Every finding on record at Park Terrace Village

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 2 of 2 kitchen observations. (Kitchen) Finding includes: On 11/18/25 at 8:57 a.m., an observation was made of the kitchen. The following was observed:Dirt and debris on the floor, behind the stove, fryer, convection oven, and steamer.Dirt and debris under stainless steel tables and under racks. Debris and grease on top of the stove, sides of the stove, and sides of the fryer.Dirt and debris behind the ice machine, steam table, and plate warmer debris observed on surfaces. Dirt and debris on the floor and under the racks in the dry pantry. On 11/18/25 at 11:11 a.m., the same was observed. On 11/18/25 at 11:13 a.m., the Dietary Manager indicated the kitchen is cleaned daily, floors are usually cleaned at night, but did not get done last night due to being short-staffed. The staff follow a cleaning schedule. On 11/18/25 at 11:29 a.m., the Administrator provided the current policy on kitchen cleanliness with an original date of 06/25. The policy included, but was not limited to: A clean, sanitary, and safe kitchen environment will be maintained at all times to ensure the health and well-being of our residents, staff, and visitors. All kitchen areas, including food preparation surfaces, equipment, storage areas, walls, and floors, must be cleaned regularly and kept free of debris, spills, and potential contaminants. This citation relates to Intake 2669490. 3.1-21(i)(2)3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure proper storage of and labeling of medications for 3 of 5 medication carts and 1 of 2 wound treatment carts. Loose pills, food, and unlabeled medications were observed in the medication and treatment cart drawers. (Treatment Cart for B Hall, A Hall Medication Cart, B Hall Medication Cart, C Hall Medication Cart) Findings include: 1. On 3/4/25 at 10:49 A.M., the Treatment Cart for the B Hall was observed with the following: 1 bottle of Peri cleaner(cleaner) without label or resident name 1 can of soda in the third drawer in the third drawer 1 pair of toenail clippers no resident name or storage bag 2. On 3/4/25 at 11:00 A.M., the B Hall Medication Cart was observed to have an open package of chewing gum without identification of ownership. 3. On 3/4/25 at 11:15 A.M., the A Hall Medication Cart was observed with the following: 1 small round pill with the number 11 1 small round orange pill with the letter F and the number 50 1 bottle of Acetaminophen (pain medication) 500 milligrams (Mg) without label or open date. 4. On 3/4/25 at 11:26 A.M., the C Hall Medication Care was observed with 2 loose Cephalothin (Antibiotic) pills in a drawer. 5. On 3/6/25 at 7:19 A.M., during a medication pass to Resident 28, Qualified Medication Aide (QMA) 14 was observed dropping a pill on the top of the B Hall Medication Cart and placed into a medicine cup that was later given to the resident. QMA 14 observed passing medications to Resident 19 who refused a stool softener pill and placed the pill in a cup and left it unlabeled in a medication drawer. During an interview on 3/4/25 at 10:55 A.M., the Assistant Director of Nursing (ADON) indicated if it comes in a bottle there should be a label. ADON also indicated there should be no food or nail clippers in the treatment or medication carts. The nail clippers should be in a plastic bag and labeled. During an interview 3/7/25 at 11:15 A.M., the Director of Nursing (DON) indicated that if a QMA drops medication it should be thrown away and a new one to replace it. If a resident refuses a medication it is to be thrown away and not left in a drawer unlabeled. Medications should be labeled with the name of the resident if put in a cup locked drawer. On 3/10/25 at 11:00 A.M., the Administrator provided a current policy Medication Storage and Expiration Policy dated 11/24. The policy indicated .food is not to be stored in . general storage areas where medications are stored .facility should destroy and reorder medications when .damaged .should be stored in accordance with manufacturers' recommendations. 3.1-25(k)(1) 3.1-25(o) 3.1-18(b)

Based on observation, interview, and record review, the facility failed to safely store and produce food under professional standards related to food items not labeled or stored properly and sanitary kitchen surfaces for 1 of 1 dietary areas observed. Findings include: During a kitchen walk through on 3/4/25 at 9:03 A.M., the following was observed: Walk in refrigerator: One pitcher labeled sweet tea, no date One pitcher labeled apple juice, dated 2/28 use by 3/1 One opened bag and two closed bags of wilting lettuce, best by date 2/23/25 Bag of sliced American cheese, opened 2/26 use 3/4 Bag of shredded cheese, opened 2/26 use 3/4 Bag of mozzarella cheese open to air, opened 2/24 use by 3/3 Walk in freezer: Bag of Canadian bacon, dated 2/6 use by 2/9 Bag of meatballs, dated 2/20 Dry storage: Box of loaves of bread directly on floor Opened bag of instant mashed potatoes, no date Opened of penne pasta, dated 1/18 Opened of macaroni noodles, no date Opened bag of egg noodles, no date Opened bag of [NAME] rigate noodles, no date Box of powdered sugar, open to air Box of puree rice mix, open to air Black handled scoop with residue sitting directly on open shelf Floor around stove and top of stove dirty with food debris On 3/7/25 at 9:37 A.M., the Dietitian indicated food should be labeled and dated according to the facility policy. On 3/10/25 at 11:00 A.M., the Administrator provided a policy titled Food Storage, revised 5/23, that indicated 4. Scoops should be kept covered in a protected area near the containers. 6. Food is stored a minimum 6 above the floor. 7. Leftover prepared foods and processed meats are to be stored in covered containers and wrapped securely. The food must be clearly labeled and dated with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded. Leftover foods can be held at 41 Fahrenheit (F) or less for no more than 3 days. The day the food was prepared shall be counted as day 1. 8. Refrigerated, ready to eat, potentially hazardous food purchased from approved vendors shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded. This opened food can be held at 41 F or less for no more than 7 days and the date marked may not exceed the manufacturer's use by date. 13. Dry storage containers with covers must be used for storing flour, sugar, pasta and partial cases of bulk foods when removed from their original container. These containers should be labeled and dated on both the container and lid. All food shall be covered or wrapped tightly, labeled, and dated. 3.1-21(i)(3) 3.1-21(I)(2)

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were performed during 3 of 3 random observations. Staff observed not performing hand hygiene during a medication pass of B Hall, using Enhanced Barrier Protection (EBP), and changing gloves during care. ( Resident 28, Resident 39, Resident 19, Resident 48, Resident 41, Resident 18, Resident 22, Resident 3) Findings include: 1. On 3/6/25 at 7:19 A.M., during a random observation of a medication pass, Qualified Medication Aide (QMA) 14 failed to perform hand sanitization prior to entering Resident 28's room. On 3/6/25 at 7:25 A.M., during a random observation of a medication pass, QMA 14 failed to perform hand hygiene prior to entering and exiting Resident 39's room. On 3/6/25 at 7:32 A.M., during a random observation of a medication pass, QMA 14 failed to perform hand hygiene prior to entering and exiting Resident 19's room. On 3/6/25 at 7:38 A.M., during a same random observation of a medication pass, QMA 14 sneezed into sleeve without performing hand hygiene and exiting Resident 48's room. On 3/6/25 at 7:45 A.M., during a random observation of a medication pass, QMA 14 failed to perform hand hygiene prior to entering and exiting Resident 41's room. On 3/6/25 at 7:50 A.M., during a random observation of a medication pass, QMA 14 failed to perform hand hygiene prior to entering Resident 18's room. During an interview on 3/7/25 at 11:01 A.M., the Infection Preventionist indicated staff should perform hand hygiene before they touch anything, before going into a resident's room, and after leaving the resident. 48147 2. On 3/7/25 at 8:39 A.M., Certified Nurse Aide (CNA) 6 was observed performing incontinence care for Resident 22. CNA 6 was not wearing a gown. An Enhanced Barrier Precaution (EBP) sign was observed above Resident 22's bed. The sign indicated that staff should wear a gown and gloves during high contact care. On 3/7/25 at 9:25 A.M., Resident 22's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and stage two pressure ulcer. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 2/17/25, indicated Resident 22 had severe cognitive impairment, was dependent on staff for toileting, and did not have a pressure ulcer. Current care plans included, but were not limited to: Resident is at risk of transferring or becoming colonized with an Multi-Drug Resistant Organizisms (MDRO) and requires enhanced barrier precautions due to a chronic wound that requires a dressing, dated 3/5/25 A Wound Management Observation note, dated 3/5/25 at 10:30 A.M., indicated Resident 22 had a stage two pressure ulcer on the right side of her sacrum. On 3/7/25 at 10:22 A.M., the Director of Nursing (DON) provided a current list of residents who were on EBP. Resident 22 was listed. On 3/7/25 at 10:39 A.M., the Director of Nursing (DON) indicated that residents on EBP had a care plan for EBP, but did not have physician orders for EBP. On 3/7/25 at 11:01 A.M., the IP indicated that if a resident was on EBP, staff should wear gown and gloves during high contact care. 48057 3. During an observation of incontinence care on 3/7/25 at 11:26 A.M., CNA 7 entered Resident 3's room, sanitized her hands, and put a gown and gloves on. CNA 7 raised Resident 3's bed with the remote, rolled Resident 3 to her side, and removed her pants and soiled brief. CNA 7 used incontinence wipes to clean Resident 3. CNA 7 removed her gloves, applied hand sanitizer, put new gloves on, and put a clean brief under Resident 3. CNA 7 looked through Resident 3's dresser and bedside table drawers with gloves on to find barrier cream. CNA 7 applied barrier cream on Resident 3's bottom, wiping the cream over the wounds on Resident 3's coccyx and left gluteal fold. CNA 7 removed her soiled glove, put a new glove on, and rolled Resident 3 back over and assisted pulling her brief and pants up. On 3/10/25 at 11:00 A.M., the Administrator provided a current policy Hand Hygiene Policy revised in 12/21. The policy indicated .hand hygiene applies to hand washing, antiseptic hand wash, and alcohol based hand rub .moments of hand hygiene include .before touching a patient, after body fluid risk, and after touching a resident . On 3/10/25 at 11:00 A.M., the Administrator provided a current undated Enhanced Barrier Precautions policy that indicated Use of personal protective equipment - gown and gloves - during high-contact resident care activities .changing briefs or assisting with toileting . Gloves and gown prior to the high-contact care activity . 3.1-18(b)(2) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity during a meal observation for 1 of 1 resident's reviewed for activities of daily living who required staff assistance to eat. (Resident 3) Finding includes: During an interview on 3/4/25 at 10:04 A.M., a family member indicated Resident 3 is not able to feed herself, and staff not always willing to assist her with eating. On 3/5/25 at 10:20 A.M., Resident 3's clinical record was reviewed. Resident 3's diagnoses included, but were not limited to, hypertensive heart disease and congestive heart failure (CHF). The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 2/15/25, indicated Resident 3 was severely cognitively impaired and was dependant on staff (staff do all of the work) for eating, toileting, showering, and transfers, and received oxygen therapy. Current care plans included, but were not limited to: Resident requires assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toileting related to: weakness, decreased mobility, incontinence, impaired cognition, Start date 6/22/22 During an observation on 3/5/25 at 12:24 P.M., CNA 5 indicated all lunch trays had been passed. Resident 3's lunch tray was sitting on her bedside table next to her, out of her reach, and staff were not feeding Resident 3. At 12:51 P.M., CNA 9 yelled down the hall to CNA 5, who was removing the lunch tray from Resident 3's room, and asked CNA 5 if Resident 3 still needed to be fed. CNA 5 stated she had forgot, and entered Resident 3's room to assist with feeding her. During an interview on 3/10/25 at 11:26 A.M., The Administrator indicated the facility did not have a written policy related to dignity but the facility's policy was to treat all residents with dignity and respect. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents observed with medications in their room. (Resident 8) Finding includes: On 3/4/25 at 10:04 A.M., a white pill and a red pill were observed in a medication cup on Resident 8's bedside table. On 3/5/25 at 12:25 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, type 2 diabetes mellitus and major depressive disorder. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated Resident 8 was cognitively intact, was dependent on staff for rolling left to right, toileting, and bathing, and received antianxiety medication, antidepressants, hypnotics, anticoagulants, diuretics, opioids, and hypoglycemic medications during the seven day look back period (1/10/25 to 1/16/25). The clinical record lacked an assessment, order, and care plan related to the resident's ability to self administer medications. On 3/6/25 at 1:19 P.M., Qualified Medication Aide (QMA) 14 indicated there were no residents who were allowed to self administer their own oral medications. On 3/6/25 at 2:02 P.M., the Administrator indicated that Resident 8 did not have a self administration of medication assessment or order. On 3/10/25 at 11:00 A.M., the Administrator provided a current Self Administration of Medication policy, dated 11/2015, that indicated Periodic evaluations of the resident's ability to self-administer medications must be made to ensure that safe and effective procedures are followed. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided according to professional standards for 3 of 3 residents reviewed for respiratory care. Residents were receiving oxygen at a flow rate that was not consistent with the physician order.(Resident 8, Resident 3, Resident 47) Findings include: 1. On 3/4/25 at 10:10 A.M., Resident 8 was observed lying in bed receiving 4 liters (L) of oxygen via nasal cannula. At that time, Resident 8 indicated she was supposed to receive 3 L of oxygen. On 3/5/25 at 12:35 P.M., Resident 8 was observed lying in bed receiving 4 L of oxygen via nasal cannula. On 3/6/25 at 1:18 P.M., Resident 8 was observed lying in bed receiving 4 L of oxygen via nasal cannula. On 3/5/25 at 12:25 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD). The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated Resident 8 was cognitively intact, was dependent on staff to roll left and right, toileting, and bathing, and was receiving oxygen therapy. Current physician orders included, but were not limited to: Oxygen at 2 liters per nasal cannula every shift, dated 1/10/25 A current risk for impaired gas exchange care plan, revised 1/20/25, included an intervention of oxygen at 2 L per nasal cannula. On 3/6/25 at 1:20 P.M., Qualified Medication Aide (QMA) 14 indicated that Resident 8 was supposed to be on 2 to 3 liters of oxygen. 48057 2. During an observation on 3/4/25 at 1:40 P.M., Resident 3 was observed laying in bed. Her nasal cannula was not in her nose and the tubing was hanging on one ear. Resident 3's oxygen concentrator was on 1 liter. On 3/5/25 at 10:20 A.M., Resident 3's clinical record was reviewed. Resident 3's diagnoses included, but were not limited to, hypertensive heart disease and congestive heart failure (CHF). The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 2/15/25, indicated Resident 3 was severely cognitively impaired and was dependent on staff (staff do all of the work) for eating, toileting, showering, and transfers, and received oxygen therapy. Current physician orders included, but were not limited to: Oxygen at 2 liters per nasal cannula every shift, start date 4/10/23 The current care plan included, but was not limited to: Resident has potential for impaired gas exchange related to: CHF, utilizes supplemental O2 (oxygen), Start date 1/17/24 Administer oxygen as ordered - 2 liters per nasal cannula, Start date 1/17/24 3. During an observation on 3/4/25 at 2:24 P.M., Resident 47's oxygen concentrator was on four liters. Resident 47 indicated she should be receiving 2 liters of oxygen. On 3/6/25 at 9:09 A.M., Resident 47's clinical record was reviewed. Resident 47's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD). The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/13/25, indicated Resident 3 was dependent on staff (staff do all of the work) for transfers, and received oxygen therapy. Current physician orders included, but were not limited to: Oxygen at 2 liters per nasal cannula every shift, start date 1/8/25 The current care plan included, but was not limited to: Resident has potential for impaired gas exchange related to COPD, Start date 5/10/24 Administer oxygen as ordered - 2 liters per nasal cannula, Start date 5/10/24 During an interview on 3/7/25 at 8:48 A.M.,Licensed Practical Nurse (LPN) 10 indicated Resident 47 should be receiving 2 liters of oxygen. On 3/10/25 at 11:00 A.M., the Administrator provided a current Oxygen Therapy policy, dated 11/2015, that indicated The nurse will coordinate the oxygen therapy services as ordered by the resident's physician. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19. Staff were observed not properly wearing PPE (Personal Protective Equipment) and practicing infection control practices. (Resident H, 200 unit) Finding includes: On 10/1/24 at 9:00 a.m., the Administrator indicated the facility had 16 residents who were COVID-19 positive. On 10/1/24 at 9:55 a.m., LPN 2 was observed to be wearing a gown, gloves, face shield, and a surgical mask underneath an N-95 mask before entering room [ROOM NUMBER], a COVID-19 positive room. room [ROOM NUMBER] had COVID-19 isolation precautions posted on the door. LPN 2 was observed to exit room [ROOM NUMBER] wearing the surgical mask, walk to the medication cart, laid the N-95 mask and face shield on top of a binder on the cart. LPN 2 was observed to prepare medications, touch the surgical mask she was wearing with bare hands, no hand hygiene done after. LPN 2 moved the face shield and N-95 mask off the top of the binder, wrote on the binder, opened the narcotic drawer with keys, charted on the computer, picked up the medication cup, donned a gown, gloves, a new N-95 mask over the surgical mask, a new face shield and entered room [ROOM NUMBER], a COVID-19 positive room. room [ROOM NUMBER] had COVID-19 isolation precautions posted on the door. LPN was observed to exit room [ROOM NUMBER] wearing the surgical mask, performed hand hygiene. On 10/2/24 at 8:38 a.m., Housekeeper 2 was observed to don a gown, gloves, face shield, a surgical mask was observed on. Housekeeper 2 entered room [ROOM NUMBER] a COVID-19 positive room. room [ROOM NUMBER] had COVID-19 isolation precautions posted on the door. On 10/2/24 at 8:54 a.m., Resident H was observed to exit room [ROOM NUMBER], a COVID-19 positive room, go to the nurses station and tell a staff member she needed something. Resident H was not wearing a mask. Two staff members were observed by the nurses station, one staff was observed by Resident H's room at the medication cart, none were heard to inform Resident H of COVID-19 isolation precautions. A resident who was at the nurses station was overheard telling Resident H she was not supposed to be out of her room, Resident H returned to her room. On 10/3/24 at 9:21 a.m., LPN 3 indicated before entering a COVID-19 positive room, a gown, gloves, face shield, N-95 mask should be worn, the surgical mask should be taken off before putting on an N-95 mask. On 10/3/24 at 10:06 a.m., the Administrator provided the current transmission-based precautions for isolation policy with a reviewed date of 4/4/24. The policy included, but was not limited to: . Droplet/Contact Precautions (formerly droplet plus precautions): is used to designate transmission-based precautions beyond droplet precautions for residents who meet the criteria for transmission-based precautions with COVID-19, which includes the use of N-95 respirator .HCP (Health Care Personal) should wear an N-95 or higher-level respirator, eye protection (i.e.; goggles or face shield that covers the front and sides of the face), gloves, and gown when caring for these residents .PPE must be appropriately doffed and discarded in trash prior to leaving the room . remove mask/ face protection and dispose before leaving the room .Limit transportation and movement outside of room to medically necessary purposes. Essential movement (therapy, showers, restroom, etc.). When transportation is necessary, ensure that the resident wears a mask and follows Respiratory Hygiene/Cough Etiquette, perform hand hygiene before leaving and upon returning to room . 3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure medications were secure, labeled correctly, stored at proper temperatures, and the temperature monitor logs were complete in 3 of 3 medication carts observed. (B/D/E hall medication carts) Findings include: 1. On 2/16/24 at 9:30 A.M., the medication cart for B hall was observed with the narcotic box within the medication cart unlocked. 2. On 2/16/24 at 9:44 A.M., the medication cart for E hall was observed with the narcotic box within the medication cart unlocked. There was a box in the top drawer of the cart that contained an opened vial of Tubersol (used to test for tuberculosis) with an open date 11/8/93. Two loose pills were observed in the cart; a pink oval pill with 5 on one side and 894 on the other, and an orange round pill with 277 on one side. During an interview on 2/16/24 at 9:50 A.M., RN 4 indicated the narcotic boxes should be locked and the loose pills should not be in the cart and then disposed of the loose pills in a drug buster solution located in the medication room. RN 4 indicated the TB (Tubersol) solution should be stored in the refrigerator and that she was unsure of the accuracy of the date on the TB solution. RN 4 removed the TB vial from the medication cart and took the TB solution to the Clinical Regional Nurse. During an interview on 2/16/24 at 10:30 A.M., the Clinical Regional Nurse observed the TB solution and indicated she had no idea what the open date wrote on the box was supposed to be but confirmed it did appear to read as 11/8/93. On 2/20/24 at 2:15 P.M., the Administrator provided the manufacturer guidelines insert from the Tubersol solution box. The guidelines indicated the solution should be stored at 35 to 46 degrees Fahrenheit, and should be discarded 30 days after first use, or after the manufacturer expiration date. 3. On 2/16/24 at 9:50 A.M., the medication cart for D hall was observed. A pink round pill with an M on one side and 2 1/2 on the other side, two opened, undated bottles of nasal spray, and an opened, undated bottle of cough syrup were observed in the medication cart. On 2/16/24 at 9:55 A.M., QMA 11 indicated the loose pill should not be in the bottom of the cart and disposed of the pill in the sharp's container on the side of the medication cart. 4. On 2/16/24 at 9:57 A.M., the medication room behind the skilled nurse's station was observed. The refrigerator that stored overflow medications had a temperature of 34 degrees Fahrenheit. The equipment temperature monitoring sheet lacked 4 of 16 days filled out for day shift (2/1, 2/4, 2/7, 2/14) and 3 of 15 days filled out for night shift (2/3, 2/6, 2/12). On 2/16/24 at 10:01 A.M., QMA 11 indicated the sheet should be filled out each shift and provided a copy of the refrigerator temperature log for the month of February 2024. On 2/16/24 the Clinical Regional Nurse provided a current policy titled Storage and Expiration Dating of Medications, revised 7/21/22. The policy stated the following: Facility should store Schedule II-V Controlled Substances, in a separate compartment within the medication carts and should have a different key or access device. Once any medication is opened, Facility should follow manufacturer guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container. Facility should monitor the temperature of medication storage areas at least once per day and monitor cold storage containing vaccines two times a day per CDC guidelines. Facility should destroy medications with incomplete or missing labels. 3.1-25(j) 3.1-25(n) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was properly labeled, oxygen and medication for respiratory complications were properly administered, or proper tracheostomy suction was provided for 5 of 7 residents at risk for respiratory complications. (Resident B, Resident 30, Resident 55, Resident 62, Resident 119) Findings include: 1. On 2/14/24 at 9:15 A.M., Resident B's clinical record was reviewed. Resident B was admitted on [DATE]. Diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), Congestive Heart Failure, and chronic respiratory failure with hypoxia. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 1/12/24, indicated resident B had moderate cognitive impairment and was receiving oxygen. Current orders included, but were not limited to: Furosemide tablet; 40 mg (milligram) Take for SOB (shortness of breath) or lower extremity edema PRN (once a day), start date 1/6/24. The administration history indicated there had been no administrations of the PRN Furosemide since the start date, 1/6/24. Oxygen at 4 liters per nasal cannula every shift, start date 1/6/24. A progress note on 2/12/24 at 2:16 A.M. indicated Resident B was using 3 liters of oxygen. A progress note on 2/16/24 at 8:55 A.M. indicated Resident B was using 3 liters of oxygen. A weekly skin assessment dated [DATE] indicated Resident B was exhibiting edema in the lower extremities. A weekly skin assessment dated [DATE] indicated Resident B was exhibiting edema in the lower extremities. A weekly skin assessment dated [DATE] indicated Resident B was exhibiting edema in the lower extremities. During an observation on 2/12/24 at 1:33 P.M., Resident B's portable oxygen tank in use at the time was observed with the dial set to 3 liters, and the oxygen tubing not dated. Resident B had noticeable edema in both lower extremities and was not wearing any compression stockings. During an observation on 2/15/24 at 1:06 P.M., Resident B's portable oxygen tank in use at the time was observed with the dial set to 2.5 liters. During an observation on 2/16/24 at 1:40 P.M., Resident B's oxygen concentrator in use at the time was observed with the dial set to 3.5 liters. Resident B was using a pulse oximetry device that read 77% oxygen. Resident B stated the nurse had removed the nail polish from the finger the pulse oximerty was on to read the oxygen level. RN 4 and QMA 3 entered Resident B's room; RN 4 confirmed the oxygen level did read 77% on the pulse oximetry device, and QMA 3 stated the oxygen liters did appear to be set below 4 because it is hard to read where the ball that measures the liters is sometimes. On 2/20/24 at 2:50 P.M., the Clinical Regional Nurse provided a copy of the PRN administration history for Furosemide 40 mg. The record lacked administration of the medication following assessments that indicated edema presented in Resident B. On 02/20/24 at 12:55 P.M., the Administrator indicated PRN medications should be administered if a resident requests them or if a nurse indicates a need for a PRN medication during an assessment. 46758 2. On 2/13/23 at 8:59 A.M., Resident 30's oxygen tubing was observed with no date on the tubing or a bag to place the tubing in. The nebulizer's tubing was not dated and the bag for the tubing was on the floor this was dated 2/12/24. On 2/15/24 at 8:48 A.M., Resident 30 was observed in bed with oxygen and nebulizer tubing not dated, On 2/14/24 at 1:26 P.M., Resident 30's clinical record was reviewed. Diagnoses included but were not limited to, acute and chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation. Resident 30's most recent Admission MDS (Minimum Data Set) Assessment, dated 12/11/23 indicated Resident 30 was cognitively intact, used oxygen, but needed extensive assistance of one for mobility, transfer, and toileting. Current Physicians orders included but were not limited to, Oxygen at 2 to 6 liters per nasal cannula. Special Instructions: Comfort measures. Every Shift - PRN ( as needed) the order was dated 1/10/24. On 2/15/24 at 8:51 A.M.,QMA (Qualified Medicine Aide) 13 indicated the day shift or night shift will change the initial bag once a week and it will be labeled with the dated. If not in use they will stay in the bag on the concentrator. 3. On 2/12/24 at 2:27 P.M., Resident 55 was observed lying in bed with a tracheostomy attached to an aerosol collar that had a humidification bottle that was not dated. There was used oxygen tubing in a bag without a date on the concentrator. On 2/16/24 at 10:19 A.M., Resident 55 was observed lying in bed with a tracheostomy attached to an aerosol collar that had a humidification bottle that was not dated and dry. On 2/19/24 at 12:59 P.M., RN (Registered Nurse) 5 was observed during tracheostomy care on Resident 55. During the procedure, removed the tracheostomy's inner cannula with clean gloves. The resident required suction during the care and the RN suctioned the resident without the inner cannula in place. On 2/21/24 at 8:44 A.M., Resident 55 was observed laying in bed with a tracheostomy attached to an aerosol collar that had a humidification bottle that was not dated. On 2/16/24 at 8:40 A.M., Resident 55's clinical review was reviewed. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, Tracheotomy, unspecified asthma. Resident 55's most current significant change status MDS ( Minimum Data Set) assessment dated [DATE] indicated the resident was cognitively intact,had a tracheostomy with oxygen. Resident 55 needed extensive assistance for transferring, mobility, and toileting. Current physician orders, included but were not limited to: Change nebulizer tubing/set once a day on Sunday dated 11/15/23. Tracheostomy orders: Change trach setup weekly on Sunday: mask/collar, oxygen tubing and humidifier dated 11/15/23. Tracheostomy orders: Change tracheostomy inner cannula. Special Instructions: with tracheostomy care dated 11/15/23. The current care plan indicates the resident has a tracheostomy and to use oxygen as ordered dated. 4/17/23. During an interview on 2/19/24 at 1:28 P.M., LPN (Licensed Practical Nurse) 23 indicated they do not suction the tracheostomy unless the inner cannula is in place. On 2/21/24 at 12:15 P.M., the Clinical Regional Nurse presented a current skill checklist Tracheostomy Suctioning Procedure dated 9/2022. The checklist indicated . insert the catheter into the trach stoma until resistance is felt without applying any suction . The Clinical Regional Nurse indicated there was no written policy but the policy for the facility was to suction the trach without the inner cannula and use the skill sheet for reference. The facility did not have a written policy addressing all aspects of the provision of tracheostomy care, including suctioning. Professional reference for the tracheostomy suctioning from the National Center of Biotechnology of Information, National Institute of Health . Suctioning should never be performed through a fenestrated tube without first inserting a non-fenestrated inner cannula, or severe tracheal damage may occur. 4. On 2/12/24 at 11:41 A.M., Resident 62 was observed laying in bed with oxygen tubing unlabeled and no bag located. On 2/16/24 at 1:45 P.M., Resident 62 was observed laying in bed with oxygen tubing in nostrils, but the humidification bottle was dry. On 2/12/24 at 11:37 A.M., Resident 62's clinical record was reviewed. Diagnoses included, but were not limited to, Malignant neoplasm of ventral surface of tongue, acute respiratory failure with hypoxia, and other pulmonary embolism without acute core pulmonale. The current Significant Change MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 62 was cognitively intact and needed extensive assistance with toileting, mobility, and eating. Current physician orders included, but were not limited to, oxygen at 3 liters per nasal cannula dated 10/12/23. 5. On 2/12/24 at 10:42 A.M., Resident 119 oxygen was observed laying across the bed without a date. On 2/15/24 at 8:54 A.M., the oxygen tubing was observed laying across the headboard of Resident 119's bed. On 2/21/24 at 8:37 A.M., Resident 119 oxygen tubing was not bagged and laying across the top of the bed. On 2/15/24 at 9:01 A.M., Resident 119's clinical record was reviewed, Diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, and acute and chronic respiratory failure with hypercapnia. The current Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 119 was cognitively intact, used oxygen, and needed partial help with transfer and mobility. Current physician orders included, but were not limited to: Change nebulizer tubing/set once a week on Sunday dated 1/24/24. Change oxygen tubing and humidity once a week on Sunday dated 1/24/24. The current care plan indicated the resident has a potential for impaired gas Resident has potential for impaired gas and has an intervention for being non-compliant with the use of oxygen and refused to allow tubing to be bagged date 2/2/24. During an interview on 2/16/24 at 1:45 P.M., the Clinical Regional Nurse indicated there was no Oxygen policy the facility follows [company name] policy for oxygen. O2 (oxygen) tubing is changed weekly and placed in a dated bag. If O2 tubing is not being used the oxygen should be a bag. Nebulizers tubing is changed weekly, and tubing is in a bag. Medication should not be left in resident room unless there is a self-administration order and assessment. This is for all forms of medications. On 2/15/24 at 10:00 A.M., the Administrator provided a current, undated, policy titled Oxygen Concentrator that stated Adjust the flow meter control knob to the flow setting prescribed by the physician. Place [nasal cannula] in a labeled bag when not in use. If prescribed, attach the humidifier bottle to the oxygen outlet connection and ensure there is water in the bottle. On 2/2024 at 2:50 P.M., the Clinical Regional Nurse provided a current policy titled PRN Medications, dated 11/15, that stated PRN medications are those medications to be given to a resident on an as needed basis. These medications are to be given to residents based on their symptoms. 3.1-47(a)(4) 3.1-47(a)(5) 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. Finding includes: On 2/12/24 at 10:13 A.M., Resident 51 indicated she was one of the last residents to get served food and her breakfast was not always hot. On 2/12/24 at 10:56 A.M., Resident 15 indicated the food was occasionally cold when it arrived to her room. On 2/12/24 at 11:29 A.M., Resident 60 indicated she had an issue with the temperature of the food. On 2/12/24 at 11:29 A.M., Resident 17 indicated the food was not always hot when it arrived to his room. On 2/12/24 at 1:27 P.M., Resident 45 indicated the food was not hot when served. On 2/12/24 at 1:47 P.M., Resident 52 indicated that the food was occasionally cold when it arrived to his room. On 2/13/24 at 2:30 P.M., Resident 32 indicated the food didn't taste good and the temperatures weren't consistently palatable. On 2/15/24 at 12:56 P.M., a test tray was obtained from the C Hall. The following temperatures were observed and recorded: Baked beans - 112 degrees Fahrenheit (F) Tenderloin - 139 degrees F Coleslaw - 46 degrees F Apples - 42 degrees F On 2/15/24 at 1:09 P.M., the Dietary Manager indicated she expected serving temperatures to be no less than 160 degrees F for hot food and no greater than 40 degrees F for cold food. On 2/19/24 at 12:45 P.M., a current Food Temperatures policy, revised 6/23, indicated All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food. 3.1-21(a)(2)

Based on interview and record review, the facility failed to monitor for behaviors in 1 of 2 residents reviewed for resident to resident altercations. (Resident 37, Resident 3) Findings include: On 2/12/24 at 9:48 A.M., Resident 3 indicated there was another resident (Resident 37) who was verbally aggressive with him, followed him around, and bothered him during the one time verbal altercation. He indicated the other resident (Resident 37) made him feel scared at that time but feels nervous sometimes now when he sees him in the hallway. At that time of the altercation, he indicated that he had made staff aware. On 2/16/24 at 1:16 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, mild intellectual disability, generalized anxiety, and depression. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/12/24, indicated Resident 3 was cognitively intact and had no behaviors. A progress note on 1/30/2024 at 7:57 P.M. indicated Resident heard hollering at another resident in the smaller dining area. Per resident, another resident was being rude and making hateful comments towards him. Education provided to residents and separated them. No other issues thus far. Resident is in his room at this time. The clinical record for Resident 3 lacked a follow up, event, observation, or care plan related to that incident. On 2/19/24 at 12:25 P.M., Resident 37's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The most recent quarterly MDS assessment, dated 12/9/23, indicated Resident 37 was cognitively intact and had physical behaviors directed towards others that occurred 1 to 3 days during the 7-day look back period. Progress notes included, but weren't limited to, the following: 11/11/2023 at 6:00 P.M. Resident came to nurses station to ask when residents were going to be going out to smoke and who would be taking them out. This nurse explained to resident that a staff member would be with the residents in a few minutes and that smoke break will be given to the residents. The resident continued to ask who was going to take the residents out to smoke. Another resident was reaching across him and pointing toward a staff member that was getting the things ready for smoke break. The resident continued asking when the [sic] would get to smoke, the other resident slapped him in the chest attempting to get the residents attention. When the other resident slapped him in the chest, this resident turned around and grabbed the resident my [sic] the shirt and was pushing and pulling the resident attempting to punch her. This nurse got up and went into the the [sic] day room and broke up the fight. The residents were sent to their rooms. This nurse called the DON (Director of Nursing) and social worker about the fight. Resident started on 15 min checks until further notice. Residents skin assessed with no abnormal findings. Resident in bed watching tv, call light in reach and water by bedside. An IDT (Interdisciplinary Team) note, dated 11/14/23, indicated there was an altercation with another resident. A care plan was created and included the interventions encourage res (resident) to wait in his room or other quiet area prior to smoke break . 11/23/2023 at 6:26 P.M. while in dining room res turned up radio which agitated another res, the other res started hollering and swinging arms as if to hit [name of Resident] and [name of Resident ] also was swinging arms as if to hit other res, no contact was made, both res removed from location, 1:1 (1 to 1 supervision) given, [name of Resident] calm after 1:1. later this shift he went into another res room without permission, redirected, 1:1 given, stated he understood he was not to go into rooms without permission. further into the shift he attempted to grab a cna between the legs at dinner time he was noncompliant with the dining room rules, refusing to cooperate, redirected 1:1 given by lpn (Licensed Practical Nurse), behav [sic] changed and remained in dining room without further incident. Responsible party [name of responsible party] updated and thanked staff for his care, [name of NP (nurse practitioner)] updated. 1/15/2024 at 7:57 P.M. res attempted to go into another res room, redirected and res compliant, several minutes later he was attempting to go outside with outside temp 8 degrees, it took several redirections before he stopped attempting to go outside, res was frustrated that it was to [sic] cold to smoke outside today, after he quit trying to go outside he gave another res the middle finger for no known reason, afterwards when LPN was speaking to him he decided to go to bed early and rest, no further incidents. 1/30/2024 at 7:58 P.M. Resident had behaviors this evening in the smaller dining room. Other residents reported that resident was making hateful and rude comments towards one of them. Resident followed the other resident (Resident 3) in his wheelchair. Staff separated the residents and education was provided. No other issues thus far. A current care plan, revised 1/5/24, indicated Resident has hx (history) of becoming easily agitated and can become physical AEB (as evidenced by) hx of grabbing and attempting to hit others. Interventions included the following: Staff will provide care with 2+ staff at all times and will use male caregivers to provide care when available, dated 1/5/24 encourage res not to sit in crowded areas, dated 1/4/24 Use of E-cig to eliminate the need to sit and wait for smoke breaks, dated 1/4/24 encourage res to wait in his room or other quiet area prior to smoke break, dated 11/13/23 The care plan was not updated following the incidents on 11/23/23, 1/15/24, and 1/30/24. The clinical record lacked an IDT note following the incidents on 11/23/23, 1/15/24, and 1/30/24. A Behavioral Health Monthly Review, dated 11/13/23, indicated behaviors reviewed were ran into nurse with wheelchair. A Behavioral Health Monthly Review, dated 1/18/24, indicated behaviors reviewed were sexual behaviors, urinating on floor, telling staff he is going to give them a hard time. A Behavioral Health Monthly Review, dated 2/10/24, indicated behaviors reviewed were sexual behaviors, depression, anxiety, pressing call light and laughing when staff come help him. The clinical record lacked a Behavioral Health Monthly Review for December 2023. An event labeled Fight between residents was created on 11/11/23 and closed on 11/14/23. There were no other events referencing resident to resident altercations. The clinical record lacked an order to monitor for behaviors. On 2/20/24 at 12:55 P.M., the Administrator indicated staff monitored for behaviors by using progress notes and care sheets in a behavior monitoring book. At that time, she indicated the care plan should be updated if a new intervention was placed. On 2/21/24 at 8:37 A.M., a binder titled Behavior Monitoring found at the nurses station was reviewed. A behavior monitoring form, dated January 2024, indicated Resident 37 had the targeted behaviors of sexual inappropriate language and inappropriate physical contact to staff on 1/1/24, twice on 1/5/24, and on 1/30/24. There were no other forms in the binder. On 2/21/24 at 8:43 A.M., CNA (Certified Nurse Aide) 17 indicated that Resident 37 smacked staff members on the bottom but was unaware of any other behaviors. On 2/21/24 at 8:44 A.M., the Social Services Director (SSD) indicated the forms in the binder weren't used anymore and behaviors got tracked monthly using the behavioral health monthly reviews for anyone who received an antipsychotic. She also indicated that any time a resident had a behavior, it was followed with an IDT note. On 2/21/24 at 9:26 A.M., the Clinical Regional Nurse indicated the behavior sheets found in the behavior monitoring binder were not a facility policy or supposed to be used in the facility, and were printed off from the Internet by a nurse. On 2/20/24 at 10:43 A.M., a current Behavioral Health policy, dated 10/22, indicated ensure that each resident receives the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were in 2 of 2 residents observed during care. Staff was observed not performing hand hygiene, changing gloves during care.( Resident 55, Resident 29) Findings include: 1. On 2/19/24 at 12:59 P.M., RN (Registered Nurse) 3 was observed during tracheostomy care on Resident 55. The following was the observation of the procedure: RN 3 did not wash hands after gloves were removed following the cleaning of the aerosol collar for the tracheostomy and the inner cannula. RN 3 placed sterile gloves on hands and handles the yankauer (suction tool) with both sterile hands. RN 3 did not wash hands prior to the application of clean gloves, before the trach stoma was cleaned with sterile water and Q-tip. RN 3 did not change gloves prior to the application of ointment on the 4 x 4 dressing around the stoma. RN 3 did not wash hands after the removal of soiled gloves and applying sterile gloves, before the changing of the inner cannula. 48057 2. On 2/20/24 at 9:58 A.M., RN (Registered Nurse) 18 was observed providing wound care to Resident 29. RN 18 sanitized her hands for 9 seconds, and applied clean gloves. RN 18 removed a dressing dated 2/19/24 from the top of Resident 29's left foot. RN 18 cleansed the wound with wound cleanser spray and gauze, then disposed of the soiled gauze in a trash bag. RN 18 opened a package of petroleum gauze and used the index finger of her hand to remove excess petroleum from the top of the gauze and rub it on Resident 29's wound. Resident 29 began to complain of pain the left foot. RN 18 then removed the petroleum gauze from the package, placed it over the wound and covered the wound with a border gauze dressing. RN 18 removed her gloves and dated the dressing, gathered the trash, and exited the Resident's room. During an interview on 2/20/24 at 10:12 A.M., RN 18 indicated hand hygiene should be performed before, during, and after wound care is provided. During an interview on 2/19/24 at 1:28 P.M., LPN (Licensed Practial Nurse) 23 indicated hands should be washed before and after changing gloves and anytime when doing a new activity such as doing a sterile procedure. On 2/20/24 at 2:50 P.M, the Clinical Regional Nurse provided a current policy titled Hand Hygiene Policy, revised 12/2021, that stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water . Before moving from work on a soiled body site to a clean body site on the same resident and Indication for hand-rubbing but not limited to . After contact with body fluids or erections, mucous membranes, non-intact skin, and wound dressing. 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan interventions were implemented for 1 of 1 residents reviewed for urinary catheter care. (Resident 57) Findings include: On 2/12/24 at 2:54 P.M. Resident 57 was observed sitting near the front door. Resident 57's catheter bag was hanging from the back of the wheelchair. There was no protective pouch covering the bag. On 2/15/24 at 7:34 A.M. Resident 57 was observed in the hall with the catheter bag hanging on the armrest of the wheelchair above waist level. There was no protective pouch covering the bag. On 2/16/24 at 8:47 A.M., Resident 57 was observed in the hall with the catheter bag hanging on the armrest of the wheelchair above waist level. There was no protective pouch covering the bag. On 2/14/24 at 9:15 A.M., Resident 57's clinical record was reviewed. Resident 57's diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), and type 2 diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment was completed on 12/26/23 and indicated resident 57 was cognitively intact. Resident 57's MDS indicated he required assistance of 1 staff for mobility, transfers, and toileting. Resident 57's care plan included interventions to position catheter bag below waist level, dated 6/14/23, and store catheter collection bag inside a protective dignity pouch, dated 6/14/23. During an interview on 12/20/24 at 12:55 A.M., the Administrator stated current care plans should be followed, or updated if a care plan intervention no longer applies. On 2/21/24 at 10:03 A.M., the Clinical Regional Nurse indicated there was not a specific policy relating to catheter care plans and provided a form titled Catheter Care Skills Competency. 3.1-35(a)

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 3 residents reviewed for MDS discrepancy. (Resident 32) Finding includes: On 2/15/24 at 10:58 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, acquired absence of right leg above knee, and generalized muscle weakness. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/21/23, indicated Resident 32 was cognitively intact, was dependent on 2 or more staff for transfers, and had no falls since the prior assessment on 8/21/23. Progress notes indicated Resident 32 sustained falls on 8/25/23, 8/26/23, 10/25/23, and 11/5/23. On 2/20/24 at 10:45 A.M. the Administrator indicated the 11/21/23 MDS quarterly assessment should be marked yes for falls for Resident 32 and was unsure why it had been marked no. At that time, she indicated the facility followed the RAI (Resident Assessment Instrument) user's manual.

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 2 of 2 residents observed with medications in their room. (Resident 32, Resident 30) Findings include: 1. On 2/15/24 at 10:15 A.M., QMA (Qualified Medication Aide) 7 was observed taking medication into Resident 32's room. QMA 7 left the medication cup with pills in it on the resident's bedside table without watching the resident take the medication. On 2/15/24 at 10:58 A.M., Resident 32's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes mellitus, congestive heart failure, hyperlipidemia, and major depressive disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/21/23, indicated Resident 32 was cognitively intact. The clinical record lacked an order or evaluation for self administration of medications. On 2/16/24 at 9:16 A.M., LPN (Licensed Practical Nurse) 14 indicated there weren't any residents who were allowed to self administer all of their medications. 46758 2. During an observation on 2/13/24 at 8:59 A.M., Resident 30 was observed administrating her own nebulizer treatment. On 2/14/24 at 1:26 P.M., Resident 30's clinical record was reviewed. Diagnoses included but were not limited to, acute and chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation. Resident 30's most recent Admission MDS (Minimum Data Set) Assessment, dated 12/11/23 indicated Resident 30 was cognitively intact but needed extensive assistance of one for mobility, transfer, and toileting. The current physician orders lacked a self-medication order for medication. The current care plan lacked a care plan for self-medication. During an interview on 2/13/24 at 9:00 A.M., Resident 30 indicated the nurses will bring medication to her, place it in the container, and then leave. During an interview on 2/20/24 at 9:06 A.M., the Clinical Regional Nurse indicated Resident 30's chart lacked a Self-Medication Assessment, the chart lacked an order to self-medicate, and the care plan lacked a care plan for self-medication also. On 2/15/24 at 12:03 P.M., the Administrator provided a current policy Self-Administration of Medication dated 11/2015. The policy indicated .an alert and self-sufficient resident may request that his or her physician provide a written order to the Community indicating an ability to self-administer medications. The physician must indicate the resident is capable of taking medications unsupervised . On 2/15/24 at 12:05 P.M., the Administrator provided a current nursing skills sheet Nebulizer (Small Volume Nebulizer-SVN-Medicated Aerosol Therapy) dated 5/2023. The skills sheet indicated . the nurse was to stay with the resident during the entire medication administration . On 2/16/24 at 9:16 A.M., LPN (Licensed Practical Nurse) 14 indicated there weren't any residents who were allowed to self administer all of their medications. On 2/15/24 at 12:03 P.M., a Self Administration of Medications policy, dated 11/15, indicated an alert and self-sufficient resident may request that his or her physician provide a written order to the Community indicating an ability to self-administer medications. The physician must indicate the resident is capable of taking medications unsupervised . The nurse at the Community must also evaluate each resident who self-administers his or her medication by completing the Self-Administration of Medication Assessment form. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure residents received supervision and consistent implementation of interventions to prevent falls for 2 of 4 residents reviewed for accidents related to falls. Fall interventions were not consistently implemented, thorough assessments of post fall needs was lacking, and care plans were not updated following falls. (Resident 32, Resident 60) Findings include: 1. On 2/13/24 at 2:30 P.M., QMA 12 was observed transferring Resident 32 from a chair to his bed using a slide board and no gait belt. On 2/15/24 at 10:58 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, acquired absence of right leg above knee, and generalized muscle weakness. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 11/21/23, indicated Resident 32 was cognitively intact, was dependent on 2 or more staff for transfers, and had no falls since the prior assessment. Progress notes indicated Resident 32 fell 14 times since admission. Fall 1 6/6/23 at 5:30 P.M. Fall was not witnessed. Resident was walking in his room without staff assistance when he lost his balance and fell . Interventions nonskid footwear, encourage [name of resident] to ask for assistance, use call light, therapy screen, and personal items in reach were added to the care plan on 6/8/23. Fall 2 6/7/23 at 4:40 P.M. Fall was not witnessed. Resident was changing his clothes in the restroom and his knees gave out. Interventions assist with toileting upon rising, before and after meals, at HS (bedtime) and PRN (as needed) and pharmacist to review meds upon admit, monthly and PRN were added to the care plan on 6/13/23. Fall 3 6/27/23 at 5:16 P.M. Fall was not witnessed. Resident was attempting to self transfer. Intervention staff to offer increased assistance d/t (due to) current condition more frequent checks was added to the care plan on 6/28/23. Fall 4 6/28/23 at 7:06 P.M. Fall was unwitnessed. Resident attempted to get up from his wheelchair and lost his balance. Intervention offer to lay resident down after HS meal was added to the care plan on 6/29/23. Fall 5 6/29/23 at 1:30 A.M. Fall was unwitnessed. Resident rolled out of bed. Intervention place sign in room reminding resident to use call light for transfers. NP (nurse practitioner) to evaluate medications with focus on newly added medications was added to the care plan on 6/29/23. Fall 6 6/29/23 at 6:30 P.M. Fall was unwitnessed. Resident was attempting to self transfer from his bed to the wheelchair. No intervention was added to the care plan at that time. Fall 7 7/10/23 at 9:00 P.M. Fall was unwitnessed. Resident was attempting to grab items in a bag on his wheelchair and fell . Intervention Request NP and Pharmacist review meds (medications) was added to the care plan on 7/11/23.(Intervention was repeated from 6/29/23). Intervention nonslip socks when not wearing shoes was added to the care plan on 7/19/23. (Repeated intervention from 6/8/23) Fall 8 8/21/23 at 2:53 P.M. Fall was witnessed. Resident slid off his wheelchair while on the facility bus. Intervention Dycem to w/c (wheelchair) was added to the care plan on 8/22/23. Fall 9 8/25/23 at 1:00 A.M. Fall was unwitnessed. Resident rolled off his bed and indicated he was having difficulty feeling bed boundaries due to his recent amputation. Interventions staff to encourage resident to be assisted to center of bed before leaving room, keep night stand away from bed to help prevent injury, and move bed against wall for bed boundaries r/t (related to) amputation were added to the care plan on 8/28/23. Fall 10 8/26/23 at 11:15 A.M. Fall was unwitnessed. Resident attempted to grab a personal item from the bedside table and leaned too far forward. Interventions staff to provide resident with a bag to keep personal items within closer reach and staff to ensure bedside table is within reach so that resident can reach personal items were added to the care plan on 8/28/23. Fall 11 10/25/23 at 7:53 A.M. Fall was unwitnessed. Resident rolled out of bed. Intervention scoop mattress was added to the care plan on 10/26/23. (Third occurrence rolling out of bed.) Fall 12 11/5/23 at 7:57 A.M. Fall was unwitnessed. Resident slid off the side of the bed while watching tv. Interventions education on use of nonskid footwear when not wearing shoes ( repeated intervention from 6/8/23 and 6/29/23) and nonskid strips next to bed were added to the care plan on 11/6/23. Fall 13 1/24/24 at 11:30 P.M. Fall was unwitnessed. Resident fell asleep while sitting on the side of the bed and fell forward off the bed. Intervention recliner in room was added to the care plan on 1/26/24. Fall 14 1/31/24 at 3:10 P.M. Fall was unwitnessed. Resident attempted to self transfer. Intervention replace non skid strips in front of bed was added to the care plan on 2/2/24. Discontinued physician orders included, but weren't limited to: Transfer resident with mechanical lift and assist of 2 staff members, dated 08/16/23 and discontinued on 02/14/24 A current risk for falls care plan, revised 2/14/24, included, an intervention, initiated 8/15/23 and discontinued on 2/14/24, which indicated all transfers to be done with mechanical lift and assist of 2. On 2/15/24 at 10:18 A.M., Resident 32 indicated staff transferred him by using a sliding board and a gait belt. On 2/15/24 at 10:36 A.M., CNA (Certified Nurse Aide) 1 indicated Resident 32 required standby assistance for transfers. She indicated the resident transferred himself using a slide board and did not require a gait belt. 48057 2. On 2/15/24 at 12:11 P.M., Resident 60's clinical record was reviewed. Diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease) and type 2 diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/18/24, indicated Resident 60 was cognitively intact and required supervision assistance of 1 staff for transfers, eating, and toileting. Resident 60's fall event history indicated 7 falls in the past 3 months and interventions placed by the IDT (interdisciplinary team) following each fall: Witnessed fall on 11/18/23 at 9:30 A.M.; Resident was trying to transfer from couch to wheelchair, staff assisted resident to the floor. Intervention put in place: Therapy will evaluate and staff will assist x 1 with transfers. Unwitnessed fall on 11/19/23 at 9:00 A.M.; Resident was using bathroom, staff found resident sitting in bathroom floor. Intervention put in place: Put up all before you fall sign. Unwitnessed fall on 11/22/23 at 10:34 A.M.; Resident fell out of chair and was found on floor by staff. Intervention put in place: Bright colored tape to call light. Unwitnessed fall on 11/22/23 at 8:40 P.M.; Resident fell out of bed, staff found sitting on floor. Intervention put in place: Resident started on a toileting program. Unwitnessed fall on 11/23/23 at 4:30 P.M.; Resident fell out of bed, staff found resident sitting on floor. Intervention put in place: Resident started on a toileting program. Unwitnessed fall on 12/6/23 at 1:30 P.M.; Resident was transferring from bed to wheelchair, staff found resident on knees at end of bed. Intervention put in place: Nonskid strips at bedside. Unwitnessed fall on 2/12/24 at 3:48 A.M.; Resident was transferring from bed to restroom, staff found on floor next to bed. Intervention put in place: Nonskid strips at bedside. (Repeated intervention from 12/6/23) During an observation on 2/15/24 at 10:45 A.M., no colored tape was observed on the call light, no call before you fall sign was able to be located in Resident 60's room. During an observation on 2/20/24 at 2:15 P.M., no colored tape was observed on the call light, no call before you fall sign was able to be located in Resident 60's room. During an interview on 2/20/24 at 12:55 P.M., the Administrator acknowledged it would be expected for a new intervention to be implemented for each fall event, the IDT reviews each fall after a fall event is created, and the IDT creates a fall note indicating the final intervention. On 2/16/24 at 2:28 P.M., a current Fall Management Policy, revised 1/23, indicated All falls will be discussed .to determine root cause and other possible interventions to prevent future falls . The care plan will be reviewed and updated. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure routine medications were available and dispensed according to physician's orders for 1 of 5 residents reviewed for unnecessary medications. (Resident 15) Finding includes: On 2/12/24 at 10:59 A.M., Resident 15 indicated that on the evening of 2/7/24 she started having uncontrollable tremors and couldn't breathe. At that time, she learned from a nurse that she was out of lorazepam. She indicated the nurse left the room to retrieve lorazepam out of the emergency drug kit (EDK), but never returned. She began screaming for someone to come back, and after about an hour of no one coming, she called 911 for help. An ambulance arrived at the facility and she was transported to the hospital where she was diagnosed and treated for withdrawal. The resident indicated during that time she felt the most lonely she had ever felt in life and wondered if she was going to die. On 2/16/24 at 8:28 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, major depressive disorder and anxiety disorder. The most recent quarterly MDS (Minimum Data Set) assessment, dated 1/15/24, indicated Resident 15 was cognitively intact, had no behaviors, and received an antianxiety medication during the 7-day look back period. Current physician orders included, but was not limited to: lorazepam (a benzodiazepine used to treat anxiety) - Schedule IV tablet; 1 mg (milligram) orally four times a day, dated 1/03/2024 A GDR (Gradual Dose Reduction) report, dated 3/6/23, indicated a GDR for lorazepam was contraindicated at this time as might lead to impaired functioning or cause psychiatric instability by excarbating [sic] a psychiatric disorder and was signed by a physician. A GDR (Gradual Dose Reduction) report, dated 9/14/23, indicated a GDR for lorazepam was contraindicated at this time as might lead to impaired functioning or cause psychiatric instability by excarbating [sic] a psychiatric disorder and was signed by a physician. A GDR (Gradual Dose Reduction) report, dated 12/2/23, indicated a GDR for lorazepam was contraindicated at this time as might lead to impaired functioning or cause psychiatric instability by excarbating [sic] a psychiatric disorder and was signed by a physician. The MAR (medication administration record) indicated Resident 15 did not receive the 8:00 P.M. dose of lorazepam on 2/5/23 and did not receive any doses of lorazepam on 2/6/23 and 2/7/23. Notes indicated waiting on pharmacy. A communication document was provided, signed by the Nurse Practitioner (NP) and dated 2/6, that indicated Resident 15 needed a new script for lorazepam 1 mg. Progress notes included, but were not limited to: 2/07/2024 at 11:15 P.M. (Recorded as Late Entry on 2/08/2024 at 2:03 A.M.) Resident was upset with previous shift because her medication was not available. Resident stated she was calling an ambulance to take her to the hospital because she had not eaten in 4 days. 2/07/2024 at 11:30 P.M. (Recorded as Late Entry on 2/08/2024 at 2:05 A.M.) Received call from ambulance dispatch that they were on their way to pick up Resident. Hospital discharge papers, dated 2/8/24, indicated Resident 15 was discharged from the Emergency Department with a primary diagnosis of benzodiazepine withdrawal. On 2/13/24 at 10:30 A.M., the Administrator indicated that there was a communication error with the NP, and the request for a new script for the lorazepam was signed by the NP, but the script was never written and the medication was never ordered. On 2/16/24 at 9:16 A.M. LPN (Licensed Practical Nurse) 14 indicated refill requests were written in the communication binder and the NP would refill them. He indicated the NP was in the facility 4 to 5 times a week including weekends. At that time, he indicated if the NP was unable to refill the medication immediately, nurses could access the EDK by contacting the on call MD (medical doctor) and having the script sent to the pharmacy. The nurse would then contact the pharmacy for an authorization code and two nurses could sign to retrieve the needed narcotic from the EDK. On 2/16/24 at 10:06 A.M., QMA (Qualified Medication Aide) 11 indicated lorazepam was kept in the EDK. On 2/16/24 at 12:31 P.M., a Reordering, Changing, and Discontinuing Orders policy, revised 1/1/22, indicated Schedule III-IV Controlled substances .requires a new prescription from the Physician/Prescriber. 3.1-25(a)

Based on observation, interview, and record review, the facility failed to prevent a friction abrasion from occurring for 1 of 2 residents observed for facility acquired skin alterations. (Resident 29) Findings include: During an observation on 2/12/24 at 2:12 P.M., Resident 29's mattress was observed to have a deep impression, and the metal bar of the bed frame beneath the mattress could be felt through the dip in the mattress. The resident expressed the wound on her bottom had occurred multiple times as a result of transferring over the spot in the mattress where the bar was palpable. She indicated the staff were aware of the defective mattress and the pressure it was causing against her skin. A new or different mattress was not provided. No grab bar was observed on the left side of Resident 29's bed. On 2/14/24 at 8:27 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) and type 2 diabetes mellitus. Resident 29's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/2/24, indicated Resident 29 was cognitively intact and required limited assistance of 1 staff for transfers. Resident 29's current care plan included, but was not limited to, the following interventions related to prevention of skin breakdown: Left grab bar to bed, dated 9/26/23. Pressure redistribution mattress on bed, dated 10/21/22. A progress note on 1/24/24 noted Resident 29 was assessed by the NP (Nurse Practitioner) and indicated a finding of a new abrasion wound on the right gluteal fold. A progress note on 1/30/24 noted Resident 29 was assessed by the NP and indicated a subsequent visit for the wound located on the right gluteal fold. A progress noted on 2/6/24 noted Resident 29 was assessed by the NP and indicated the wound on the right gluteal fold was resolved. A progress note on 2/13/24 noted Resident 29 was assessed by the NP and indicated a wound was assessed on the right gluteal fold; Resident 29 was complaining of tenderness. During an observation on 2/16/24 at 9:00 A.M., there was not a grab bar on the left side of Resident 29's bed to assist with transferring. During an interview on 02/20/24 at 2:58 P.M., the Administrator indicated Resident 29's defective mattress had been removed on 2/14/24. On 2/16/24 at 2:40 P.M., the Administrator provided a policy titled Skin Management Program, revised 5/22, and stated A plan of care will be initiated to include resident specific risk factors and contributing factors with the appropriate interventions implemented. 3.1-40(a)(1)

Based on observation, record review, and interview, the facility failed to ensure accurately completed staff sheets were posted daily for 8 of 8 days during the survey. (2/12,2/13,2/14, 2/15, 2/16, 2/19,2/20,2/21) Findings include: On 2/12/24 at 8:48 A.M., a staffing sheet was observed sitting on a table across next to the receptionist desk. The sheet included but was not limited to the following information: Shift hours for RN (Registered Nurse), LPN (Licensed Practical Nurse) and CNA (Certified Nursing Assistant). Total number of RN, LPN, and CNA for each shift Total hours of RN, LPN, and CNA for each shift The sheet lacked specific hours worked when the discipline does not work a full 12 hour shift denitrified on the form (7 A.M. to 7 P.M. and 7 P.M. to 7 A.M.). On 2/13/24 at 8:00 A.M., a staffing sheet was observed sitting on a table across next to the receptionist desk. The sheet included but was not limited to the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift Total hours of RN, LPN, and CNA for each shift The sheet lacked specific hours worked by each discipline when the full shift was not worked during the specified shift. On 2/14/24 at 8:00 A.M., a staffing sheet was observed sitting on a table across next to the receptionist desk. The sheet included but was not limited to the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift Total hours of RN, LPN, and CNA for each shift The sheet lacked specific hours worked by each discipline when the full shift was not worked during the specified shift. On 2/15/24 at 8:00 A.M., a staffing sheet was observed sitting on a table across from next to the receptionist desk. The sheet included but was not limited to the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift Total hours of RN, LPN, and CNA for each shift The sheet lacked specific hours worked by each discipline when the full shift was not worked during the specified shift. On 2/16/24 at 8:04 A.M., a staffing sheet was observed sitting on a table across from next to the receptionist desk. The sheet included, but was not limited to the following information: Shift hours for RN, LPN, and CNA Total number of RN, LPN, and CNA for each shift Total hours of RN, LPN, and CNA for each shift The sheet lacked specific hours worked by each discipline when the full shift was not worked during the specified shift. On 2/19/24 at 8:00 A.M., a staffing sheet was observed sitting on a table across next to the receptionist desk. The sheet included but was not limited to the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift Total hours of RN, LPN, and CNA for each shift The sheet lacked specific hours worked by each discipline when the full shift was not worked during the specified shift. On 2/20/24 at 8:05 A.M., a staffing sheet was observed sitting on a table across next to the receptionist desk. The sheet included but was not limited to the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift Total hours of RN, LPN, and CNA for each shift The sheet lacked specific hours worked by each discipline when the full shift was not worked during the specified shift. On 2/21/24 at 8:00 A.M., a staffing sheet was observed sitting on a table across from next to the receptionist desk. The sheet included but was not limited to the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift Total hours of RN, LPN, and CNA for each shift The sheet lacked specific hours worked by each discipline when the full shift was not worked during the specified shift. On 2/16/24 at 8:30 A.M., the Administrator provided the staffing sheets dated 2/12/24, 2/13/24, 2/14/24, 2/15/24. 2/16/23. The sheets included but were not limited to the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift. Total hours of RN, LPN, and CNA for each shift. The sheets did not specify which actual hours were worked by each discipline during the specified shift when the total hours worked were not equal to the number of staff. On 2/21/24 at 9:38 A.M., the Administrator provided the staffing sheets dated 2/19/24, 2/20/24, 2/21/24. The sheets included but were not limited to the following information: Shift hours for RN,LPN, and CNA. Total number of RN, LPN, and CNA for each shift. Total hours of RN, LPN, and CNA for each shift. The sheets did not specify which actual hours were worked by each discipline during the specified shift when the total hours worked were not equal to the number of staff. During an interview on 2/19/24 at 10:05 A.M., the Administrator indicated she was not able to find the actual hours worked when asked to distinguish. On 2/19/24 at 1:23 P.M., the Administrator provided a current Posted Nurse Staffing Data and Retention Requirements policy dated 7/2019. The policy indicated the facility must post the following information at the beginning of each shift .The total and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for providing care per shift: Registered nurses, Licensed practical nurses, and Certified nursing aides .Total hours should include the total actual hours worked on each shift including partial shifts .

Based on observation, interview, and record review, the facility failed to ensure a resident was provided adequate supervision and assistance, and was transferred with the assistance of two staff as the resident required, resulting in a fall with a hip fracture, for 1 of 1 resident reviewed for falls, in a sample of 7. Resident D Findings include: On 8/13/12 at 9:25 A.M., Resident D was observed sitting in a wheelchair in the hallway, with an abductor pillow (to keep her hips in alignment) between her knees. On 8/13/12 at 10:55 A.M., the clinical record of Resident D was reviewed. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated May 18, 2012, indicated the resident's Brief Interview for Mental Status (BIMS) score was 3, with 15 indicating no memory impairment. The MDS assessment indicated Resident D required extensive assistance of two+ staff for transfer and toilet use. A Plan of Care, dated 6/23/12, indicated a problem of "Potential or Actual ADL (activities of daily living)/Mobility deficit...r/t (related to)...Dementia (Alzheimers), Hx (history) Sz (seizures) As evidenced by: Generalized weakness, Decreased ability to understand others, Cannot remember step by step instructions..." The "Goal" indicated, "Will transfer with 2 assist with gait belt...." An additional Plan of Care, dated 6/23/12, indicated a problem of "Fall/Injury Risk related to: History of Falls..." Interventions included: "Transfer: 2A (assist)." Nursing progress notes, dated 6/28/12 at 10:00 A.M., indicated: "...CNA stood up resident to toilet her and resident fell to floor onto her buttocks...Confused, Is there pain? No...Provider orders: Monitor for now...." A physician communication note, dated 6/28/12 at 3:30 P.M., indicated: "...The problem/symptom I am calling about is lt (left) hip pain (with) transferring...Other things that have occurred with this problem/symptom are Fall this AM...New orders Xray lt hip...." A nursing progress note, dated 6/29/12 at 6:00 A.M., indicated, "...Xray results received. Transcervical fracture of (left) femur neck with mild superior displacement of distal segment...Currently waiting on physician orders." A nursing progress note, dated 6/29/12 at 9:00 A.M., indicated, "Order received to send to (name of hospital) for eval (evaluation) of Fracture lt hip...." A "DCR (daily clinical rounds)" note, dated 6/29/12 and untimed, indicated, "Fall. CNA attempting to transfer alone - requires A2 (assistance of 2). Portable xray shows fracture...CNA inserviced, Care plan updated." On 8/13/12 at 2:00 P.M., during interview with the Director of Nursing (DON), she indicated Resident D was supposed to have the assistance of two staff for transfer, and a CNA transferred her by herself, resulting in the fall. The DON indicated the CNA assignment sheet specified that the resident required the assistance of two staff. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents' plans of care were implemented, in that a resident was not transferred with the assistance of two staff, resulting in a fall with a [MEDICAL CONDITION], for 1 of 1 residents reviewed for falls (Resident D); and failed to change a pressure ulcer dressing every other day, for 1 of 3 residents reviewed for pressure ulcers (Resident B), in a sample of 7. Findings include: 1. On 8/13/12 at 9:25 A.M., Resident D was observed sitting in a wheelchair in the hallway, with an abductor pillow (to keep her hips in alignment) between her knees. On 8/13/12 at 10:55 A.M., the clinical record of Resident D was reviewed. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated May 18, 2012, indicated the resident's Brief Interview for Mental Status (BIMS) score was 3, with 15 indicating no memory impairment. The MDS assessment indicated Resident D required extensive assistance of two+ staff for transfer and toilet use. A Plan of Care, dated 6/23/12, indicated a problem of "Potential or Actual ADL (activities of daily living)/Mobility deficit...r/t (related to)...Dementia (Alzheimers), Hx (history) Sz ([MEDICAL CONDITION]) As evidenced by: Generalized weakness, Decreased ability to understand others, Cannot remember step by step instructions..." The "Goal" indicated, "Will transfer with 2 assist with gait belt...." An additional Plan of Care, dated 6/23/12, indicated a problem of "Fall/Injury Risk related to: History of Falls..." Interventions included: "Transfer: 2A (assist)." Nursing progress notes, dated 6/28/12 at 10:00 A.M., indicated: "...CNA stood up resident to toilet her and resident fell to floor onto her buttocks...Confused, Is there pain? No...Provider orders: Monitor for now...." A physician communication note, dated 6/28/12 at 3:30 P.M., indicated: "...The problem/symptom I am calling about is lt (left) hip pain (with) transferring...Other things that have occurred with this problem/symptom are Fall this AM...New orders Xray lt hip...." A nursing progress note, dated 6/29/12 at 6:00 A.M., indicated, "...Xray results received. Transcervical fracture of (left) femur neck with mild superior displacement of distal segment...Currently waiting on physician orders." A nursing progress note, dated 6/29/12 at 9:00 A.M., indicated, "Order received to send to (name of hospital) for eval (evaluation) of Fracture lt hip...." A "DCR (daily clinical rounds)" note, dated 6/29/12 and untimed, indicated, "Fall. CNA attempting to transfer alone - requires A2 (assistance of 2). Portable xray shows fracture...CNA inserviced, Care plan updated." On 8/13/12 at 2:00 P.M., during interview with the Director of Nursing (DON), she indicated Resident D was supposed to have the assistance of two staff for transfer, and a CNA transferred her by herself, resulting in the fall. The DON indicated the CNA assignment sheet specified that the resident required the assistance of two staff. 2. On 8/10/12 at 9:25 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident B had a pressure ulcer on his coccyx. The clinical record of Resident B was reviewed on 8/10/12 at 11:50 A.M. A physician's orders [REDACTED]." On 8/13/12 at 10:40 A.M., a wound assessment was requested. LPN # 1 assisted the resident to stand. A dressing, dated 8/10/12, was observed on his coccyx area. The outside edge of the dressing appeared soiled with a brownish material. When LPN # 1 removed the dressing, it was observed to be saturated with a tannish drainage. LPN # 1 indicated she thought the pressure wound was a Stage IV, but would check the skin sheets. LPN # 1 indicated she wasn't sure why the dressing was dated 8/10/12, but that she would change it. On 8/13/12 at 2:00 P.M., during interview with the DON, she indicated the pressure ulcer dressing was supposed to be changed every other day, and she did not know why the dressing had not been changed the previous evening. On 8/14/12 at 8:55 A.M., during interview with the DON, she indicated she had spoken to the 2 nurses working on 8/12/12. The DON indicated the dressing change is performed on the 3:00 P.M.-11:00 P.M. shift during the week. The DON indicated the nurses work 12 hour shifts on the weekends, from 7:00 A.M. to 7:00 P.M., and 7:00 P.M.-7:00 A.M., and the day shift nurse indicated she informed the oncoming night shift nurse that she didn't get the treatment done. This federal tag relates to Complaint IN 632. 3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure a resident reported by family to have a cough was assessed, that the physician was contacted timely, and that care was planned and implemented for management of the respiratory care. The deficient practice resulted in delay in medical evaluation. Evaluation resulted in treatment for [REDACTED]. (Resident C) Findings include: The clinical record for Resident C was reviewed on 8/13/11 at 12:25 p.m. physician's orders [REDACTED]. Nursing Progress Notes, dated 6/29/11 at 12 noon indicated, "(Name), FNP (Family Nurse Practitioner) seen (sic) pt (patient) today d/t (due to) family states she is congested and cough worried that she may have pneumonia again. Cough @ night. (Symbol for no) new orders @ this time." A Progress Note, signed by the nurse practitioner and dated 6/29/11, indicated and "Acute" visit with "Subjective: Pt. (patient) very drowsy. Family reports cough at night. Nurses have not heard cough. Pt. states she would 'sleep even more if they would let me.'" Objective data indicated, "...Recent vital signs: afebrile...Lungs: Within normal limits/clear...Sinuses non-tender. Slight amount of drainage down throat....Assessment: Cough not significant. Lethargy...Plan: Recheck: As necessary....Drowsiness continues (symbol for with) behaviors stay stable may consider (arrow pointing down) [MEDICATION NAME]. For now will observe." An Accident/Incident Report, dated 6/14/11, and Nursing Progress Notes, dated 6/14/11 at 9:00 a.m. and 10:00 p.m. indicated the resident's most recent vital signs were measured on that date. Nursing Progress Notes for 7/4/11 at 1:20 p.m. indicated, "Call placed to triage D/T family (daughter) states mother has congestion & cough wants atb (antibiotic) & neb (nebulizer) tx (treatment). Reported seen by (name of attending physician) on 6/23/11 and (name of nurse practitioner) on 6/29/11 (symbol for with) (symbol for no) new orders. Will send info to (name of attending physician) in am (morning). Resident LOA (leave of absence) (symbol for with) family." Nursing Progress Notes for 7/4/11 at 1:30 p.m. indicated, "Daughter notified that triage will notify (name of attending physician) in a.m. verbalize understanding." Nursing Progress Notes for 7/4/11 at 1:45 p.m. indicated, "Triage returned call. States (name of attending physician) called in new orders received. Daughter notified." physician's orders [REDACTED]." Nursing Progress Notes for 7/4/11 failed to indicate when the resident returned from leave of absence with family on that date. The Medication Administration Record (MAR) for 7/4/11 indicated the resident received medications at the facility on 7/4/11 at 8:00 p.m. Documentation in Nursing Progress Notes failed to indicate an assessment of the resident's vital signs and respiratory system, including cough, breath sounds, and oxygen saturation from 6/15 through 7/8/11. No Progress Notes were recorded from 7/4/11 until 7/8/11. Documentation on the MAR and Respiratory Treatment Record indicated no doses of the nebulizer treatment were administered from 7/4/11 until 7/8/11 at 8:00 p.m. During interview on 8/13/11 at 12:15 p.m. in regard to location in the clinical record for vital signs and respiratory assessments, the Director of Nursing (DON) indicated vital signs and respiratory assessments would be in Nursing Progress Notes. Nursing Progress Notes for 7/8/11 at 2:30 p.m. indicated, "Chest X-ray today d/t congestion. Family request tx to be routine. Triage will return call (symbol for with) orders regarding breathing tx." Nursing Progress Notes for 7/8/11 at 2:40 p.m., indicated, "X-ray notified of order." Nursing Progress Notes for 7/8/11 at 6:00 p.m., indicated, "N/O (new order) per triage. [MEDICATION NAME] Neb tx BID et (and) q 4 (symbol for hours) prn. Pharmacy notified. Left message for family." Report of a chest x-ray, dated 7/8/11, indicated the document was faxed from radiology on 7/8/11 at 8:56 p.m. The report indicated, "Impression: Chest: Mild [MEDICAL CONDITION] vascular congestion in both lower lung fields. Comment: ...Clinical correlation is requested...." A stamped "Faxed" on the report indicated, "7/9/11." During interview on 8/15/11 at 11:30 a.m., in regard to when the physician was notified of the results of the chest x-ray for 7/8/11, the DON indicated the physician would have received the report before the facility so would have been aware of the report when orders were received for nebulizer treatments twice daily on 7/8/11 at 6:00 p.m. Documentation failed to indicate the physician was made aware of the results of the chest x-ray and need for clinical correlation. Documentation in Nursing Progress Notes for 7/8/11 until 7/13/11 failed to indicate vital signs and respiratory assessment. No Nursing Progress Notes were recorded from 7/8/11 until 7/13/11. The Respiratory Treatment Record for July 2011 for "[MEDICATION NAME] U/D q 4 (symbol for hours) prn cough" indicated the nebulizer treatment was administered 7/9/11 at 8:00 a.m. and included pulse and respiratory rates and breath sounds of wheezes and diminished before and after the treatment. Documentation failed to indicate the physician was notified of the breath sounds. Other doses were administered one to two times daily through 7/16/11, with indication of pulse and respiratory rates and breath sounds of clear/diminished or diminished before treatments and clear/diminished or clear after treatments. Documentation failed to indicate the physician was notified of the diminished breath sounds. Documentation failed to indicate an assessment related to the need for the prn doses of the nebulizer treatment. The MAR indicated routine doses of the [MEDICATION NAME] nebulizer treatment were administered at 8:00 a.m. and 8:00 p.m. from 7/8/11 at 8:00 p.m. through 7/16/11 at 8:00 a.m. Documentation failed to indicate assessments related to the routine treatments Nursing Progress Notes for 7/13/11 at 8:30 a.m., indicated, "Returning from rehab dining. Color pale. Unable to walk. Placed in W/C (wheel chair) returned to room put to bed. Denies pain. VS (vital signs) 124/66 - 98 (symbol for degrees) - 78 (pulse) - 32 (respiratory rate). O2 (oxygen) sat (saturation) 83 (arrow pointing right) 91%. Lungs diminished. (Name) FNP here @ this time." Nursing Progress Notes for 7/13/11 at 9:00 a.m. indicated, "New orders. O2 on @ 3 L/PNC (liters per nasal canula). IV (intravenous) started L (left) forearm. D51/2 NS @ 60 ([MEDICATION NAME] 5%, one-half normal saline at 60 cc per hour). Family aware of order." A Progress Note, dated 7/13/11 and signed by the nurse practitioner, indicated, "Subjective: ...Patient moaning, denies pain. Can't tell us what is wrong. Can't coordinate extremities to walk. Objective: Some acute distress...pale, warm, ashy around lips, does have occasional cough, Lungs: within normal limits/clear; rales (sic)...lack of muscular coordination. When re (checkmark) about an hour later, pt alert, color good, talking & visiting (symbol for with) family. O2 still variable, but breathing reg (regular) & even, non-labored....Plan: Recheck as necessary...." physician's orders [REDACTED]. Keep sats greater than 90%, IV D5NS @ 60/hr (sic). Stat (immediate) chest x-ray, CBC (complete blood count), BMP (basic metabolic profile), UA & C&S (urinalysis with culture and sensitivity." A report of the chest x-ray, dated 7/13/11, indicated, "Impression: Chest: ...infiltrate in the right lower lung field....Comment: ...infiltrate in the right lower lung field. The lung fields are otherwise essentially clear." physician's orders [REDACTED]." This federal tag is related to Complaint IN 580. 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to ensure supervision and assistive devices were provided to prevent accidents, for 1 of 7 sampled residents reviewed for falls, in the sample of 19, and for 1 of 1 supplemental sample resident reviewed for falls, in the supplemental sample of 3, in that one resident was repositioned with one staff member, with assessments indicating the need for two, and the resident fell to the floor resulting in a subdural hematoma, and one resident had repeated falls without changes in interventions. (Residents #56, #97) The facility also failed to ensure 1 of 1 resident reviewed for elopement was provided supervision to prevent exiting the building, following attempts to exit, and then she was successful in exiting the building. (Resident #48) Findings include: 1. On 7/27/11 at 10:40 a.m., resident # 56 was observed being taken out of the building on a stretcher. LPN #2 and RN #1 indicated it was Resident #56 and she had fallen. When queried, they indicated she had an air mattress and 1/4 siderails and she had fallen from bed. When queried further, they indicated she was being turned by a staff member and fell out of bed. When queried about staff present during the turning and repositioning, they indicated there was only one staff member, that she only required one. They indicated she had a "goose egg" on her forehead and they were sending to the emergency room . They indicated she was alert and talking and had told the CNA not to worry, it was just an accident. Resident #56's clinical record was reviewed at 11:00 a.m. on 7/27/11. The most recent Minimum Data Set Assessment (MDS), a quarterly assessment dated [DATE], indicated the resident required extensive assistance of two plus staff for bed mobility. The care plan, dated 12/9/10, indicated she was on a Bed Mobility Program. The program indicated, "4-5 inch roll to be placed under knees while in bed. There will be no breakdown. Resident to be cued to assist with bed mobility. CNA to keep pillow case clean and dry. Report to nurse any skin breakdown." The goal indicated, "Resident continue to help with bed mobility, no breakdown noted." Program notes included, but were not limited to, the following: "9/30/10 3:00 PM ...Resident given verbal cues to assist with bed mobility..." The resident's ADL (Activities of Daily Living) reports, completed by CNAs by computer, were provided by the Minimum Data Set (MDS) coordinator, on 7/27/11 at 4:00 p.m. The reports indicated the resident was provided limited to extensive assistance of one person for bed mobility, except for the following dates and shifts: 7/10/11 Shift 2 total assist of 2 staff, 7/12/11 Shift 2 extensive assistance of 2 staff, 7/14/11 Shift 2 extensive assistance of 2 staff, 7/15/11 Shift 2 extensive assistance of 2 staff, 7/17/11 Shift 2 extensive assistance of 2 staff, 7/18/11 shift 2 total assist of two staff, 7/19/11 Shift 3 extensive assistance of 2 staff, 7/20/11 Shift 2 total assist of 2 staff, 7/22/11 shift 2 extensive assist of 2 staff, 7/23/11 Shift 2 extensive assist of 2 staff, 7/26/11 Shift 2 total assist of 2 staff. Nurses' notes included, but were not limited to, the following: "7/4/11 2 AM Res (resident) resting quietly in bed, resp (respirations) WNL (within normal limits), skin W/D (warm and dry), requires assist of i (one) for ADL's, ii (two) assist for bed mobility, hoyer (mechanical) lift for transfers, incont (incontinent) bowel, F/C (foley catheter) patent et draining cl (clear) yl (yellow) urine, able to voice wants et needs, call light in reach." "7/27/11 10 a (a.m.) Called to res. room res. lying on floor on back on (L) (left) side of bed. During care res. tumbled out of bed 3.7 cm (centimeter) X 1.2 cm hematoma noted (with) laceration (with) large amt (amount) of blood. Applied pressure. Able to get hematoma to stop bleeding. Pupils equal (and) reactive to light. Transferred res. back to bed (with) hoyer (with) 4 assist." The Accident/Incident Report, in the clinical record, indicated the following: "CNA doing care rolled res. over (and) res. fell on floor." The Immediate Action taken to Prevent Further Incidents was "2 assist for ADL's, bariatric bed (with) bolsters (with) 1/2 SR's (siderails)." On 7/27/11 at 2:40 p.m., LPN #2 provided the Nursing Assistant Assignment Worksheets. They had been updated on that date. The Assistant Director of Nursing #1 (ADON) and LPN #2 indicated, at that time, the sheets had just been updated for Resident #56. She had previously been identified as an assist of 1 staff with 1/4 siderails. The current direction was for 2 assist and 1/2 siderails. Both staff members indicated she had always been turned with one person before. CNA #2 was interviewed, at 4:35 p.m. on 7/27/11. She indicated she turned the resident by herself, but she always turned her towards her, to prevent her going over the edge. The Director of Nursing (DoN) was interviewed, on 7/28/11 at 9:00 a.m. She indicated she had not realized what the MDS said, just what the staff were doing. "She's okay to turn (with) 1...if they are pulling her up in bed, they would use 2." She indicated the resident was on an air mattress and they were slick. She further indicated, "of course, from now on, she'll be 2 assist." She indicated the resident had been admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. 2. Resident #97's clinical record was reviewed on 7/26/11 at 4:30 p.m. The resident's quarterly Minimum Data Set (MDS) assessment, dated 6/11/11, indicated the resident required extensive assistance of two persons for transfers, and had a history of [REDACTED]. The resident's care plan for fall prevention and management, dated 3/28/11 and reviewed 6/13/11, indicated the resident required one person for transfers. Interventions included, but were not limited to, the following: High/Low bed, 1/4 siderails, bed/chair sensor Added in response to falls were the following: 2/18/11 non skid slippers 5/1/11 chair sensor 6/5/11 bed sensor staff educated 6/4/11 family educated 7/6/11 gripper socks applied 7/11/11 skin tear treatment. Resident 15 minute checks, staff inserviced. Nurses' notes included, but were not limited to, the following: -Accident/Incident Report, dated 6/5/11 at 6:45 a.m., "Resident ambulating self to toilet (with) use of walker and slippers on. Res. slipped in rm (room) fell to floor landing on buttocks. No apparent injury." The form indicated the resident required two for assistance getting up. The immediate action taken to prevent further incidents was "instructed res. to have staff assist to rest (restroom)." There was no indication of a bed sensor being in use or alarming. -Accident/Incident Report, dated 7/6/11 7:20 a.m., indicated "Resident from bathroom to beside bed in w/c - attempted to sit on bed - sat on floor." The resident indicated, "There was a slick spot on the floor." The Immediate Action taken to prevent further incidents was to "(check) alarm - gripper socks." -Accident/Incident Report, dated 7/11/11 at 4:00 a.m., indicated, "Res. ambulating to bathroom (without) assist fell to floor landing on buttocks. Res. turn bed alarm off." The resident received a skin tear to the right forearm. The Immediate Action to prevent further incidents was, "15 min (checks)." On 7/27/11 at 3:20 p.m., the Director of Nurses (DoN) was interviewed. She indicated she was unsure about the alarm on 7/6/11. The resident was using alarms at that time. She indicated since they wrote "check alarm" on the report,it must not have been on. "She was known to turn them off; we'd hide them and she'd find them." The 7/11/11 fall indicated she had turned the alarm off. On 7/27/11 at 9:00 a.m., the DoN indicated any new interventions would have been noted on the care plan. She indicated the resident was an independent lady and she was not sure what would have worked, short of one on one care. 3. Resident #48's clinical record was reviewed on 7/25/11 at 10:05 a.m. The resident was admitted to the facility 11/28/03. Her [DIAGNOSES REDACTED]. The resident's most recent full comprehensive assessment, dated 4/8/11, indicated no issues with behaviors. The assessment indicated she required extensive assistance of 2 staff for transfers and required assistance with all activities of daily living. The nursing progress notes had an Accident/Incident Report, dated 2/15/11 (no time), indicating, "Resident observed outside by staff member et returned to ICF (intermediate care facility) unit." The Immediate Action taken to prevent further incidents was "15 minute checks initiated, wanderguard placed on w/c (wheelchair), follow plan of care; toilet et put to bed (after) supper meal." A DCR (daily care review) team note, written by the Social Worker and dated 2/16/11 (no time), indicated the following: "...On Feb. (February) 15th, 2011 (Resident's name) because exit seeking and went outside on her own and wander-guard was placed on w/c (wheelchair) at this time." According to a summary documented by the Social Worker at that time, the resident did not have a history of exit seeking. There had been one incident when several residents and family members were exiting one door in November, 2010, going next door to a church for a Thanksgiving meal, that the resident had gone towards the door as well. Otherwise, no history of exit seeking. The investigation into the elopement was reviewed on 7/27/11 at 3:00 p.m. and included statements from staff. CNA #3's statement indicated he had worked the B hall and he had seen the resident approximately 7:25 p.m. to 7:30 p.m. on 2/15/11. He indicated she had set the door alarm off. CNA #3 took her back up the hall and indicated CNA #5 took her to the nurse, LPN #3 for increased supervision. CNA #4's statement indicated she worked on A hall on 2/15/11 and saw the resident outside the break room at 7:25 p.m. She indicated she brought the resident back toward the nurses station and told her the A hall door was not an exit. She indicated LPN #3 was present. CNA #5's statement indicated he was on C hall and B hall. He saw the resident attempting to exit the B hall doorway. He took her back to LPN #3, at her medication cart in the doorway of the unit dining room, for increased supervision and then went to shower another resident. He indicated it was between 7:20 and 7:30 p.m. The Dietary Aide who found the resident indicated in her statement she had clocked out at 7:49 p.m. and went directly to the front door. She indicated as she exited the front door, she heard the resident's safety belt alarm sounding. The resident was outside the building, near the administrator's office window. She called the facility and LPN #3 and LPN #1 came out to get the resident. Staff interviews did indicate the door alarm had sounded, but were unclear if it was turned off after they found her, or before. The Dietary Aide was interviewed, on 7/28/11 at 12:00 noon and repeated her observation of leaving out the front door and seeing the resident outside the administrator's window, in her wheelchair, half on the pavement and half in the grass. The investigation indicated they had done a full body assessment and the resident had no injury. The outside temperature was documented as 45 degrees. The last completed elopement risk assessment was dated 12/13/10. The facility identified the resident had impaired cognition, independently mobile, anxious episodes, inability to recognize familiar people, places and objects, had restless, irritable episodes. Their determination was she was not at risk for elopement, accepted the facility as her home, and acknowledged the need to be there at that time. The procedure for Elopement-Management, dated April 1999, with revisions January 2006 and October 2008, was provided by the Social Service Director and included, but was not limited to, the following: Policy "The Interdisciplinary Team (IDT) will re-evaluate cognitively impaired residents who have attempted, unsuccessfully or successfully, to leave the center without supervision...individualized interventions will be developed and initiated to manage the elopement behavior." Procedure "Determine the following: Was the resident trying to leave the center? If yes, ask the resident why and where they were trying to go." "Re-evaluate assessments, as applicable..." "Determine if there is a pattern to the exit seeking behavior." "Review and/or update the Elopement Plan of Care..." "review and revise individualized interventions that may prevent further elopement attempts..." 3.1-45(a)(2)