Every finding on record at Parkside Post Acute and Rehabilitation

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Food Storage: Cold Foods and Labeling and Dating, the facility failed to ensure frozen food wrappers were intact and that food items were not expired. This deficient practice had the potential to cause cross contamination of unwrapped meat and foodborne illness affecting 135 of 142 residents receiving meals prepared in the kitchen.Findings include:Review of the facility's policy titled Food Storage: Cold Foods revised February 2023 revealed under Procedures: .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.Review of the undated facility policy titled Labeling and Dating revealed under Importance of Labeling and Dating: Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. Under Guidelines for Labeling and Dating: Direct food labels must include the food item name, date of preparation, receipt, removal from freezer and use by date. Under Use By Dating Guidelines revealed: The manufacture's expiration date, when available, is the use by for unopened items.Observation made on 8/4/2025 at 10:00 am in the dry food pantry revealed a case of name of product mustard was identified with an expiration date of 7/30/2025. Also identified was double baking powder with an expiration date of 5/29/2025. The following seasonings/spices located on a shelf outside the pantry had illegible labels on the ground nutmeg, dill weed, and ground ginger. Expiration dates could not be identified. One bottle of apple cider vinegar with a use by date written on it of 7/8/2025 was observed.An interview with the Kitchen Manager on 8/4/2025 at 10:45 am confirmed there were spices and seasonings in the food preparation area that were expired or did not have an expiration date that was legible on the packaging. In the dry pantry, there was a case of mustard that had an expiration date of 7/30/2025. There were also packages of double acting baking powder that had an expiration date of 5/29/2025. The Kitchen Manager confirmed the dates of all expired and illegibly labeled items. Also, the Kitchen Manager confirmed there was an open box of meat in the freezer that was not closed/sealed properly. The Kitchen Manager stated expectations were for expired foods to be thrown out as soon as possible and expiration dates were checked daily, ensuring there were no out of date foods and opened items were closed/sealed properly.An interview on 8/4/2025 at 10:04 am with the Dietary District Manager confirmed the list of expired items that were identified, as well as the items that did not properly display expirations dates. Stated expectations were for staff to ensure that items are disposed of once expiration dates have passed and to ensure that items received into the kitchen were properly dated and stored. All staff were expected to check dates on food items regularly.

Based on observations, staff interviews, and review of the facility's policy titled, Heating, Ventilation, and Air Conditioning (HVAC), (Packaged Terminal Air Conditioner (PTAC)): Clean Air Filters, the facility failed to maintain a clean, homelike environment by not ensuring that the PTAC unit filters were free of debris in 2 of 48 rooms (A9, A8 located in A Hall) and failed to ensure PTAC unit grills were free of debris in 1 of 48 rooms (A8 located in A Hall) . The deficient practice had the potential to affect resident comfort, air quality, and infection control.Findings include: Review of the facility policy titled, Heating, Ventilation, and Air Conditioning (HVAC), (Packaged Terminal Air Conditioner (PTAC)): Clean Air Filters”, documented under section titled, Steps, 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If filter is dirty, either wash or replace depending on type of filter. If clean, reinstall filter. 3. Re-install access cover. 4. Clean grill on cover. 5. Close and make sure it is secure. 6. At a minimum, air filters are to be replaced or thoroughly cleaned depending on type of filter every three months. Observation on 8/4/2025 at 11:36 am and 8/25/2025 at 2:03 pm in Room A9 revealed gray, fuzzy debris on the PTAC filters. Observation on 8/4/2025 at 11:23 am and 8/5/2025 at 2:02 pm in Room A8 revealed gray, fuzzy debris on the PTAC filters and additional debris on the unit’s grill. Interview and observation on 8/7/2025 at 10:30 a.m. with the Maintenance Director (MD) revealed he is solely responsible for the inspection, cleaning, and upkeep of all PTAC units throughout the facility. He confirmed that the PTAC filters in Room A9 contained gray, fuzzy debris and that the PTAC filters and grill in Room A8 also contained debris. He emphasized that proper PTAC maintenance was critical for resident comfort, air quality, and infection control. He stated his expectation is that all PTAC units remain clean, fully functional, and resident-ready at all times, with routine cleaning and inspections conducted on a schedule. Interview on 8/7/2025 at 11:41 am with the Administrator revealed PTAC filters were to be cleaned monthly and whenever a resident was admitted or discharged . She stated that a possible negative outcome of unclean filters was compromised air quality, which could affect residents with respiratory issues in a healthcare setting. During an interview and observation on 8/7/2025 at 12:55 pm with the MD, he outlined the current efforts and plans in place to address ongoing facility repair needs and environmental improvements. Any unit reported to be malfunctioning or excessively dirty was addressed immediately.

Based on observations, staff interviews, record review, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to maintain appropriate infection control practices by not using sterile procedure during tracheostomy care for one of 60 sampled residents (R) (R120), not storing respiratory equipment in an approved container for two of 60 sampled R's (R2 and R5), not protecting shared medical supplies from contamination during wound care for one of 60 sampled R's (R10), by storing personal items on clean linen carts, and by staff not adhering to contact precautions by entering a room with a sign for contact precautions without proper PPE (personal protective equipment). The deficient practices had the potential to contribute to the transmission of infectious organisms among residents, staff, and visitors.Findings include: A review of the facility's policy titled Infection Prevention and Control Program, dated June 2025 revealed under Policy Statement: Facility’s infection prevention and control policies/practices are intended to facilitate in maintaining a safe, sanitary, and comfortable environment and to prevent and manage transmissions of disease and infections. Under Standards of Practice: 1. The objectives of our infection control policies and practices are to: Prevent, detect, investigate, and control infections in the facility. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard precautions. Maintain records of incidents and corrective actions related to infections. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Under PRECAUTION GUIDELINES…Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. Review of the facility’s policy titled “Tracheostomy Care” revised 4/5/2024 revealed under Policy Statement: revealed under Purpose: Residents who have a tracheostomy will have trach care done as ordered by a physician or as needed to keep the airway clean and unobstructed. Under Procedure Guidelines: Clean The Removable Inner Cannula: … 2. Put on sterile gloves. 3. Set up supplies on a sterile field. … 9. Keep one hand sterile and one hand dirty. 1. Review of the electronic medical record (EMR) revealed resident R120 was admitted to the facility with pertinent diagnoses including but not limited to chronic respiratory failure with hypoxia (low oxygen levels in the blood), and hemiplegia and hemiparalysis following cerebral vascular accident. Review of R120’s five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated R120 was identified having severe cognitive impairment. Section GG, Functional Status, revealed R120 required extensive assistance for activities of daily living (ADLs) with one/two or more-person assistance. Section O, Special Treatments, Procedures, and Programs, revealed R120 receives continuous oxygen via tracheostomy. Review of R120 care plan dated 6/24/2025 indicated a problem of has a tracheostomy. Goals included but not limited to no signs and symptoms of infection through the review date. Interventions included but not limited to give humidified oxygen as prescribed, suction as necessary, use universal precautions. assist with coughing as needed. Review of the “Physician’s Orders” for R120 included but was not limited to: Order dated 7/9/2025 for Tracheostomy care every shift and prn using aseptic technique. Remove the inner cannula, clean with half strength H2O2 (peroxide) and sterile H20 (water), dry with sterile gauze and cotton swab. Re-insert the inner cannula, turn to lock. Clean outer cannula/stoma with sterile H20, rinse with sterile H20, pat dry with sterile gauze. May use split sterile gauze PRN (as needed). Observation on 8/6/2025 at 8:19 am Respiratory Therapist (RT) SS donned (put on) non-sterile exam gloves, opened sterile suction catheter and proceeded to suction R120’s tracheostomy. Interview on 8/6/2025 at 8:21 am with RT SS confirmed suctioning was a sterile procedure and sterile gloves should have been worn. RT SS also shared that the suction valve was only held while removing the suction catheter and R120 was suctioned about every three hours. An interview with the Director of Nurses on 8/7/2025 at 2:00 pm revealed using non-sterile exam gloves during suctioning of a trach was an unacceptable practice. 2. Review of R10’s quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive decline, Section I, Active Diagnoses, revealed pertinent diagnoses including but not limited hypertension, renal insufficiency, and depression. Immediately after wound care observation on 8/6/2025 at 10:16 am on R10, RN GG placed the hand sanitizer back into the plastic bag without sanitizing the outside of the bottle or the clear plastic bag, transported the clear plastic bag into the hallway and placed the clear plastic bag onto the wound care dressing cart located in the hallway outside of the resident's room door. RN GG verbalized that her plan was to bring it out of the room and clean it with bleach wipe. 3. Review of R2’s quarterly MDS assessment dated [DATE] revealed a BIMS score of 0, indicating R2 was not able to complete, Section I, Active Diagnoses, revealed pertinent diagnoses including but not limited to heart failure, hypertension, non-Alzheimer’s dementia, and respiratory failure. Review of R5’s quarterly MDS assessment dated [DATE] revealed a BIMS score of 5, indicating severe cognitive decline, Section I, Active Diagnoses, revealed pertinent diagnoses including but not limited to hypertension, diabetes mellitus, and cerebral vascular accident (CVA). Observation on 8/4/2025 and 8/5/2025 revealed R2’s CPAP (continuous positive airway pressure) mask stored inside a cluttered nightstand drawer with miscellaneous personal items, including papers, coins, and loose debris. The mask was not in a clean, dry, dust-free container as per manufacturer guidelines and facility policy. Observation on 8/4/2025 and 8/5/2025 revealed R5’s CPAP mask placed on the seat of a bedside chair without protective covering. The surface contained visible dust and lint. Interview on 8/6/2025 at 3:45 pm with DON confirmed that CPAP masks should be stored in a clean, dry, dust-free container or designated storage bag to prevent contamination. The DON acknowledged the observed storage methods did not meet facility expectations. 4. Observation on 8/5/2025 at 12:43 pm revealed a linen cart containing a personal staff cell phone. Interview with laundry aide MM on 8/5/2025 at 12:43 pm confirmed that only linens should be stored inside the linen cart. However, she acknowledged storing her personal cell phone inside the cart, stating it was so her supervisor could reach her if needed. Interview with Certified Nursing Assistant (CNA) EE on 8/5/2025 at 12:48 pm revealed that she was not aware of any policy restricting items other than linen inside the linen carts and had not received any training specific to linen cart contents. Interview with LPN KK on 8/5/2025 at 12:56 pm revealed that she was unsure about any linen policy and stated that when deciding what items could be stored in the linen cart, “it depends on where it came from.” 5. Observation on 8/6/25 at 12:26 pm revealed Licensed Practical Nurse (LPN) BB enter room C6-P, which had signage for Contact Precautions related to Pneumonia- Methicillin-Resistant Staphylococcus aureus (MRSA), wearing only gloves and no gown, in violation of the facility's infection control expectations and signage instructions. Interview with LPN BB on 8/6/2025 at 12:30 pm confirmed she entered the isolation room without donning (putting on) a gown and acknowledged failure to follow Contact Precautions and further recognized the importance of PPE use and acknowledged the potential for spreading infection. Interview with Staff Development Coordinator (SDC) on 8/5/2025 at 2:46 pm and on 8/6/2025 at 5:20 pm revealed that she had not provided any training to staff on proper linen cart use and contents. Additionally, confirmed that for isolation precautions, staff should wear gowns, gloves, and goggles. Interview with Director of Nursing (DON) on 8/5/2025 at 3:20 pm and on 8/6/2025 at 5:05 pm confirmed that staff were expected to wear gown and gloves when entering Contact Precaution rooms and stated that the SDC is responsible for training clinical staff while the Director of Environmental Services trained laundry aides on clean linen carts. Additionally, they do not have a clean linen cart policy.

Based on observations, staff interviews, record review and review of facility's policy titled, Water Temperature Policy, the facility failed to keep the residents free of accident hazards as evidenced by water temperatures above 110 degrees Fahrenheit (F) in 8 of 138 resident rooms (A2, A4, E31, E19, E16, E3, B10 and B12 located in A, B, and E Halls ) and in 1 of 3 showers (B Hall). The deficient practice had the potential to cause injury to residents residing in these rooms.Findings include: Review of the facility provided document titled Water Temperature Policy revealed under Policy Statement: Hot water temperature at all resident-use fixtures shall not exceed 110- degrees Fahrenheit per Georgia Administrative Code Rule 111-8-56.18. Physical Plant Standards. Review of the facility's TELS system (maintenance reporting system) and water temperature logs from 1/27/2025 to 8/4/2025 revealed temperatures consistently ranging from 107 degrees F to 108 degrees F in most areas, with the kitchen water temperature recorded at 120 degrees F. Review of resident skin assessments and shower documentation dated 8/4/2025 revealed no evidence of burns or skin injuries related to hot water exposure. Observations on 8/4/2025 from 11:58 am to 12:04 pm of water temperature checks in resident shared bathrooms revealed the following readings exceeding the 110 degree F threshold: Rooms A13 and A15 at 114.9 F, Rooms A12 and A10 at 118.6 degrees F. Interview on 8/4/2025 at 2:53 pm with the Maintenance Director (MD) revealed he had been employed at the facility for five years and checked water temperatures daily. He stated water temperatures were supposed to be below 110 degrees F and typically range between 107 degrees F and 111 degrees F. He reported new hot water boilers were installed last year, replacing 10 older units, after residents complained of cold water. He stated water temperatures tend to be cooler in rooms farther from the water tanks. Observations on 8/4/2025 from 2:54 pm to 3:04 pm with the MD of water temperature checks in resident shared bathrooms revealed the following readings exceeding the 110 degrees F threshold: Rooms A2 and A4: 114 degrees F. The MD stated the water temperatures were going to be corrected immediately and the Administrator was made aware. Follow-up observations on 8/4/2025 at 5:40 pm conducted with the MD and Administrator showed corrected water temperature readings as follows: Rooms A2 and A4, 106 degrees F. Additional observations on 8/4/2025 from 6:37 pm to 6:41 pm conducted with the MD and Administrator revealed the following corrected water temperature readings: Room E3,106.3 degrees F; Room E19,103.0 degrees F; Room E31, 103.3 degrees F. Interview on 8/7/2025 at 11:41 am with the Administrator confirmed that water temperatures were expected to be maintained at or below 110 degrees F and that a possible negative outcome of noncompliance was that residents could be burned.

Based on record review, resident and staff interviews, and review of the facility policy titled, Administration of Medications, the facility failed to document medication administration for 2 of 60 sampled residents (R) (R122 and R102. This deficient practice created an inaccurate record of care and services provided to the residents which had the potential to affect continuity of care.Findings include:1. Review of the facility policy titled Administration of Medications dated June 2025 documented under Procedure: .5. Each time you administer a medication, you need to be sure to have the right documentation. Under Procedure: .10. The individual administering the medication must initial the resident's electronic medication administration on the appropriate line entry after giving each medication and before administering the next ones, or document in wet ink the administration of medication.11. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document in space provided for that drug and dose.Review of R122's electronic medical record (EMR) revealed he was admitted to the facility with diagnoses including but not limited to cellulitis of right lower limb, muscle weakness, need for assistance with personal care, adhesive capsulitis of right and left shoulder, major depressive disorder, and gastroesophageal reflux disorder (GERD).Review of R122's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates R122 was cognitively intact.Review of R122's Physician's Orders included but was not limited to an order dated 4/28/2025 for Lexapro oral tablet 5 milligrams (mg) give one tablet by mouth one time a day related to major depressive disorder, an order dated 1/24/2025 for omeprazole 20 mg capsule give 1 tablet by mouth one time a day for GERD, an order dated 1/24/2025 for lactobacillus capsule give 1 capsule by mouth one time a day for probiotic, an order dated 1/27/2025 for a weekly skin assessment, perform one time a day every 8 days for monitoring, an order dated 1/25/2025 for thiamine hcl (hydrochloride) oral tablet 100 mg give 1 tablet by mouth one time a day for supplement, an order dated 1/25/2025 to observe the resident closely for significant side effect monitoring related to anti-depressant medication use, an order dated 1/24/2025 to assess pain levels every shift, an order dated 7/15/2025 for behavior monitoring every shift, and an order dated 1/29/2025 to check for abnormal bruising related to anticoagulant (blood thinner) use.Review of R122's July 2025 Medication Administration Record (MAR) revealed no documentation on 7/15/2025 for administration or refusal of R122's Lexapro and omeprazole, yet other medications to be administered that morning were documented as given. Further review revealed no documentation on 7/22/2025 for administration or refusal of R122's lactobacillus capsule, thiamine tablet, weekly skin assessment, anti-depressant medication use monitoring, pain level assessment, behavior monitoring, checking for abnormal bruising or bleeding related to anticoagulant use, or psych (psychiatric) meds (medications) monitoring, yet other medications for that shift were documented as administered.In an interview on 8/7/2025 at 11:50 am, Licensed Practical Nurse (LPN) TT confirmed the lack of documentation for administration or refusal on 7/15/2025 and 7/22/2025. She confirmed that it didn't give an accurate representation of resident care and stated that anytime a medication was given, it should be documented.In an interview on 8/7/2025 at 3:00 pm, the Director of Nursing (DON) stated that she expected there to not be any holes in the MAR and stated that potential negative outcomes could affect continuity of care.2. Review of R102's EMR revealed he was admitted to the facility with diagnoses including but not limited to need for assistance with personal care, fracture of right lower leg, chronic diastolic (congestive) heart failure, major depressive disorder, and generalized anxiety disorder.Review of R102's significant change MDS assessment dated [DATE] revealed a BIMS score of 15, which indicates R102 was cognitively intact.Review of R102's Physician's Orders included but was not limited to an order dated 7/1/2025 for aspirin give one tablet by mouth one time a day for heart disease, an order dated 7/1/2025 for duloxetine give 1 capsule by mouth one time a day for depression, an order dated 7/1/2025 for magnesium oxide give 1 tablet by mouth one time a day for supplement, an order dated 7/1/2025 for potassium chloride give 1 tablet by mouth one time a day for heart disease, an order dated 7/1/2025 for spironolactone give 1 tablet by mouth in the morning for hypertension, an order dated 7/1/2025 to observe the resident closely for significant side effect monitoring related to anti-anxiety medication use, an order dated 7/1/2025 to observe the resident for significant side effects related to anti-depressant medication use, an order dated 7/1/2025 to assess pain level, an order dated 7/1/2025 for docusate sodium to give 1 capsule by mouth two times a day for constipation, an order dated 7/1/2025 for furosemide give 1 tablet by mouth two times a day for heart failure, an order dated 7/14/2025 to monitor for any discomfort or change in condition every 12 hours for foot fracture, and an order dated 7/1/2025 for sacubitril-valsartan oral tablet give 1 tablet by mouth two times a day for heart failure.Review of R102's July 2025 MAR revealed no documentation on 7/22/2025 for administration or refusal of R102's morning medications and monitoring, yet an as needed (prn) tramadol was documented as administered on 7/22/2025 at 0800 (8:00 am).

Based on observations, staff interviews, and review of the facility policies titled, Storage of Medications and Biologicals and Administration of Medications, the facility failed to ensure the secure storage of medications by not locking medication carts when unattended for one of six medication carts. The deficient practice had the potential to allow residents, unauthorized staff, or visitors to access medications and biologicals, or to tamper with items stored on the cart.Findings include: Review of the facility's policy titled Storage of Medications and Biologicals reviewed April 2025, revealed under Policy Statement: The facility shall ensure medications and biologicals are stored appropriately and securely at any given time. Review of the facility's policy titled Administration of Medications reviewed June 2025 revealed under Procedure: .16. The medication cart should be locked at all times. 1. Observation and interview on 8/6/2025 at 11:19 am revealed a medication cart was left open and unattended in Hallway AI with no nurse in sight. When a staff member was asked who the cart belonged to, she identified it as belonging to Licensed Practical Nurse (LPN) Charge Nurse BBB, who was in Room A2 with a resident. Upon exiting the room, LPN BBB confirmed she was using the cart and stated she had been providing nail care for the resident. She explained that she left the cart open when she quickly grabbed alcohol from it to clean the resident's nails, stating she wanted to complete the task before the resident changed his mind. She estimated she had been in the room for approximately two minutes. The LPN BBB acknowledged the cart was open and confirmed medication carts were not supposed to be left unlocked when unattended. LPN BBB stated a possible negative outcome of leaving a cart unlocked was that someone could access and take medications. Interview on 8/7/2025 at 11:15 am with the Director of Nursing (DON) revealed she was aware of the incident and had discussed it with LPN BBB. The DON stated the nurse acknowledged the error and understood it was against expectations. The DON confirmed that the expectation was that unattended medication carts must remain locked at all times. She stated possible negative outcomes include medications going missing or being taken by someone for whom they were not prescribed. Interview on 8/7/2025 at 11:41 am with the Administrator confirmed that medication carts were required to remain locked when unattended. She stated that a possible negative outcome of an unlocked cart was that someone could take medications, which could result in harm. 2. An observation on 8/6/2025 at 8:30 am revealed LPN ZZ walked away from a medication cart on the A hall and entered a resident room leaving the medication cart unattended. Observation on 8/6/2025 at 8:30 am of LPN ZZ during medication administration was noted to leave a medication storage card that still contained medication on top of the cart unattended. The medication was Ranolazine Extended Release (ER) which was for treatment of chronic chest pain. An interview on 8/6/2025 at 8:31 am with LPN ZZ confirmed that she left the Ranolazine Extended-Release Tablets on top the medication cart. LPN ZZ also confirmed that she should not have left this medication unattended and that she should have locked the medication away in the medication storage cart. An interview on 8/7/2025 at 2:00 pm with the DON confirmed that nurses should not leave anything on top of the medication cart unattended, and that the facility's policy and practice was to store this medication inside of the medication cart and lock the cart.

Based on observations, staff and resident interviews, record review, and review of facility policies titled Urinary Catheter Care, Anchoring and Changing, the facility failed to provide proper catheter care and positioning for one of 16 residents (R) (R71). Specifically, staff failed to provide correct cleaning and failed to ensure the catheter drainage bag was properly positioned. The deficient practice had the potential to cause pain, trauma to the urethra, catheter-associated urinary tract infections (CAUTIs), and impaired drainage.Findings include:Review of the facility policy titled Urinary Catheter Care, Anchoring and Changing revised March 2024 revealed under section 10: .10. For the male resident, .cleanse the meatus outward., and section 16 revealed: .16. Secure foley catheter drainage bag below level of bladder and above the floor. Catheter drainage bags will be covered when residents are in a public area.Review of the electronic medical record (EMR) revealed R71 was admitted to the facility with pertinent diagnoses including but were not limited to benign prostatic hyperplasia (BPH), type 1 diabetes mellitus, stage 3 chronic kidney disease, atrial fibrillation, hypertension, chronic obstructive pulmonary disease (COPD), and anemia.Review of R71's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Section GG, Functional Abilities and Goals, indicated that R71 was dependent requiring Substantial/Max Assistance.Review of R71's care plan dated 7/9/2025 included a problem of foley catheter use related to BPH (benign prostatic hyperplasia), with goals to prevent Urinary Tract Infection (UTI) and maintain comfort. Interventions included: provide catheter care per protocol, monitor for signs of infection, and ensure drainage bag is below level of bladder.Review of Physician Orders included but were not limited to:Order dated 6/29/2025 for Foley catheter monthly change due to BPH.Order dated 4/9/2025 for Catheter care and output every shift.Order dated 8/7/2025 for Urinalysis (UA) with culture for hematuria.Order dated 2/17/2025 for Enhanced Barrier Precautions (EBP).Review of nursing notes dated 8/3/2025 revealed R71 was transferred to the local hospital after bleeding was observed in the foley catheter. The note documented the catheter had been changed the previous day, the Nurse Practitioner (NP) was notified and gave the order to send the resident to the hospital for further evaluation. A follow-up nursing note on 8/4/2025 documented R71 returned from the hospital.Observation on 8/5/2025 at 2:57 pm with Certified Nursing Assistant (CNA) LL and CNA NN revealed staff performed catheter care for R71. During care, CNA LL supported the penis at the corona, not the meatus, as required for best practice. The catheter tubing was taut and not detached from the bed. When the resident was turned for peri care, the catheter pulled taut, and CNA NN was asked to unhook it by CNA LL, indicating it was not managed properly. Blood was visible in the catheter tubing during this observation.Interview on 8/5/2025 at 3:17 pm with CNA LL revealed she believed she had supported the catheter at the meatus and stated that she did notice the blood in the catheter tubing and collection bag.Interview on 8/5/2025 at 3:00 pm with Licensed Practical Nurse (LPN) JJ reported that the catheter bleeding may have been caused by improper handling of the catheter tugging during transfers or care. He stated he had flushed the catheter and notified the physician.Observation and interview on 8/6/2025 at 1:35 pm with R71 revealed the catheter drainage bag was not visible on either side of the bed. When questioned, LPN JJ discovered the catheter bag was under the resident, who had recently been transferred from his wheelchair to the bed. The resident complained of pain and discomfort. LPN JJ removed R71's pants, retrieved the catheter bag, hung it beside the bed, and returned the call light to the resident as it was found out of reach on the floor.Interview on 8/6/2025 at 1:50 pm with CNAs QQ and RR, who performed the transfer, confirmed the resident had been left with the catheter under him and pants around his knees under the covers. CNA RR stated it was CNA QQ's responsibility to hang the catheter. CNA QQ provided no rationale for the improper catheter positioning.Interview on 8/6/2025 at 5:20 pm with the Staff Development Coordinator (SDC) revealed that staff were trained to transfer a resident with a urinary Foley catheter by securing the catheter and drainage bag to the resident during the transfer to prevent pulling and kinking of the tubing. Once the resident was positioned in bed, the drainage bag should be secured to the bed and kept below the level of the resident. She further explained that when providing catheter care for a male resident, staff were instructed to hold the shaft of the penis with one hand while using the other hand containing a washcloth to clean outward along the catheter tubing. She provided the facility's catheter care policy, but it did not specify where to hold the catheter during care. Based on this, she trained staff to hold the shaft of the penis, as the policy lacks direction on catheter stabilization. When asked whether this method reflected best practice and ensured resident safety, particularly considering the potential for trauma due to a lack of support at the meatus, the SCD acknowledged that this was not best practice and agreed that not supporting the catheter at the meatus could cause trauma to the resident.Interview on 8/6/2025 at 5:05 pm with the Director of Nursing (DON) confirmed that staff were expected to hook Foley catheter drainage bags below the level of the bed. She further explained that during catheter care for a male, staff should use one hand to hold the tip of the penis and, with the other hand, wrap a towel and cleanse downward along the catheter. When asked whether this technique aligns with best nursing practice and whether it was safe in terms of preventing potential trauma, specifically, whether or not supporting the catheter at the meatus could lead to pulling or injury. The DON reviewed the facility's policy. She stated that the policy did not address holding the catheter at the meatus during care.

Based on observations, record review, resident and staff interviews, and review of the facility policy titled, Administration of Medications, the facility failed to follow physician orders for two of 60 sampled residents (R). Specifically, the facility failed to follow physician orders related to colostomy care for R90 and administration of medications for R122. The deficient practice had the potential to compromise the residents' health and safety.Findings include: Review of the facility policy titled Administration of Medications dated June 2025 documented under Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Under section Procedure: .3. Medications must be administered in accordance with the orders, including any required time frame. 1. Review of R90's electronic medical record (EMR) revealed he was admitted to the facility with diagnoses including but not limited to hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, need for assistance with personal care, dysphagia (swallowing problems), and colostomy status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R90 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognition. Section GG, Functional Abilities and Goals, revealed resident is dependent on staff for toileting and personal hygiene. On 8/4/2025 at 10:40 am during initial interview with R90, she stated that her colostomy bag had not been changed or emptied for five days. R90 displayed the colostomy bag which appeared to be full of bowel but not distended. She continued that the nursing staff did not change the bag routinely and only changed it when it began leaking. Review of physician's orders for R90 revealed the physician's orders stated, Clean around ostomy with soap and water every shift for maintenance, added 7/8/2025 at 19:00. Review of Treatment Administration Record (TAR) for July 2025 showed gaps in colostomy care July 12025, through July 8, 2025; and July 24, 2025 and July 25, 2025. An interview with Certified Nursing Assistant (CNA) AA on 8/7/2025 at 2:05 pm further confirmed that CNAs were instructed to empty colostomy bags and clean up any leakage but were not authorized to remove bags or cleanse the stoma. CNA AA stated her understanding that physician orders require stoma cleaning by nursing staff each shift. An interview on 8/6/2025 at 2:30 pm with LPN BB revealed that the stoma for R90 was not being cleaned daily with soap and water as ordered by the physician. LPN BB stated that the CNA observed the site and bag during morning dressing and notified her if cleaning or changes were needed. She continued that she checked off the CNA observation as a cleaning if nothing needed or if there was no leak or issue with the bag. On 8/6/2025 at 2:35 pm, LPN BB had marked the cleaning as complete for the day but stated she did not perform a cleaning of the stoma. Physician orders require nursing staff to clean the stoma each shift. Interview on 8/7/2025 at 1:50 pm with the Director of Nursing (DON) confirmed that nursing staff were responsible for cleaning the stoma with soap and water every shift. It was noted that LPN BB marked the task as completed on 8/6/2025 but later admitted that the cleaning was performed by the CNA, which was inconsistent with facility policy and physician orders. The DON clarified that CNAs were only permitted to empty colostomy bags and report measurements, while stoma cleaning and bag replacement were nursing responsibilities. 2. Review of R122's EMR revealed he was admitted to the facility with diagnoses including but not limited to cellulitis of right lower limb, muscle weakness, need for assistance with personal care, and adhesive capsulitis of right and left shoulder. Review of R122's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, which indicates R122 was cognitively intact. Review of R122's care plan initiated 2/10/2025 indicated a focus of the resident having the potential for pain related to cellulitis of the right lower extremity (RLE), impaired mobility, capsulitis of the left and right shoulders. Interventions included but were not limited to administer analgesic per physician (MD) orders. Review of R122's Physician's Orders included but was not limited to an order dated 1/24/2025 for tramadol HCl oral tablet 60 milligrams (mg) give one tablet by mouth every eight hours as needed for pain. Review of R122's 8/2025 medication administration record (MAR) printed on 8/7/2025 revealed that on 8/4/2025, tramadol was documented as administered at 1814 (6:14 pm) and 2148 (9:48 pm). During an interview on 8/6/2025 at 2:28 pm with R122, when asked if he was given two doses of tramadol, R122 stated that he told a CNA that he was in pain so the CNA went to a nurse different from who had already administered his tramadol, and that nurse came to his room to offer it. He stated that he told the nurse to take it back and confirmed he only had the first dose. During an interview on 8/7/2025 at 11:50 am, Licensed Practical Nurse (LPN) TT confirmed the documentation of two doses of tramadol on 8/4/2025 and confirmed that the second dose was not administered in the appropriate time window. She stated that if it was an error, the nurse would have had to cross it off in the narcotic book as an error and if the resident didn't take it, then it should have been destroyed and there should be evidence of it being destroyed on the comments section of the narcotics sheet. She confirmed that the tramadol was signed out on the narcotic sign out sheet but was not marked as an error. When asked if the nurse should have attempted to administer the second tramadol at that time, she stated that if it was not according to the 8-hour window, then no. She further stated that she did not know why the nurse offered it at that time, but according to the times documented in the system, she should not have. When asked what could be a potential negative outcome if the resident had taken the second dose, she stated that the resident could have gotten sick or overdose. In an interview on 8/7/2025 at 3:00 pm, the Director of Nursing (DON) stated that she expected nursing staff to follow physician orders. She confirmed from the MAR that the as needed (PRN) tramadol was administered at 1848 and 2148 based on the documentation. She stated that the second nurse could only have administered the dose if there was an additional doctor order. Without the order, that would not have been appropriate to administer it in that time window. If it was an error, the nurse should have gotten another nurse to waste it with her and it would have been documented on the narcotic sheet as wasted. The DON further stated that a potential negative outcome could be a possibility of overdose.

Based on record review, staff interviews, and review of the facility's policy titled, Preadmission Screening and Annual Resident Review (PASARR) Policy, the facility failed to obtain a level II PASARR screening for one of 60 sampled residents (R) (R41). The deficient practice had the potential to prevent R41 of achieving the highest practicable mental, physical, and psychosocial well-being.Findings include:Review of the facility's policy titled Preadmission Screening and Annual Resident Review (PASARR) Policy revised 5/15/2025 revealed in the section titled Policy Statement: It is the policy of this facility to screen all potential admissions on an individualized basis. As part of the preadmission process, this facility participates in the Preadmission Screening and Resident Review (PASARR) screening process (Level ll (follow your state recommended guidelines or specific state criteria for PASARR) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMl/SMD), intellectual disability (lD) or related condition. Based upon the Level I screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level ll screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level I screen. Annually and with any significant change of status, the facility will complete the PASARR Level I screen for those individuals identified per the Level ll screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly.Review of the electronic medical record (EMR) for R41 revealed she was admitted to the facility with diagnoses that included, but were not limited to, chronic kidney disease, stage 3; dementia with behavioral disturbance; generalized anxiety disorder; major depressive disorder, recurrent moderate; delusional disorder; auditory hallucinations and cognitive communication deficit.Review of R41's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicates severe cognitive impairment. Section E, Behaviors, revealed physical and verbal behavioral symptoms directed towards others occurred 1-3 days per week and wandering was noted. Section GG, Functional Abilities and Goals, revealed functional limitations including substantial/maximal assistance with toileting, dependent with bathing and dressing, and setup or supervision for eating. Section I confirmed the primary condition as dementia with behavioral disturbance.Review of R41's care plan dated 6/4/2025 included the following focus areas: R41 has a diagnosis of delusional disorder. R41has impaired cognitive function related to dementia with behavioral disturbances. R41is a part of the Adventure Group due to elopement risk related to wandering aimlessly due to dementia. R41has demonstrated physical and verbal behaviors towards staff when trying to assist with Activities of Daily Living (ADL) care related to dementia, including: 5/18/2025 - Resident was kicking another resident on the leg. 10/1/2024 - Resident grabbed another resident's wheelchair. 10/1/2024 - Resident hit another resident on her ear while in the dining room.10/1/2024 - Resident noted arguing with another resident in hallway. 8/22/2024 - Resident hit another resident on the leg when asked to leave the resident's room. 1/16/2024 - Resident demonstrated physical aggressive behaviors by trying to kick staff when trying to redirect. Interventions in the care plan included reality orientation, psych consults, supervision for ADL tasks, safety interventions to prevent falls, and maintaining dignity and privacy during personal care.Interview on 8/6/2025 at 11:50 a.m. with Social Worker (SW) VV revealed when residents were admitted , their diagnoses were reviewed to determine if a PASARR Level 2 was required. For residents with mental health diagnoses, a Level 2 was initiated if they were expected to stay long-term but not for short-term residents unless they knew they were expected to stay long term. SW VV stated diagnoses such as generalized anxiety disorder, developmental disabilities, paranoia, or suicidal ideation may trigger Level 2. SW VV verified that Level 2 PASARR had not been completed for R41, only Level 1. She verified and provided a copy of a Level 1 application that was resubmitted on 3/25/2025. She explained that when the resident initially came in, a different social worker handled the case, and a Level 2 PASSARR should have been submitted. SW VV stated the resident transferred to long-term care on 2/1/2024 and she was currently auditing records to ensure all eligible residents have PASARR Level 2 submitted. SW VV noted a potential negative outcome from not obtaining a Level 2 PASARR would be missing specialized care, such as psychotherapy.Interview on 8/7/2025 at 10:52 am with the MDS Director (MDSD) revealed R41's primary diagnosis was chronic kidney disease, stage 3 effective on 11/2/2024, and secondary diagnosis of dementia with behavioral disturbance effective 11/2/2023. The MDSD further confirmed anxiety, depression, and delusional disorders were also noted and confirmed they were considered mental health diagnoses.Interview on 8/7/2025 at 11:15 am with the Director of Nursing (DON) confirmed that all residents meeting eligibility criteria based on mental health or intellectual disability diagnoses should have a Level II PASARR submitted immediately, regardless of short-term or long-term status. The DON confirmed that R41 met criteria and should have had a Level II PASARR.Interview on 8/7/2025 at 11:41 am with the Administrator confirmed that PASARR screenings must follow federal regulations and should be initiated for eligible residents regardless of the expected length of stay.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Oxygen Therapy Policy, the facility failed to obtain a physician's order for oxygen (O2) for one of 12 residents (R) (R165) and failed to ensure that O2 was administered as ordered for one of 12 Rs (R120) who use O2. This deficient practice had the potential to cause respiratory complications and inadequate oxygenation.Findings include: Review of the policy titled Oxygen Therapy Policy revised 4/1/2025 revealed under Standard of Practice: 1. Oxygen therapy is to be used with a written order by a physician. 1. Review of the electronic medical record (EMR) revealed R165 was admitted to the facility with diagnoses including but not limited to malignant neoplasm of the glottis, tracheostomy, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). There was no completed Minimum Data Set (MDS) assessment for R165 at time of survey. The care plan for R165 did not include any problem statements regarding respiratory, tracheostomy care, or O2 needs. Review of the Physician's Orders for R165 included but was not limited to: Order dated for 8/4/2025 documented OXYGEN 2 LITERS/28% TRACH COLLAR RT MAY TITRATE TO KEEP O2 SATS GREATER THAN 88%-92%. Observation and interview on 8/4/2025 at 12:50 pm revealed R165 was lying in bed in an approximately 45 degree angle. R165 was alert and oriented, receiving O2 via tracheostomy. R165 was unable to clearly verbally communicate, she was able to understand and write to communicate. The O2 concentrator was set at 3.5 liters per minute (LPM) with humidifier, filter had a small amount of debris. R165 did not know what her O2 level should be set to on the machine. R165 indicated (by writing) that she had been in the facility since 7/22/2025. Observation of R165 on 8/5/2025 at 1:00 pm revealed her sitting up in bed eating from a lunch tray. She gave a thumbs up when asked how she was doing today. The O2 concentrator was observed to be set on 2 LPM. Observation of R165 on 8/6/2025 revealed her sitting in her wheelchair by her bed eating lunch, smiling and did not appear to be in distress. The O2 was set to 2 LPM. Observation of R165 on 8/7/2025 revealed her sitting up in her bed watching TV and eating. She indicated with a thumbs up that she was doing well. When asked if she had any issues or concerns, she shook her head no. O2 was set to 2 LPM. Interview on 8/4/2025 at 3:32 pm with Licensed Practical Nurse Unit Manager (LPN UM) II revealed she was notified by one of the Respiratory Therapists (RT) HH that R165 had no order for her O2. EMR review with LPN UM II confirmed R165 was admitted on [DATE] and had been on O2 since admission and an initial RT note was documented on 7/24/2025. LPN UM II further reviewed the nursing admission note which stated O2 on at 3 liters per minute (l/m) with no order and no notation of R165 have a tracheostomy. LPN UM II stated clinical staff made O2 rounds every Monday and between nursing and respiratory staff should be monitoring and ensuring orders were present, and if not, action should be taken immediately to contact her or the provider directly for assistance and orders. Interview on 8/4/2025 at 3:42 with RT HH revealed he rounded on R165 this morning and her oxygen was on by way of trach collar at 2 LPM. RT HH also shared he was not surprised upon observation that O2 flow was at 3.5 LPM. RT HH revealed upon receiving order, he did adjust her O2 flow to 2 LPM. RT HH further shared respiratory therapy was on site from 7:00 am to 7:00 pm every day and after-hours nurses were responsible for monitoring and care of tracheostomy residents. Interview with the Director of Nursing (DON) on 8/7/2025 at 1:57 pm revealed that any resident that came into the facility with a tracheostomy was assessed by the respiratory therapist (RT). RT initially set up the resident's room and initially assessed the resident as that was one of their main responsibilities. Orders for O2 were checked the next day at the morning meeting with department leadership to ensure they were in place and accurate. O2 was monitored by nursing and RT. The DON stated that her expectation was that O2 orders were in place for residents that required them and not having an order for O2would mean they were administering it without orders, which should not be done. The DON was informed that R165 had been admitted on [DATE] and did not have any O2 order in the medical record until 8/4/2025, which she stated should not be the case since those orders should be in the chart and accurate. Additionally, the resident's O2 was initially observed to be on 3.5 LPM and later the order in the EMR was for 2 LPM. The DON stated that orders in the EMR should be followed as written. 2. Review of the electronic medical record (EMR) revealed R120 was admitted to the facility with diagnoses including but not limited to chronic respiratory failure with hypoxia (tracheostomy in place), congestive heart failure, paroxysmal atrial fibrillation, hemiplegia following cerebral infarction, moderate malnutrition, pressure ulcers, generalized muscle weakness, dysphagia with gastrostomy tube, and advanced dementia without behavioral disturbances. Review of R120's 5-Day MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment and section GG, Functional Abilities, indicated that R120 required total assistance with all activities of daily living (ADLs). Review of the Physician's Orders for R120 included but was not limited to: Order dated 8/5/2025 for Oxygen 5L (liters) via trach (tracheostomy) collar with instructions that respiratory therapy may titrate to maintain oxygen saturation above 92% (percent); frequency noted as every shift for shortness of breath (SOB). Order dated 6/24/2025 for Humidified oxygen at 28% to trach collar continuously. Order dated 7/13/2025 to change and date all respiratory supplies and tubing weekly and clean the oxygen concentrator filter if present; frequency: every Sunday, day shift. Order dated 7/9/2025 for Ipratropium-Albuterol nebulizer treatment, 3 mL (milliliters) via trach twice a day, for SOB/wheezing. Order dated 7/9/2025 for tracheostomy suction every 4 hours and as needed (PRN). Review of R120's Respiratory Progress notes included but was not limited to: Pulmonary Function Note dated 8/4/2025 revealed that the resident's oxygen flow rate was documented as set to 2 liters per minute (LPM). Pulmonary Function Note dated 8/5/2025 revealed that the resident's oxygen flow rate was documented as set to 2 LPM. Pulmonary Function Note dated 8/7/2025 revealed that the resident's oxygen flow rate was documented as set to 2 LPM. Observation on 8/4/2025 at 1:00 pm of R120 O2 concentrator revealed that the O2 was set at 1 LPM. Interview with Licensed Practical Nurse (LPN) JJ on 8/4/2025 at 1:00 pm confirmed the 1 LPM setting and stated, I don't touch the oxygen. That's the RT's job. I just change the tubing when ordered. Interview on 8/4/2025 at 1:10 pm with Respiratory Therapist (RT) HH revealed,the resident should be at 2 liters to meet the prescribed 28%. He referenced previous notes indicating a recommendation of 1.5 liters and acknowledged that 1 liter is insufficient and should be adjusted to 2 liters. Interview on 8/4/2025 at 2:46 pm with Staff Development Coordinator (SDC) revealed that she does not provide tracheostomy care training and deferred responsibility to the DON. Interviews on 8/5/2025 at 4:55 pm and 8/7/2025 at 3:42 pm with the DON confirmed that RT staff were contracted and receive training via name of online education. The DON further stated, RTs must follow the physician orders as written and notify the Unit Manager or DON if the order needs to be changed.

Based on record review, interviews, and review of policies titled Notification of Resident's Change in Condition, and Laboratory Testing, the facility failed to notify the physician and responsible party (RP) for a change in condition for one of 44 sampled residents (R) (R660). Specifically, facility staff failed to report critical urinalysis lab results for R660, who experienced actual harm on 12/16/2023, resulting in the resident being hospitalized for 11 days with urosepsis (sepsis caused by urinary tract infection) and acute renal failure. Findings include: Review of the policy titled Notification of Resident's Change in Condition revised 9/1/2019 indicated the policy statement as the facility will promptly notify the resident, his or her attending physician, and responsible party of changes in the patient's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights, etc.). Practice Guidelines: Quality of Care - notification of changes - required notifications to Medical Doctor, legal representative, interested family, and resident of injurious accident, significant change in condition-treatment, transfer or discharge, change in room or roommate, or change in legal rights. Step 1. The Nurse Supervisor/Charge Nurse will notify the resident's attending physician when there has been: d. A significant change in the patient's physical/emotional/mental condition e. A need to alter the patient's medical treatment significantly f. A need to transfer the patient to a hospital/treatment center i. Instructions to notify the physician of changes in the patient's condition Step 2. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the family/responsible party b. There is a significant change in the patient's physical, mental, or psychosocial status e. It is necessary to transfer the patient to a hospital/treatment center Step 4. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident, family, or responsible party of any changes in his/her medical care or nursing treatments. Step 5. The Nurse Supervisor/Charge Nurse will record in the resident's clinical record information relative to changes in the patient's medical/mental condition or status. The Nurse Supervisor/Charge Nurse will document the name of the responsible party that was notified of the change, date, time and response in the electronic health record (EHR). Review of the policy titled Laboratory Testing dated 9/1/2018, indicated the policy was that diagnostic testing will be completed according to the facility's routine laboratory schedule and/or as ordered by the primary care physician, physician assistant, nurse practitioner, or clinical specialist. The Standard of Practice section indicated when lab results are received, the Charge Nurse will indicate this on the lab log. The ordering clinician is to be promptly notified of the laboratory results that fall outside the desired clinical reference ranges. Critical lab results will be phoned to the ordering clinician when received with supporting documentation placed in a Nurse Progress Note. Non-critical abnormal laboratory results will be faxed to the ordering clinician when received. Indicate on the lab log/lab results: date the ordering clinician was notified; date of the ordering clinician's response; indicate if new orders were obtained; family notification; signature of nurse providing notification. Review of the clinical record revealed R660 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), muscle weakness, and unspecified lack of coordination. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated no cognitive impairment. Section H documented that R660 had occasional urinary incontinence. Section I documented she had not had a urinary tract infection (UTI) 30 days prior to the assessment. Review of the Progress Note dated 12/9/2023, written by Nurse Practitioner (NP) GG, documented that R660 complained of painful urination and stated, I think my UTI has returned. Current diagnoses documented hypertension, rheumatoid arthritis, and urinary tract infection. The plan included urinalysis (UA) with a culture and sensitivity (C/S) for dysuria (painful urination). Review of the lab [company name] revealed urinalysis was collected on 12/11/2023 and the results reported on 12/14/2023 documented abnormal results of blood 2+, white blood cells (WBC) too numerous to count (TNTC), culture source - urine, culture organism listed klebsiella pneumoniae greater than (>) 100,000. The report included a sensitivity report. Review of the electronic medical record (EMR) did not reveal evidence that R660's physician was notified of the lab result and there was no evidence that orders related to the lab result were received from the ordering physician for treatment of R660's UTI. Review of the Progress Note dated 12/16/2023 at 5:52 am, written by Licensed Practical Nurse (LPN) PP, documented Resident running temperature at 8:30 pm 101.7 F, gave Tylenol. At 5:40 am her temperature was 101.4 F. At 7:36 am, NP GG called, awaiting a return call. Review of the Progress Note dated 12/17/2023 at 3:58 am, written by LPN QQ, documented Resident was transferred to [hospital] as per her son's request. She was administered Tylenol by the outgoing nurse for a low-grade temp. She was diaphoretic at the time she left the facility. Review of [hospital] Emergency Department (ED) records dated 12/16/2023 documented Resident resides in a nursing home and family came to visit her today. The family wanted her transported to the emergency department for evaluation as she has had similar symptoms to UTI's in the past. Admitting diagnoses include sepsis-urinary tract infection and acute renal failure. Interview on 3/23/2024 at 9:05 am, Director of Nursing (DON) revealed the process for laboratory results was when lab results are reported, they show up in the EMR under the results tab. She stated the staff who receives the lab report is responsible for notifying the provider of the results. She stated labs are reviewed and discussed daily including lab orders, labs collected, and lab results, with any actions taken or needed to be taken related to the lab results. During further interview, she stated she was not employed at the facility at the time R660 was a resident, and she cannot state the reason the Physician, NP, or responsible party were not notified of R660's abnormal lab results. Interview on 3/23/2024 at 9:48 am, LPN AA stated when lab results are returned, the nurse taking care of the resident is responsible for notifying the physician of the abnormal results and then should document the notification in the progress notes. During further interview, she stated the nurse notifies the unit manager (UM) of the results and actions taken. She stated the nurse's documentation should include the lab results, the call to the physician and family of results, and the notification of the UM. Interview on 3/23/2024 at 3:16 pm, DON verified the results for the urinalysis collected on 12/11/2023 for R660 were reported to the facility on [DATE] as abnormal. She stated she would have to look in the medical records department for documentation of notification given to the provider and orders received related to the laboratory results from 12/14/2023. Interview on 3/24/2024 at 8:45 am, the DON revealed she had not been able to locate any documentation related to physician notification or orders/instructions related to R660's UA results from 12/14/2023. During continued interview, she stated they are still reviewing audits that were conducted in December of 2023. Interview on 3/24/2024 at 9:55 am, the Administrator was asked for documentation related to notifying the Physician of R660's abnormal lab results. She replied that the facility identified an issue with its previous laboratory provider and changed to its current provider in October 2023. She stated they identified issues related to laboratory results and have a Process Improvement Plan (PIP) in place that was started after they changed laboratory providers in October 2023. She did not address the issue related to the Physician and responsible party not being notified of R660's abnormal lab results, when the lab results were reported to the facility on [DATE]. Interview on 3/24/2024 at 10:35 am, the Medical Director stated he did not remember if the facility had contacted him regarding R660's urinalysis result, but he would have the NP contact the surveyor regarding the resident. Interview on 3/24/2024 at 11:55 am, NP GG stated she could not remember if the facility had notified her of R660's abnormal UA with C&S lab results from 12/14/2023. She stated she did not keep records of when staff notified her about resident lab results, but revealed if she had been notified, she would have given the nurse orders for the treatment for R660's UTI. During further interview, she stated if a resident had an elevated temperature, she would have sent the resident to the emergency room to prevent any delay in treatment. Three requests were made to facility staff for documentation of Physician notification and orders related to the lab results received and were not provided during the survey. Cross Refer F690

Based on record review and staff interviews, the facility failed to provide appropriate treatment and care for one resident (R) (R660) with a severe urinary tract infection (UTI). Abnormal urinalysis (UA) and culture and sensitivity (C&S) results were reported to the facility on [DATE] and the facility failed to seek medication for treatment. Actual Harm occurred on 12/16/2023 when R660 was admitted to the hospital for 11 days with a urinary tract infection and acute renal failure. The sample size was 44. Findings include: Review of the electronic medical record (EMR) revealed R660 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), muscle weakness, and lack of coordination. She was discharged on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed R660 was occasionally incontinent of urine and no urinary tract infections 30 days prior to the assessment. Review of the EMR revealed a Progress Note dated 12/9/2023 documented resident complained of painful urination and stating, I think my UTI has returned. Nurse Practitioner (NP) GG indicated her plan to obtain a urinalysis (UA) with culture and sensitivity (C/S) if indicated for dysuria (painful urination). Review of the EMR revealed a physician's order for urinalysis (UA) with culture and sensitivity (C/S) dated 12/10/2023. Medication order for telmisartan-hydrochlorothiazide (a diuretic medication used to treat high blood pressure) 40 milligrams (mg) one tablet by mouth two times a day for hypertension dated 12/6/2023. Review of EMR revealed the dietitian documented on 12/11/2023 that the diuretic medication telmisartan-hydrochlorothiazide may cause fluid shifts. Review of the December 2023 Physician Orders revealed an order dated 12/10/2023 for urinalysis (UA) with culture and sensitivity (C/S) if indicated. Review of the EMR revealed the UA was collected on 12/11/2023 with results returned to facility on 12/14/2023 as abnormal for 2+ blood, white blood cell (WBC) - too numerous to count (TNTC) with culture resulted as: Source - Urine, organism - greater than (>) 100,000 Klebsiella pneumoniae. Continued review revealed there was no evidence documenting that the facility staff informed the physician of the laboratory results nor any documentation of orders related for treatment of the UTI. Review of the December 2023 Weights and Vitals Summary documented R660's body temperature was trending upwards, beginning 12/13/2023 with temperature recorded as 100.9 degrees Fahrenheit (F), and 12/15/2023 temperature was recorded at 101.7 F. There was no recorded temperature for 12/14/2023. Review of EMR revealed nursing note dated 12/16/2023 at 5:52 am, documented R660 was running a temperature of 101.7, gave Tylenol, at 5:40 am temperature was 101.4 and at 7:36 am, Physician/NP (MD/NP) called and awaiting return call. Review of EMR revealed a Progress Note - Change of Condition documented on 12/16/2023 at 11:00 pm with the situation documented as evaluation - urinary continence (new or worsening). There was no provider response or feedback documented on the form. Review of EMR revealed a Progress Note dated 12/17/2023 at 3:58 am documenting R660 was transferred to the hospital per her son's request. Review of the hospital records with admitted [DATE] and discharge date of [DATE] documented the following: *12/16/2023 - Chief Complaint: generalized weakness - family wanted resident transported to the emergency department (ED) for evaluation - she has had similar symptoms with UTI's in the past *12/16/2023 - Vital signs: blood pressure 110/62, pulse 92, temperature 100.1 Fahrenheit (rectal) *12/17/2023 - low-grade temperature - treated with antibiotics, attempts to straight cath resident as she was receiving IV fluids but unable to obtain urine, lab values revealed acute renal failure *12/17/2023 - History & Physical - labs on 12/16/2023 - white blood cell count (WBC) was high (11.6), with relative neutrophils high (88.6) and absolute neutrophils high (10.3), sodium (Na) level was low (128), blood urea nitrogen (BUN) was high (80), and Creatinine was high (6.10). The plan of care (POC) was documented as empiric intravenous (IV) antimicrobial treatment in the emergency department (ED) *12/17/2023 - Nephrology was consulted for acute kidney injury (AKI). Labs - Creatinine 6.1 improved to 4.9, WBC 12.56 (high), Na 130 (low), BUN 82 (high). The plan of care was to continue IV fluids and IV antibiotics, monitor renal function and urine output daily. *12/20/2023 - Nephrology progress note revealed the AKI likely secondary to hypovolemia and UTI. The assessment and plan documented - sepsis UTI - patient currently on Rocephin, urine culture growing gram negative rods and positive for klebsiella pneumonia, needs an appointment as an outpatient with Nephrology. *12/27/2023 - Discharge summary - resident was admitted to the hospital on 12/16/2023 at 9:27 pm and was discharged on [DATE]. Brief Hospital Course documented care was managed for Sepsis - UTI. The principal discharge diagnosis was acute renal failure. The physician documented R660 was currently on Rocephin, had a temperature max of 102.7 F, and urine culture was positive for klebsiella pneumonia. Interview on 3/23/2024 at 3:16 pm, the DON confirmed documentation that R660 stated she had painful urination and thought her UTI was back and that a urine specimen was collected on 12/11/2023 for the UA and C&S ordered by NP GG. During further interview, she verified the results from the UA and C&S were reported to facility on 12/14/2023. She verified R660 was sent to the hospital on 12/16/2023 for change in condition related to elevated body temperature. Interview on 3/24/2024 at 11:55 am, NP GG revealed if the facility notified her of R660's abnormal UA & C/S results from 12/14/2023, she would have given the nurse orders for treatment. She stated she would expect the nursing staff to relay their nursing assessment at the time of the phone call and if there was anything going on such as elevated temperature, she would have sent the resident to the emergency room for treatment to prevent any delay in treatment. Cross Refer F580

Based on observations, record review, interviews, and review of the facility's Holiday Newsletter, policy titled Cleaning and Disinfecting Residents' Rooms, and the Material Safety Data Sheet (MSDS) for Rapid Multi Surface Disinfectant Cleaner, the facility failed to ensure the environment was free from potential accident hazards. Specifically, R2 had an electrical power strip lying in the bed with her, providing electrical to multiple devices. In addition, the facility failed to ensure a chemical spray bottle with cleaning solution was properly stored while not in use placing R82 at risk for exposure to the chemical. The sample size was 44. Findings include: Review of the facility's Holiday Newsletter Volume 5 Edition 12 dated December 2022, indicated extension cords are NEVER allowed in the facility. Extension cords are prohibited, except when used on a portable appliance, such as a vacuum cleaner. NFPA 70 440.8; IFC 605.4. Review of the policy titled Cleaning and Disinfecting Residents' Rooms reviewed November 2020 revealed General Guidelines: Number 3. Manufacturer's instructions will be followed for proper use of disinfecting products. c. Storage. Number 8. Use heavy-duty gloves (and other PPE as indicated) for housekeeping tasks. a. Gloves, protective eyewear and masks may be indicated to reduce exposure levels to disinfectant chemicals. Review of the MSDS for Rapid Multi Surface Disinfectant Cleaner revealed in Section 7. Handling and Storage - Advice on safe handling: Do not ingest. Do not get in eyes, on skin, or on clothing. Do not breathe dust/fume/gas/mist/vapors/spray. Use only with adequate ventilation. Wash hands thoroughly after handling. Conditions for safe storage: Keep away from strong bases. Keep out of reach of children. Store in suitable labeled containers. 1. Review of the clinical record revealed R2 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (MS), hypertension, muscle weakness, pulmonary embolism (PE) without acute cor pulmonale, and chronic pain. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) of 14 indicating little or no cognitive impairment. Section GG indicated R2 was dependent on staff for transfers and mobility with functional limitations in range of motion with impairments on both sides of lower extremities. Observation on 3/22/2024 at 9:41 am and at 11:19 am, revealed an electrical power strip lying in the bed with R2. The power strip was plugged into a wall outlet and the red light was illuminated indicating the power strip had power. The power strip had 3 cords plugged into it. Observation on 3/23/2024 at 9:48 am, revealed R2 was lying in bed. An electrical power strip was lying in the bed and positioned at the top left side of the bed, with the red indicator light illuminated, indicating the power was on. Interview on 3/23/2024 at 9:38 am, R2 informed surveyor that the power strip was placed on her bed approximately two weeks ago, and stated when it is on the floor, the cords plugged into the power strip come out and she was unable to use them. Interview on 3/23/2024 at 9:52 am, Certified Nursing Assistant (CNA) NN revealed she provided care for R2 on 3/22/2024 and today and was aware the electric power strip was on the bed. During further interview, CNA NN stated that she was aware the power stirp should not be on the bed due to the potential risk for fire. She stated she had entered a work order into the electronic system on 3/18/2024 but had not reported the issue to a supervisor. Review of the facility's electronic work order record dated 3/17/2024 through 3/22/2024 revealed no evidence of a work order for the maintenance department related to the power strip in use by R2. Interview on 3/23/2024 at 9:57 am, Assistant Director of Nursing (ADON) revealed during compliance rounds this morning, she assisted R2 her with her breakfast. She stated she did not notice the power strip in her bed at the time. During further interview, the ADON confirmed that the power strip should not be placed on R2's bed, and stated whoever knew it was there, should have removed it immediately. Interview on 3/23/2024 at 10:10 am, Director of Nursing (DON) revealed a resident should never have a power strip in the bed. She further stated the power strip should have been removed immediately and the supervisor informed. Interview on 3/23/2024 at 11:17 am, Assistant Maintenance Director MM revealed he checks the electronic maintenance system several times a day for repair issues needed in the facility. He stated he had not seen anything in the electronic system related to a power strip being used in a resident's room, until today. The Maintenance Assistant reviewed all work orders entered into the electronic system from 3/17/2024 through 3/22/2024 and verified a work order had not been previously entered into the system. 2. Review of clinical record revealed R82 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic systolic congestive heart failure, chronic obstructive pulmonary disease (COPD), dementia with behavioral disturbances, and generalized anxiety disorder. Review of the Admission MDS assessment dated [DATE] revealed a BIMS of 12 indicating moderate cognitive impairment. Section GG revealed the resident is independent with ambulation. Observation on 3/23/2023 at 8:48 am in room C12, R82 was ambulating from the bathroom using a rolling walker. The surveyor observed an unlabeled spray bottle of cleaning solution sitting in front of the television. Certified Nursing Assistant (CNA) KK was observed to pick up the bottle of cleaning solution and place it behind the television. This action was verified by Licensed Practical Nurse (LPN) Unit Manager (UM) BB, who removed the cleaning solution from the room and stated it should not be there. Interview on 3/23/2024 at 8:59 am, CNA KK stated she should have removed the cleaning solution from the room. During continued interview, she stated she was aware that it was not supposed to be there, which was why she placed it behind the television when she saw a surveyor standing in the room. Interview on 3/23/2024 at 10:22 am, Housekeeper LL stated she was asked to clean the sticky floor in room C12. She revealed she was rushing to clean the floor because the breakfast trays were on the unit to be delivered, and she knew she was not allowed to clean during meal service. She stated she was aware that cleaning solutions/chemicals should never be left in residents' room, and stated it was left there by mistake. During further interview, she identified the contents of the spray bottle cleaning solution as Rapid Multi-Surface Disinfectant Cleaner. Interview on 3/23/2024 at 10:43 am, Director of Environmental Services revealed the bottle of cleaning solution left in R82's room contained Rapid Multi-Surface Disinfectant Cleaner and verified it should not have been left in the room. She stated the housekeeping staff are trained to not put chemicals/cleaning solutions down in resident's rooms, but to return it to the cleaning cart immediately after each use. Interview on 3/23/2024 at 11:21 am, Administrator revealed that cleaning chemicals should never be left in a resident's room unattended. She stated the CNA was aware that the cleaning chemical should have been removed, and stated she became nervous when she saw a surveyor in the room. During further interview, the Administrator revealed residents should not have a power strip lying in the bed at any time. She stated the facility did not have a policy related to electrical power strips or a policy that addressed accidents and hazards. She provided a newsletter addressing extension cords, which was given to residents and their families.

Based on observations, record review, staff interview, and review of the policies titled Care Plan Policy and Smoking Policy for Residents, the facility failed to develop a care plan for three of 44 sampled residents (R) R108 for Post-Traumatic Stress Disorder (PTSD), R116 for dementia, and R126 for smoking. Findings include: Review of the facility's Care Plan Policy, reviewed 10/25/2022, revealed the policy is that each resident would have a plan of care to identify problems, needs, and strengths that would identify how the facility staff would provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Standards of Practice: Number 2. A care plan to identify past trauma would be developed through input of the resident and/or resident representative to prevent re-traumatization to the resident. Number 10. Areas of concern or potential concern and residents' strengths would be addressed with measurable goals and specific person-centered approaches to promote attainment or maintenance of the goal(s). 1. Review of the clinical record revealed R108 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, schizoaffective disorder, and post-traumatic stress disorder (PTSD). Review of a Mental Health Note dated 6/8/2023 documented the resident was displaying symptoms indicative of PTSD, including agitation, irritability, hostility, hypervigilance, emotional detachment, and intrusive thoughts. Further review revealed R108 reported two men raped the resident on two occasions. Additionally, the resident reported a history of domestic violence, physical abuse, emotional abuse, kidnapping, and being forced to play Russian [NAME]. The clinician diagnosed the resident with acute PTSD. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R108 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section revealed no moods exhibited; Section E behaviors revealed resident displayed rejection of care four - six days during look back period; Section I revealed a diagnosis of PTSD. Review of the current care plan revealed there was no comprehensive plan of care developed to address R108's diagnosis of PTSD. 2. Review of clinical record revealed R116 was admitted to the facility on [DATE] with a diagnosis of dementia with other behavioral disturbances and adjustment anxiety disorder. Review of the Significant Change MDS assessment, dated 12/15/2023, revealed R116 had a documented BIMS score of 10, indicating moderate cognitive impairment. Section D revealed the resident reported feeling down and depressed for two - six days of the look back period. Section I revealed a diagnosis of dementia. Review of R108's MD orders revealed an initial order for psych services on 6/6/2023, Seroquel (a medication used to treat mental health conditions) 23 milligrams (mg) by mouth daily at bedtime and Aricept (a medication used to treat symptoms of Alzheimer's disease) 10 mg by mouth daily at bedtime. Review of the current care plan for R116 revealed there was no comprehensive plan of care developed to address R116's diagnosis of dementia. Interview on 3/23/2024 at 8:32 am, Assistant MDS Coordinator (AMDS) revealed that she developed resident care plans by reviewing the resident's diagnoses and MDS assessments. She explained that staff discuss additional resident information during clinical meetings, and any changes to the care plans were added based on that information. During further interview, she stated that any behavioral or psych components of the care plan, including interventions, were handled by the Social Worker (SW). The AMDS did not know why there was no comprehensive care plan developed for R108 for PTSD. The AMDS acknowledged that R116 had no care plan for dementia and stated he did not know why one had not been developed. Interview on 3/23/2024 at 8:41 am, Social Worker (SW) stated based the residents' psych notes and recommendations and other clinical information, she tailored the residents' care plan to reflect any interventions or special needs the residents might have based on their diagnoses and symptoms. She stated she did not know the reason why R108 had PTSD and stated she had not reviewed the 6/8/2023 mental health notes. She indicated that if she had reviewed the notes, she would have personalized R108's care plan to reflect her symptoms and interventions. During further interview she acknowledged that R116 had a diagnosis of dementia, and verified there was no care plan developed. She stated R116 should have had a care plan for dementia developed but could not answer why one was not developed and added that it may have been overlooked. 33548 3. Review of the facility policy titled Smoking Policy for Residents dated 9/1/2018, revealed the policy of the facility is to establish and maintain safe resident smoking policies in accordance with resident rights and preferences. Standards of Practice: Number 2. Residents who smoke will have a plan of care related to this activity. Review of the clinical record revealed R126 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, anxiety disorder, and convulsions. Further review revealed a smoking assessment was completed on 12/28/2023 indicating resident was safe to smoke and he signed a smoking contract on 12/29/2023 indicating that he understood the smoking policy and the rules. Review of the current care plan revealed there was no care plan developed to address R126 smoking. Interview on 3/23/2024 at 10:50 am, MDS Coordinator revealed that she is not responsible for developing and entering resident care plan for smoking. The MDS Coordinator stated that the activities department is responsible for developing resident care plans for smoking. The MDS coordinator confirmed that no smoking care plan had been developed for R126. The MDS Coordinator revealed that each department that is responsible for a certain section of the MDS assessment and there is no oversight to ensure all aspects of the residents care plan have been addressed. Interview on 3/23/2024 at 10:55 am, Activities Director (AD) revealed that the activities department is responsible for the development of care plans for residents who smoke. The AD confirmed that there was no care plan for R126 smoking, and stated it should have been, it was an oversite. Interview on 3/23/2024 at 12:35 pm, DON stated that she expects a care plan for smoking to have been developed for R126. The DON revealed that she expects each department to develop care plans for their assigned sections. During further interview, she indicated there is not a specific staff member to ensure all necessary areas are addressed in a resident care plan,

Based on observations, record review, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policies titled, Hand Washing/Hand Hygiene Policy and, Perineal (Skin) Care for Incontinent Resident, the facility failed to implement an effective Infection Control Program to prevent the development and transmission of communicable diseases and infection. Specifically, the nursing staff failed to offer and/or encourage hand hygiene for residents during meal delivery by four of four staff members observed delivering meals; housekeeping staff failed to perform hand hygiene between resident rooms and between glove changes on one of five halls (A Hall); and nursing staff failed to change gloves and perform hand hygiene when going from dirty to clean during incontinent care for one of two sampled residents (R#90) reviewed for incontinent care. The census was 153. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Hand Hygiene Guidance, updated 1/30/2020, retrieved from https://www.cdc.gov/handhygiene/providers/guidelin.html, indicated, Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g. [for example], placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. Review of the facility's Hand Washing/Hand Hygiene Policy, reviewed 11/20/2020, revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. Review of the facility policy titled Perineal (Skin) Care for Incontinent Resident, reviewed October 2018, revealed that after providing perineal care, staff were to 10. Remove gloves and discard. Wash hands. 11. Place dry brief on the resident. 12. Replace any other articles of clothing that may have been removed . Upon completion of the procedure, staff were to, 16. Wash hands. 1. Observations on 3/29/2022 from 1:20 p.m. to 1:56 p.m. on A Hall, Certified Nursing Assistant (CNA) AAA was observed delivering meal trays to residents in rooms A7 and A13; CNA GG was observed delivering meal trays to residents in rooms A13, A16 and A14; CNA SS was observed delivering meal trays to residents in rooms A10, A15 and A14; CNA BBB was observed delivering meal trays to residents in rooms A9, A12, A11 and A14. The identified rooms were shared rooms with double and triple occupancy. Although the observed CNAs performed hand hygiene on their own hands prior to delivering the meal trays to the different residents, they did not encourage or offer hand hygiene to the residents when they delivered their noon meal. Interview on 3/29/2022 at 2:11 p.m. with R#104 stated she was not encouraged or offered hand hygiene before she ate her meal. The resident stated that it would be a good idea to have something to clean her hands with before she ate. Interview on 3/29/2022 at 3:07 p.m. with the Administrator, stated her expectation was that staff performed hand hygiene on themselves and encourage/offer hand hygiene to the residents as well. She stated hand hygiene was important to ensure residents' hands were clean when they ate their meals. Interview on 3/29/2022 at 3:27 p.m. with the Director of Nursing (DON), stated nursing staff should not only perform hand hygiene on themselves but should provide the same to the residents. The DON stated hand hygiene was important for infection control and prevention. Per the DON, nursing staff should perform and/or encourage hand hygiene for the residents to ensure the residents ate their meals under clean conditions. Interview on 3/30/2022 at 8:24 a.m. with CNA GG, stated the residents were given bed baths during morning care and the residents' hands were cleaned during the morning care as well. CNA GG stated he relied on the hand cleaning conducted during the morning care as sufficient. The CNA stated he had been trained on indications for hand hygiene, to include but not limited to after using the bathroom, between resident contacts, before donning and after doffing gloves. The CNA indicated he thought the residents should be doing hand hygiene on themselves. Interview on 3/30/2022 at 11:55 a.m. with CNA SS, stated she had been trained on the need to perform hand hygiene prior to serving meals to residents and the importance of performing or offering hand hygiene to residents during meal delivery. During further interview, she stated she was supposed to carry a portable container of hand sanitizer with her; however, she did not. The CNA verified that she failed to perform hand hygiene and failed to offer the same to the residents because she forgot to do it. 2. Observations on 3/30/2022 at 9:23 a.m. with Housekeeper DDD, who was working on the B Hall, began cleaning room eight. The housekeeper emptied the trash, got a cloth out of a white bucket on the housekeeping cart, and wiped down all the surfaces in the room, including the door handles and the bathroom. Housekeeper DDD stated the solution was peroxide disinfectant solution that was premixed in the janitor's closet. After completing the cleaning for room eight, Housekeeper DDD took the cart and moved down to room [ROOM NUMBER] on the B Hall. She removed her gloves and donned a new pair of gloves. At 9:30 a.m., Housekeeper DDD replaced the paper towels in the room, emptied the trash out of the room and the bathroom, then took a cloth out of the white bucket on the top of the housekeeping cart and wiped down the door handles, the countertop by the television, and the handles on the bathroom. She then wiped down the bathroom sink, came out of the room and put the cloth in a plastic bag, then changed her gloves without doing hand hygiene. The housekeeper walked down the hall with the gloves on and returned at 9:39 AM, removed her gloves, and put a new pair of gloves on without performing hand hygiene. The housekeeper then started cleaning room [ROOM NUMBER] on the B Hall. Interview on 4/1/2022 at 10:09 a.m. with the Housekeeping Supervisor, stated glove changes should occur between every room upon entering, and hand hygiene should occur between glove changes. 3. Review of the clinical record for resident (R) #90 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, indicating moderate cognitive impairment. Section G revealed that resident required extensive physical assistance of two people for toilet use. Section H revealed R#90 was always incontinent of bladder and bowel. Review of the care plan dated 3/11/2022 revealed resident was incontinent of bowel. Interventions included checking the resident as required for incontinence and to wash, rinse, and dry the perineum. Observation on 3/28/2022 at 11:07 a.m. with CNA GG providing incontinent care for R#90. There was feces noted on the left hip and right heel. CNA GG was in the process of providing incontinent care and was wearing gloves. There were no clean gloves visible or within reach of CNA GG during the provision of incontinent care for R#90. CNA GG removed wet wipes from a wipe container and cleaned the feces from the resident's hip and foot. CNA GG then used wipes to clean the resident's anal region. CNA GG did not change or remove gloves before applying a clean incontinent pad underneath the resident and putting a new brief on the resident. CNA GG then removed the soiled top sheet and blanket and replaced them with clean linens. Still wearing the same gloves, CNA GG put a clean gown on the resident. After covering the resident up, CNA GG removed the gloves, placed them in the trash, and asked the resident if they wanted their facial hair shaved. The resident stated they would like to be shaved. CNA GG walked to the supply cart, located outside the resident's room, but at the door entry, and without washing or sanitizing their hands, grabbed a handful of gloves from the supply cart. Interview on 3/29/2022 at 1:20 p.m. with CNA GG, stated that when providing incontinent care, he applied two pairs of gloves because sometimes they bust open. CNA GG stated that during the surveyor's observation on 3/28/2022, the CNA was wearing two sets of gloves and removed the first set after providing incontinent care and you just didn't see me. I put them in the trash. Review of the CNA Competency/Skills Checklist dated 8/16/2021 for CNA GG revealed the CNA was very competent with perineal care. Interview on 3/30/2022 at 1:49 p.m. with CNA SS, stated she did not apply two sets of gloves when providing care. Interview on 3/30/2022 at 1:54 p.m. with CNA TT, stated he did not wear two sets of gloves when providing care. Interview on 3/31/2022 at 11:24 a.m. with the DON, stated that when providing incontinent care, gloves should be changed during the care being provided if the resident was soiled. She stated if staff wiped feces from a resident, they should change their gloves before touching anything else. The DON stated that staff were allowed to apply two sets of gloves if the staff member thought they may soil the gloves. The DON stated CNA GG should have changed gloves and washed his hands prior to placing a clean brief on the resident. Interview on 3/31/2022 at 12:00 p.m. with the Administrator, stated when staff were providing incontinent care, they should change gloves in between touching surfaces and the resident. The Administrator stated CNA GG should have changed gloves after providing incontinent care, and before putting a clean brief on the resident. The Administrator confirmed staff were allowed to wear two sets of gloves; however, it was not the norm. Interview on 3/31/2022 at 4:22 p.m. with CNA VV, stated she did not wear two sets of gloves when providing care and stated staff were not allowed to do that. Interview on 3/31/2022 at 4:34 p.m. with Licensed Practical Nurse (LPN) WW indicated she did not wear two sets of gloves while providing care. During an interview on 04/01/2022 at 8:37 a.m. with Licensed Practical Nurse (LPN) BB indicated she did not wear two sets of gloves while providing care.

Based on record review, staff interviews, and review of the facility policy titled, Notification of Resident's Change in Condition, the facility failed to ensure the physician was immediately notified when resident (R) R#32, complained of pain following a fall for one of three residents reviewed for falls. Findings include: Review of the facility policy titled, Notification of Resident's Change in Condition, revised September 1, 2019, indicated, Standards: This facility will promptly notify the resident, his or her attending physician, and Responsible Party of changes in the patient's medical/mental condition and/or status. Action: 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician when there has been: a. An accident or incident involving the patient. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed that R#32's Brief Interview for Mental Status (BIMS) score was nine, indicating moderate cognitive impairment. Resident required supervision with one-person assistance for transfers and set-up only for walking in the room. R#32 had one fall with major injury and one fall with no major injury since admission or prior assessment. Review of care plan, revised on 1/18/22, revealed the resident had a pubis fracture related to a fall. Interventions included monitoring/documenting the resident's pain on a scale of 0 to 10 before and after implementing measures to reduce pain. Review of the Nurses' Notes dated 1/4/22 at 6:30 p.m., revealed the nurse observed the resident lying on her back on the floor. The resident reported she was getting ready to sit on the commode and lost her balance. The nurse assessed the resident, then assisted her back to bed. During further review, the Nurse's Notes indicated R#32 sustained a hematoma to the back of the head and a cold compress was applied. The resident denied pain and was able to move upper and lower extremities. The note indicated the physician, and a family member were informed. Review of the Nurses' Notes, dated 1/5/22 at 2:00 a.m. and signed by Licensed Practical Nurse (LPN) II, revealed R#32 was alert and able to make her needs known. The note indicated the resident complained of pain to the buttocks and left anterior thigh but was able to move the leg with little discomfort. Tylenol was administered. The note also indicated the nurse would continue to monitor. There was no documentation to indicate the physician was consulted regarding the resident's complaint of post-fall buttock and thigh pain. Review of the Nurses' Notes, dated 1/9/22 at 11:22 p.m. and signed by Registered Nurse (RN) KK, revealed that upon assessment, resident was unable to walk like used to be. The nurse notified the physician and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Nurses' Notes, dated 1/9/22 at 4:04 p.m., revealed R#32 was observed in bed and reported pain to the left hip related to the recent fall. The note indicated an order was received for bilateral hip x-rays. Review of the Radiology Report, dated 1/9/22 at 9:01 p.m. revealed there was an acute fracture of the resident's left pubic rami with mild displacement and modest [CONDITION(S)], but no left hip fracture. Review of a Communication note dated 1/11/22 at 10:41 a.m. revealed a call was placed to R#32's family member to discuss the x-ray results and transfer to the hospital. The note indicated the x-ray showed a pelvic bone fracture, [CONDITION(S)] disease, osteopenia, and [CONDITION(S)]. The note also indicated the resident was not a candidate for surgical intervention and would return to the facility from the hospital once her blood pressure was stabilized. During an interview on 3/30/22 at 10:15 a.m. with LPN II stated when a resident was found on the floor, she would assess them for injuries and pain. She would then notify the family and physician, as well as follow any orders that were given. LPN II stated R#32 used the toilet independently but was a high fall risk. During further interview, she stated R#32 had a fall on 1/4/22, complained of pain, and an x-ray was ordered a few days later. LPN II was asked why the x-ray was not ordered until 1/9/22, when resident complained of pain to the left anterior thigh and buttocks on 1/5/22? LPN II stated they did not correlate R#32's complaints of thigh and buttock pain to the fall that occurred the previous day. She stated she administered pain medication to the resident but did not notify the physician about her complaints of pain. During an interview on 3/30/22 at 10:30 a.m. with RN KK revealed resident was independent with toileting. She stated that LPN JJ notified her on 1/4/22 that R#32 was found on the floor of the bathroom. During further interview, she stated LPN JJ assessed R#32 and she was able to move all extremities with no complaints of pain and R#32 was able to ambulate back to bed with assistance. She revealed when R#32 complained of pain on 1/9/22, she notified the physician, who then ordered an x-ray. During an interview on 3/30/22 at 10:40 a.m. with LPN JJ stated she found R#32 on the floor on 1/4/22 and R#32 did not complain of pain at that time. She stated R#32 could move all extremities and was able to ambulate back to bed with assistance immediately following the fall. LPN JJ further stated it was normal practice to wait a few days after a fall to get an x-ray if a resident complained of pain. She stated that if R#32 had complained of pain the day after a fall, she would have notified the physician to get an x-ray. During further interview, LPN JJ stated did not know why the facility waited five days to get an x-ray for R#32. During an interview on 3/30/22 at 12:55 p.m. with the Medical Director (MD) HH stated if the facility notified him when a resident had a fall and there were complaints of pain, he would order an x-ray. MD HH then stated he did not remember if the facility notified him when R#32 complained of pain on 1/5/22 following the fall on 1/4/22. During an interview on 3/31/22 at 11:42 a.m. with the Director of Nursing (DON) stated when a resident had a fall, the nurse would do a fall, pain, and skin assessment, then notify the responsible party, and physician for any follow-up orders. The DON further stated she expected the nurses to notify the MD if a resident complained of pain following a fall to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 4/1/22 at 10:55 a.m. with the Administrator, stated she expected the nursing staff to notify the MD if a resident was complaining of pain following a fall. LPN II administered Tylenol to the resident for pain and should have notified the physician of R#32's complaints of pain.

Based on observations, record review, and interviews, the facility failed to ensure showers were regularly provided as scheduled and facial hair was removed when needed for one resident (R) #58 of three sampled residents reviewed for activities of daily living (ADLs). Findings include: Review of the Admission Record revealed R#58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed that R#58 was moderately impaired in cognitive skills for daily decision-making per staff assessment for mental status. R#58 was dependent on two-plus person physical assistance for bathing and required extensive assistance of one person for personal hygiene, including shaving. Review of the care plan, revised 8/17/21, revealed a goal to have R#58's ADL needs met. The interventions indicated the resident was totally dependent on one staff member to provide a bath/shower and was totally dependent on one staff for personal hygiene and oral care. A review of Hospice Aide Visit Notes revealed for the month on January 2022, R#58 was provided a complete bed bath two times, 1/3/22 and 1/10/22. For the month of February, R#58 was provided a complete bed bath seven times in February 2022, on 2/2/22, 2/9/22, 2/11/22, 2/16/22, 2/18/22, 2/23/22, and 2/25/22. For the month March 2022, R#58 was provided a complete bed bath six times in March 2022, on 3/2/22, 3/9/22, 3/11/22, 3/16/22, 3/18/22, 3/30/22. A review of the Visual/Bedside Kardex Report, used by the certified nurse aides (CNAs) as a quick reference on the type of care a resident required, indicated R#58 received hospice services and was totally dependent on one staff member to provide the bath/shower, personal hygiene, and oral care. Observations on 3/28/22 at 1:21 p.m. and 3:54 p.m., R#58 was lying in bed in her room, wearing a blue gown. The resident's hair was greasy and uncombed. There was long facial hair on her chin and upper lip. Review of the Shower/Bath Sheet, dated 3/29/22, indicated R#58 received a shower on the 6:00 a.m. to 2:00 p.m. shift. The sheet indicated the resident's linens were changed, her hair was washed, and she was shaved. However, observations on 3/30/22 revealed R #58 still had facial hair and her hair was still greasy. Observation on 3/30/22 at 8:40 a.m., 3/31/22 at 9:27 a.m. and 4/1/22 at 9:28 a.m., R#58 was lying in bed in her room. The resident's hair was greasy and uncombed, and the resident had long hairs on her chin and upper lip On 4/1/22 at 10:18 a.m., surveyor attempted to call CNA JJJ, who documented on the shower sheet that the resident received a shower on 3/29/22. Message was left for the CNA to return call but had not received a return call as of the end of the survey. On 4/1/22 at 10:47 a.m., an interview was attempted with R#58's hospice provider. There was no response by the end of the survey. Interview on 3/31/22 at 11:24 a.m., the Director of Nursing (DON) stated the CNA's gave showers at least twice a week. The DON stated it was brought to her attention that the baths were being documented every shift, every day, instead of when they were provided. The DON stated if the resident was on hospice, the hospice CNA would usually give the bath/shower, but if they were not able to provide it, then the facility staff would. She stated the resident's hair should be shampooed once a week or per the resident's preference, and the resident should be shaved as needed, regardless of whether they were male or female. The DON stated she was not aware R#58 was not getting routine baths. Interview on 4/1/22 at 8:44 a.m., with Licensed Practical Nurse (LPN) CCC, revealed hospice came to see the resident two to three times a week and that hospice provided the showers for R#58. Interview on 4/1/22 at 9:28 a.m., with LPN FFF, revealed hospice provided bed baths for R#58 two to three times a week. She stated the resident required a bed bath and was unable to have showers, because the resident's legs were too contracted to get on a shower gurney. LPN FFF stated the hospice CNA should be washing the resident's hair at least once a week and shaving them as needed. LPN FFF agreed R #58 had long facial hair and needed to be shaved. She stated she was going to have a facility CNA shave the resident since it had not been done. LPN FFF stated if hospice was unable to give the resident a bed bath, then the facility staff would do it. Interview on 4/1/22 at 9:52 a.m., with CNA GGG, revealed showers were given two to three times a week depending on the resident, and their hair should be washed once a week or as needed. CNA GGG stated both male and female residents should be shaved if needed, on their shower days. CNA GGG stated she did not know if hospice documented the showers they gave. She stated she did not document showers for R#58 since they were given by hospice. She stated the hospice CNA should also be shaving the resident. Interview on 4/1/22 at 10:07 a.m., with Registered Nurse (RN) HHH, revealed showers were done two to three times a week, depending on the resident's preference. She stated hospice provided showers to their residents, and the facility would only do the shower if hospice was unable to. Interview on 4/1/22 at 10:52 a.m., the Administrator stated the facility staff had identified a problem with the documentation of showers when they were monitoring resident grievances. She stated she expected the staff to offer showers and not just bed baths. She stated if hospice did not show up to provide care for one of their residents, then the facility staff should provide the care instead. The Administrator stated shaving should also be offered with showers for men and women.

Based on observations, record review, interviews, and review of facility policies, the facility failed to ensure causative factors for falls were investigated and documented, interventions were developed and implemented to address the causative factors, and care planned interventions to prevent falls were consistently implemented for one resident (R) R#46, of three sampled residents reviewed for falls. Findings include: Review of the facility policy titled, Fall Prevention Protocol Policy, dated 9/1/18, revealed 4. After an incident of a fall: a. Complete the Post Fall Risk Assessment; b. Notify MD [medical doctor] and Resident Representative; c. Start neuro [neurological] check if there is a suspected head injury or for an unwitnessed fall as per facility protocol; d. Complete pain assessment after the fall; e. Fall placed on the 24-hour report; f. Refer to therapy or restorative nursing as deemed appropriate; g. Referrals, interventions, care plan updated completed in the clinical meeting; and h. Review fall incident during the clinical meeting with a root-cause analysis. Review of the facility policy titled, Incident Report - Documentation, Investigation, and Reporting, revised 9/20/2021, revealed 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident and then notify of the Director of Nursing (DON) and Administrator. 2. The Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record. The nurse notes should contain the following documentation: a. Clear, objective facts of what occurred; b. A thorough assessment of the resident's condition at the time of the accident/incident. (This assessment should include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident), c. Any quotes by the resident and/or witness involved or present at the time of the accident/incident; d. Any treatment provided; e. Any contacts made or attempted with the resident's physician, family, legal representative or any other health care professional or person involved with the resident's care; f. The resident's outcome and any information concerning the incident; and g. The nurse's signature, date and time of the charting. The policy indicated the following information should also be included on the incident report, if applicable, 5. The supervisor designee is to document the investigation of the event and the interventions put into place. They will ensure that the care plan is updated, that the medical record contains documentation of the event, and that the resident has been added to the 24-hour report. 6. Indicate the follow up intervention put into place to prevent reoccurrences. Review of the clinical record for R#46 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to left femur fracture, right patella (knee) fracture, muscle weakness, lack of coordination, [CONDITION(S)], disorder of bone density, and a history of falls. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Section G revealed resident required extensive assistance of two-plus people for activities of daily living (ADLs). The resident used a wheelchair as a mobility device and the resident had no falls since the prior assessment. Review of the care plan revised 12/21/2021, revealed resident was at risk for falls and had a history of falls related to poor balance, poor communication/comprehension, and unsteady gait. Interventions included Physical therapy (PT) to evaluate and treat as needed (PRN), provide clutter free environment with unobstructed pathways for wheelchair mobility, place resident at nursing station for observation, maintain in high traffic areas when out of bed to wheelchair, encourage/remind resident to use call light and call for assistance. Keep call light in reach, encourage resident to call for assistance with transfers/mobility, frequent rounds while in wheelchair, provide extensive assist of one to two with transfers/mobility, place essential items in reach. Review of an Incident Report, dated 6/21/2021 at 5:30 p.m., revealed R#46 was observed lying on the floor on her stomach with her legs stretched out under a wheelchair. The report indicated the resident stated she fell on her knees picking up paper from the floor. A complete body assessment was done, and the right knee was noted to be red, slightly swollen, warm, and tender to the touch. The report indicated nurse practitioner (NP) was notified, who then ordered an x-ray. The report indicated there were no predisposing environmental, physiological, or situational factors that contributed to the fall and no witnesses to the fall. Per the report, no immediate interventions were initiated to prevent the resident from falling again. Review of the Fall Risk assessment dated [DATE] at 6:41 p.m. revealed a score of 12. According to the Instructions a score of 10 or greater indicated the resident should be considered at high risk for falls and a prevention protocol should be immediately initiated and documented on the care plan. Review of care plan revised 6/21/2021 revealed R#46 was to be sent to emergency room for evaluation and an orthopedic referral for a knee injury. No interventions were documented to prevent the resident from falling again per the care plan. Continued review of the care plan documented resident had four additional falls in four months. Review of the Nurse's Note, dated 6/22/2021 at 8:30 a.m., revealed the resident was transferred to emergency room due to an abnormal x-ray result. Review of the Nurse's Note, dated 6/22/2021 at 3:30 p.m., indicated the resident returned to the facility with an immobilizer to the right leg. Review of the Physical Therapy Treatment Encounter Note, dated 6/23/2021 revealed R#46 was diagnosed with a patellar fracture, was fitted with a knee immobilizer, and was to be non-weight-bearing (NWB) with the knee immobilizer on at all times. The note indicated the resident was waiting for a follow-up appointment with an orthopedic doctor. Review of an Incident Report, dated 7/24/2021 at 9:46 p.m., revealed Certified Nursing Assistant (CNA) was doing rounds and observed R#46 on the floor beside the bed. Per the report, the CNA notified the nurse. The report indicated the nurse performed a range of motion (ROM) assessment on the resident, which was within normal limits (WNL), with the knee immobilizer to the right knee intact. The report indicated the resident was confused, there were no predisposing environmental factors, and the bed was in the lowest position. During further review, the report indicated there were no witnesses and that notifications were made to the family and physician. Per the report, no immediate interventions were initiated to prevent the resident from falling again. Review of the care plan updated on 7/24/2021, following a recent fall, denoted an intervention for a medication review was to be conducted; however, there was no documentation that the medication review was completed. Review of Physical Therapy Treatment Encounter Notes dated 7/26/21 revealed no documentation that R#46 had a fall the previous day or of new interventions implemented for the resident's safety; however, the note indicated the resident received bed mobility training, standing pivot transfer training, and postural training during the therapy session. Review of an Incident Report dated 10/3/21 at 8:04 a.m. revealed resident was observed lying on her back on the floor with complaints of pain to the right knee. The report indicated the resident stated she was reaching for the wheelchair and slid off the bed to the floor onto her knees. Further review indicated both knees were red, and the resident was medicated for pain. Per the report, neurological checks were initiated, and an x-ray was ordered of the bilateral knees. The note indicated the resident had a dislocation of the left knee. The report noted there were no predisposing environmental, physiological, or situational factors related to the fall. The report indicated there were no witnesses to the event and that notifications were made to the family and physician. No immediate interventions were initiated to prevent the resident from falling again according to the report. Review of an eInteract Change of Condition Evaluation dated 10/3/2021 indicated R#46 had a fall at 8:24 a.m. and resident's bilateral knees had redness with no swelling, though the resident complained of pain. The evaluation indicated the resident was medicated for pain, the physician was notified, and orders were received for an x-ray of the bilateral knees. Review of Physical Therapy Treatment Encounter Note dated 10/4/2021 indicated the resident was being trained on techniques to improve the ability to self-support on the edge of the bed for increased safety and techniques to improve postural stability. The note did not reference the resident's fall from the previous day. Review of care plan updated 10/3/2021 following residents recent fall, to include encouraging the resident to call for assistance and obtaining a right knee x-ray. However, encouraging the resident to call for assistance was a not a new intervention, and the order to obtain an x-ray was not a fall prevention intervention. Review of the Incident Report, dated 10/14/2021 at 7:28 a.m. indicated R#46's roommate called out for help and a CNA entered the room and found R#46 lying on the floor with her head toward the end of the bed. Per the report, the resident stated she was trying to get in her wheelchair. The report indicated a head-to-toe assessment was done with no injuries noted, and the resident was able to move all extremities. The report indicated the resident was assisted back to bed and was provided with incontinence care and fluids. The report revealed the resident then began to complain of pain to the right foot and right knee, rated at a severity of four (on a scale of one to ten, with ten being the worst possible pain). The report indicated the resident was administered pain medication, which decreased the pain level to a three. The report indicated there were no predisposing environmental and physiological factors but did list ambulating without assistance as a predisposing situational factor. The report indicated there were no witnesses, and notifications were made. The report revealed the resident was encouraged to always use the call light to call for help, and the bed was placed in the lowest position. Review of an eInteract Change in Condition Evaluation dated 10/14/2021 at 1:26 p.m. indicated R#46 had a fall that morning while trying to transfer without assistance from the bed to the chair. The evaluation indicated the resident had no injury though there was discoloration to the right foot. Per the evaluation, the resident was medicated for complaints of pain to the foot and right knee. Review of the Fall Risk assessment dated [DATE] indicated a score of 14, which indicated the resident remained at high risk for falls. Review of Physical Therapy Treatment Encounter Notes, dated 10/15/2021, revealed no documentation of the resident's fall the previous day nor any new interventions implemented for the resident's safety; however, the note indicated the resident participated in gait training, therapeutic activities to increase functional skills, and bed mobility and transfer skills. Review of the care plan updated on 10/14/20/21 revealed an intervention of placing residents' bed in the lowest position. Review of the Incident Report dated 10/23/2021 at 6:40 p.m. revealed a nurse heard R#46 screaming and entered the room to find R#46 lying on her left side on the floor between the bed and the window. The report indicated the resident stated she was trying to put some books in her bag when she fell . The report indicated the resident was unable to move her left leg without screaming in pain and stated, I can't move my left leg. It hurts real bad. The report noted the resident was rolled onto a sheet and lifted to the bed by four staff members. Per the report, the NP was notified and ordered the resident to be sent to a hospital. The report indicated there were no predisposing environmental factors, that impulsiveness was a predisposing physiological factor, and that predisposing situational factors included the call light being within reach and the bed being in the lowest position. The report indicated there were no witnesses, and that notifications were made to the resident representative. Review of an eInteract Change in Condition Evaluation dated 10/23/2021 indicated R#46 was heard screaming and was found lying on her left side on the floor complaining of severe pain to the left hip area, rated at a severity of ten (on a scale from one to ten, with ten being the worst possible pain). The evaluation indicated the primary care clinician was notified with recommendations to send the resident to the hospital for evaluation. No other interventions were documented. Review of the Fall Risk assessment dated [DATE] revealed a score of 15 for R#46, which indicated the resident remained at high risk for falls. Review of an Admission Note, dated 10/28/2021 at 4:30 p.m. revealed the resident returned to the facility via stretcher and was able to move her arms and right leg independently but was unable to move the left leg. The note indicated the resident had an elastic bandage to the left upper thigh from a surgical procedure done on the left femur, and staples were present to the surgical site. Review of a Nurse's Note, dated 10/29/2021 at 7:15 p.m. revealed the resident complained of pain and discomfort to the left hip related to fracture. Interview on 3/30/2022 at 3:55 p.m. with Licensed Practical Nurse (LPN) LL, stated when a resident fell , they were assessed by an LPN or supervisor, the family and physician were notified, and if required, the resident was sent to the hospital for x-rays or received in-house x-rays, if possible. During further interview, she stated when implementing new interventions, they look at the care plan to see what is already in place and call the manager or Director of Nursing (DON) and discuss with them what interventions to put into place to prevent another fall. She revealed that the facility did not update the care plan every fall, only falls with injury, and the care plan was updated by the MDS staff. She stated they did tell the resident to use her call light. Interview on 3/31/2022 at 9:32 a.m. with LPN FFF, stated after a resident fell , they were assessed for injury and, moved back into the bed or wheelchair to do a full body assessment. She stated the incident report asked what interventions were put into place at the time of the fall, and then at the morning meeting, the interventions were discussed with the nursing team, and they care planned it. She stated she was the nurse working when R#46 fell and broke her femur in October of 2021. After reviewing the incident report from that fall, LPN FFF stated the resident was sitting up in her wheelchair and was trying to put books away and fell . She stated the resident was able to go where she wanted, and the LPN was not aware of an intervention to keep the resident in a high traffic area. Observation on 3/31/2022 at 9:50 a.m. revealed R#46 was lying in bed, and the bed was not in a low position. Interview on 3/31/2022 at 9:50 a.m. with CNA GGG stated she was assigned to float and not assigned to any hall. She stated she was unsure if R#46 was a high fall risk and was not aware of any fall precautions for her. She stated she did not know if the resident was supposed to be in a low bed. CNA GGG observed the resident in bed at this time and confirmed the bed was not in a low position. Interview on 3/31/2022 at 9:57 a.m. with LPN CCC stated R#46 had been doing well with therapy and had no falls since fracturing her leg in October of 2021. She stated fall interventions for R#46 included a low bed but checked and confirmed R#46's bed was not in a low position at that time. Interview on 3/31/2022 at 11:24 a.m. with the DON, stated after a fall, the nurse performed an assessment of the resident and completed a fall, pain, and skin assessments. She stated the physician and responsible party should be notified of a fall and the nurse may put in a progress note. Per the DON, nursing administration reviews falls to determine whether the fall was documented and whether the skin and pain were assessed. The DON stated they did not do a formal investigation of the falls, but they were discussed in the morning clinical meetings, and they look at the documentation and the circumstances to know what type of interventions to put into place. She stated the MDS staff update the care plan with the interventions. She stated they were not documenting the root cause of falls, even though they were having a meeting and discussing it. The DON stated after R#46's fall in June of 2021, according to the care plan, the resident was sent to the emergency room for an orthopedic evaluation and no interventions were put into place after the resident returned to the facility. She also stated after the 10/23/2021 fall, according to the care plan, the resident was sent to the emergency room for evaluation and when the resident returned to the facility, no new interventions were initiated. She stated new interventions should have been initiated after each of these falls. Interview on 4/1/2022 at 10:52 a.m. with the Administrator, stated after a resident fell , a nurse should assess the resident for pain, fall risk, and injuries, and then, during the clinical meetings, the fall would be discussed to determine interventions and make referrals to therapy. She stated the facility had a performance improvement plan (PIP) for falls to include that an investigation should be done at the point of the event and statements should be collected from the staff. She said this information should be reviewed by the clinical nurse manager and therapy for proper documentation, noting they were expected to look at the environment for causes and any needs the resident had, such as bathing or toileting, and a review of behaviors. The Administrator stated she expected the fall with interventions to be documented on the incident report. She stated the incident report was an internal record and not part of the medical record, so a narrative note should be documented in the medical record to reflect what was on the incident report.

Based on record review, staff interviews, and review of the facility policies titled, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policies titled, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Admission Record revealed R#7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that R#7 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had trouble falling or staying asleep almost every day. R#7 exhibited behavioral symptoms not directed toward others daily. The resident received antipsychotic medication seven days out of the seven-day assessment period and antianxiety medication one day out of the seven-day assessment period. R#7 did not receive any psychological therapy by any licensed mental health professional in the last seven days. Review of the care plan revised 2/22/2022 revealed resident has impaired cognitive function/dementia or impaired thought process related to dementia. He has episodes of yelling out at times. Interventions to care include administering medications as ordered, providing behavioral health consults as needed, and assisting the resident with a meaningful program of activities. Review the Order Summary Report revealed R#7 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses' Notes dated 2/17/2022 at 1:44 p.m. revealed the physician ordered a psychiatric (psych) consult for R#7, and to increase the resident's [MEDICATION(S)] to one milligram (mg) every six hours as needed (PRN). The note was signed by Licensed Practical Nurse (LPN) PP. Interview on 3/31/2022 at 12:20 p.m. with LPN CCC, stated when the physician writes or gives a verbal order for a resident to receive a psychiatric consult, the nurse should give the order to the social worker, who would then add the resident to the list for the psychiatric nurse practitioner to see. Interview on 3/31/2022 at 12:23 p.m. LPN PP stated she would give all orders for psychiatric consults to the secretary to set up an appointment. Interview on 3/31/2022 at 12:28 p.m. with the Director of Nursing (DON), stated the nurses should give any orders for a psychiatric consult to the social worker, who would then contact the psychiatric nurse practitioner. Interview on 3/31/2022 at 2:47 p.m. with the Social Worker LLL, stated if a resident had a psychiatric consult, she would add them to the list of residents for the psychiatric nurse practitioner to see on her next visit in the building. Social Worker LLL further stated she was not aware that R#7 had a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 3/31/2022 at 2:58 p.m. with the DON, stated she expected all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During further interview, she stated the nurse who received the order should have given it to the SW, who keeps a list for the psychiatric nurse practitioner to see on her next visit. Interview on 3/31/2022 at 3:31 p.m. with the psychiatric nurse practitioner, stated she had not seen R#7 for a psychiatric consultation. She further stated the SW would notify her of all referrals and confirmed she had not received a referral for R#7. Interview on 4/1/2022 at 9:00 a.m. with the Secretary XX, stated she sets up appointments for residents, but if a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Secretary XX stated she had not received any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 4/1/2022 at 10:55 a.m. with the Administrator, stated she expected the nurse to give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated there was no documentation that R#7's psychiatric consultation was given to the psychiatric nurse practitioner.

Based on observations, record review, staff interviews, and review of a facility policy titled, Controlled Substances, the facility failed to ensure controlled substances were accurately documented on a destruction form for 4 of 59 controlled substances reviewed. Findings include: A review of the facility's policy titled, Controlled Substances, revised [DATE], indicated Standards: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled medications. Number 14. Controlled medications remaining in the facility after the order has been discontinued or expired are retained in the facility in a securely locked area with restricted access until destroyed by two licensed clinicians or as otherwise directed by state regulation. Interview on [DATE] at 3:08 p.m. with the Director of Nursing (DON), stated Schedule II controlled medications were double locked in the DON's office. Per the DON, the pharmacist came to the facility approximately once a month to complete medication destruction. She stated the procedure for destruction is to place the medications in cat litter or coffee, with water added and placed in a sharp's container. During further interview, she stated a biohazard company picks up the biohazard containers and removes them from the facility. The DON stated the facility's records of receipt and disposition of controlled medications were documented on a carbon copy form, which was signed by three staff members (the DON, the pharmacist, and another nurse) when the medications are destroyed. The DON provided a Certificate of Inventory and Destruction form that was dated [DATE]. Review of the Certificate of Inventory and Destruction form dated [DATE] revealed there were three signatures at the bottom: the DON, Licensed Practical Nurse (LPN) YY, and Licensed Pharmacist (LP) EE. The DON stated that she filled out the form and verified it was her handwriting. There were three liquid medications that did not indicate an amount destroyed. All other oral medications had an amount listed as destroyed. The DON stated she did not know why she did not include the liquid amount but stated they were destroyed. She stated that all wasted medication should have an amount listed on the form. Further review of the Certificate of Inventory and Destruction, dated [DATE], indicated resident (R) R#9 had [MEDICATION(S)] (an anticonvulsant), with no strength or amount destroyed documented. R#160 had [MEDICATION(S)] (an opioid pain reliever) with a strength of 100 milligrams (mg) per 5 milliliters (ml), with no amount destroyed documented. R#158 and R#159 had [MEDICATION(S)] 100 mg per 20 ml, with no amount destroyed documented. A review of Controlled Drug Record - Liquids, Multidose for R#9 revealed the amount of [MEDICATION(S)] that should have been documented on the Certificate of Inventory and Destruction form was 20 ml. A review of Controlled Drug Record - Liquids, Multidose for R#160 revealed the amount of [MEDICATION(S)] that should have been documented on the Certificate of Inventory and Destruction form was 15 ml. A review of Controlled Drug Record - Liquids, Multidose for R#159 revealed the amount of [MEDICATION(S)] that should have been documented on the Certificate of Inventory and Destruction form was 13.75 ml. A review of Controlled Drug Record - Liquids, Multidose for Resident #160 revealed the amount of [MEDICATION(S)] that should have been documented on the Certificate of Inventory and Destruction form was 28.5 ml. Interview on [DATE] at 3:53 p.m. with Licensed Pharmacist (LP) EE, stated the DON should complete the Certificate of Inventory and Destruction before the Pharmacist arrived at the facility. The LP clarified that the numbers listed on the [MEDICATION(S)] medications were the strength in milligrams per milliliters. LP EE stated that he must have looked at the Controlled Drug Record - Liquids, Multidose form, along with the medication, and verified the amount that was wasted. Phone interview on [DATE] at 5:05 p.m., LP EE stated he had reviewed his carbon copy of the Certificate of Inventory and Destruction form and confirmed that he signed off that all medications that were wasted and did not know why the form did not include the amount wasted. LP EE again stated he had compared the Controlled Drug Record - Liquids, Multidose form with the medication that was wasted. Interview on [DATE] at 10:49 a.m. with the Administrator stated the Pharmacist and the DON destroyed the medications together. The Certificate of Inventory and Destruction form was provided to the Administrator, who stated that the form did not show how much medication was destroyed and that it should have been filled out completely. The Administrator stated they had never had an issue before with medication destruction. Interview on [DATE] at 11:02 a.m. with LPN YY verified that her signature was on the Certificate of Inventory and Destruction form and stated she had witnessed the destruction of the medications. LPN YY stated that she did sign off that all the medications were disposed of but did not know why the amount was not documented. LPN YY stated she remembered disposing of the liquid medication with LP EE and the DON.