for all the nurses and aides with the Director of Health Service (DHS)/Director of Nursing (DON). At 2:09 PM, the training the staff had taken was been provided by the DHS/DON but not the clinical skill competencies. The DON did not provide the requested clinical skill competencies prior to survey exit. A review of the facility policy, Caregiver Annual Competency Evaluation Guidelines undated, revealed, Policy: It is the policy of (facility) to comply with regular performance evaluations to ensure individuals working in the campus as nurse aides are competent to perform the nursing and nursing related services they perform. Purpose: To ensure resident's care needs are met. Procedure: The Director of Health Service (DHS) or designee will complete a caregiver competency evaluation for certified nursing assistant. DHS will schedule and review the competency evaluation with the nursing assistant. The caregiver competency will be completed no less than annual. Nursing assistant, Evaluator and DHS will sign the Caregiver Annual Competency Evaluation form. The Caregiver Annual Competency Evaluation form will be stored in the employee personnel file . A review of the facility policy Guideline for Handwashing/Hand Hygiene dated 02/09/17 revealed, 1. All health care workers shall utilize hand hygiene frequently and appropriately .3. Health Care Workers shall use hand hygiene at times such as: b. Before/after preparing/serving meals, drinks, tube feedings, c. Before/after having direct physical contact with residents .

This citation pertains to intake numbers MI 829 and MI 845. Based on interview and record review the facility failed to monitor and prevent resident to resident abuse for 2 sampled Residents (R901 (perpetrator) and R902) of three residents reviewed for abuse, resulting in a scratch and bleeding to R902's forehead and the potential for psychosocial distress based on the reasonable person concept. Findings include: On 2/23/22 at 8:45 AM, incident and accident (I/A) records were reviewed involving I/As which occurred between R901 and R902 on 10/11/21 and 10/14/21. A review of the I/A on 10/11/21 revealed that R901 entered R902's room on 10/11/21 at 6:20 PM, and staff heard noise coming from R902's room and witnessed R901 in R902's room, and to strike R902 on the right side of their face with an open hand. R901 was redirected by staff out of R902's room and back to their room. R902 was observed to have scratch marks and bleeding on their forehead. On 2/23/22 at 8:50 AM, the I/A involving R901 and R902 which occurred on 10/14/21 at 2:04 PM, was reviewed and indicated that staff heard yelling coming from R902's room and witnessed R901 in R902's room, striking R902 on the top of their head with an open hand. R901 was redirected by staff out of R902's room and back to their room. On 2/23/22 at 9:05 AM, R901's electronic medical record (EMR) was reviewed and revealed that R901 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R901's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that R901 had a severely impaired cognition. R901 was discharged from the facility on 10/20/21. On 2/23/22 at 9:10 AM, R902's EMR was reviewed and revealed that R902 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R902's most recent MDS dated [DATE] revealed that they had a severely impaired cognition. On 2/23/22 at 1:00 PM, Social Services Director (SSD) F was interviewed about the incidents which occurred between R901 and R902 on 10/11/21 and 10/14/21. SSD F indicated that R901 would become agitated when there was excessive noise and/or excessive amounts of other residents around them. [R901] did better in small groups. SSD F indicated that they did not witness either incident involving R901 and R902. On 2/23/22 at 3:45 PM, Certified Resident Care Associate (CRCA) D was interviewed regarding the incidents involving R901 and R902. CRCA D indicated that they were walking down the 300 unit on 10/11/21 and witnessed R901 in R902's room, striking R902 in the face with their open hand. CRCA D indicated that R901 was redirected out of the room and back to their room. CRCA D was interviewed about interventions utilized to prevent R901 from entering other residents rooms. CRCA D stated, We tried to always keep an eye on [R901]. If [R901] was not in their room we would locate them. At times it was difficult to monitor [R901] when you get busy. On 2/24/22 at 10:20 AM, CRCA E was interviewed regarding incidents involving R901 and R902. CRCA E indicated that on 10/14/21 [R902] was hollering out, I went down to their room and witnessed R901 in [R902's] room hitting [R902] on top of their head with a closed fist. I redirected R901 out of the room and back to their room. CRCA E was interviewed about interventions utilized to prevent R901 from entering other residents rooms. CRCA E stated, We attempted to monitor [R901] as best as we could. On 2/24/22 at 10:30 AM, the Administrator (NHA) was interviewed and asked about their expectations for staff in regards to monitoring residents who wander. The NHA stated, Wandering residents should be redirected as needed and all staff are aware that they need to do this. On 2/24/22 at 10:45 AM a facility policy and procedure titled Abuse and Neglect Procedural Guidelines Revised Date: 8/29/19 stated the following, Purpose: [Corporation] has developed and implemented processes, which strive to ensure the prevention .of suspected or alleged resident abuse .3. Definitions: Abuse is the willful infliction of injury .It includes .physical abuse .Willful as used in this definition of abuse means the individual must have acted deliberately .b. Physical Abuse-includes .hitting, slapping, punching .i. Resident to resident abuse with or without cause . On 2/24/22 at 11:00 AM, a facility policy and procedure titled Behavior Planning and Intervention no date, stated the following, (Standard Operating Procedure) SOP Details .3. Provide a safe place for a resident to wander freely without risk .7. Rechannel behaviors by engaging residents in activities .

Based on observation, interview, and record review the facility failed to store respiratory equipment in a sanitary manner affecting three residents (R 50, 102, and 104) of three sampled residents reviewed for respiratory care with the potential for the preventable spread of infections. Findings include: R 102. On 01/14/20 at 8:41 AM, R 102 was not in the room, it was observed that R 50 had an oxygen O2 concentrator and the nasal cannula tubing was draped over the concentrator. Record review of R 102's Electronic Health Record (EHR) revealed that R 102 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment ((MDS) dated [DATE] revealed R 102 had an intact cognition and needed one person assistance with Activities of Daily Living. On 01/14/20 at 1:58 PM, R 102 was interviewed regarding the O2 therapy received at the facility and stated, I don't use the O2 continuously, they come in and put the thing on my finger if it's 89 or below they put it on me. If it's 90 or above they take it off. R 50. On 01/14/2020 at 8:49 AM R 50 was interviewed regarding the care received at the facility. During the interview it was observed that R 50 had a nebulizer (for inhaled medications) on the bedside stand and the mouth piece for the tubing was lying on the bed side stand. R 50 was asked about receiving respiratory treatments and stated, They come in and put the medicine in it and come back when it's done. Record review of R 50's EHR revealed that R 50 was admitted into the facility on [DATE] and readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated , 12/26/2019 revealed that R 50 had an intact cognition and needed extensive assistance with ADLs. R 104. On 01/14/2020 at 8:58 AM R 104 was interviewed regarding the care received at the facility and stated, I don't know if I have anything to complain about. During the interview it was noted that R 104 had a nebulizer on the bedside stand and the end of the tubing was lying on the bedside stand. R 104 was asked about the nebulizer and stated, I don't know what that is for. Record Review of R 104's HER revealed that R 104 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS revealed R 104 had a severely impaired cognition and needed extensive assistance with ADLs. On 01/14/ at 9:13 AM, Nurse A was asked about the facility's policy and procedure regarding respiratory care equipment and stated, (R 50) must have had a treatment on the midnight shift. Normally we wash it off and let it dry before we put in the bag. (R 102's) should be in a bag and is in a wheel chair right now and has a tank. On 01/16/2020 at 10:00 AM, the Infection Control Preventionist (ICP) was asked about the surveillance of infection control concerns and stated, We make rounds and we find a problem we investigate and start in-services. Review of the facility's policy and procedure regarding respiratory care equipment titled, RESPIRATORY EQUIPMENT dated as Approval Date: (YEAR)0511 revealed in section 3. c. After completion of therapy: ii. Rinse container in fresh tap water; iii. allow to dry on a clean paper towel or gauze sponge. f. Store circuit in plastic bag .

Based on observation, interview, and record review, the facility failed to ensure adequate hand hygiene and gloving during meal preparation and service, affecting the facility and two sampled (#'s 17 and 25 ) residents, resulting in the potential for cross-contamination and transmission of communicable diseases and infections. Findings include: On 3/4/19 at 11:15 AM, Dietary Cook D was observed preparing food items for the lunch meal service. Dietary Cook D was observed lifting the lid on the trash can to throw away some trash. Cook D then put on disposable gloves, without first washing her hands. Cook D began slicing oranges. Cook D then lifted the lid of the trash can with her gloved hand to throw away some trash, and went back to slicing oranges, without first washing her hands. Cook D was observed a third time lifting the lid of the trash can with her gloved hands, and again returned to work without first washing her hands. On 3/4/19 at 11:30 AM, Dietary Cook E was observed preparing lunch items at the grill and fryer. Dietary Cook E was observed lifting the lid of the trash can with his bare hand to throw away trash, and returned to lunch preparation without first washing his hands. Cook E lifted the lid 2 more times, without washing his hands. Cook E was observed touching the food contact surfaces of the plates that were being used for the lunch meal. On 3/4/19 at 11:45 AM, Dining Services Assistant F was observed handling and rinsing soiled dishware to load into the dishmachine. Dining Services Assistant F then went to the clean side of the dishmachine, and began to put away the clean dishware, without first washing her hands. On 3/4/19 at 2:30 PM, Director of Food Services C was queried about the expectations for handwashing by the kitchen staff, and confirmed that staff should wash their hands after touching the trash can lid and after handling soiled dishware. Director of Food Services C stated, Looks like we need to do some inservicing. According to the 2013 FDA Food Code Section 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: .(E) After handling soiled equipment or utensils; (H) Before donning gloves for working with food; and (I) After engaging in other activities that contaminate the hands. On 03/04/19 at 9:20 AM, Certified Nurse Assistant (CNA) A was observed entering Resident (R) #25's room, touched their shoulder and set-up R#25's food tray. CNA A picked up R#25's toast with bare hands and put jelly and butter on toast. CNA A did not wash her hands or sanitize before entering the next room. On 03/04/19 at 9:25 AM, observed CNA A entering R#17's room, touched the tray table and set-up R#17's food tray. CNA A picked up R#17's toast with bare hands and placed jelly and butter on the toast. On 03/04/19 at 9:32 AM, an interview was conducted with CNA A in regards to hand hygiene during meal times. CNA A stated, I needed to wash my hands between residents and wear gloves when touching the food. I'm not sure why I didn't do the right thing, since I been a CNA A for [AGE] years. On 03/04/19 at 12:31 PM, an interview was conducted with Infection Control Preventionist (ICP) in regards to hand hygiene during meal time. ICP B stated, The team is expected to wash their hands between residents and wear gloves when applying jelly and butter to toast. The CNA notified me about the incident. On 03/06/19 at 10:12 AM, an interview was conducted with the Director of Nursing (DON) in regards to hand hygiene during meal time. DON stated,The staff is expected to wash their hands before passing out the food trays and between any contact. A record review was completed of the facility's policy titled, Guideline for Handwashing/Hand Hygiene dated with a revision date 02/09/17. The policy revealed: Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol?based hand rub (ABHR). 1. All health care workers shall utilize hand hygiene frequently and appropriately. 2. Residents shall be given the opportunity and assistance to wash their hands. 3. Health Care Workers shall use hand hygiene at times such as: a. Reporting to work; before/after eating; after smoking, toileting, blowing nose, coughing, sneezing, etc. b. Before/after preparing/serving meals, drinks, tube feedings, etc. c. Before/after having direct physical contact with residents. d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc.

Deficient Practice Statement #1 This citation pertains to intake # Based on interview and record review, the facility failed to obtain an order and transfer 1 resident (#5) to the hospital in a timely manner, out of 1 resident sampled for hospitalization , from a total sample of 15, resulting in prolonged suffering and illness, a continued decline in health, and eventually death of the resident. Findings include: On [DATE] at 9:00 a.m., Family Member C was contacted via phone and interviewed. Family Member C stated, She (Resident #5) came to the facility for rehab only and was there for about 3 weeks. I just feel like they didn't assess her. During the whole time (while admitted in facility) she wasn't eating. We would even bring food in to her to try to get her to eat. We would even try to feed her and the staff would never even bother to check on her to see how she was eating. I guess they assumed we (the family) were going to take care of it. When they finally sent her to the hospital the ER (emergency room ) doctor asked us (the family) what they (the facility) were doing about her UTI (urinary tract infection). We had no idea she even had an infection. She went into cold shock (a serious or fatal condition that is caused by severe infection in the blood that dangerously lowers the body temperature) and passed away at the hospital. On [DATE] at 9:15 a.m., a record review of the face sheet and the Minimum Data Set (MDS) assessment for Resident #5 was completed. According to the MDS dated [DATE], Resident #5 had a moderately impaired cognition. The face sheet revealed that Resident #5 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On [DATE] at 9:23 a.m., a record review of Resident #5's vital signs during her course of stay in the facility was completed and revealed the following: Temperature and Respirations were within normal limits. The pulse rate (P) of Resident #5 was between ,[DATE] beats per minute (bpm) until [DATE], after that date with the exception of [DATE], [DATE] and [DATE], the pulse rate was over 100 bpm. Normal pulse rates according to the American Heart Association (www.heart.org) are between ,[DATE] bpm. Normal blood pressure (BP) readings according to the American Heart Association (www.heart.org) are ,[DATE]. The blood pressure readings for Resident #5 were low readings from [DATE]-[DATE] with the exception of [DATE] and [DATE]. Significant low blood pressure readings were recorded on [DATE] (,[DATE]), [DATE] (,[DATE]), [DATE] (,[DATE]), and [DATE] (,[DATE]). The initial admission blood pressure reading for Resident #5 was ,[DATE]. On [DATE] at 9:30 a.m., a record review for the laboratory blood draws (lab) for Resident #5 was completed and revealed the following: [DATE] Sodium level low at 133 (normal ,[DATE], sodium regulates fluids in the body). Potassium low at 2.9 (normal 3XXX,[DATE].3, potassium helps regulate heart rate and function). [DATE] Sodium 132 Potassium 3.2 [DATE] Sodium 127 Potassium 3.6 On [DATE] at 8:59 a.m., a record review of the Progress Notes (nursing) for Resident #5 was completed and revealed the following: [DATE] 1:58 p.m. BP ,[DATE] P 134 Res (Resident #5) noted with hands shaking and c/o (complaints of) dizziness .assisted back to bed with HOB (head of bed) lowered and FOB (foot of bed) elevated. BP increased to ,[DATE]-Dr. (doctor) aware changed BP meds, stat labs. [DATE] 10:37 p.m. Having dry emesis after couple of bites .states she (Resident #5) has no appetite and feels like anything she swallows just won't go all the way down. [DATE] 9:03 a.m. Dr. notified of Na (sodium) 127, labs ordered. [DATE] 10:02 p.m. .Overall feeling like not being self (Resident #5) .Per Dr.1500cc fluid restriction . [DATE] 9:54 p.m. .Significant weakness .very weak .per resident (#5) statement not feeling like self . [DATE] 6:02 a.m. .Requesting [MEDICATION NAME] (medication used for anxiety) for anxiety .Continued to call staff every ,[DATE] min (minutes) requesting more [MEDICATION NAME] .Stated she (Resident #5) had been on the toilet for 3 hours (was not) .Very weak in bed difficult to redirect. Speech clear mumbled at times .too weak for toilet (transfer) . [DATE] 8:02 a.m. M/S (mental status) changes .HR (heart rate) fluctuating between ,[DATE]. BP low ,[DATE] SpO2 91 % (normal oxygen levels between ,[DATE]% on room air) on 3L (liters of oxygen) temp (temperature) 99.3. Increased confusion and hallucinations. Nurse attempted straight cath (catherization to obtain urine sample to test for an infection in the urine), no urine available. Dr. notified sent to ER (emergency room ). On [DATE] at 9:25 a.m., a record review of the Progress Notes (physicians) was reviewed for Resident #5 and revealed the following: [DATE] Patient (Resident #5) was seen today for [MEDICAL CONDITION] BP ,[DATE], improved to ,[DATE] .Had to be placed in reverse trendleburg BP ,[DATE] . Assessments/Plan Could be multifactorial (BP) with hx (history) [MEDICAL CONDITION](hypertension) and on diuretics (water pills) also patient's oral intake has not been good lately .Advised to drink plenty of fluids. Continue to monitor BP closely; cut down [MEDICATION NAME] (blood pressure medication), d/c (discontinue) diuretics, check lytes (labs) and renal functions. [DATE] (authored by Nurse Practitioner A) K (potassium) 3.2 low BP ,[DATE] [DATE] (authored by Dr.B) Reason for seeing resident: abn (abnormal) labs. BP ,[DATE] Assessment/Plans-Acute [MEDICAL CONDITION] (low sodium) asymptomatic (not showing symptoms) .Will continue with fluid restrictions. Will repeat BMP (basic metabolic panel lab) .Will hold diuretics .cannot give due to [MEDICAL CONDITION]. On [DATE] at 11:00 a.m., a record review of the Events was completed for Resident #5. On [DATE], [DATE] and [DATE] each had a notation in regards to Resident #5 vomiting. On [DATE] at 11:14 a.m., a record review was completed of the facility policy titled Notification of Change in Condition revised on [DATE] and revealed under the heading Procedures the following information: #1. Resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner. On [DATE] at 11:20 a.m., a record review of the Advanced Directives for Resident #5 revealed that the resident had signed her own directive and elected to be a full code (choosing to receive full resuscitation efforts, including life sustaining measures). On [DATE] at 11:37 a.m., an interview with the Director of Nursing (DON) was completed. During the interview the DON had access to the medical record for Resident #5. The DON was queried in regards to continued low blood pressure readings and the worsening of Resident #5's lab work, increased pulse and decline in overall health while in the facility. The DON stated, I see lots of communications with the doctors and notes. Lots of notifications to the doctor. Based on the review of the chart, I don't see anywhere we were ignoring symptoms. The DON was further queried in regards to Resident #5 being a full code and if the nurses are allowed to make a clinical judgement to send a resident (particularly pertaining to Resident #5's blood pressure readings on [DATE] of ,[DATE] and ,[DATE], [DATE] ,[DATE], [DATE] ,[DATE], and [DATE] ,[DATE])to the hospital, the DON did not provide and answer or response. On [DATE] at 1:12 p.m., an interview with the Administrator was completed in regards to the events that led up to the transfer to the hospital for Resident #5. According to the Administrator he had reviewed the medical record and stated, Her (Resident #5) blood pressure was all over the place. The Dr. seen her and ordered labs and adjusted her medications. She (Resident #5) was her own person (made her own medical decisions) and was talking to them (the staff) at the time (on [DATE] while blood pressure was low). The nurses are allowed to send someone to the hospital, absolutely, if they feel they need it. On [DATE] at 12:54 p.m., a record review of the physician orders [REDACTED]. On [DATE] at 1:10 p.m., Clinical Support RN E had provided a copy of the hospital records for Resident #5 and stated, The nurse practitioner and doctor spoke with the family about her (Resident #5) options and the resident made her own decisions (to not go to the hospital). Documentation was requested of those conversations but not provided by the end of the survey. On [DATE] at 1:49 p.m., a record review was completed of the hospital notes for the hospital stay that Resident #5 had from [DATE]-[DATE] and revealed the following: Patient (Resident #5) presents tachypnea (rapid breathing), [MEDICAL CONDITION] (increased heart rate) and confused .At nursing facility normally A+O x 3 (alert and oriented), declining mental status .EMS (Emergency Medical System) found patient to be hypoxemic 89% on home 2 L (liters of oxygen) .initial pressures (BP) ,[DATE] .UA (urinalysis) demonstrates many bacteria. Under the heading Plan stated the following: Sepsis (a severe infection in the blood) problem Comfort care, terminal wean (patient was placed on ventilator and weaned off), patient pronounced (dead) ,[DATE] (2017). Ivanz started ,[DATE] (2017-an antibiotic) .Fluid resuscitation [MEDICATION NAME] (a potent medication given intravenously to bring up severely low blood pressures) for [MEDICAL CONDITION], contact isolation (isolation from infection). Under the heading hospital course the following was stated: .Sepsis .Was admitted to the MICU (medical intensive care unit) for urosepsis (serious urinary infection that has spread to the blood) from ,[DATE]-,[DATE] (2017) .Despite IV (intravenous) abx (antibiotics) patient (Resident #5) was still not responsive .Still requiring pressure support with Levo (Levophen), fluids, and sedation. Patient required thermal support as well as continued to lose heat .Clinically patient's neurological status decreased over the course in ICU from ,[DATE]-,[DATE]. Family was continually at bedside and at ,[DATE] family decided to place patient on a terminal wean. After cessation of medications and being taken off vent (ventilator) patient was put on comfort care and patient eventually expired. [MEDICAL CONDITION]ly ,[DATE] [MEDICAL CONDITION] . On [DATE] at 2:23 p.m., an interview with Dr.B was completed in regards to the decline in health of Resident #5. Dr. B stated, She (Resident #5) had numerous problems, [MEDICAL CONDITION] [MEDICAL CONDITION] and was on multiple diuretics. I would have sent her out sooner if her BP would not have come up, I guess some of it is my fault because she was on so many diuretics. We had to stop the diuretics. On [DATE] at 2:38 p.m., an interview was completed with Nurse Practitioner (NP A). NP A stated, I don't remember a whole lot about her, if I spoke with the family about something I would have documented it. If they (the family) would have wanted her (Resident #5) to be sent to the hospital I would have sent her out unless I felt it was clinically unnecessary. I believe I stopped the diuretics. On [DATE] at 2:48 p.m., an interview was completed with Registered Dietitian (RD D) via phone. RD D stated, I do remember there being a concern with her (Resident #5) po (oral food) intake. I spoke with (NP A) about it and we put some supplements in place. The following information is a source from the University of (NAME)land Medical Center (www.umm.edu) [MEDICAL CONDITION]: [MEDICAL CONDITION], blood pressure drops, resulting in shock. Major organs and body systems, including the kidneys, liver, lungs, and central nervous system may stop working properly because of poor blood flow. A change in mental status and very fast breathing may be the earliest signs [MEDICAL CONDITION]. In general, symptoms [MEDICAL CONDITION] can include: Chills Confusion [MEDICAL CONDITION] or Fever hypothermia or low body temperature Lightheadedness due to low blood pressure Rapid heartbeat Outlook (Prognosis) Sepsis is often life threatening, especially in people with a weak immune system or a long-term (chronic) illness. Damage caused by a drop in blood flow to vital organs such as the brain, heart, and kidneys may take time to improve. There may be long-term problems with these organs. Requested a policy [MEDICAL CONDITION] management, no policy received by the end of the survey. Deficient Practice Statement #2 Based on observation, interview and record review, the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for one (#15) of one Residents reviewed for management of [MEDICAL CONDITION], of a total sample of 15, resulting in lack of assessment, monitoring, and documentation of heart failure symptoms, a 17.7 pound weight gain, and the potential for a decline in overall health status. Findings include: On [DATE] at 9:57 AM, Resident #15 was observed in their room in a chair. The Resident's legs were not elevated and their feet were placed on the floor. White colored, wound dressings were observed wrapped around both of the Resident's lower legs from approximately three inches below the Resident's knees to above their ankles. Both of the Resident's feet were observed to have significant [MEDICAL CONDITION] and were red in color. When queried regarding their legs and feet, Resident #15 indicated their legs get so swollen they blister and that is why the dressings were in place. When asked about the frequency that staff obtain their weight, Resident #15 stated, A couple times since I've been here. Not often. On [DATE] at 4:29 PM, Resident #15 was observed sitting in a chair in their room. The Resident's legs were not elevated. The Resident's legs and feet were extremely [MEDICAL CONDITION] in appearance. The Resident's feet were bare and were red and flaky in appearance. A white colored wrap dressing was in place to both of their legs from just above the ankle to approximately three inches below their knees. Record review on [DATE] at 12:37 PM revealed that Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADL's). On [DATE] at 8:59 AM, Resident #15 was observed sitting in their room in their chair with their legs not elevated. The Resident's legs and feet were extremely [MEDICAL CONDITION] (swollen) in appearance. The Resident's feet were bare, dark red in color, with flaking areas of white tissue. An interview was conducted with Nurse K on [DATE] at 9:04 AM. When queried regarding Resident #15's [MEDICAL CONDITION], Nurse K indicated the Resident always has lower extremity [MEDICAL CONDITION]. With additional inquiry regarding the dressings in place on both of the Resident's lower legs, Nurse K stated, (Resident #15) had blisters that burst. When queried if the [MEDICAL CONDITION] and blisters were related to the Resident's [DIAGNOSES REDACTED]. No further explanation was provided. On [DATE] at 1:55 PM, record review of Resident #15's medical record revealed the following active care plans: High Risk medications: [REDACTED]. The care plan included the following interventions: -Administer medications per MD orders. Observe and report effectiveness as needed . (Start Date: [DATE]). -Encourage fluids throughout the day if not contraindicated (Start Date: [DATE]). -Labs per Dr's order (Start Date: [DATE]). -Observe cardiovascular system and fluid status to determine effectiveness of diuretic therapy (e.g., [MEDICAL CONDITION], jugular vein distention, mental confusion, shortness of breath, abnormal breath sounds, abnormal heart sounds) (Start Date: [DATE]) . -Observe for signs of fluid and electrolyte disturbances (Start Date: [DATE]). Excess fluid volume related to decreased glomerular filtration rate (GFR) . Long Term Goal: Resident has balanced inputs and outputs; breath sounds clear; vital signs within acceptable range; stable weight; no increasing [MEDICAL CONDITION] (Start Date: [DATE]; Edited: [DATE]). The following interventions were included in the care plan: -Administer prescribed diuretics, as appropriate . -Encourage and assist resident to elevate lower extremities and reposition as needed . -Maintain fluid and sodium restrictions as indicated. -Monitor and document therapeutic effect of diuretic. -Monitor for lower extremity [MEDICAL CONDITION] and report to physician. -Monitor weight. -Note presence of increase dyspnea, tachypnea, orthopnea, [DIAGNOSES REDACTED] nocturnal dyspnea, persistent cough. -Notify Physician of abnormal clinical findings as ordered. Review of progress note documentation within the medical record at this time did not reveal assessment, documentation of [MEDICAL CONDITION] status and/or pertinent cardiac/respiratory assessment for Resident #15. On [DATE] at 2:35 PM, an interview was completed with MDS Nurse L. When queried regarding care plan pertaining to monitoring the Resident's cardiovascular status, [MEDICAL CONDITION], and weight and frequency of weight assessment and monitoring, Nurse L reviewed the medical record and indicated the Resident's weight was being obtained monthly. On [DATE] at 3:36 PM, an interview was completed with the Director of Nursing (DON). When queried regarding facility assessment, monitoring, and documentation for Resident's with [MEDICAL CONDITION], the DON indicated care is individualized for each Resident. When queried regarding assessment and monitoring for Resident #15, the DON reviewed the Resident's medical record and stated, (The Resident) is weighed monthly and wound care is also seeing them. With further inquiry regarding observations of [MEDICAL CONDITION], dependent positioning of the Resident's legs, and weight monitoring, the DON reviewed the medical record and stated, The order (physician order) is to weigh (Resident #15) once a month. Their last weight was 178.8 lbs. (pounds) on [DATE]. When asked if the Resident was on any dietary or fluid restrictions related to the [MEDICAL CONDITION], the DON replied, No. With further inquiry pertaining the monitoring of Resident #15's [MEDICAL CONDITIONS], and medical status including standards of care for individuals with [MEDICAL CONDITION], the DON indicated that facility staff assess Resident's frequently and in multiple ways. With further inquiry regarding documentation of assessments, the DON replied (Resident #15) isn't a skilled patient so they (staff) don't document every day. The DON reviewed the Resident's medical record at this time and was unable to provide documentation of frequent and applicable nursing assessment. On [DATE] at 3:48 PM, an observation occurred of Nursing Assistant M obtaining Resident #15's weight utilizing a chair scale. The Resident's weight at this time was 196.5 lbs (weight gain of 17.7 lbs in 19 days). On [DATE] at 3:55 PM, an interview was completed with the DON. When queried regarding the Resident's weight, the DON stated, We will get a full set of vital signs, re-weight (the Resident), and weigh them weekly. On [DATE] at 4:10 PM, a record review of facility policy entitled, Guidelines for Weight Tracking (Reviewed Date: [DATE]) revealed, Purpose: To ensure Resident width is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration . Unless otherwise indicated or ordered by the physician the Resident will have their weight taken and recorded monthly. A policy/procedure was requested, but not received by the conclusion of the survey, pertaining to monitoring of Residents with [MEDICAL CONDITION].

Based on observation, interview and record review, the facility failed to provide appropriate assessment, services, and treatment to maintain or improve mobility for one (# 12) of one Residents reviewed for mobility and functioning, of a total sample of 15, resulting in Resident #12 enduring functional decline, reduction in Range of Motion (ROM), diminished mobility, decreased independence, and unnecessary pain. Findings include: On 12/6/17 at 9:35 AM, Resident #12 was observed sitting in a Geri-chair in their room. The Resident's fingers on their left hand were observed to be positioned pointed straight outward and their thumb positioned inward toward the palm of their left hand. The Resident's right hand was in a claw-like position with their fingers bent downward and positioned at approximately a 70 degree angle. The Resident's right thumb was positioned inward toward the palm of their hand. At 2:06 PM on 12/6/17, an interview and observation of Resident #12 occurred. The Resident was observed sitting in a Geri-chair in their room. The Resident's fingers on their left hand were observed to be positioned pointed straight outward and their thumb positioned inward toward the palm of their left hand. The Resident's right hand was in a claw-like position with their fingers bent downward and positioned at approximately a 70 degree angle. The Resident's right thumb was positioned inward toward the palm of their hand. When asked questions, Resident #12 would shake their head to indicate yes or no and would also respond verbally with one word answers. When queried regarding their hands, Resident #12 stated, Stuck. With asked if they were able to move their hands, the Resident did not move their fingers and stated, Stuck. Record review on 12/7/17 at 11:50 AM revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, had impaired ROM in bilateral upper and lower extremities, and required extensive to total assistance to perform Activities of Daily Living (ADL's). Review of Resident #12's care plans at this time revealed a care plan entitled, Resident requires staff assistance to anticipate needs for the completion of ADL tasks d/t (due to) Dx (diagnosis) [MEDICAL CONDITION](stroke). (Resident) also has agitated behaviors at times and may require more time with ADL care (Start Date: 12/20/16, Edited: 12/7/17). The care plan included the intervention, Therapy evals as indicated with treatment as ordered to maintain my level of function (Created: 3/6/17). Review of Resident Progress Note documentation in Resident #12's medical record did not reveal nursing documentation pertaining to the Resident's ROM. Physician Documentation, authored by Physician B on 11/14/2017 at 9:30 AM revealed, .Musculoskeletal: No [DIAGNOSES REDACTED] swelling or joint tenderness, extremities without cyanosis, neck supple, ROM intact spine and extremities . On 12/11/17 at 8:32 AM, Resident #12 was observed in lying in bed in their room. The Resident was positioned on their back with both hands visible. The Resident's fingers on their left hand were observed to be positioned pointed straight outward and their thumb positioned inward toward the palm of their left hand. The Resident's right hand was in a claw-like position with their fingers bent downward and positioned at approximately a 70 degree angle. The Resident's right thumb was positioned inward toward the palm of their hand. An interview was conducted with Nursing Assistant H on 12/11/17 at 11:18 AM. When queried regarding Restorative Nursing services within the facility, Nursing Assistant H replied, Restorative dining? With further inquiry regarding facility staff that are responsible for completing active and passive ROM exercises with Residents to ensure they maintain functional levels, Nursing Assistant H stated, Therapy does that. On 12/11/17 at 11:20 AM, an interview was completed with Therapy Manager F. When queried regarding Restorative Nursing services within the facility, Therapy Manager F stated, There is no real restorative nursing (program) here. When asked about Resident #12, Therapy Manager F stated, (Resident #12) has been on and off case load (therapy services) a few times. When queried regarding Resident #12's hands and fingers, Therapy Manager F reviewed therapy documentation for Resident #12 and stated, We did work with (the Resident's) hands with some fine motor but there was no significant improvement. Therapy Manager F further stated, The last time (Resident #12) was on case load was a year ago. Therapy Manager F also indicated, We also do quarterly (therapy) screens. The only thing noted for (Resident #12) was sliding in wheelchair. That was in October. We would have looked at other issues if we would have noticed them then. When queried if the Resident had contractures in their hands when last evaluated by therapy services, Therapy Manager F reviewed the Resident's documentation and stated, No deficit noted before. When queried regarding facility policy/procedure to prevent functional decline, decreased ROM, and contracture development for Residents, Therapy Manager F stated, We would just have to pick them back up on caseload. We could maybe do splints or something like that. On 12/11/17 at 11:38 AM, observation Resident #12 occurred with Therapy Manager F. The Resident was sitting in their Geri Chair. The Resident's fingers on their left hand were observed to be positioned pointed straight outward and their thumb positioned inward toward the palm of their left hand. When asked by Therapy Manager F, Resident was unable to grasp and/or move their fingers on their left hand. Therapy Manager F proceeded to manually move the Resident's left hand and fingers. The Resident's right hand was in a claw-like position with their fingers bent downward and positioned at approximately a 70 degree angle. The Resident's right thumb was positioned inward toward the palm of their hand. When asked by Therapy Manager F, Resident #12 was unable to open their right hand and extend their fingers. Therapy Manager F proceeded to attempt to manually move and extend the fingers on the Resident's right hand. When Therapy Manager F attempted to move the Resident's fingers with minimal movement, Resident # 12 displayed facial grimacing and pulled their right hand away from Therapy Manager F. When queried if moving their hand and fingers hurt, Resident #12 nodded their head to indicate Yes. An interview occurred with Therapy Manager F at this time. When queried regarding Resident #12, Therapy Manager F stated, The right hand is definitely worse. They are not able to open it. When queried further regarding facility policies/procedures, Therapy Manager F stated, Typically if nursing sees anything we will get a referral. Therapy Manager F then stated, We (Therapy services) will look at (Resident #12) now that we know. An interview was conducted with the Director of Nursing (DON) on 12/11/17 at 12:06 PM. When queried regarding a Restorative Nursing program within the facility, the DON replied, We do not have a Restorative program yet. When queried further regarding the performance of active and passive ROM exercises with Residents, the DON stated, Nursing Assistants do passive ROM (with Residents) when dressing. With further inquiry regarding documentation of ROM exercises, the DON stated, No (documentation). At this time, the DON was questioned regarding Resident #12's care plans and whether or not ROM exercises were included. The DON reviewed the Resident's care plans and stated, Nothing in the care plan for hand and ROM. When queried regarding facility policies/procedures and why Resident #12's decreased ROM had not been observed and addressed by facility staff, the DON was unable to provide an explanation. An interview was conducted with the DON on 12/11/17 at 1:38 PM. The DON stated, I talked to therapy and they said there is no decline. The DON provided progress note documentation for Resident #12 authored by Occupational Therapist G. The progress note was dated 12/11/17 at 1:03 PM and stated, Patient has full PROM (Passive Range of Motion) in L (left) wrist and hand. Patient tends to keep fingers and wrist in flexed position at rest. Will continue to monitor and contact family in order to possible splint as needed. When queried further regarding observation of the Resident's right hand and fingers and why the documentation did not include assessment ROM in right hand and fingers, the DON did not provide an explanation. On 12/11/17 at 1:49 PM, an interview was completed with Therapy Manager F. When queried regarding progress note documentation of full PROM, Therapy Manager F stated, Full PROM means full movement in all planes. When queried if Resident #12 had full PROM when they assessed the Resident (on 12/11/17 at 11:38 AM), Therapy Manager F stated, No, but I am not going to second guess (Occupational Therapist G's) assessment. Maybe that is full ROM for (Resident #12). With further inquiry if documentation of full PROM meant full ROM, Therapy Manager F stated, Yes. An interview and observation of Resident #12 was conducted with Occupational Therapist G on 12/11/17 at 1:54 PM. When queried regarding the progress note documentation, dated 12/11/17 at 1:03 PM, not addressing ROM in the Resident's right hand and fingers and observation of the Resident being unable to extend the fingers on their right hand, Occupational Therapist G stated, (Resident #12) can fully extend their hand but they do grimace. On 12/11/17 at 1:59 PM, observation of Resident #12 occurred with Occupational Therapist G. Resident #12 was observed in their room sitting in their Geri-chair. The Resident's upper body was leaning over the right side of the Geri-chair upon entering the room. Occupational Therapist G was observed manually extending the Resident's fingers on their right hand. As Occupational Therapist G extended the Resident's fingers, the Resident displayed facial grimacing and pulled their hand away from Occupational Therapist G. With manual movement, the Resident's hand and fingers were not observed to be straight with their wrist. The maximum movement observed, before the Resident pulled away, was when the Resident's hand and fingers were at approximately 35 degrees. When queried regarding pain, Occupation Therapist G stated, It's definitely painful and Resident #12 nodded their head indicating the movement was painful. An interview and record review was completed with Therapy Manager F and Occupational Therapist G on 12/11/17 at 2:09 PM. When queried regarding Resident #12's prior level of functioning, Occupational Therapist G reviewed therapy documentation and stated, The initial (therapy) assessment was on January 4th 2017. That assessment indicates (Resident #12) could hold utensils (for eating) with assistance. When queried if the Resident was able to hold eating utensils with assistance at this time, Occupational Therapist G replied, No, (Resident #12) doesn't feed themselves now. Occupational Therapist G then stated, On 2/2/17 (Resident #12) could self feed with no reports of pain. After further review of documentation, Occupational Therapist G stated, No complaints of pain with extension in any of the documentation. When queried further, Occupational Therapist G stated, I would say yeah, there has been a decline and (the Resident) is in pain. At this time, Therapy Manager F provided a paper document entitled, Range of Motion assessment dated [DATE]. The document indicated Resident #12 had movement in both of their wrists and fingers that was slow, spastic, uncoordinated, or rigid. The document further indicated the Resident had No limitation in ROM of both wrists and severe limitation of fingers on both of their hands. When queried regarding measurements of limitations and/or further documentation, Therapy Manager F stated, We (Therapy) just did this assessment real quick when we first opened and started getting patients for a baseline. With further inquiry regarding specific documentation, Therapy Manager F stated, That is all there is. Record review of Occupational Therapy Plan of Care documentation for Resident #12 on 12/11/17 at 3:00 PM revealed the Resident received last received therapy services in the facility from 1/4/17 to 3/31/17. Additional review revealed documentation that Resident #12 had intact gross and fine motor control of their right upper extremity and severely impaired gross and fine motor control of their left upper extremity. On 12/11/17 at 3:10 PM, a review of OT (Occupational Therapy) - Therapist Progress note, dated 2/24/17, revealed, The patient demonstrates fair (26-75% accuracy) fine motor coordination of B (bilateral) hands . The patient is able to feel self after set-up utilizing spill proof cup for 70% of meal requiring moderate assistance (26-75% assist) . The patient is able to rinse dentures with maximum assistance (76-99% assist) while sitting. On 12/11/17 at 3:15 PM, a review of OT (Occupational Therapy) Daily Treatment notes revealed the following documentation: -3/7/17: Pt (Patient) working with inclined surface reaching forward to remove and replace 1 (inch) wood dowels for improved sitting balance and unilateral reaching . -3/8/17: Patient completed self drinking with min assist to get a good grasp in B (bilateral) hands and to remove lip when sip cup got too empty . Patient requested to self feed pudding since it was a small bowl and easy access with spoon. Patient completed this task with min (minimal) PA (Physical Assist) to scoop last few bites and tilt the cup. Patient completed rinsing off dentures with mod (moderate) pa . -3/9/17: .Patient did squeeze stress ball with B hands approximately 20 times each in order to increase ind (independence) with holding various items. Patient did tolerate PROM to all joints for BUE . -3/21/17: Pt completed AROM of BUE (Bilateral Upper Extremities) during cone stacking exercise . On 12/11/17 at 3:30 PM a review of facility policy entitled, Program Guidelines: Restorative Mobility Program (Revised 5/15/16) revealed the following: Purpose: To encourage increased independence and maintain mobility through services that promotes circulation, stimulates and strengthens muscles, reduces the potential of falls and increases self-esteem. The policy further revealed, Initiate documentation of the Resident program in the EHR (Electronic Health Record) indicating participation and number of minutes that interventions are provided.