Every finding on record at Pavilion of Ottawa

Based on interview and record review the facility failed to ensure a grievance was resolved for 1 of 3 residents (R3) reviewed for resident's rights in the sample of 14.The findings include:On 2/20/26 at 10:33 AM, V8 (R3's daughter) said last month, she had brought a concern regarding R3's missing tooth (two natural teeth) to staff including V1 (Administrator) and V2 (Director of Nursing). V8 said no one can tell her what happened to R3's missing tooth or how R3 lost her tooth. Did it just come off in her mouth? What caused it to fall off? V8 said as of today, no one yet (at the facility) came back to tell her what happened.On 2/20/26 at 12:30 PM, V11 (CNA) said a couple of weeks ago, she noticed R3 tapping her mouth, she has dementia so she cannot speak, it looked like she lost a tooth. V11 said this was reported to the Nurse who said she will refer R3 to the dentist.R3's progress notes dated 1/27/26 documents, Oral visual check done, deny pain and discomfort, no redness or swelling on her gums noted. 1 right lateral tooth noted missing. daughter aware.On 2/20/26 at 12 PM, V2 (Director of Nursing) said an electronic mail was sent to V8 (R3's daughter) on 1/27/26 to let V8 know that the facility was looking into how R3 had a missing tooth. On 1/30/26, V2 said V8 added additional teeth missing per R3's profile picture. Now there was a total of 2 missing teeth. As of today 2/20/26, there was no update to V8 because no one knew what happened to R3's missing tooth. R3 had not been referred to the dentist.Review of the Facility's grievance log did not include V8's concerns of R3's missing tooth as confirmed by V1 (Administrator) and V2 (DON) Both said it should have been logged with the resolution. On 2/20/26 at 2PM, V1 (Administrator) said today, R3 will be referred to the dentist and V8 will be updated.The facility Policy on Grievance Complaint Process (undated) documents, 5. Upon receiving a grievance and complaint report, the administrator or designee will begin an investigation into the allegation. 6. The Resident Grievance/Complaint investigation report form must be completed within 5 working days of the incident. 7. The resident or person acting on behalf of the resident will be informed of the findings of the investigation as well as any corrective action recommended within 10 working days of the filing of the grievance or complaint.

Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, and served in a manner to prevent cross-contamination. This failure has the potential to affect all 124 residents in the facility.The findings include:The CMS (Centers for Medicare and Medicaid Services) form 671 dated 8/26/2025 showed 124 residents resided in the facility.On 8/27/2025 at 8:20 AM, V2 (Director of Nursing) said the facility did not have any residents with a feeding tube. On 8/26/2025 between 9:45-10:15 AM, while doing the initial Kitchen observation, a scoop was left inside of the large container of thick-it (a powder used in food preparation to thicken food consistency). The scoop was directly on the powder mixture. The handle was touching the powder.On 8/26/2025 at 11:09 AM V11 (Cook) prepared the pureed foods (hamburger patties) for the lunch meal, then separated the pureed meat into several small pans for the different halls they were to be served on. V11 picked up half of the pans and held them against her clothing when she was taking them to put in the hot box until the lunch meal. V11 then picked up the remaining pans to put in the hot box and held them against her body while taking them to the hot box. During that same time, V12 (Dietary Aide) was making barbecue sauce in a large metal bowl. After making the barbecue sauce, V12 picked up the bottles of condiments used to make the sauce and held them against her clothing while taking them to put in the refrigerator. On 8/26/2025 at 12:47 PM, V13 (Dietary Aide) obtained the temperature of the foods in the steam table on the 200-hall kitchenette. V13 left the same gloves on for the lunch service. V13 placed both gloved hands on the steam table, touched the meal tickets, the Styrofoam plates, the handle to the door of the refrigerator, the handles on the utensils in the individual food items, reached into the bag of buns, grabbed a bun with the gloved hand, then used both gloved hands to separate a slice of cheese from the stack, and placed the cheese on the burger. V13 repeated these steps of touching the meal tickets, the Styrofoam plates, the handles on the utensils in the food items, reaching into the bag to grab a bun, and grabbing a slice of cheese with her gloved hands. V13 did not remove the gloves and wash her hands or change gloves during the lunch observation. On 8/26/2025 at 12:55 PM, V14 (Cook) was in the kitchenette on the 800-hall serving food to the residents. V14 touched the steam table, the meal tickets, the handles to the utensils in the food items on the steam table, reached into a bag, grabbing a bun with the same gloves, then grabbing a slice of cheese and placing it on the burger. V14 repeated the same process of touching the meal tickets, Styrofoam plates, handles to the utensils, then using the same gloves to grab a bun and a slice of cheese when plating the food for the residents on the 800-hall. V14 did not remove the gloves and wash her hands or change gloves during the lunch observation. On 8/2620/25 at 3:45 PM, V10 (Dietary Manager-DM) said dietary staff should not be touching door handles to the refrigerator, placing their gloved hands on the steam table, touching the handles of the utensils, then touching ready-to-eat items like buns or cheese, that is cross-contamination. V10 said tongs should be used to grab the buns and ready-to-eat food items. V10 said the scoops should not be in the dried food containers because that is cross contamination. The scoops should be put in a bag and placed on the top of the container. On 8/28/2025 at 9:03 AM, V10 (DM) said dietary staff should not be holding pans of food or condiments against their clothing, that is cross-contamination. V10 said he has talked to V12 about that several times. On 8/28/2025 the facility provided their 2021 policy and procedure titled Food and Nutrition Services Sanitation and Food Safety Handwashing. The policy showed Food and nutrition services employees will practice safe food handling to prevent foodborne illness. The policy showed food and nutrition services employees will thoroughly wash their hands and exposed areas of their arms with soap and water in the designated hand-washing sink at the following times.After handling soiled equipment and utensils.The facility's 2017 policy and procedure titled Food and Nutrition Services Sanitation and Food Safety-Service showed Dishes and utensils are handled in a way which does not contaminate the surface the food touches. Care is taken to observe the following steps.Avoid touching the eating surface of the dish or bowl. The facility was not able to provide a policy and procedure addressing safe food handling to prevent cross-contamination during meal preparation or meal service regarding glove use, touching ready-to-eat foods, or not allowing clothes to touch items during food preparation prior to exiting the facility.

Based on observation, interview, and record review, the facility failed to provide assistance with shaving facial hair for 3 female residents (R48, R57, R65) and failed to provide assistance with grooming, shaving and denture care for 1 resident (R131). This failure affected 4 of 4 residents (R48, R57, R65, R131) reviewed for activities of daily living in the sample size of 49.The findings include:1. On 08/26/2025 at 11:56 AM observed R48 seated in a wheelchair at the nurse's station on the 800 unit and noted facial hair to chin area that appeared thick and course and was approximately 4-5 milliliters in length. R48 indicated that the girls help me with her chin hair. No aides were observed present on unit at this time.On 08/27/2025 at 12:14 PM, observed R8 seated at the dining room table on the 800 unit and noted facial hair to her chin area that appeared thick and course that was approximately 2-3 milliliters in length at this time.R48's face sheet showed an admission date of 05/14/2025 with a past medical history not limited to morbid obesity, dementia, muscle weakness, and need for assistance with personal care. R48's care plan with last completion date of 08/25/2025 reads in part: has a deficit in activities of daily living (ADL) abilities and requires staff assistance initiated on 05/14/2025. Interventions included but not limited to: daily morning and bedtime (AM/HS) care, assist with dressing and grooming tasks, oral care twice daily and as needed, and shower/bed bath per schedule.R48's Minimum Data Set (MDS) Section GG-functional abilities dated 08/13/2025 indicated that R48 requires setup or clean-up assistance with personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene).Review of R48's progress notes for last 30 days showed no documentation regarding any refusals of care.2. On 08/26/2025 at 12:04 PM, observed R57 near room with visible facial hair to her top lip and her bottom lip above chin area that was approximately 3-5 milliliters in length. R57 was not aware that she had any visible facial hair. On 08/27/2025 at 12:33 PM, R57 was observed in the dining room on the 800 unit with a small amount of facial hair visible to her lower lip area above chin area that was approximately 1-3 milliliters in length at this time.R57's face sheet showed an admission date of 08/12/2023 with a past medical history not limited to Alzheimer's disease, dementia, and muscle weakness.R57's care plan with last completion date of 07/24/2025 reads in part: has impaired cognitive function and impaired thought processes; is at risk of possible abuse/neglect related to relying on others for care needs; has a deficit in ADL abilities and requires staff assistance, has impaired mobility and weakness. Interventions included: AM/HS care daily, assist with dressing and grooming tasks, oral care twice daily and as needed, provide resident with equipment in order for her to perform oral care, facial washing, and upper body grooming with minimal assistance from staff. Encourage her to do as much as possible. Encourage her also to select clothing to wear each day and donning/doffing upper body attire. Assist as needed; shower/bed bath per schedule, initiated 08/13/2023.R57's MDS Section GG-functional abilities dated 07/17/2025 indicated that R57 requires supervision or touching assistance with personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). Review of R57's progress notes for last 30 days showed no documentation regarding any refusals of care.3. On 08/26/2025 at 10:16 am and 08/27/2025 at 10:43 AM, observed R65 seated in her wheelchair in her room and noted facial hair to her chin area, hair appeared uncombed, and had an overall disheveled appearance. R65 was dressed in clothes and indicated on both days that she was ready for the day.R65's face sheet showed an admission date of 05/12/2020 with a past medical history not limited to dementia, morbid obesity, muscle weakness, and anxiety disorder. R65's care plan with last completion date of 06/05/025 reads in part: bathing/hygiene deficit related to diagnosis of gout, anxiety, irritable bowel syndrome, dementia. She has weakness in her bilateral lower extremities; at risk of possible abuse/neglect related to residing in a nursing home and relying on others for care; is dependent on staff for meeting emotional, intellectual, physical, and social needs; has a deficit in ADL abilities and requires staff assistance related to weakness, history of falls, osteoarthritis to bilateral knees, gout, anxiety, dementia and type 2 diabetes. Interventions included but not limited to: AM/HS care daily; assist with dressing and grooming tasks, provide resident with equipment in order for her to perform oral care, facialwashing, and upper body grooming with minimal assistance from staff, encourage her to do as much as possible; encourage her also to select clothing to wear each day and donning/doffing upper body attire, assist as needed; shower/bed bath per schedule.R65's MDS dated [DATE] indicated that R65 requires partial/moderate assistance with personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). Review of behavior progress notes for last 30 days showed one documented incident for refusal of care dated 07/29/2025 that documented an agency staff entered the room to assist R65. Resident told agency staff, I do not want you to help me your skin is a different color then the regular staff. No other refusal of care notes were noted. 4. On 08/26/2025 at 10:33 AM and 08/27/2025 at 10:46 AM, R131 was observed lying in bed wearing a gown with facial hair to his cheeks, mouth and chin area that appeared thick and course. R131's dentures appeared unclean with visible food debris in between teeth and throughout the top denture. Resident said he has not been washed up yet and he has not taken out his dentures for a few days. R131's overall appearance on both days was disheveled and fingernails appeared long with visible debris beneath nails to both hands. On 08/27/2025 at 12:50 PM, observed R131 seated in a wheelchair next to the bed feeding himself lunch. R131 was wearing hospital gown and indicated that he doesn't recall if he had been washed up yet, then said that he has not had a shower since he admitted 1-2 weeks ago. R131 was unsure of when his shower days were then said an aide told him yesterday that she would shave him but then the aide never came back to do it. R131 indicated that he needed to be shaved and could probably shave himself with an electric razor if he was pushed up to a mirror. No aides were observed present on unit at this time.Review of R131's records on 08/26/2025 through 08/28/2025 documented an admission date of 08/19/2025. Care plan with last completion date of 08/26/2025 reads in part: has a deficit in ADL abilities and requires staff assistance due to infection of right knee prosthesis, impaired mobility, history of spinal fusion, arthritis, weakness. Interventions included: AM/HS care daily; assist with dressing and grooming tasks; oral care twice daily and as needed, provide resident with equipment in order for her to perform oral care, facial washing, and upper body grooming with minimal assistance from staff. Encourage her to do as much as possible. Encourage her also to select clothing to wear each day and donning/doffing upper body attire, assist as needed; shower/bed bath per schedule.R31's admission MDS indicated in progress, section GG-functional abilities was not completed. Review of R131's progress notes since admission showed no documentation regarding any refusals of care.On 08/28/2025 at 08:24 AM, V2 (Director of Nursing) said female residents should not have visible facial hair, then indicated that resident grooming is typically done on shower days, which includes shaving residents and trimming their fingernails when needed. V2 added that partial bed baths are done in between shower days, and all residents should receive oral/denture care daily. V2 (DON) also said that grooming and shaving should be performed unless a resident is combative, is resistive to being shaved, or is adamant about not having facial hair removed.On 08/28/2025, facility provided care plan report page 7 of 8 for R57 and highlighted the following, I am resistive to care related to refusing personal cares with date initiated 01/17/2025. Facility also provided care plan report for R65 and highlighted on page 5 of 11, I am resistive to care related to showering dated 06/03/2025; on page 2 of 8, highlighted I will decline and refuse care sometimes and I easily get upset or agitated with date initiated 03/11/2021; and on page 5 of 8 highlighted, I have my routine and I get upset if this disrupts that was undated. Facility did not provided any documentation for refusals of care upon exit for R57 or R65.Activities of Daily Living (ADL) care policy dated 11/2015 reads in part: to meet the grooming and hygiene needs of residents with dignity and privacy. To encourage residents to achieve independence while providing the assistance needed. The basics for ADL care should be implemented whenever a procedure or task occurs. Basics for ADL care include .ask the resident for permission to assist with or preform ADL care. If given permission proceed.notify nurse of anything unusual.Denture Care includes to ask the resident to remove their dentures. If they cannot remove them, wearing gloves gently move the upper denture from side to side and pulldown. Place the dentures in an emesis basin or denture cup. Remove the lower denture by using an upward movement while rocking the denture from side to side. Place the denture in an emesis basin or denture cup. Take the dentures to the sink, rinse off any food particles, clean them with denture cleaner, rinse and cover with fresh water. Remove your gloves and wash your hands. When inserting dentures, wash your hands and put on gloves. Rinse the dentures with fresh water and take to residents' bedside. Offer the resident a drink of water first to moisten their mouth. Ask resident to place the dentures in their mouth if unable place the lower plate in the resident's mouth first. Special Oral Care: if resident is unable to tolerate teeth brushing or to wear dentures provide special oral care. Wash your hands and put on gloves. Place a towel under the resident's chin. Ask resident to open their mouth if they are unable to, gently open the resident's mouth by placing one hand on the chin and pressing down. With your free hand insert a moistened applicator in the mouth, use mouthwash or other oral cleanser to moisten the applicator. Wipe the roof of the mouth, the inside of the cheeks, the tongue and the teeth. Change applicators frequently during the process. If the resident is unable to turn their head assist them with positioning their head so you can reach both sides of their mouth. After cleaning their mouth, rinse mouth with fresh water moistened applicators. Dry residents face. Apply a water soluble lubricant to moistener lips, mouth and tongue. Discard the used applicators. Remove the towel and place in soiled linen container. Position residents head for comfort and proper alignment. Remove the gloves and wash your hands. Combing and Brushing Hair includes to brush and comb the resident's hair daily, after bath care, when getting up from bed and as needed. Gently brush and comb only small amounts of hair at a time. If the resident cannot sit up, ask them to turn their head, if they cannot turn their head gently turn the residents head from side to side to comb all sides. Style the resident's hair according to his or her preference. Clean the brush and comb. Store them in the resident's bedside stand. If dryness, redness, flakes, skin irritation or sores are noted to the scalp notify the nurse. Shaving with safety razor: prior to shaving a resident check with the nurse to ensure they are not on blood thinners. Dampen the resident's beard with a warm washcloth to soften it. Apply shaving cream. Begin at sideburns and work down over the cheek and chin. Keep the skin tight as you shave this helps prevent nicks. Rinse the razor after each stroke. Have the resident tip their head back, if possible, use up-ward strokes under the chin and jaws. When finished shaving the resident rinse the extra soap off the face. Dry the skin and apply after shave. Discard the safety razor in the sharps container. If the resident is nicked or an unusual area is noted to the resident's skin notify the nurse. If the resident is a women shave only the areas with facial hair and apply facial moisturizer instead of aftershave. Shaving with electric razor: apply pre-shave if desired. Plug in razor and turn on. Shave cheeks first, then around the mouth and down the neck last. If possible, have resident tip their head back when shaving the neck. For a razor with a flat or flexible head use short up and down motion with the grain of the beard. For a razor with a circular head use small, circular motions. When shave is completed wipe extra pre-shave off face. Pat face dry. Apply after shave. Clean electric razor and store away.Fingernail Care: place a towel under hand or foot prior to providing nail care. Collect nail clipping in the towel. Discard the nails after each hand or foot. Nail care includes daily cleaning of nails and as needed, and nail trimming as needed. Clean hands. Gently remove dirt from around and under each nail with an orange stick. Trim nails on fingers in an oval shape. Trim toenails trim straight across. Do not trim nails below the skin line. Do not trim diabetic's toenails. Smooth trimmed nails with an emery board. If hand or nails are very soiled soak each hand in soapy water before nail care or if possible complete nail care after a shower or bath. When nail care is completed apply lotion to hands and feet. Place soiled towel in soiled linen bin. Partial Bath: if possible, take the resident to the bathroom to provide am care. After giving the resident time to void. Provide am care. A partial bath consists of washing the residents face, the underarms, under breasts, and peri-area, or any other soiled area. Provide privacy and dignity for the resident by exposing only the area of the body that is being washed.Dressing: encourage resident to choose the clothes they will wear. Encourage resident to dress self as much as possible. If assistance is needed begin dressing the resident on their weak side. Assist as needed with putting on clean undergarments, socks and slacks. Next put on shirt, blouse or dress. Finish with putting on shoes. Assist with buttoning and zippering as needed.R131's face sheet, care plan and MDS were requested from V2 (Director of Nursing) on 08/28/2025 but were not provided upon exiting survey.

Based on observation, interview, and record review, the facility failed to ensure multiple insulin pens and a vial of liquid morphine were properly labeled with an open and discard date in accordance with professional standards. This failure affected 6 of 6 residents (R5, R8, R41, R74, R82, R94) reviewed for medication storage in the sample size of 49. The findings include: On 8/27/2025 at 10:38 AM, R94's long-acting prefilled insulin pen had a yellow sticker with a spot to document Date Open, Date Exp (expired), and initials. The sticker was not filled out or initialed. The cap for the pen had a tamper resistant red tape which indicated the pen had been opened. V4 Licensed Practical Nurse (LPN) stated she had given R49's long-acting insulin that morning and the pen had already been previously opened and used prior to the morning of 8/27/25. On 08/27/2025, medication storage and labeling task was performed by this surveyor with V6 (Registered Nurse) on the 800 unit with the following findings. At 12:22 PM, observed two glargine insulin pens for R82 and one glargine (lantus) insulin pen for R5 with the red tamper-evident tape broken on each insulin pen that were visibly used and not labeled with either an open date or a discard date. Also observed a glargine (basaglar) insulin pen for R8 with the red tamper-evident tape broken that was visibly used and labeled with an open date of 08/22/2025 but no discard date or staff initials indicated. V6 then said that she will just add a discard date to R8's insulin pen and proceeded to use a spread sheet with insulin expiration dates to determine discard date. On 08/27/2025 at 12:24 PM, V6 (RN) indicated that R8 and R82 were both administered insulin in the morning, then indicated that she labels all insulin pens upon opening, with the date opened, the discard date and her initials. On 8/27/25 at 12:53 PM, the 500-unit medication cart was reviewed with V9 (Licensed Practical Nurse) present. The narcotic box had two multi-dose vials of liquid morphine in it. One vial was for R41, and the other vial was for R74. Neither vial was dated with an open date or expiration date. R41's corresponding count sheet for the morphine showed the first day of administration was 7/24/25. R74's corresponding count sheet for the morphine showed the first day of administration was 6/13/25. V9 (LPN) stated both vials should be dated to show when they were opened. Nurses need to know that so we can follow how long it is good for. V9 said expired medications have the potential to be less effective. V9 stated both R41 and R74 are residents on hospice and the morphine is needed to treat their pain or shortness of breath. R5's face sheet showed an admission date of 11/08/2024 with a past medical history not limited to type 2 diabetes mellitus. Review of R5's records active orders revealed no current order for insulin glargine (lantus). Review of R5's discontinued orders showed an order to inject10 units of insulin glargine 100 unit/ml solution with pen-injector subcutaneously at bedtime related to type 2 diabetes mellitus was discontinued on 06/30/2025. Review of R5's June 2025 eMAR also showed the insulin glargine was discontinued on 06/30/2025 at 12:38 PM and was last administered to R5 on 06/29/2025 at 08:00 PM (2000). R94's Face Sheet showed an admission date of 7/3/24 with a diagnosis of type 2 diabetes. R94's Order Summary Report showed an order for 20 units of long-acting insulin to be given daily in the morning. R8's face sheet showed a last admission date of 07/29/2024 with a past medical history not limited to type 2 diabetes mellitus. Review of R8's active orders showed an order to inject 25 units of insulin glargine (basaglar) 100 unit/ml solution with pen-injector subcutaneously in the morning, and 15 units at bedtime related to type 2 diabetes mellitus with a start date of 06/12/2025. Review of R8's eMAR for August 2025 documented that insulin glargine is scheduled to be administered at 08:00 AM and 08:00 PM and documented that V6 (RN) administered the 08:00 AM dose to R8 on 08/27/2025. Record also documented that R8 has received this insulin glargine daily throughout the month. R82's face sheet showed a last admission date of 11/14/2024 with a past medical history not limited to type 2 diabetes mellitus. Review of R82's active orders showed but not limited to inject 40 units of insulin glargine 100 unit/ml (milliliter) solution with pen-injector subcutaneously every morning and at bedtime related to type 2 diabetes mellitus with a start date of 07/28/2025. Review of R82's electronic medication administration record (eMAR) for August 2025 documented that insulin glargine is scheduled to be administered at 09:00 AM and 09:00 PM (2100) and documented that V6 (RN) administered the 09:00 am dose to R82 on 08/27/2025. Record also documented that R82 has received this insulin glargine daily throughout the month. On 8/27/2025 at 1:13 PM, V2 (Director of Nursing) stated that insulin pens should be dated with the date opened, the expiration date, then initialed by the nurse. V2 added that nurses have a spread sheet used to determine the 30 day expiration date after opening the insulin and should not be used past thirty days because there is a risk that the medication is not as effective and the risk for contamination is increased. V2 then said that nurses should be checking the label on the pen prior to use, pen should be returned to pharmacy if the label is blank, and if the seal is broken, that indicates that the pen had been used. On 08/28/2025 at 08:24 AM, V2 (DON) said insulin pens should be labeled with the date opened and the discard date because the potency is not effective after recommended discard date. V2 then said that any discontinued insulins should be discarded and should be removed the med cart. Labeling of Medication Containers policy (MM 05/01/09) reads in part: all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations.Labels for individual drug containers shall include all necessary information, such as, the resident's name; prescribing physician's name; name, address, and telephone number of the issuing pharmacy; name, strength, and quantity of the drug; prescription number (if applicable); date that the medication was dispensed; appropriate accessory and cautionary statements; expiration date when applicable; and directions for use.In addition to the above information, multi- dose vials must be dated and initialed t the time they are opened. Multi-dose vials are to be discarded after 28 days of being opened. The facility provided pharmacy documentation (undated) showing the morphine medication expires one year from the dispense date or manufacturer's expiration date, whichever is sooner. The facility's Labeling of Medication Containers policy dated 5/1/09 states under the multi-dose vials dating section: 6.multi- dose vials must be dated and initialed at the time they are opened.

Based on observation, interview, and record review, the facility failed to ensure the device used to check residents' blood sugar levels (a glucometer) was disinfected according to the manufacturer's instructions, to prevent cross-contamination for 9 of 9 residents (R3, R10, R13, R20, R34, R40, R75, R107, and R127) reviewed for glucose checks in the sample of 49.The findings include:On 8/26/2025 at 12:13 PM, V15 (Licensed Practical Nurse-LPN) performed a blood glucose test on R127 prior to the lunch meal. After checking R127's blood sugar level, V15 used a micro-kill disinfectant wipe to clean the glucometer. V15 did one swipe across the glucometer, then place the glucometer on a tissue that was on the medication cart. At 12:26 PM, V15 used the same glucometer to check R3's blood sugar level prior to the lunch meal. After obtaining the blood sample, V15 placed the glucometer on the windowsill in R3's room. V15 picked up the glucometer, informed R3 of the results and went out of the room. At 12:28 PM, V15 used the micro-kill wipes again on the glucometer, wiping the glucometer for 5 seconds before placing the glucometer on the same tissue that was used after checking R127's blood sugar level. V15 put the glucometer in the 200-hall medication cart a minute later when it was dried.On 8/27/2025 at 2:18 PM, V16 (LPN/Infection Prevention Nurse) and V17 (Assistant Director of Nursing-ADON) identified the residents on the 200-hall that receive blood glucose level checks. V17 (ADON) said the nurses should disinfect the glucometers with the Clorox wipes that are in the medication carts. V16 (LPN/IP nurse) said the glucometer should be kept wet with the Clorox wipe for at least 3 minutes to disinfect the glucometer. V16 said if the nurse is doing another glucose check, there should be another glucometer ready to go. V16 and V17 said the nurse should make sure the glucometer is cleaned according to the manufacturer's instructions to make sure it is sanitized and does not cross-contaminate to another resident. V17 provided the list of residents on the 200-hall that get blood glucose checks. The list identified R3, R10, R13, R20, R34, R40, R75, R107, and R127 as the residents receiving blood glucose checks on the 200-hall. On 8/27/2025 at 3:19 PM, V17 (ADON) said she looked at the instructions on the micro-kill wipes and the nurse must keep the glucometer wet with the wipe for 3 minutes to disinfect the glucometer.On 8/28/2025 at 12:41 PM, V2 (Director of Nursing) brought this surveyor a copy of the label on the micro-kill wipes. V2 said it is hard to read the copy, but the label showed the nurses need to keep the glucometer wet for 3 minutes with the micro-kill wipes to disinfect the glucometer.On 8/28/2025 the facility provided R3, R10, R13, R20, R34, R40, R75, R107, and R127's admission Records and Order Summary Reports. The admission records showed R3, R10, R13, R20, R34, R40, R75, R107, and R127 all had a diagnosis of diabetes mellitus. The Order Summary reports showed all these residents had an order for accu checks (blood glucose monitoring). The facility's midnight census report, printed on 8/27/2025, showed all of the previously listed residents reside on the 200-hall of the facility. The facility's policy and procedure titled Cleaning and Disinfecting Resident Care Items and Equipment, with a revision date of June 2022, showed Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.the following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care.Semi-Critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible.The facility's policy and procedure titled Cleaning and Disinfecting Blood Glucose Meters, with a revision date of January 2014, showed, It is the policy of the facility to clean and disinfect blood glucose meters that are shared between residents. Indirect contact transmission - Patient-care devices (e.g., electronic thermometers, glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients. The procedure showed.4. Use gloves to obtain droplet of blood on to glucose test strip. 5. Dispose of used finger stick devices and lancets at the point of use in an approved sharps container. Never reuse needles, syringes, or lancets. 6. Remove gloves and wash hands. 7. Apply new gloves. 8. Thoroughly clean all visible soil or organic material (e.g., blood) from glucometer prior to disinfection. 9. Using gloves as indicated wash vigorously with disinfectant and allow for drying time as indicated per manufacturer. 10. Perform hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other residents. 11. Follow manufacturer's guidelines for cleaning and disinfecting of glucose meters. Specific guidelines for glucose meters may vary with the manufacturer. Consult with manufacturer to determine which cleaning procedures, specific to glucose meter sharing, should be adhered to. 12. In the absence of manufacturer's recommendations, the glucometer is considered a semi-critical device, follow policy for cleaning semi-critical devices. Use of disinfectants, antiseptics, and germicides are in accordance with manufacturers' instructions and EPA or FDA label specifications to avoid harm to staff, residents and visitors and to ensure effectiveness . All personnel who perform these tasks are trained with regard to proper procedure, protective equipment required (if any), and safety precautions . All products and processes used for cleaning, disinfection and sterilization are approved by Infection Control Committee/Infection Preventionist. The policy and procedure showed Note: When selecting a disinfecting cleaning product, you will want to look at contact time. In other words, you want to be aware of the length of time the disinfectant must be in contact with the item being cleaned for the germ/bacterial to be considered killed. Some product item may be as short as one minute, another product it may be ten (10) minutes.On 8/28/2025 at 9:28 AM, V1 (Administrator) provided instructions via email for micro-kill germicidal bleach wipes. The instructions showed 4. Ensure contact time: Wipe the surface to ensure it remains visibly wet for the entire contact time required by the product's label. The necessary contact time varies depending on the organism (e.g., 30 seconds for many bacteria and viruses, but 3 minutes for Clostridium difficile spores).

Based on observation, interview, and record review the facility failed to ensure wheelchair foot rests were in place for a resident during transport and failed to ensure a resident's medication was secured. This applies to 2 of 9 residents (R77, R74) in the sample of 49. The findings include: 1. R77's admission Record (Face Sheet) showed an admission date of 7/7/23 with diagnoses to include Alzheimer's (dementia), muscle weakness, osteoarthritis, history of falling, osteoporosis, and weakness. R77's Care Plan showed she was a mechanical lift transfer. R77's 6/11/25 Minimum Data Set (MDS) showed she required Partial/Moderate assistance for wheelchair transports of 50 feet and she was totally dependent upon staff for transport of 150 feet. On 8/26/2025 at 12:12 PM, R77 was in the central common area of the locked memory care unit. R77 was in her wheelchair. V3 Agency Certified Nursing Assistant (CNA) transported R77 to the dining area. As V3 pushed R77 in her wheelchair, R77's right foot was dragging and skipping along the floor (R77's other foot was supported on a footrest). The distance V3 pushed R77 was at least 60 feet. On 8/27/2025 at 1:26 PM, V2 Director of Nursing (DON) stated residents who are able to keep their legs elevated and are only being transported a short distance, may be moved without a wheelchair footrest; however, V2 stated since R77's foot was dragging on the ground a footrest should have been used. V2 said residents can fall out of wheelchairs or sustain broken bones when wheelchair footrest is not used appropriately. The facilities Equipment- Self Propel Wheelchair policy (Effective 11/2013) showed Any resident who is being transported in the wheelchair off their assigned unit should have footrests.2. R74' face sheet dated 8/28/25 showed diagnoses including but not limited to dementia, heart disease, kidney disease, anxiety disorder, and cataracts. 2. R74's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed staff setup assistance for eating and staff supervision for oral hygiene. R74's physician order report dated 8/28/25 showed an order for Fluticasone propionate nasal suspension, one spray in each nostril in the morning for allergies, itchy eyes/nose (start dated 5/5/25). On 8/26/25 at 10:37 AM, R74 was lying in bed sleeping and the bedside table was over his waist. The table had a bottle of fluticasone nasal spray sitting on it which was directly within reach. There was no nursing staff in the room or immediate area. On 8/27/25 at 9:05 AM, R74 was seated in a wheelchair in his room. R74 stated he did not know how to take his medications. The nurses give him all medications and they tell him when to do it. R74 said he had no idea when or what type of medications he was prescribed. On 8/27/25 at 12:53 PM, V9 (Licensed Practical Nurse) stated R74 is somewhat alert and oriented but he is not able to take his medications on his own. V9 said the nasal sprays are not something R74 can do by himself. He definitely needs help with those. On 8/28/25 at 9:01 AM, V2 (Director of Nurses) stated it is not common for the residents to self-administer medication here. There is no way to safely lock medications in resident rooms. An assessment would first need to be done to determine if a resident can safely take them alone. Nurses should never leave medications in the room. There is the potential for the resident to take it incorrectly or not take it at all. All medications, including over the counter ones, should be stored properly. That means locked in a medication cart or medication room. V2 verified there was no assessment for R74 to self-administer medications. V2 stated there are no residents in the building that take medications on their own. The facility's Administering Medications policy revision dated 11/2020 states: Medications shall be administered in a safe and timely manner, and as prescribed. The same policy states: Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely, and resident has successfully completed a competency for self-administration.

Based on observation, interview, and record review the facility failed to keep a resident's urinary catheter off of the floor; failed to keep catheter tubing below the level of the resident's bladder, and failed to have orders or diagnoses in place for an indwelling catheter. This applies to 2 of 3 residents (R43, R128) reviewed for urinary catheters in the sample of 49. The findings include: 1. R43's Face Sheet showed an admission date of 11/10/24 with diagnoses to include dementia, interstitial cystitis (bladder pain and/or urgency), and urinary retention. R43' Care Plan showed [R43] has a UTI (urinary tract infection) and is at risk for recurrent UTI's.(11/18/24) On 08/26/2025 at 11:50 AM, R43 was sitting in her wheelchair in the common area on the locked memory care unit. R43's catheter tubing exited her lower pant leg and discharged into a catheter bag suspended under the seat of her wheelchair. At least 18 inches of R43's catheter tubing was laying on the floor. In the middle of the tubing was a clip. On 8/26/2025 at 12:09 PM, V4 Licensed Practical Nurse (LPN) moved R43, in her wheelchair, to the dining room; over 60 feet away. During the transport, R43's wheelchair wheel rolled over R43's tubing, twice, and the tubing dragged along the floor. On 8/27/2025 at 1:21 PM, V2 Director of Nursing stated catheter tubing should not be on the floor, should not be dragged along the floor, and should not be run over with a wheelchair. V2 stated this is to prevent UTI's. The facility's Urinary Catheter Care policy (3/2014) showed, The primary purpose for giving daily urinary catheter care is to prevent infection. Maintain aseptic technique at all times when handling and caring for the urinary catheter. When moving, transferring, or positioning the resident, make sure that all tubes are positioned in such a manner that they will not be pulled out or cause injury to the resident.When the resident is in a wheelchair, the urine tubing is placed over the cross-bars under the seat and is not kinked or curled. The bag is then place in the urinary bag holder. 2. R128's admission record shows she was admitted to the facility on [DATE]. The 8/27/25 order summary reports show R128 had orders to change a urinary drainage bag and monitor urinary output and an order to be placed on enhanced barrier protection due to indwelling urinary catheter. The orders did not show a diagnosis for R128 to have the catheter or size of the urinary catheter. R128s care plan for urinary catheter does not list any reason or diagnosis for her to have the catheter. On 8/27/25 at 1:25 PM, R128 was sitting in her wheelchair by the bed and her urinary catheter bag was in a dignity bag under the wheelchair. V5 certified nursing aide (CNA) placed a gait belt around R128s waist. V5 removed the urinary drainage bag from under the wheelchair and held the bag well above the level of R128s bladder, hooking the bag to her pants. V5 continued to transfer R128 from the wheelchair to the bed. On 8/28/25 at 11:00 AM, V2 said when a resident is admitted with an indwelling urinary catheter, the orders should include when to change the catheter, the size, and a diagnosis is required. She said all of the information should be in in the physician orders. V2 said we were not clear as to why R128 had the catheter, we reached out to her son as well and he did not know. She said there should have been a diagnosis. V2 said the urinary drainage bag should always remain below the level of the bladder, so the urine does not back up in the tubing. The facility's 3/2014 policy for urinary catheter care documents the primary purpose for giving daily urinary catheter care is to prevent infection. Infection control measure: the (drainage) bag must be held lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate for 1 of 1 resident (R9) reviewed for oxygen in the sample of 49. The findings include: R9's face sheet dated 8/28/25 showed diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, emphysema, cerebral atherosclerosis, and dependence of supplemental oxygen. R9's facility assessment dated [DATE] showed severe cognitive impairment. R9's order summary report dated 8/28/25 showed an order for oxygen at three liters via nasal cannula every shift for dyspnea (difficulty or shortness of breath), start dated 7/22/25. R9's care plan showed a focus area for the risk of acute exacerbation of COPD and the use of oxygen at two liters per nasal cannula (initiated 5/13/25). The same care plan showed to administer the oxygen at two liters per continuous nasal cannula per physician orders. On 8/27/25 at 10:05 AM, R9 was seated in a high back wheelchair in her room. R9 had an oxygen tank on the back of her wheelchair and the tubing was in her nose via nasal cannula. The oxygen tank setting showed the needle in the red (empty) zone. The setting was at three, but no oxygen was being administered. R9 removed the nasal cannula and said she did not feel any air coming through the tubing. At 10:13 AM, V8 (Certified Nurse Aide) was called into the room and observed the tank. V8 said R9 needs her oxygen every day, 24/7. R9 exited the room and notified the floor nurse. V7 (Registered Nurse) entered the room and verified the oxygen tank was empty. V7 said R9 needs it running continually due to her COPD. V7 said R9 could get shortness of breath or trouble breathing if it is not running as ordered. The oxygen saturation levels could plummet. On 8/28/25 at 9:05 AM, V2 (Director of Nurses) stated nurses should always be following physician orders. Residents run the risk of hypoxia and shortness of breath if oxygen is not given as ordered. All staff should be looking at the oxygen supplies during cares to ensure everything is running correctly. On 8/28/25 at 10:20 AM, V18 (Registered Nurse) stated resident care plans should match what the physician has ordered. We always follow the physician order but the care plan also directs the plan of care. The facility's Oxygen Administration policy last revision dated 3/20 states under the preparation section: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan for any special needs of the resident. The same policy states under the steps in the procedure section: 9. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, interview, and record review the facility failed to identify fall risks and follow policy and procedures to prevent falls for two (R1 and R2) of three residents reviewed for falls in the sample of three. These failures resulted in R1 falling from wheelchair to the floor, bleeding, pain, bruising, and hospital visit with a diagnosis of nasal fracture and receiving sutures. These failures also resulted in repeat falls for R2. Findings include: The facility's undated Fall Management policy and procedure documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The responsibility to respect a resident's choices is balanced by considering the potential impact of these choices on other residents and the facility's obligation to protect the residents from harm. The facility will educate the resident and his or her family and staff regarding significant risks related to a resident's choice. Incorporating a resident's choices into the care plan, along with the family's and staff's input can help balance the interventions to reduce the risk of an accident, while honoring the resident's autonomy. This policy documents staff, family, roommate, and any other witness statements and Statements will be utilized as part of the root cause analysis. The facility's Accidents and Incidents policy and procedure, dated 5/2015, documents The facility provides an environment that is free from accident hazards over which the facility has control. The facility provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazard and risk, evaluating and analyzing hazard and risk, implementing interventions to reduce hazard and risk, monitoring for effectiveness and modifying interventions when necessary. Avoidable Accident means that an accident occurred because the facility failed to identify an environmental hazard or individual risk or the need for supervision and/or evaluate/analyze the hazard and risk and/or implement interventions consistent with the resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident and/or monitor the effectiveness of the interventions and modify the interventions as necessary in accordance with the current standards of practice. The facility's Resident Transfers and Safety Devices policy and procedures, dated 10/2017, documents All residents are assessed at time of admission for transfer ability. Residents who are unable to transfer themselves independently or with minimum assistance shall be transferred following the principles of this policy to allow for maximum safety during resident transfer. Transfers shall always be conducted following the principles of proper body mechanics, and safely. Each C.N.A. (Certified Nursing Assistant) must wear a (transfer) belt when transferring a resident. All resident falls and/or injuries occurring during resident transfer shall be reported to nurse. The incident will be reviewed and analyzed to determine the potential cause and corrective action. Assure (transfer) belt is in position on resident and Use the (transfer) belt on the resident, as with any transfer when transferring a Resident. The facility's (Transfer) Belts policy and procedure, dated 3/2014, documents A (transfer) belt is a required part of a CNA, nurse and therapist uniform. The CNA, nurse, or therapist shall place his/her (transfer) belt around his/her waist or in their pocket where it will be readily available for use when transferring or ambulating residents. If the CNA, nurse or therapist does not use the ambulation/(transfer) belt and a fall or injury occurs to him/her or the resident, it shall result in disciplinary action. The facility's Incident Log documents the following: R1 had a witnessed fall on 2/26/25 at 10:10 am; and R2 was lowered to the floor on 3/2/25 at 7:35 am and on 3/8/25 at 7:55 pm. 1. The Face Sheet for R1, documents R1 was admitted to the facility with the following diagnoses: Hemiplegia (paralysis) and Hemiparesis (weakness) following Cerebral Infarction (stroke) affecting right dominant side, Vascular Dementia, Epilepsy, Cerebral Infarction due to Embolism of Left Cerebellar Artery, Oral Phase Dysphagia, Slurred Speech, History of Transient Ischemic Attack (TIA-small strokes) and Cerebral Infarction. The Quarterly MDS (minimum data set) Assessment for R1, dated 3/21/25, documents R1 is cognitively intact, is moderately hard of hearing and usually understands others, and has no documented behaviors. R1 has functional limitations in range of motion to both upper and lower extremities on one side, uses a wheelchair and walker for mobility. R1 requires moderate to maximum assist with activities of daily living, transfers, and walking. The current Care Plan for R1 documents R1 is at a high risk for falls due to weakness and hemiplegia of right side. The Witnessed Fall investigation for R1, dated 2/26/25 at 10:10 am, documents (R1) was being wheeled down the hallway for an appointment and put his feet down causing him to fall out of the wheelchair onto his face. R1 was assessed with laceration to R1's nose between nostrils and bridge of nose and complained of pain to nose. This Investigation documents Predisposing Factors as Range of Motion Deficits and Hemiplegia (partial or total paralysis)/Hemiparesis (weakness on one side of body). V7 CNA's (Certified Nursing Assistants) statement is documented as: I asked the resident if he wanted his footrests on and he said no. I was pushing him down the hallway to the front to leave for an appointment and he put his feet down and fell forward out the wheelchair onto the floor. R1's statement documents I put my feet down and I shouldn't have. R1 was observed lying on the floor with laceration to nasal septum. Heavy amount of blood present. Laceration is full thickness. Skin tear to bridge of nose observed. Skin tear is partial thickness total flap loss. R1 was transported to a local hospital with bruise, laceration, and skin tear to his face. R1 returned to the facility with diagnosis of nasal fracture and received two sutures to nose laceration. This investigation documents Foot dropped during transport as the root cause analysis. The Wound Assessment Details Report for R1, dated 2/28/25, documents photos of R1's wounds and the following documentation as: Nasal Septum laceration, Bridge of Nose skin tear, and Facial bruising are all facility - acquired and caused by trauma sustained by a fall and identified on 2/26/25. R1's Nasal Septum laceration measured 1.0cm (centimeters) by 0.2cm by 0.1cm with two sutures in place and dried scab forming. Swelling to nose present. The photo shows swelling to nose and sutured split at septum. R1's Bridge of Nose skin tear measured 0.8cm by 0.3cm by 0.1cm with partial thickness total flap loss and scant amount of serosanguineous (thin watery fluid) drainage present. The photo shows swelling to R1's nose and pink/red open wound. R1's Facial bruising measured 4.0cm by 4.0cm with deep purple/red coloring. The hospital Imaging Results for R1, dated 2/26/25, documents maxillofacial CT (computed tomography) was completed for R1 due to Facial trauma, blunt, fall. The Impression documents the following: 1. Comminuted fractures of the nasal bone, with overlying soft tissue swelling; 2. Acute fracture of the anterior nasal septum; 3. Hematocrit levels in the left maxillary sinus and sphenoid sinus. Bubbly secretions likely representing blood products within the nasal cavity. On 3/28/25 at 2:18 pm, R1 was sitting up in a wheelchair in his room without leg/footrests on his wheelchair. Two leg/footrests were resting on the floor in R1's closet. Scarring noted to R1's nasal septum area and to the bridge of R1's nose. R1 was unable to move his right arm and hand but able to raise right foot and leg off the floor. R1 demonstrated how he moves his wheelchair independently by lifting both of his legs as if walking his wheelchair. R1 stated he doesn't like to use the leg rests in the facility because he can't propel his wheelchair with them on. R1 stated he can propel his own wheelchair slowly and for short distances to and from the dining room with rest periods at times. R1 stated (2/26/25) he was in his wheelchair going out for a doctor appointment and V7 CNA was going fast, because you have to in order to get up the ramp (incline in hallway). R1 stated my foot got caught and it stopped the wheelchair from going and I fell right out of my chair. My face made contact with the cement floor. Broke my nose and cut my face up. They (hospital) put stitches on the bottom part of my nose. I was a mess. The worst fall I've had in my life. It was terribly painful. R1 stated he uses the leg rests now if he goes out for appointments. On 3/28/25 at 12:30 pm, V1 Administrator stated in February (2/26/25) R1 had a fall from his wheelchair. V7 CNA was pushing R1's wheelchair, R1's foot hit the floor and R1 went forward out of his wheelchair. R1 did get a nasal fracture and now uses pedals if he is being pushed. R1 cannot always propel his own wheelchair but can move short distances with his feet but not enough to get around due to his stroke. On 3/28/25 at 3:20 pm, V5 RN (Registered Nurse) stated V7 CNA pushed R1 up the inclined hallway, turned onto the 500 hallway, and V5 RN was right behind them. When V5 RN got to the 500 hallway R1 fell from his wheelchair onto the floor just past the fire doors. V8 CNA witnessed it as well. V5 RN stated If (R1) would have had his leg rests on it wouldn't have happened. On 3/28/25 at 3:28 pm, V8 CNA stated she was standing at the charting station on the 500 hall and saw V5 CNA pushing R1's wheelchair down the hall. V8 CNA stated she heard V5 CNA telling R1 she was going to go get R1's leg rests because it wasn't safe, and that R1's feet were scuffing coming up the inclined hallway. V8 CNA stated about that time R1 dropped his feet down on the floor and went forward out of his wheelchair on to the floor. On 4/1/25 at 11:23 am V2 DON (Director of Nursing) and V4 LPN (Licensed Practical Nurse)/Restorative Nurse stated R1 was being pushed in his wheelchair by V7 CNA and R1 dropped his foot causing R1 to fall forward out of his wheelchair. V4 LPN stated R1 probably held his foot up so long going up the inclined hallway, got tired, and dropped his leg. R1 didn't ask for a rest period. V2 DON and V4 LPN/Restorative Nurse stated V7 CNA should have alerted the Nurse if R1 was refusing his leg rests. On 4/1/25 at 2:00 pm, V7 CNA stated she was R1's CNA on 2/26/25. V7 CNA stated she was pushing R1 in his wheelchair to the front of the facility for a doctor's appointment. R1's feet buckled, and he put his feet down. I didn't realize he had put them down, and (R1) went right out (of the chair) on his face. V7 CNA stated R1 was bleeding, R1's nose split, and R1 was complaining of pain to his face and nose. V7 CNA stated, I should have been more adamant about using R1's leg rests. 2. The Face Sheet for R2 documents R2 was admitted to the facility with the following diagnoses: displaced Fracture of Lower Epiphysis (separation) of Right Femur, Morbid Obesity, Spinal Stenosis of Lumbar Region with Neurogenic Claudication, Intervertebral Disc Degeneration of Lumbar Region, Wedge Compression Fracture of Fourth Lumbar Vertebra, Right Artificial Knee Joint, and History of Falling. The Quarterly MDS (minimum data set) Assessment for R2, dated 2/17/25 documents R2 is cognitively intact with no documented behaviors. R2 has no range of motion impairments to her upper and lower extremities and uses a wheelchair for mobility. R2 requires moderate assistance for oral hygiene, personal hygiene and rolling side to side in bed and maximum assist for remaining activities of daily living, all transfers, positioning, and wheelchair mobility. R2 did not have any falls prior to this assessment. The current Care Plan for R1 documents R2 is at high risk for falls due to weakness and a history of falls in the community and was lowered to the floor by facility staff on 3/2/25 and 3/8/25. This Care Plan documents interventions as: 3/2/25 Resident current illness and to be assessed by physician; and 3/8/25 Resume restorative programs in therapy gym. The Lowered to the Floor investigation for R2, dated 3/8/25, documents Staff informed (V6 RN/Registered Nurse) that (R2) was lowered to the floor. Upon entering room (R2) was observed on knees facing the bed. R2 stated My knees just gave out. I felt my right ankle twist a little. R2 complained of pain when right ankle was moved. At the time of the incident there were no visible injuries. Bruising to anterior right knee was reported post incident. Predisposing Factors included: History of falls, Gait imbalance, Prone to bruising, Recent illness, and occurred during transfer. V9 CNA's (Certified Nursing Assistant's) statement documents V9 CNA informed V6 RN that R2 was lowered to the floor. R2's statement documents R2 stated My knees just gave out. I felt my right ankle twist a little. The Notes section documents X-ray results are negative, and resident continues to have weakness due to illness and is unable to participate in restorative programs in therapy gym and for Restorative programs to resume. This investigation documents the root cause analysis as: recent illness, weakness, prone to bruising/lowered to floor. On 3/28/25 at 2:30 pm, R2 was sitting in a wheelchair with a mechanical lift sling underneath her. R2 had visible light discoloration to her right knee. R2 stated she had a fall on 3/2/25 and the facility changed her from one assist to two assist. R2 stated on 3/8/25 she was in her room and one CNA (V9) was helping her get out of her wheelchair to go to bed. R2 stated I'm inpatient and head strong. Thought I could do it. R2 stated the CNA did not use the lifting belt, and she slid down the bed and hurt her knees. R2 stated I probably wouldn't have fallen if there had been two staff. R2 stated the facility did get x-rays and she did not break anything. R2 stated the pain is much better now but since her last fall the staff use the mechanical lift for transfers and I don't like it and feel like I am not getting any stronger by using it. On 4/1/25 at 6:15 pm, V6 RN stated V9 CNA reported to V6 that (R2) had to be lowered to the floor. V6 RN stated when she got to R2's room, R2 was on her knees facing her bed and was complaining of ankle pain and after assessing R2 V6 RN called and got an order to x-ray R2's ankle. V6 RN stated the next day she saw bruising to R2's right knee and got an order to x-ray R2's knee and all the x-rays came back negative for fractures. V6 RN stated V9 CNA told V6 RN that he had transferred R2 by himself without a transfer belt and R2 was supposed to be transferred with the assistance of two staff and a transfer belt and R2 reported this same information. On 4/1/25 at 3:55 pm, V9 CNA stated he transferred R2 on 3/8/25 from her wheelchair to bed by himself and did not use a transfer belt. V9 CNA stated prior to this time, R2 was able to stand, transfer, turn, and take a few steps. This time (R2) said she couldn't move her left leg. R2 was facing the bed and just went down onto her knees. V9 CNA stated he was given a written warning because he didn't use a transfer belt during the transfer and (R2) was supposed to be two assist and I did it by myself and should not have. On 4/1/25 at 11:23 am, V2 DON (Director of Nursing) and V4 LPN (Licensed Practical Nurse)/Restorative Nurse stated after R2's fall on 3/2/25 she was changed to a two assist for transfers and the staff were all educated, and it was added to her profile in the computer system and over R2's bed. On 3/8/25 V9 CNA transferred R2 by himself and was reprimanded at that time. V2 DON and V4 LPN/Restorative Nurse confirmed a transfer belt is to be used for all resident transfers.

Based on observation, interview, and record review the facility failed to ensure range of motion was implemented for a resident with functional limitations and failed to ensure an assistive device was in place for a resident with a contracture for four of four residents (R19, R38, R1 and R6) reviewed for range of motion in a sample of 40. Findings include: The facility's Range of Motion and Contractor Assessment and Preventions policy, dated 10/2019, documents that the objectives of range of motion exercise is to preserve resident's present range of motion. 1. R19's Restorative Program Note, dated 9/11/24, documents that R19 requires AAROM, active range of motion program, along with dressing and grooming. R19's Functional Abilities and Goals, dated 9/11/24, documents that R19's has an impairment to one side of her upper extremities. This form documents that R19 required substantial/maximal assistance for activities of daily living. On 10/24/24 at 10:15 AM, R19's Rehab/Restorative Assessment, dated 9/11/24, active assist range of motion-to prevent limitations, to be performed BID (twice daily) to bilateral upper and lower extremities. From 8/1/24 through 10/23/24 there were 43 times that R19's AAROM was not signed out as being completed. 2. R38's diagnosis include: Hemiplegia and hemiparesis, affecting the left non-dominate side. R38's Functional Abilities and Goals Assessment, dated 7/5/24, documents that R38 has an impairment to one side of her upper extremity. This form also documents that R38 requires substantial/maximal assistance for all cares. R38's Care Plan, dated 11/16/23, documents that R38's has a deficit in activities of daily living abilities and requires staff assistance due to impaired mobility and weakness with left sided hemiplegia following recent cerebral infarction. R38 requires active range of motion programming at least twice daily by working each joint using extension, flexion, abduction, and adduction 10-15 repetition, do not pass the point of resistance. If pain is seen, stop activity immediately and notify the nurse. R38's Rehab/Restorative: Passive Range of Motion-To prevent limitations to be performed BID (twice daily) was not started until 10/15/24. R38's Range of motion was only completed 6 times from 10/15/24 through 10/23/24. R38's range of motion was not completed prior to 10/15/24 as documented in R38's care plan. On 10/23/24 at 1:45pm, V6 Restorative Nurse, stated that range of motion is to be completed twice daily. V6 stated that there are two restorative aides that do the range of motion during the week on day shift, but on the weekends the floor staff are to do the range of motion. V6 verified that if it is not signed out it is not being done. V6 stated that there are residents that refuse daily, so the staff will quit asking or attempting to do the range of motion. V6 verified that there is no documentation that either R19 or R38 refused range of motion. On 10/24/24 at 8:45am, V2, Director of Nursing stated that R38's range of motion was not started until 10/15/24. V2 also verified that since 10/15/24, R38's range of motion was not being done as care planned. 31283 3. R1's current medical record documents the following diagnoses: Difficulty in Walking; Primary Generalized Osteoarthritis; Muscle Weakness; Cachexia, and Neuralgia and Neuritis. R1's Minimum Data Set Assessment (dated 09/16/24) Section GG, documents R1 has impairment of both sides to her lower extremities. On 10/21/24 at 09:37 AM, R1 was lying in bed covered with a blanket with her eyes closed. R1 appeared comfortable, and two 1/2 side rails were attached to R1's bed and were secured in the upright position. R1 stated she utilizes her bed rails to turn herself in bed. R1 then stated she prefers to spend most of her time in bed. On 10/22/24 at 12:35 PM, V12 (R1's son) stated R1 recently admitted under Hospice services. V12 stated his biggest concern is that R1, Needs to continue to receive consistent exercises to maintain her mobility. Especially in her legs. R1's medical record documents the following restorative programming exercises are currently in place: Restorative AAROM (Active Assistive Range of Motion) program: To prevent limitations to BUE (bilateral upper extremities) and BLE (bilateral lower extremities), to be performed BID (twice daily). R1's Monthly Restorative Documentation Report (dated 08/2024 - 10/2024) documents R1 did not receive range of motion exercises twice daily as ordered on 42 days during this time frame. On 10/23/24 at 12:50 PM, V2 (Director of Nursing) confirmed R1's range of motion exercises have not been completed twice daily as indicated. 4. R6's medical record documents the following diagnosis: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side. R6's Minimum Data Set Assessment (dated 09/30/24), Section C, documents a Brief Interview for Mental Status of 15, indicating R6 is cognitively intact. Section GG of this same assessment documents R6 has impairment of one side of her upper and lower extremities. R6's Restorative Program Note (dated 09/30/24) documents the following: Restorative Programs: Active Range of Motion, Splint/Brace Assistance, Dressing/Grooming. This same form documents, Splint/Brace Assistance: Carrot splint to be applied to left hand at rest, may remove during ADLs (activities of daily living), transfers and activities. R6's medical record documents the following restorative programming exercises are currently in place: Restorative AAROM (Active Assistive Range of Motion) program: To prevent limitations to be performed BID (twice daily) to RUE (right upper extremity) and BLE (bilateral lower extremities). R6's Monthly Restorative Documentation Report (dated 08/2024 - 10/2024) documents R6 did not receive range of motion exercises twice daily as ordered on 33 days during this time frame. On 10/23/24 at 12:50 PM, V2 (Director of Nursing) confirmed R6's range of motion exercises have not been completed twice daily as indicated. On 10/21/24 at 09:30 AM, R6 was reclined in her wheelchair watching television covered with a blanket. R6 was receiving oxygen at 3 liters via nasal cannula from an oxygen condenser and had a full mechanical lift sling in place underneath of her. R6's cell phone, call light and several personal items were within her reach. R6 stated she was recently sent to the hospital for my breathing and just returned to the facility and has been taking antibiotics since she returned. R6 stated her biggest concern is, the food is horrible. I don't have any teeth and they give me toast. R6 denied any other complaints at this time. R6's left wrist and hand was contracted, and the digits of her left hand appeared rigid and stiffened. No therapeutic appliance was in place at this time. On 10/23/24 at 01:05 PM, R6 was sitting in her wheelchair with her bedside table positioned in front of her eating a large salad. V10 (R6's Daughter) was sitting next to R6 assisting her with lunch. A washcloth was loosely in place in R6's left hand at this time. V10 stated, They never put the carrot in my hand. They forget and just stick a washcloth in it. V10 stated, She is rarely ever holding the carrot when I visit. R6 stated staff does not assist her with range of motion exercises twice daily, I try to exercise my (left) arm myself. R6 pointed out a carrot-shaped hand orthosis device that was sitting on a nearby dresser and stated, The carrot is sitting right over there. On 10/23/24 at 01:25 PM, V11 (Licensed Practical Nurse) confirmed R6 does not have her carrot splint in place and stated, It should be in place.

Based on interview and record review, the facility failed to perform a PASARR (Pre-Admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of three residents (R103) reviewed for PASARR screening, in the sample of 40. Findings include: The facility policy, Preadmission Screening and Annual Resident Review (PASARR), dated (effective) 11/18/2023 documents, This facility promotes and supports a resident centered approach to care. The purpose of this guideline is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability. This includes incorporating the recommendations from the PASARR level 11 determination and evaluation in the residents' assessment, care plan and transition of care; and referring all level 11 residents and all residents with new or evident conditions related to Level 11 review upon significant change in status assessment. R103's current Physician Order Sheet, dated October 2024 documents that R103 was admitted to the facility on [DATE] with the following diagnoses: Depression and Anxiety Disorder. R103's current Care Plan, dated 11/23/2022 includes the following Focus Areas: (R103) is at risk of possible abuse/neglect related to admission to the facility for long term care, a history of perpetrating/being a victim of abuse, cognitive deficits, emotional deficits, and relying on others for care needs. 12/15/23 LCSW (Licensed Clinical Social Worker) seeing (R103) for therapy session. Dx (Diagnosis) of PTSD (Post Traumatic Stress Disorder) added. On 10/22/24 at 2:27 P.M., V3/Social Services Director verified that R103 has not had a PASAAR rescreen upon the emergence of a newly diagnosed severe mental illness, on 12/15/23.

Based on observation, interview, and record review, the facility failed to provide grooming assistance for one of three residents (R12) reviewed for activities of daily living assistance in a sample of 40. Findings Include: The facility policy, ADL (Activities of Daily Living) Care, dated 11/2015 directs staff, To meet the grooming and hygiene needs of residents with dignity and privacy. Shaving: If the resident is a woman, shave only the areas with facial hair and apply moisturizer instead of aftershave. R12's current Physician Order Sheet, dated October 2024 documents the following diagnoses: Vascular Dementia, Osteoporosis, Cervical Spondylolysis, Polyosteoarthritis, Polymyalgia Rheumatica, Rheumatoid Arthritis and Weakness. R12's current Care Plan, dated 10/15/2024 includes the following Focus areas: (R12) has a deficit in ADL (Activities of Daily Living), physical mobility and requires staff moderate to total assistance from staff. (R12) has generalized weakness, impaired balance, strength and endurance. Also included are the following Interventions: Assist with dressing and grooming tasks. On 10/21/24 at 10:03 A.M., R12 was seated in a wheelchair in her room. 1/2-inch long facial hair was present to R12's entire chin. On 10/21/24 at 1:45 P.M., V2/Director of Nursing verified the presence of the chin hairs on R12 and that R12 should be shaved.

Based on observation, interview, and record review, the facility failed to ensure the staff covered hair in a sanitary manner while in the kitchen. This failure has the potential to affect all 124 residents at the facility. Findings include: The facility's Hair Restraints/Jewelry/Nail Polish/False Eyelashes Policy, Dated 2017, documents: Food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. On 9/26/23 at 10:25am, V6 Dietary Manager was observed with staff in the facility kitchen. V6's hair on the back of her head was uncovered. V10 Cook and V11 Cook were preparing the facility's lunch meal for residents. V10 and V11 were observed to have hair uncovered on the sides and/or back of their heads. On 9/26/23 at 10:25am, V6 Dietary Manager and V10 Cook stated that for kitchen staff, all their hair was supposed to be covered. V6 stated, I have been running around a lot and it came out. On 9/27/23 at 2:05pm, V6 Dietary Manager stated: Anyone who enters the kitchen should have a hairnet on and staff should have all their hair covered when in the kitchen. The Resident Census and Conditions of Residents (Centers for Medicare and Medicaid Services/CMS 672) form, dated 9/26/23, documents 124 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to revise Care Plans to be resident specific for five (R10, R12, R20, R78, and R108) of 25 residents reviewed for Care Plan revision in a sample of 31. Findings include: The facility's Care Plans, Comprehensive Person-Centered Policy, dated 4/2017, documents Policy Statement: A comprehensive, person-centered care pan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. On 9/26/23 at 11:13am and on 9/28/23 at 11:00am, R12 was lying in bed with her CPAP (Continuous Positive Airway Pressure) mask on and machine running. R12's current Physician Order Sheet/POS documents CPAP every shift - patient may apply and remove per self at bedtime and when napping with oxygen at 4 liters to bleed (flow) in. R12's current Care Plan does not include any cleaning of or cares for the CPAP machine and equipment. On 9/28/23, at 11:24am, V7 Minimum Data Set/MDS Coordinator confirmed that R12's Care Plan does not include any care of R12's CPAP machine and it should. 34131 2. On 9/26/23 at 9:56am, R108's room had oxygen tubing and a humidifier dated 9/24/23. On 9/27/23 at 11:30am and 9/28/23 at 3:08pm, R108 was in her room with oxygen on. R108's current order summary report, dated 9/29/23, documents Oxygen per Nasal Cannula at (3) L/min (liters/minute) continuous every shift with an order date of 7/28/23. R108's current care plan does not include her oxygen use. On 9/29/23 at 12:19pm, V13 MDS/Minimum Data Set Director stated I just updated (R108's) care plan yesterday to include her respiratory and oxygen status. It should have been on the care plan. 30678 3. On 9/26/23 at 11:15 am, R10 was sitting in a wheelchair in her room watching television. During conversation R10 began talking through clenched teeth with some anxiety when talking about her clothing at home that her family member had not yet brought to her. On 9/27/23 at 8:45 am, and 9/28/23 at 9:40 am, R10 was sitting up in a wheelchair in her room watching television. There were no behaviors observed. R10's current Care Plan does not document any identified behaviors for R10. On 9/29/23 at 2:15 pm, V7 MDS (Minimum Data Set) Coordinator confirmed R10's behaviors were not identified on R10's Care Plan and should be. 4. On 9/28/23 at 9:18 am, R20 was sitting in a reclining wheelchair in the dining room being assisted with breakfast meal. No behaviors observed. On 9/28/23 at 9:43 am, V14 LPN (Licensed Practical Nurse) stated R20 does not exhibit any behaviors at all, speaks in a word or two but no behaviors or issues. The current POS for R20 documents the following Physician Orders: Celexa 10 mg, 0.5 tablet by mouth one time a day for Major Depressive Disorder; Donepezil 10 mg 1 tablet by mouth in the evening Dementia with Behavioral Disturbance; Lorazepam 2 mg, Give 1 tablet by mouth every 30 minutes as needed for seizures if more than 3 doses are required contact hospice; and Risperdal 0.25 mg, Give 1 tablet by mouth one time a day every Monday, Wednesday, Friday, Saturday related to PTSD (Post Traumatic Stress Disorder). R20's current Care Plan does not document any identified behaviors. On 9/29/23 at 12:20 pm, V4 SSD (Social Service Directed) confirmed R20's Care Plan has not been revised to include identified behaviors or triggers due to R20's decline, and R20 only gets agitated with cares at times due to his dementia, not the PTSD. 5. On 9/26/23 at 10:24 am, 9/27/23 at 11:00 am, and 9/28/23 at 10:10 am, R78 was sitting in a wheelchair in her room. An eight ounce mug with a lid was resting on the overbed table, and a BiPap (Bilevel Positive Airway Pressure) machine was resting on the night stand with the mask and tubing connected to the machine, and hanging over top the machine. On 9/28/23 at 10:10 am, R78 stated she had been monitoring her fluids at home prior to coming to the facility and strictly follows what her doctor told her to do. R78 stated she is on a 1500 ml fluid restriction and uses the same 8 ounce mug she used at home so she can track her fluid intake easily. R78 stated she does not take the water from the nurse to drink with her medications and uses her own mug water. R78 stated she rents a BiPap machine from a local company who comes to the facility monthly to check the machine and change the tubing and mask. R78 stated no staff have cleaned her tubing or mask since she came to the facility. The current POS (Physician Order Sheet) for R78 documents 1500 ml (milliliters) Fluid Restriction every day; Breakfast 420 ml; Lunch 400 ml; and Nursing 200 ml for total of 1020 ml for day shift. Dinner 180 ml and Nursing 200 ml for total of 380 ml. Every night shift 100 ml. Record total amount consumed in 24 hours 1500 ml. The current Care Plan for R78, documents R78 with a 1200 ml Fluid Restriction; 720 ml from dietary and 480 ml from nursing daily and was not revised to the current 1500 ml Fluid Restriction order. This same Care Plan does not include cleaning of or cares for R78's BiPap machine and equipment. On 9/29/23 at 2:15 pm, V7 MDS Coordinator confirmed R78's fluid restriction and Bipap machine were not correct/identified on R78's Care Plan and should be.

Based on observation, interview, and record review, the facility failed to ensure a respiratory treatment was administered according to facility policy for one (R54) of one residents reviewed for breathing treatments during medication administration; and failed to ensure a residents respiratory equipment is routinely cleaned for two (R12 and R78) of four residents reviewed for respiratory care in a sample of 31. Findings include: 1. The facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, dated 11/2013, documents The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Steps in the Procedure: 6. Obtain baseline pulse, respiratory rate and lung sounds .16. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .21. When treatment is complete turn off nebulizer and disconnect T-piece, mouthpiece and medication cup .23. Obtain post-treatment pulse, respiratory rate and lung sounds. 24. Rinse nebulizer pieces after use: a. Wash pieces with warm water. b. Allow to air dry on a paper towel .26. When equipment is completely dry, store in a plastic bag with the date on it. R54's current Physician Order Sheet/POS documents an order for Ipratropium Bromide & Albuterol 0.5mg (milligrams)/3mg per 3ml (millimeters) vial. One vial inhale orally four times a day related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Rinse nebulizer set-up after each use and allow to dry. Once dry put in plastic bag with residents name and date. On 9/27/23, at 11:08am, R54 was lying in bed. V9 Registered Nurse/RN put Ipratropium Bromide & Albuterol liquid in the nebulizer medication cup, handed R54 the mouth piece, then turned on the nebulizer machine and left the room. At this time, V9 stated that V9 typically does not stay in the room during the treatment if the resident can do the treatment by themselves. (R54) is very good and will even shut it off by herself when done. On 9/27/23, at 11:21am, V9 returned to R54's room and waited two to three minutes for the treatment to be completed. V9 turned off the nebulizer machine. R54 handed V9 the mouth piece. V9 rinsed the medicine cup and mouth piece with water, shook off excess water, then attached them to the tubing and put them back into R54's blue canvas bag on R54's bed. On 9/27/23, at 2:26pm, V9 RN stated that this is her normal way of administering a nebulizer treatment. I only listen to their lungs if there is a problem or reason to, or if they were recently put on nebulizer treatments. I usually rinse it then shake it out and place it back in (R54's) bag without letting it air dry on a paper towel. On 9/28/23, at 2:15pm, V2 Director of Nursing/DON stated the following: It is expected for the nurse to stay in the room during nebulizer treatments or return periodically to monitor the resident, and to assess lungs and vitals before and after the treatment. Staff are expected to rinse the nebulizer equipment with water, and let it dry on a paper towel. 2. The facility's CPAP/BiPAP (Continuous Positive Airway Pressure/BiLevel Positive Airway Pressure) Support policy, dated 11/2014, documents General Guidelines for Cleaning: 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device .4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5. Humidifier (if used): b. Clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. 6. Filter cleaning: a. Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. b. Replace disposable filters monthly. 8. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to dry. R12's current Physician Order Sheet/POS documents Cpap every shift - patient may apply and remove per self at bedtime and when napping with oxygen at 4 liters to bleed (flow) in. On 9/26/23, at 11:13am, R12 is lying in bed with the CPAP on. R12 stated that her CPAP equipment does not get cleaned and has not been changed for six months. On 9/28/23, at 11:00 AM, V12 Registered Nurse/RN was unable to find any parameters for routine cleaning of R12's CPAP in R12's clinical record; V12 is unaware of cleaning being done. On 9/28/23, at 11:24am, V7 Minimum Data Set/MDS Coordinator V7 stated that R12's CPAP nasal mask and tubing was replaced in June, but R12's CPAP equipment should be cleaned routinely. 30678 3. On 9/28/23 at 10:10 am, a BiPap machine was resting on R78's night stand with the tubing and mask resting over top of the machine. On 9/28/23 at 10:15 am, R78 stated her tubing and mask are not being cleaned regularly. The current POS (Physician Order Sheet) for R78, documents BiPap 12/5/5% Frequency: HS (hour of sleep) every evening and night shift. On 9/28/23 at 11:30 am, V7 MDS (Minimum Data Set) Coordinator stated respiratory equipment should be cleaned routinely.

Based on observation, interview, and record review the facility failed to ensure a diagnosis, targeted behaviors, and indication for the use of an antipsychotic medication was in place for a resident with Dementia for one (R10) and failed to ensure a PRN (as needed) psychotropic medication did not exceed a duration of 14 days without a physician evaluation and rationale for continued use for one (R20) of five residents reviewed for unnecessary medications in the sample of 31. Findings include: The facility's Psychotropic Medication policy and procedure, dated 11/2013, defines This same policy defines A psychotropic drug is any drug that affects brain activities associated with mental processed and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotics, anti-depressants, anti-anxiety and hypnotics. This same policy documents The prescribing and administration of psychotropic drugs is based on a comprehensive assessment of the resident. Residents who have not used psychotropic dugs are not given these dugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents must be free of unnecessary drugs. (Unnecessary drugs are any drug when used in excessive dose, excessive duration, without adequate monitoring or without adequate indications for its use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued.) Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record: Schizophrenia; Schizo-affective disorder; Schizophreniform disorder; Delusional disorder; Mood disorders (e.g. bipolar disorder, depression with psychotic features, and major depression); Psychosis in the absence of dementia; Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g. high dose steroids); Tourette's Disorder; Huntington Disease; Hiccups, Pruritus (for short term of 7 days); or nausea and vomiting associated with cancer or chemotherapy. Residents do not receive psychotropic drugs pursuant to PRN/as needed orders unless that medication is necessary to treat a diagnosed specific condition. PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of the medication and documents their rationale for continued use in the resident's medical record for the duration of the PRN order. 1. The Order Summary Report for R10, dated 9/28/23, lists the following diagnoses: Dementia with behavior disturbance, Restlessness and Agitation, and Anxiety Disorder. This same Report documents a Physician Order for the Antipsychotic medication Quetiapine Fumarate 25 mg (milligrams): Give 0.5 (half) tablet by mouth at bedtime every Monday, Tuesday, Wednesday, Thursday, Friday and Sunday for potential for harm to self or others related to Dementia with behavioral disturbance. The Order Summary Report for R10, dated 9/28/23, also documents a generic generalized order Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting, etc. Interventions 1. Activities; 2. Change Position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 (one-on-one) every shift for Behavior Monitoring. Indicate number of behaviors per shift (use C for continuous). Indicate non-pharm (pharmacological) interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. The CNA (Certified Nursing Assistant) electronic computer charting system does not document any identified targeted behaviors for R10 that are to be monitored. The MAR (Medication Administration Record) for R10, dated July through September 2023, documents the same generic list of behaviors in R10's Order Summary Report: Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting etc. Interventions 1. Activities; 2. Change position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 every shift for behavior monitoring. Indicate number of behaviors per shift. (Use C for continuous) Indicate non-[harm interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. July through September MAR's all document no generic behaviors identified. There are no specific individualized targeted behaviors listed for R10 to be documented. The Quarterly MDS Assessment, dated 11/1/22, documents R10 as cognitively intact, with no identified behaviors, and no SMI (Serious Mental Illness) diagnoses. The Quarterly MDS Assessment, dated 12/31/22, documents R10 with moderately impaired cognition with no identified behaviors, and no SMI diagnoses. The Quarterly MDS Assessment, dated 4/1/23, documents R10 as cognitively intact, with no identified behaviors, and no SMI diagnoses. The Annual MDS (Minimum Data Set) Assessment, dated 7/1/23, documents R10 is moderately impaired for cognition, 1 to 3 days for rejection of cares, and no SMI diagnoses. The current Care Plan for R10 documents, date initiated 5/12/2020 Focus area as: (R10) Uses psychotropic medication Quetiapine R/T (related to) Dementia with sundowning with no resident specific identified behaviors to monitor for. The generic interventions listed include: Monitor/record occurrence of for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. On 9/26/23 at 11:16 am, R10 began talking quickly with some mumbling and talking through her teeth and became anxious when talking about clothing that a family member had not yet brought in for her. On 9/27/23 at 8:45 am and on 9/28/23 at 9:40 am, R10 was sitting in her room in a wheelchair watching television with no behaviors, and on 9/28/23 at 9:40 am R10 smiled and waved at this writer. On 9/28/23 at 9:40 am, V14 LPN (Licensed Practical Nurse) stated (R10) will only holler out or yell if you disrupt her routine, otherwise she is good and doesn't exhibit any other behaviors. (R10) does not hit or have any physical behaviors, and is pleasant and cooperative as long as her routine stays the same and you don't enter her room in the morning until after she has opened the door. V14 LPN stated the only behaviors R10 exhibits is occasional hollering or yelling out. On 9/28/23 at 3:39 pm, V2 DON (Director of Nursing) confirmed there are no individualized identified targeted behaviors listed for R10, is unsure what behaviors R10 exhibits, and stated the CNA's (Certified Nursing Assistants) only document in the computer system if the resident has a behavior which alerts the Nurse. At that same time, V2 stated the staff do not have an individualized resident centered behavior type tracking that they do each shift for (R10), and only document if a behavior occurs. On 9/28/23 at 4:00 pm, V3 ADON (Assistant Director of Nursing) stated she does all the psychotropic medication tracking and monitoring for the residents. V3 stated R10 is receiving Quetiapine for Dementia with behavioral disturbances. When asked what the identified behaviors were for R10, V3 stated Dementia with sun downing. 2. The Order Summary Report for R20, dated 9/28/23, documents the following diagnoses: Dementia with behavioral disturbance, Mental Disorders due to known physiological condition, and PTSD (Post Traumatic Stress Disorder), and MDD (Major Depressive Disorder). This same Report documents a physician order on 9/11/23 as: Lorazepam 2 mg (milligrams), Give 1 tablet by mouth every 30 minutes as needed for seizures, if more than 3 doses are required contact hospice. The Order Summary Report does not list seizures as a current diagnosis for R20, or a stop date for the Lorazepam. The Order Summary Report for R20, dated 9/28/23, documents a generic generalized order Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting, etc. Interventions 1. Activities; 2. Change Position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 (one-on-one) every shift for Behavior Monitoring. Indicate number of behaviors per shift (use C for continuous). Indicate non-pharm (pharmacological) interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. The MAR (Medication Administration Record) for R20, dated July through September 2023, documents the same generic list of behaviors in R20's Order Summary Report: Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting etc. Interventions 1. Activities; 2. Change position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 every shift for behavior monitoring. Indicate number of behaviors per shift. (Use C for continuous) Indicate non-[harm interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. July through September MAR's all document no generic behaviors identified. There are no specific individualized targeted behaviors listed for R20 to be documented. The current Care Plan for R20 documents, date initiated 4/20/2022 Focus area as: (R20) Uses antianxiety medication as needed for end of life care, air hunger, restless and comfort. This plan of care does not mention R20 with seizure diagnosis, activity, or interventions related to seizures. On 9/26/23, 9/27/23, and 9/28/23 between the hours of 9:00 am through 4:00 pm, R20 was observed lying in bed with eyes closed, up in a reclining wheelchair, and covered with a blanket for breakfast and noon meals. R20 was fed by staff and taken back to his room and put back into bed. R20 did not exhibit any behaviors or seizure activity on these days. On 9/29/23 at 12:20 pm, V4 SSD (Social Service Directed) stated R20 had a seizure one evening that was pretty extensive and he was given medication for it that night. On 9/28/23 at 3:40 pm, V2 DON stated R20 had a seizure one evening and the doctor ordered Lorazepam for it and only gets the Lorazepam as needed. On 9/28/23 at 4:00 pm, V3 ADON stated she does all the psychotropic medication tracking and monitoring for the residents. V3 stated R20 receives Lorazepam on a PRN (as needed) basis if he has a seizure, and confirmed there is no stop date for R20's Lorazepam order.

Based on observation, interview, and record review the facility failed to identify a potential viral infection, immediately report signs and symptoms to the Medical Director, remove potential symptomatic staff from work, obtain stool/emesis specimens, and delayed diagnosis. These failures resulted in continuation of the spread of an unknown virus to 53 (R1 through R53) of 129 residents and 24 staff experiencing varying symptoms of nausea, vomiting, diarrhea, chills and elevated temperature. Findings include: The facility's Infection Control Plan, Revised 6/2022, documents Infection control and prevention program refers to a multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of healthcare-associated infections are implemented and followed by Healthcare Personnel, making the healthcare setting safe from infection for residents. An effective Infection Control Program utilizes the following components; Surveillance: monitoring residents and healthcare personnel for acquisition of infection and/or colonization; Investigation: identification and analysis of infection problems or undesirable trends; Prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device-and procedure-related infections; Control: evaluation and management of outbreaks; and Reporting: provision of information to external agencies as required by state and federal law/regulation. This same policy documents Outbreak: When symptoms suggesting and infectious outbreak occur, and an investigation to define the nature and magnitude of the outbreak. The goal of the investigation is to promptly identify problematic organisms, stop ongoing transmission and reduce the risk of further events. A systematic approach is needed to verify the diagnosis, form a case definition, create a line list, implement infection control and prevention measures, and contact (State Agency) to report and maintain communication for further guidance. Actions may include but are not limited to . Implementing policies to prevent the spread of infections that include promoting consistent adherence to Standard Precautions, transmission based precautions and other infection control practices; Contract with a lab to provide supplies needed, to collect and process any testing required. Include arrangements for reporting results to any required authorities . Notify the local Department of Public Health, State Officials and other key stakeholders and make arrangements for a more detailed investigation by experts if the status of the outbreak warrants such measures; Develop a unit: maintain rooms to isolate residents as needed, who have viral respiratory infections, gastroenteritis, and other infectious diseases that are transmitted by airborne droplets, contaminated food or water, etc. so that new cases can be prevented . Institute screenings for anyone entering the facility . The IP (Infection Preventionist) will develop a testing place and response strategy to address infectious disease outbreaks. Pursuant to the plan and response strategy, the facility shall test residents and facility staff for infectious diseases listed in Section 690.100 of the Control of Communicable Diseases Code in a manner that is consistent with current guidelines and standards of practice . The IP will arrange for testing of residents and staff for the control or detection of infectious diseases when: The facility is experiencing an outbreak; or Directed by the Department or the certified local health department where the chance of transmission is high, including, but not limited to, regional outbreaks, epidemics, or pandemics. The facility's General guidance for Managing an Outbreak, Revised 6/2022, documents An Outbreak is Generally Defined as: .Occurrence of three (3) or more cases of the same infection over a specified period of time an in a defined area . food poisoning is defined as two (2) or more cases in persons who shared the same meal . diarrhea is defined as anything exceeding the endemic rate, or a single case if unusual for the facility. The Administrator or designee will be responsible for: Telephoning a report to the health department. The Infection Preventionist and Director of Nursing Services will be responsible for . notifying the Medical Director and the Attending Physicians. The nursing staff will be responsible for notifying the Director of Nursing Services of symptomatic residents; Providing infection surveillance data in a timely manner; Initial testing or obtaining laboratory specimens as directed . Initiating isolation precautions as directed or as necessary. If an outbreak is identified, personnel will be responsible to: Notify Administrator, DON (Director of Nursing)/designee, IP and/or Medical Director of any unusual signs and symptoms or events . Follow Core Principals of infection prevention and control . Use PPE appropriately . Notify their supervisor immediately if any new case is suspected both residents and staff. The facility's Stool Cultures in a Suspected Enteric Organism or Food-borne Outbreak, Revised 6/2022, documents An outbreak of suspected food-borne illness is defined as three (3) or more residents with clinically significant diarrheal or loose stools that occur within 24 hours of each other who have common exposure to each other, or share common space, or have consumed the same food. When an outbreak is suspected, the facility takes immediate action to confirm diagnosis and investigate appropriately. 1. When an outbreak is suspected, a stool specimen will be sent to the laboratory for culture and sensitivity. Any residents or staff who exhibit similar symptoms after that time also will have stool samples sent to laboratory for culture and sensitivity. 2. Enteric (food-borne) pathogens should be considered under these circumstances and would include Salmonella, shigella, Campylobacter, and E. Coli etc. 3. Until lab results are available, isolation precautions should be considered and residents who are ill should be assisted to perform good hand hygiene after a stool, should not be included in the dining room, recreational activity, or other group activities until symptoms resolve. 4. Staff exhibiting symptoms should be sent home pending lab results and symptoms resolved. 5. The Infection Preventionist has the authority to order these cultures under the direction of the Medical Director. The facility's Surveillance & Investigation policy and procedure, dated 5/2022, documents Infections that should be included in routine surveillance include those with . a. Evidence of transmissibility in a healthcare environment; b. Available processes and procedures that prevent or reduce the spread of infection . d. Specific pathogens that are associated with serious outbreaks. (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza.). If a communicable disease outbreak is suspected, this information will be communicated to the Charge Nurse and Infection Preventionist immediately. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification . The Charge nurse will notify the Attending Physician and the Infection Preventionist of suspected infections . When transmission of Healthcare-Associated Infections continues despite documented efforts to implement infection control and prevention measures, the appropriate state agency and/or specialist in infection control and epidemiology will be consulted for further recommendations. The facility's HCW (Healthcare Worker) Self-Reporting of Infection policy and procedure, dated 6/2022, documents As part of the facility infection prevention program it is the employee's responsibility to notify their supervisor or the Infection Preventionist of any identified or potential infection with an infectious disease . In compliance with our established policies governing employee health, you must report the following conditions to your supervisor, or to the Infection Preventionist: 1. Temperature of 100 degrees Fahrenheit or greater; 2. Nausea/Vomiting; 3. Acute diarrheal illness (severe) with other symptoms (i.e., fever, abdominal cramps, bleeding, etc.) or diarrhea lasting longer than twenty-four (24) hours . 13. Any other conditions as required by the (State Agency) or CDC. 14. Failure to comply with reporting will result in disciplinary action. The facility's Isolation - Categories of Transmission - Based Precautions, Revised 1/2014, documents Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis . wear gloves when entering the room . wear a disposable gown upon entering the Contact Precautions room. The facility's Contact Precautions policy and procedures, Revised 5/22, document: Contact Precautions are intended to prevent transmission of infectious agents, like MDRO's (Multiple Drug Resistive Organisms), that are spread by direct or indirect contact with the resident or the resident's environment. In addition to Standard Precautions, use Contact Precautions to prevent nosocomial spread of organisms that can be transmitted by direct resident contact (hand or skin-to-skin contact that occurs when performing resident-care) or by indirect contact (touching) of environmental surfaces or contaminated resident care equipment. Contact Precautions require the use of gown and gloves on every entry into a resident's room . Contact Precautions may be considered for residents who have: 4. diarrhea and fecal incontinence, or 5. Other epidemiologically significant organisms as determined by the facility's Infection control staff and Medical Director. Masks and eye protection, under Standard Precautions, should be worn during resident care activities that are likely to generate splashes of sprays of blood, body fluid, secretions, and excretions. The facility's I-NEDSS (Illinois' National Electronic Disease Surveillance System) Infectious Disease Reporting policy and procedure, dated 5/22, documents Should any resident (s) or staff be suspected or diagnosed as having a reportable communicable/infectious disease according to State-specific criteria, such information shall be promptly reported to appropriate local and/or state health department officials. If the disease or condition is also listed as a Nationally Notifiable Infectious Disease according to the CDC (Centers for Disease Control), the Infection Preventionist, or designee, shall notify the CDC of the occurrence(s). All reportable infectious diseases (residents' or employees') must be reported to the infection Preventionist as soon as definite diagnosis is made or strongly suspected . Infectious Diseases Reportable Immediately by Telephone include: Any unusual case or cluster of cases that may indicate a public health hazard . Botulism, foodborne . Influenza A, variant. The facility's Infection Control Guideline for the Dietary Department, Revised 1/2014, documents Dietary staff: 1. Maintain good health . 6. Are monitored for compliance with policies, procedures, and practices . 8. Do not work if they are ill with a gastrointestinal illness, or have been diagnosed with a food-borne illness. On 7/20/23 at 1:30 pm there was no signage at the entrance of the facility informing visitors that the facility was currently in outbreak status. The facility's Outbreak Line Listing, provided on 7/20/23, documents two symptomatic residents on 7/17/23 (R10 and R11); 28 residents on 7/18/23 (R3, R5, R7, R9, R12 thru R35); and 14 residents on 7/19/23 (R2, R4, and R36 thru R47); and three residents on 7/20/23 (R1, R6, and R48). The Outbreak Line Listing, provided on 7/21/23, documents three additional symptomatic residents (R8, R49 and R50). The Outbreak Line Listing, provided on 7/26/23 documents one additional symptomatic resident (R51) was added on 7/23/23; one additional symptomatic resident (R52) was added on 7/24/23; and one additional resident (R53) was added on 7/26/23. The facility's Outbreak Line Listing, provided on 7/26/23, documents the first symptomatic staff member was V7 Assistant Dietary Manager, with onset of 7/13/23 with fever, diarrhea, nausea, muscle aches, and fatigue. The second symptomatic staff member was V20 Cook for second shift, with onset date of 7/14/23 with diarrhea, nausea and fatigue. The third symptomatic staff member was V21 Dietary Manager, with onset date of 7/17/23 with vomiting, fever, and diarrhea. On 7/20/23 at between 1:30 pm through 3:05 pm, a tour of the facility was completed. There was no Outbreak signage noted at the entrance to the facility and no staff were visible wearing masks, gowns, or gloves in common areas, on the hallways, or when entering resident rooms. The facility Wings identified the following wing and Residents as being in isolation for the facility's Outbreak: 200 Wing identified R35; 500 Wing identified R2, R4, R9, R10, R12 through R17, R36 through R42; 600 Wing identified R43 through R47; 800 Wing identified R3, R18 through R30 and 400 Wing identified R4 and R31 through R34. At the entrance to the 400 Wing (Alzheimer's locked unit) a sign was posted to the door that read Guests: Masks are to be worn at all times. After entering the 400 Wing staff, various residents, and visitors were noted throughout the open floor plan and in resident rooms not wearing any PPE. On 7/21/23 at 9:00 am, a sign announcing Facility is in Outbreak was noted on a table in front of the entrance door in an eight by ten frame and was not visible until after entering the facility automatic double doors. On 7/21/23 between 12:00 pm through 1:00 pm, a tour of the facility was completed. During this tour there were multiple staff wearing masks in all areas of the facilities, visitors not wearing masks and random staff not wearing masks in the hallways and common areas. The facility Wings identified the following wing and Residents as being in isolation for the facility's Outbreak; 200 Wing identified R8 and R50; 500 Wing did not identify any residents this day; 600 Wing identified R6 and R47; 800 Wing identified R1 and R3 and V R3's Family Member was visiting R3 and walked to the community dining area without wearing PPE; and 400 Wing identified R4, R31, R48 and R49. On this same date at 12:30 pm, the 800 Wing dining room had residents being served the noon meal. R26 and R29 who were previously symptomatic on 7/18/23 were being assisted in the dining room. On 7/20/23 at 1:30 pm, V1 Administrator stated the facility is currently in an outbreak status and the LHD (Local Health Department) came and just left and is helping us. V1 stated the facility started an investigation on 7/19/23 and feel it started with V7 Assistant Dietary Manager who had symptoms but didn't think it was a big deal and worked anyway. That's how it happened. V1 stated three kitchen staff and a CNA (Certified Nurses Aide) were symptomatic first. V1 stated a few residents were sent to the local hospital but not GI (gastrointestinal) symptoms. V1 also stated there was one resident who passed away who had vomited one hour prior to passing but she had not been sick. V1 stated the LHD reached out to her yesterday (7/19/23) morning and came to the facility today to investigate and help and just left the facility. V1 Administrator stated the facility did not report to the LHD or the State Agency because the LHD called her on 7/19/23 so they were aware. V1 stated she has no confirmed tests for Noroviurs but is treating it as Norovirus. V1 stated first symptomatic residents exhibiting symptoms was on 7/17/23. V1 stated the facility collected and sent stool samples out for R1, R2, and R9 but has not received results yet. Confirmed Outbreak rooms are identified with Orange Stock paper with black I due to not have enough regular Isolation signs to use. On 7/20/23 at 2:48 pm, V7 Assistant Dietary Manager stated on 7/13/23 he was having some bodyaches and a low grade temperature but he felt ok, tested for COVID and it was negative, called his supervisor and was told to go ahead and go into work. V7 stated later in the day I had a diarrhea stool but that is not out of the ordinary for me due to my stomach issues. V7 stated the next day (7/14/23) he still had body aches and diarrhea but went to work and confirmed he did not call his supervisor. V7 stated he was off the weekend (7/15 and 7/16) and returned to work on Monday (7/17/23) without symptoms. V7 stated that V20 Cook for second shift went to the doctor on 7/12/23 and reported that the doctor tested her for strep and it was positive, got medicine and then returned to work on Wednesday (7/17/23) and worked through 7/19/23 and was sent home today (7/20/23) due to having diarrhea. V7 Assistant Dietary Manager also stated V21 Dietary Manager called in on Monday (7/17/23) because she wasn't feeling well and came back to work yesterday (7/19/23) to do inventory and then got sent home. V7 stated he had been around his best friends daughter who had thrown up a couple of times and wonders if he maybe he got something from her. V7 stated symptomatic residents are eating in their rooms and everyone else eats in the dining room. On 7/21/23 at 9:00 am, V1 Administrator stated Health Department had a meeting with (State Agency) yesterday and the Health Department told us to stop the dining room meals and now all residents are eating in their rooms. V1 Administrator stated V21 Dietary Manager went to her doctor yesterday and was told she had a stomach virus but did not test V21. V1 also stated the facility is still waiting for the stool culture results for R1, R2, and R9 and the lab said it could take two to five days to get results. On this same date at 10:02 am V1 Administrator stated as of noon yesterday (7/20/23) everyone is eating in their rooms and we placed a sign at the entrance table for visitors, and all staff have been inserviced and should be wearing mask, gown and gloves when entering symptomatic resident rooms and washing their hands before exiting the residents room. On this same date at 11:37 am, V1 Administrator stated the virus seems to have started with V7 Assistant Dietary Manager who has chronic IBS (Irritable Bowel Syndrome) and not sure what to do about that. V1 also stated We are keeping everyone in isolation until 48 hours after they are symptom free. The same with staff. On 7/21/23 at 9:34 am, V6 LPN (Licensed Practical Nurse)/IP (Infection Preventionist) stated an investigation was started on 7/19/23 because there were so many people who became symptomatic. V6 LPN/IP stated We traced it back to V7 Assistant Dietary Manager in the kitchen, who said that he had to relieve himself during one of the meal services. V6 stated It started in the kitchen with V7 Assistant Dietary Manager, so he didn't do something right. V6 LPN/IP stated the CNA's and Nurses were told if someone had a loose stool they were supposed to let me know so we could stool/emesis samples but by the time we got down there it was either on the floor, in the garbage can, or the staff had already cleaned it up. I was not going to get a sample off the floor or from the garbage can. V6 LPN/IP stated stool samples were obtained from R2 and R9 on 7/19/23 and from R1 on 7/20/23. On 7/26/23 at 12:30 pm, V2 DON (Director of Nursing) stated she worked the morning of 7/19/23 on the 800 wing and was not aware of any of the residents having symptoms until that morning upon arriving at the facility. V2 stated generally the staff call about everything and I would have expected them to notify myself and V6 LPN/IP. They did not notify V6 LPN/IP either. V2 DON stated, I called V54 Medical Director on the morning of 7/19/23 and told (V54) what was going on with symptomatic residents on the 500 and 800 wings and asked if we could do Norovirus tests and he said to go ahead and get stool samples. (V54) said we should do four or five. V2 DON stated As of 7/19/23 we kept everyone symptomatic in their rooms in contact isolation with sign and bin outside their room. V2 DON stated residents who were not symptomatic were able to be in the dining room separated from others and everyone was to wear a gown, gloves, and mask in symptomatic resident rooms. V2 DON stated we had two residents with symptoms on the 17th but it is not abnormal for some residents to have diarrhea. The evening of 7/18/23 is when everything really started happening. I was not aware. I do feel that if things would have been started earlier, or we would have known, we could have helped stop the rapid spread of this virus. On 7/25/23 at 2:55 pm and 7/26/23 at 2:30 pm, V21 DM (Dietary Manager) stated she does not recall V7 Assistant Dietary Manager calling in to work sick this month. V7 Assistant Dietary Manager comes to work, does his job, and knows if he is sick he should not be working. V21 DM stated she was on vacation the week of 7/17/23 and is not aware of anyone working while being sick or they would have been sent home, no one reported anything to her, and stated they all (dietary staff) know that if they are ill with nausea, vomiting, diarrhea or fever they cannot work. V21 stated she did not know that V7 Assistant Dietary Manager had not been feeling well until she returned from her vacation. V21 DM stated V65 Dietary Aide/Cook did call her on Sunday 7/10/23 while (V21) was on vacation and (V21) told V65 that she would need to call V7 Assistant Dietary Manager. V21 stated she did remind V65 that it is her scheduled weekend staff are supposed to try and find their own replacement before calling in and all V65 said was she was not going to be able to find anyone to work and said I'll just go to work. V21 DM stated This to me is that you're not really sick or you wouldn't be going to work. V21 DM stated again, They all know that if they are ill with nausea, vomiting, diarrhea, fever they cannot work. V21 DM stated she did not know what happened while she was gone on vacation. 1. The Quarterly MDS (minimum data set) assessment, dated 5/6/23, documents R1 is cognitively intact, requires extensive assist of one with bed mobility, transfers, walking, locomotion, toileting, personal hygiene, and bathing and limited assist with set up for eating. R1 is frequently incontinent of urine and occasionally incontinent of bowel. The current Care Plan for R1, documents (R1) is on contact isolation related to Norovirus symptoms. The Order Summary Report, dated 7/21/23, documents Clear liquid diet every shift until 7/21/23 1:59 am and Contact Isolation every shift until 7/21/23. On 7/20/23 at 3:20 pm, R1 was in lying in her bed with isolation signage posted to the frame of her door. On 7/21/23 at 1:18 pm, R1 was sitting up in a wheel chair in her room with the same isolation signage posted on door frame. On 7/21/23 at 1:18 pm, Entered R1's room with gown, gloves, and mask on. When asked R1 if staff wear gown, gloves, and/or mask in her room, R1 stated, Oh no, no one has come in here dressed like you, this is the first I have seen. No one has worn a gown or gloves into my room, just a mask. R1 stated, I was so sick. Have never had such extreme diarrhea ever in my life. It was diarrhea on top of diarrhea. The Nurse told me it was some kind of flu. R1 stated a stool sample was sent to the laboratory yesterday and she has not heard any results yet. R1 also stated her son got sick after visiting her. The Progress Note for R1, dated 7/19/23 at 4:19 pm, documents Resident c/o (complained) of diarrhea. Loose, watery brown colored stool noted in toilet. No other GI (gastrointestinal) c/o at this time. The Note, dated 7/20/23 at 8:02 am, documents Stool sample collected at this time d/t (due to) diarrhea. The Note, dated 7/20/23 at 10:52 am, documents Covid swab completed with negative result. The Note dated, 7/20/23 at 2:16 pm, documents POA (Power of Attorney) and MD (Medical Doctor) notified. The Laboratory results for R1's stool sample, dated 7/22/23 documents stool specimen obtained on 7/20/23 with diagnosis listed as Diarrhea, unspecified. The Final result for Norovirus PCR (polumerase chain reaction) test: Test not performed and Canceled on 7/22/23 at 2:23 pm; Incorrect collection container submitted. 2. The Quarterly MDS for R2, dated 5/22/23, documents R2 is cognitively intact, requires limited assist of one for bed mobility, locomotion, and personal hygiene. R2 requires extensive assist of one for transfers, toileting, and bathing. R2 requires limited assist with set up for eating and is occasionally incontinent of urine and always continent of bowel. The current Care Plan for R2, does not document anything for R2 regarding the facility's current outbreak or isolation precautions. The Order Summary for R2, dated 7/21/23, does not document any orders regarding the facility's current outbreak. On 7/20/23 at 2:14 pm, R2 was lying in bed with visitors in his room who were not wearing PPE. Isolation signage was on the door frame. On 7/21/23 at 12:30 pm, R2 was sitting up in a wheel chair in his room eating lunch. On 7/21/23 at 12:46 pm, R2 stated the day before yesterday (7/19/23) he had diarrhea for about half of the day and the facility only fed him bread and water. R2 stated he doesn't understand what has been going on and doesn't like it. It was only half a day and then I was fine, nothing else. R2 stated his roommate had it worse than (R2) but is better now. R2 stated They (staff) don't know what is going on here. Someone said they think it was food poisoning but no one will say and they won't let us come out of our room now. I just find it all crazy. The Progress Note for R2, dated 7/19/23 at 11:21 am, documents R2 received Tylenol. The Note at 4:02 pm, documents Resident presents with diarrhea, low grade temp (temperature), Tylenol given. POA and APN (Advance Practice Nurse) aware. The Note at 4:36 pm, documents Resident swabbed for Covid 19, results negative. The Note at 6:14 pm, documents Stool obtained, sent to lab. The Laboratory results for R2's stool sample, dated 7/22/23, documents stool specimen obtained on 7/19/23 with diagnosis listed as Acute gastroenteropathy due to other. The Final result for Norovirus PCR test: Test not performed and Canceled on 7/22/23 at 2:27 pm; Incorrect collection container submitted. 3. The Annual MDS for R3, dated 5/18/23, documents R3 has moderately impaired cognition and requires extensive assist of two staff for bed mobility, transfers, walking, and toileting; requires extensive assist of one for locomotion, personal hygiene and bathing and supervision with set up assist for eating; and is occasionally incontinent of urine and always continent of bowel. The current Care Plan for R3, documents R3 was hospitalized and received IV (intravenous) fluids for hydration. R3's Care Plan does not address the facility's current outbreak or isolation status for R3. The Hospital discharge records for R3, dated 7/20/23, documents R3 was hospitalized from 7/19/23 through 7/20/23 with diagnoses: Respiratory Insufficiency and Hypoxemia and returned to the facility on antibiotics. The Order Summary Report for R3, dated 7/21/23, does not include isolation orders or any orders regarding the facility's current outbreak status. On 7/20/23 at 3:19 pm, R3 was lying in bed, no isolation signage to room. On 7/21/23 at 1:10 pm, R3 was sitting up in a wheel chair in her room with an isolation sign posted to the door frame of her room. V19 R3's Family Member was visiting without wearing PPE. On 7/21/23 at 1:55 pm, V19 R3's Family Member exited R3's room, without performing hand hygiene and walked to the empty dining area. On 7/21/23 at 1:55 pm, R3 stated she had diarrhea before she went to the hospital and hasn't had any since she came back. R3 stated she wasn't sure why she went to the hospital. On 7/21/23 at 2:00 pm, V19 R3's Family Member stated (R3) only had diarrhea one day and went to the hospital and I don't know why she is in isolation. V19 did state the facility had informed him of the facility outbreak status. The Progress Note for R3, dated 7/18/23 at 6:30 am, document Nausea, vomiting and diarrhea. Anti diarrheal medication given. In bed, eyes closed at this time, Call light within reach. Colace and Miralax (medications) held due to diarrhea. The Note at 1:02 pm, documents Resident seen by V60 NP (Nurse Practitioner). No new orders noted. The evening doses of Colace and Miralax held. The Progress Note for R3, dated 7/19/23 at 10:22 am, documents Observed resident in bed HOB (head of bed) elevated responding lethargically. Vitals taken. Temp (temperature) 98.0, B/P (blood pressure) 93/61, P (pulse) 85, R (respirations) 15, SpO2 (blood oxygen level) 83%, (V61) NP notified. Supplemental oxygen started at 2L (liters) via nasal cannula. The note at 10:48 am, documents SOB (shortness of breath), lethargic, altered mental status. The Note at 10:52 am, documents New order to send to ED (emergency department) per (V61 NP). 911 here to transport. Call placed to (V19 R3's Family Member.) The Progress Note for R3, dated 1/19/23 at 11:06 am, V60 NP documented NP was called to see (R3) because of altered mental status and low oxygen saturations. Yesterday (7/18/23) she had GI symptoms of vomiting and diarrhea. This morning the nurse noticed she was more out of it and not acting herself. She (R3) is usually up in her chair and talking. This morning she did not want to get out of bed. She is having a hard time answering questions and following commands. Her oxygen saturation was initially 83% and she was placed on 2L. When I (V60 NP) arrived she was only at 87-88% and titrated her (R3) oxygen up to 4L and she eventually came up to 95%. She (R3) still could not follow commands and was very slow to respond to questions. She knew her birthday but not where she was or the year. 911 was called and she was sent out with EMS (emergency management systems.) . Altered mental status: Acute, unstable . Low oxygen saturation: Acute, Unstable continue 4L nasal cannula. Send to ER (emergency room ) via 911 . Diagnoses: 1.) Altered metal status, unspecified. 2.) Hypoxemia. The Laboratory reports for R3 do not include any stool specimens being collected or sent to the facility lab. 4. The Quarterly MDS for R4, dated 5/2/23, documents R4 with moderately impaired cognition, requires extensive assist of two staff for bed mobility, dressing, toileting; totally dependent of two staff for transfers and bathing; extensive of one staff for eating and personal hygiene; and is frequently incontinent of urine and bowel. The current Care Plan for R4 documents (R4) is on contact isolation related to Norovirus symptoms. The Order Summary Report for R4, dated 7/21/23, documents order 7/21/23 Clear liquid diet every shift until 7/22/23 1:59 am. No isolation orders are included in R4's current physician orders. On 7/20/23 at 2:22 pm, R4 was lying in bed. No Isolation signage is posted to R4's door or door frame. On 7/21/23 at 1:00 pm, R4 was lying in bed with isolation signage posted to R4's door frame. V62 CNA (Certified Nursing Assistant) was standing in R4's room, next to R4's bed assisting R4 with noon meal. V62 CNA was not wearing gown, gloves, or mask at this time. On 7/21/23 at 1:05 pm, V9 LPN (Licensed Practical Nurse) stated R4 has been symptomatic with outbreak symptoms and is in contact isolation. V9 LPN looked into R4's room and confirmed that V62 CNA should have a gown, gloves and a mask on while in R4's room. V9 LPN told V62 CNA that she should have PPE while in the room. V62 CNA reached over to to the wheel chair in the room, picked up a gown, mask and gloves and put them on and continued to feed R4. The Progress Notes for R4, da [TRUNCATED]

Based on interview and record review, the facility failed to ensure a resident's call light was answered in a timely manner to meet the resident's need for one of four residents (R3) reviewed for accommodation of needs in the sample of four. Findings include: The facility's Call Lights Policy, dated 8/14/21, states, Purpose: 1. To respond promptly to resident's call for assistance. Procedure: 1. All facility personnel must be aware of call lights at all times. 2. Answer all call lights promptly whether or not the staff person is to the resident. 3. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as possible. The Residents' Rights for People in Long Term Care Facilities, dated 11/18, documents the facility must provide residents services to keep their physical and mental health at their highest practical level and the facility must provide care that promotes residents' quality of life. The facility's Certified Nursing Assistant/CNA Job Description, undated, states, Essential Duties and Responsibilities: Answers residents' call lights promptly and courteously. The facility's Resident Council Minutes for May 2023 states, We need more CNAs/Certified Nursing Assistants on the floor. R3's Facesheet documents R3 admitted to the facility on [DATE] with diagnoses to include but not limited to: Nondisplaced Traverse Fracture of Right Patella; Morbid Obesity; Nondisplaced Fracture of Greater Trochanter of Right Femur; Generalized Muscle Weakness; Difficulty Walking; Unsteadiness on Feet; and a Previous Fall. R3's Minimum Data Set/MDS Assessment, dated 5/23/23, documents the following: R3 is cognitively intact with no memory impairments, scoring a 15 out of 15 on the Brief Interview of Mental Status (BIMS); R3 is always continent of urine and bowel; R3 requires extensive assistance of two plus persons physical assist for transfers, bed mobility, walking in room, and toilet use; R3 is not steady, only able to stabilize with staff assistance for moving on and off the toilet; R3 has range of motion impairment on one side of R3's lower extremities; and prior to R3's current illness, R3 was independent for R3's self care needs, including toilet use. R3's Current Care Plan at the time of R3's admission documents the following: (R3) has a deficit in ADL/Activities of Daily Living abilities and requires staff assistance due to fall in the community with fracture of right patella. WBAT (Weight Bearing as Tolerated) to RLE (Right Lower Extremity) with immobilizer in place at all times. (R3) is alert oriented and able to make needs known. with an intervention of Assist with all transfers and maintain any weight bearing restrictions.; (R3) is at risk of falls due to history of fall in the community with fracture. (R3) has impaired mobility and weakness and requires assistance with transfers. (R3) takes medications that increase her risk of falls. with an intervention of Call light in reach and answer in a timely fashion.; and Assist me with my personal cares as needed. On 5/31/23 at 10:26 AM, V13 (R3's Family Member) stated, On 5/23/23 shortly after 8:00 AM, I came to visit (R3). (R3's) call light was on when I got there. I asked (R3) how long her light has been on and she said at least a half hour. (R3) said she had to go to the bathroom badly. I took (R3) to the bathroom myself. The nurse came in the room when we were finishing and told me to not transfer (R3) on my own. I talked to (V2/Director of Nursing) right after that happened because I shouldn't have to be the one who helps (R3) to the bathroom. A couple days later, (5/25/23) (R3) called me very upset that she had to go to the bathroom so bad and had been waiting over an hour for help. (R3) ended up soiling herself because no one ever came. (R3) knows when she has to go to the bathroom. That shouldn't have happened. I came to the facility and went to the Administrator (V1). I let her know I wanted to take (R3) home that day with me since no one seemed to be taking care of her there (at the facility). On 5/31/23 at 3:19 PM, R3 stated, I wasn't at the facility for a very long time. I didn't need very much, just help to go to the bathroom. One day (5/23/23), (V13) had to help me to the bathroom because no one was coming in. I had already been waiting a half hour. The day I came home (5/25/23) was even worse. I waited over an hour. I remember I saw a male nurse in the hallway. I was thinking, 'Why is no one coming in? Why does it take that long?' I had to pee so bad that it hurt. They were giving me laxatives and I didn't know it. I kept pushing my button over and over. I don't know if that does anything, but I really needed help, so I just kept pushing it. I was screaming and hollering for someone to 'please, help me.' No one came. I ended up having an accident. I had to be cleaned up of (urine and stool). I know when I have to go to the bathroom, I shouldn't be having accidents. Before I broke my leg, I could get up and down and do everything on my own. I can't do that right now. I ended up going home later that day. I now have a commode here in my living room. I would rather do that and be able to go to the bathroom when I need instead of waiting hours for help over there. On 5/31/23 at 12:40 PM, V2 (Director of Nursing) stated that on 5/23/23, V13 came to V2's office upset with R3's call light wait times. (V13) said that (R3) had waited over a half hour and that (V13) took (R3) to the bathroom herself. V2 stated this occurred around 8:30 AM, which was breakfast time. V2 stated, I could see longer (call light) wait times if it was around breakfast. On 5/31/23 at 1:13 PM, V6 (Social Service Director) stated that V6 was aware of R3 and V13's concerns regarding call light wait times. V6 stated R3 was offered to change rooms earlier in the week to a floor that wasn't as heavy and R3 declined due to the rooms being smaller. V6 stated on 5/25/23, V13 was very upset and went to V1 stating that V13 wanted to take R3 home. V6 stated R3 complained to V6 that it takes a while for staff to get to R3. V6 stated that V6 would normally complete a grievance or complaint form for R3 and V13's concerns but V6 overlooked that. V6 stated a whole investigation was completed after V13's concerns. V6 verified R3 discharged home the day of the 5/25/23 incident per R3's and V13's request. On 6/1/23 at 9:57 AM, V15 (Licensed Practical Nurse) stated that V15 walked into R3's room on 5/23/23 as V13 was walking R3 back from the bathroom. On 6/1/23 at 10:38 AM, V14 (Certified Nursing Assistant) stated the following: R3 was alert and oriented and able to make needs known; R3 was continent of urine and bowel; R3 required assistance to use the bathroom; and V14 assisted R3 in being cleaned up of urine and bowel in R3's bed. On 5/31/23 at 3:09 PM, V1 (Administrator) stated that is the expectation that call lights are to be answered as soon as possible. V1 stated all staff was re-educated on 5/25/23, during the investigation into R3 and V13's call light concerns. V1 stated that no staff member should walk past a call light without going in to check on the resident. V1 stated that if the resident needs something that person cannot provide, the staff member should let the resident know they will get someone to help. V1 stated, If anyone is waiting 20 minutes or more, that is too long.

Based on observation, interview, and record review, the facility failed to follow a treatment dressing change order for one (R1) of four residents reviewed for treatments in a sample of four. Findings include: R1's current treatment orders, dated 11/28/22, document: Right lateral calf: Cleanse hematoma with wound cleanser. Pat dry. Apply skin prep, non-adherent gauze, calcium alginate, silicone boarder foam; every day shift every other day for wound management. R1's current diagnosis include: Personal history of other venous thrombosis and embolism; personal history of diseases of the skin and subcutaneous tissue; venous insufficiency (chronic/peripheral). R1's Skin Only Evaluations, dated 11/22/22 and 11/28/22 document: Traumatic wound. Right lower extremity lateral; right lower extremity wound bed is moist red and granular, no slough erythema or odor. Edges flat and intact. Tolerates dressing change well. R1's current Care Plan documents: (R1) is at risk for skin breakdown due to fragile skin due to normal aging process, history of skin issues, fluctuations in oral intake. R1's Treatment Administration Record (TAR) dated 12/2022, indicated no wound treatment to R1's right lateral calf for scheduled treatment date of 12/2/22. On 12/8/22 at 12:05pm, V9 Certified Nursing Assistant (CNA) stated that on 12/4/22, she assisted V8 Licensed Practical Nurse (LPN) with R1's wound treatment and dressing change to R1's right lower extremity; stated that she saw a date of 11/30/22 on R1's soiled dressing. V9 stated that V8 asked V10 Licensed Practical Nurse (LPN) and V9 (CNA) to look at the soiled dressing to make sure she was not reading the date wrong. V9 stated that both she and V10 verified the date was 11/30/22. On 12/8/22 at 12:35pm, V8 (LPN) stated that R1 had an order to treat the wound on R1's right lower extremity every other day; that V8 changed R1's dressing on 12/4/22 after she removed a soiled dressing dated 11/30/22 with (V11 Licensed Practical Nurse/LPN's) initials written on it. (Noted that the TAR for R1 indicated that V11's signed off the treatment for 11/30/22.) V8 stated that the next treatment for R1's right lower extremity should have been done on 12/2/22. At this time, V8 also stated that the soiled dressing had adhered to R1's wound area and stated that both she and V10 (LPN) were able to remove the soiled dressing after some time by using saline to soak the dressing for several minutes, being careful not to cause any undue skin irritation with the least amount of damage to R1's skin. Stated that R1 was concerned with the amount of saturated blood on the soiled dressing and that R1 stated, Look at that blood. On 12/8/22 at 12:50pm, V10 (LPN) stated that she assisted V8 (LPN) on 12/4/22 with R1's dressing change; stated that she does have wound care certification; that V8 was unable to get R1's soiled dressing off due to it was saturated with blood, stiff, and stuck and adhered to R1's leg. V10 stated, After soaking the dressing, was able to pull it off in a safe manner; no signs of infection were noted. On 12/8/22 at 2:35pm, V3 (LPN)/Wound Nurse stated that she was scheduled to do R1's wound treatment on 12/2/22 but did not. V3 stated, I did not do (R1's) treatment; don't know for sure if I asked someone else to do it; just did not get time to do it, ran out of time. V3 stated that (V8 Licensed Practical Nurse/LPN) advised V3 regarding issue with R1's treatment and that (V8) had changed the dressing on 12/4/22 (per schedule).

Based on interview and record review, the facility failed to provide an ordered medication for one of three residents (R1) reviewed for medication administration, in a sample of five. FINDINGS INCLUDE: The facility policy, Administering Medications, dated (revised) 11/2020 directs staff, Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. R1's facility Face Sheet documents that R1 was readmitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/22 at 9:41 A.M., V3/Registered Nurse/Assistant Director of Nurses (ADON) verified that R1 did not receive the medication (Xandi) from 6/19/22 through 6/27/22 when R1 was admitted to the hospital for a prolonged stay. At that time, V3/ADON stated, I am unaware of (facility) staff contacting the pharmacy to request the medication. On 8/9/22 at 12:17 P.M., V7/Facility Pharmacist stated, The facility did not order the medicine (Xandi) from us (June 19, 2022 through June 27, 2022). We (Pharmacy) never delivered the medication to the facility.

Based on observation, interview and record review, the facility failed to ensure interventions were in place to prevent skin breakdown and remove compression stockings and assess the underlying skin for skin impairment for one of four residents (R53), reviewed for pressure wounds, in a sample of 41. This failure resulted in the development of multiple, unstageable, necrotic pressure wounds to the feet and heels, a delay in healing with resulting delay in a facility discharge . Findings include: The facility policy, Prevention of Pressure Ulcers/Injuries, dated (revised) 1/2019 directs staff, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. The most common site of a pressure ulcer is where the bone is near the surface of the body, including the heels. Pressure can also come from bandages and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident and often times become infected. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. The facility policy, Applying Anti-Embolism Stockings (TED Hose), dated (revised) 11/2013 directs staff, The purpose of this procedure is to improve venous return to the heart, to improve arterial circulation to the feet, to minimize [CONDITION(S)] to the legs and feet, and to prevent complications associated with [CONDITION(S)] and pulmonary embolism. Verify that there is a Physician's order for anti-emboli stockings. If there is no order for anti-emboli stockings, contact the Attending Physician to obtain orders. (Note: Document the receipt of telephone orders in the resident's medical record.) Stockings that are sized incorrectly can increase the risk of pressure and skin irritation, casing harmful pressure gradients which impede blood flow. If possible, anti-emboli stockings should be applied in the morning, prior to the resident getting out of bed. Remove the stockings every eight hours and inspect the skin. Leave the stockings off for 30 minutes and reapply, as ordered. R53's facility Admission Record documents that R53 was admitted to the facility on [DATE], from a local hospital with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R53's Physician Orders, dated 01/06/22 includes multiple medication orders, orders for Physical Therapy and Occupational Therapy and partial weight bearing for to the left lower extremity. No Physician orders are included for R53's anti-emboli stockings. R53's Clinical Admission Evaluation, dated 01/06/22 documents, (R53) is alert and oriented. (R53) has antiembolic treatment (TED Hose and elevate legs) with no calf tenderness and normal left and right pedal pulses. R53's Skin Evaluation form, dated 01/06/22 documents, Current skin issues: Surgical wound to left hip is 17.9 CM (Centimeters) X 0.1 CM. Skin intact save for surgical incision to left hip. R53's electronic Medical Record, dated 1/7/2022 documents, BIMS (Brief Interview for Mental Status) Score: 15.0 Intact cognitive response. R53's facility SBAR (Situation, Background, Assessment, Recommendation) Communication form, dated 1/22/22 at 5:30 P.M. documents, (R53)'s left lower leg started to bleed. Dried blood noted on bed. TED hose taken off. Steri strips placed. No active bleeding anymore. Measures 6 CM (centimeter) X 6 CM. R53's Skin Only Evaluation form, dated 01/22/22 at 9:54 P.M. documents, Skin Issue #1: Unstageable pressure ulcer/injury to right heel. Skin Issue #2: Unstageable pressure ulcer/injury to left heel. Skin Issue #3: Unstageable pressure ulcer/injury to left side of left foot. Skin Issue #4: Unstageable pressure ulcer/injury to right and left sides of right foot. R53's electronic Nursing Progress Notes, dated 1/24/2022 document, Communication with MD/Family. POA (Power of Attorney) updated and wounds discussed and treatments explained, verbalizes understanding. Ortho (Orthopedics) called and notified of skin/tissue damage related to TED hose and that they are being removed at this time. (R53) added to wound MD list for this week. R53's Wound Care Initial Evaluation Notes, dated 01/27/22 document, (R53) has multiple wounds. (R53) has an unstageable (due to necrosis) pressure wound to the right heel. Site 1: Unstageable pressure wound to the right heel, full thickness, measures 8.1 CM X 5.0 CM with 100% black necrotic tissue. The best medical estimate of the time required for this wound to heal with continued Physician evaluation and intervention is 105 days. Site 2: Unstageable pressure wound to the left heel, full thickness, measures 6.5 CM X 5.0 CM with 90% black necrotic tissue. Site 3: Unstageable Deep Tissue Injury of the left lateral foot, partial thickness, measures 5.0 CM X 5.5 CM. Site 4: Wound of the left, lateral leg, full thickness, measures 4.5 CM X 4.0 CM X 0.1 CM. R53's January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/13/22 at 8:40 A.M., V10/Wound Nurse prepared to perform wound care for R53. A black, necrotic wound, measuring 5 CM X 5 CM was present on R53's right heel. An additional 1 CM X 0.6 CM unstageable wound was present to R53's right lateral foot with a 0.7 CM X 1 CM unstageable wound present to R53's right medial foot. R53's left lower lateral foot showed a full thickness wound measuring 4.5 CM X 3 CM X 0.4 CM and an additional unstageable 5 CM X 3.5 CM pressure wound to R53's left heel. On 4/11/22 at 10:53 A.M., R53 stated, I came to the facility in January (2022). I had fallen at home and broke my hip. I was wearing those long white socks (anti- embolic stockings) when I was admitted and the staff never took them off of me or looked underneath of them, for a week. When they finally took them off, I had a big wound to both of my heels and a wound to my left lower leg. I was supposed to have gone home by now. Now I have to stay until these wounds heal. I want to go home. On 4/12/22 at 2:45 P.M., V11/Certified Nursing Assistant (CNA) stated, I have been a CNA here for four years. I work all over, but am often assigned to 600 Hall. I don't remember if I was here the night (R53) was admitted . I was working the night V12/Certified Nursing Assistant (CNA) discovered the wounds on (R53). (V12/CNA) took me in (R53's) room and showed me the wounds to both of (R53's) heels. They were black. And (R53) had a wound to (R53's) left lower leg. At that time, (R53) said his TED hose had not been removed since he had been admitted . I don't remember taking (R53's) TED hose off. Normally we remove TED hose before bed, wash them, hang them to dry and put them back on in the morning. On 4/12/22 at 2:55 P.M., V13/Registered Nurse (RN) stated, I was the nurse who was present the night (1/22/22) we find the wounds on (R53's) leg and heels. The CNA (V12) noticed some bleeding from (R53s) leg. I took (R53's) TED hose off and found unstageable wounds to his bilateral heels and left lower leg. I don't remember if (R53's) TED hose had ever been off before that. On 4/12/22 at 2:59 P.M., V12/Certified Nursing Assistant (CNA) stated, I don't remember ever taking (R53's) TED hose off. On that night (01/22/22) (R53) was complaining of his heels hurting. I saw blood on (R53's) TED hose and went and got the Nurse. When she took off the hose, he had black areas to both of his heels and a wound to his left lower leg. (R53) said no one had taken his TED hose off before that night. On 4/13/22 at 9:15 A.M., V10/Wound Nurse stated, (R53) came with TED Hose on. He had a hip fracture and that is common practice due to a resident's immobility. (R53's) skin was intact upon admission, except for his surgical wound. When we discovered the wounds on (R53's) leg and heels, (R53) told us his TED hose had not been removed for about a week and they were too tight. During our investigation, we discovered (R53) never had a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Typically TED Hose are taken off at bedtime, the skin underneath is assessed and the TED Hose are reapplied in the morning, before a resident gets out of bed. (R53) wasn't getting showers at that time due to his surgical wound, so his TED Hose wound have been left on during his bed bath. On 4/13/22 at 10:52 A.M., V8/Licensed Practical Nurse stated, (R53) had an order to apply Skin Prep to his heels at bedtime. I didn't take his TED Hose off, I just pushed them back, put the skin prep on and then pulled the TED Hose back in place. On 4/13/22 at 2:20 P.M., V16/R52's family member stated, (R53) is alert and with it. (R53) lived at home and took care of himself before he fell and broke his hip. When (R52) came to the facility it was only supposed to be for a short time and then (R53) was supposed to go home. (R53) told me the staff didn't remove his stockings (TED Hose) and monitor his skin and that's what caused the wounds to his leg and feet. Yesterday was (R53's) birthday and (R53) cried all day because he can't go home and he is afraid he is going to lose his legs due to the wounds. (R52) said he doesn't want to live like this. On 4/14/22 at 8:30 A.M., V17/Wound Doctor stated, If TED hose were left on for a period of time, they could lead to the development of necrotic wounds. On 4/14/22 at 8:44 A.M., V2/Director of Nurses verified the facility policy for TED hose is to obtain a Physician's order for the TED hose, remove the TED hose at bedtime and monitor the skin underneath and reapply the TED hose each morning. V2/DON also confirmed the staff had not obtained a Physician's order for R53's TED hose, nor were R53's TED hose removed daily.

Based on interview and record review, the facility failed to ensure slings used for mechanical lift transfers were in good repair for one resident (R87) of nine residents reviewed for falls in the sample of 28. This failure resulted in R87 falling and sustaining a left ankle fracture. Findings include: Facility policy, Washing/Care of Mechanical Lift Slings, undated, documents The slings are inspected by the laundry staff at the time they are washed. If a sling is frayed or appears to need repair, it is removed from use and given to the laundry supervisor or restorative supervisor. R87's Incident Note/Nursing Note, dated 2/1/18, documents R87 continued on post fall assessment. R87's Nursing Note, dated 2/2/18, documents R87 left the facility for an x-ray of (R87's) left ankle. On 4/27/18 V1 Administrator provided investigation documentation for R87's fall on 2/1/18. This included documentation stating Verbal counseling given to (V11 and V12/Certified Nursing Assistants) on checking slings for defects before transferring a resident. The investigation notes provided document on 2/1/18 Aides state 'We just started to lift (mechanical) from wheelchair when the strap slipped.' This investigation also documented that staff were educated on proper sling usage on 2/2/18. R87's physician progress notes [REDACTED]. On 4/27/18 at 10:49am, V11(CNA) stated that on 2-1-18 V11 and V12 hooked R87's sling to a mechanical lift and that as they began to lift it, the strap broke and R87 fell to the floor. On 4/27/18 at 12:00pm, V20 (Licensed Practical Nurse/LPN) stated that the strap of R87's sling had broken on the top left side. On 4/27/18 at 10:55am, V19 (CNA Coordinator/Laundry Supervisor/Housekeeping Supervisor) stated that laundry aides are responsible for examining slings for wear and tear; this is done prior to sling use by CNAs. V19 stated that all laundry employees are given inservices on what to do if slings are worn or damaged. On 4/27/18 at 10:55am, V19 stated that the laundry staff check to see if slings are getting worn or bad or if threads are loose; old ones are discarded. V19 stated that the sling used for R87 should have been thrown out and not used by CNAs for transfers. On 4/27/18 at 10:55am, V19 stated that on 2/1/18, V18, Laundry Aide was working. V19 said that V18 informed V19 that V18 only checked the straps attached to R87's sling but did not examine the loops. On 4/27/18 at 10:40am, R87 confirmed that the staff transferred (R87) on 2/1/18 from the wheelchair to R87's bed. R87 stated the sling the staff was using was rotten! R87 stated Ask the CNAs, they will tell you the same thing. R87 stated when R87 slipped R87 landed on the floor and xrays showed that R87's left ankle was fractured.

Based on interview and record review, the facilty failed to follow their plan of care to ensure safety alarm devices were in place to prevent falls for one of three residents (R1), reviewed for falls in a sample of three. These failures resulted in R1 falling and fracturing R1's left arm. Findings include: Facility electronic Physician order [REDACTED]. R1's Minimum Data Set (MDS), dated [DATE], documents the following: (R1) is moderately impaired; and requires extensive assistance with two person assist for transfers. R1's current careplan documents the following: (R1) is a new admit to the facility and orient to facility and surroundings; (R1) has a deficit in ADL (activities of daily living) abilities and requires staff assistance with all transfers; and (R1) is at risk for falls and will continue with a tab alarm and a pressure pad for safety. R1's facility nurses notes dated 6/16/17 at 1:50pm, 6/15/17 at 7:20pm, and 6/15/17 at 1:38am document R1 had a fall with no injuries. R1's facility skilled charting notes, dated 6/17/17 at 2:22pm, document the following: (R1) has short-term memory impairment; impaired decision making ability; confused; extensive assistance for balance; assistance with transfers; poor safety awareness; keep in high visibility area with alarm in place. R1's facility nurses notes, dated 6/17/17 at 8:02pm documents (R1) was on the floor of (R1's) room complaining of left shoulder pain. (R1) stood up and took a few steps because (R1) wanted to change (R1's) clothes. R1's incident report, dated 6/17/17 and revised 6/26/17, documents (R1) stood up from sitting in (R1's) wheelchair (which has a pressure alarm) and took a few steps. (R1) said (R1) wanted to change (R1's) clothes. It also documents R1's fall alarm is in place, and R1 has a history of falls, confusion, and gait imbalance. R1's X-Ray from local hospital, dated 6/17/17, documents R1 has a nondisplaced humeral neck fracture of left humerus. On 6/29/17 at 3:10pm, E7 Certified Nurses Aid (CNA) stated the following: (R1) was in his room in the recliner with his pressure alarm under him; the alarm is cordless and the alarm box was outside of (R1's) door when I heard it alarming; when I first saw (R1) earlier (in the night) he was in his recliner, but when I answered the alarm he was sitting at the edge of his bed; I turned off the alarm because he was at his bed and I went to take care of another resident; I did not put on his tab alarm or move his pressure alarm; and when (E8 CNA) went into (R1's) room he was on the floor. On 6/30/17 at 7:10am, E8 CNA stated the following: I had put (R1) in his room earlier in the night with his pressure pad under him; I was taking care of another resident when I heard (R1's) alarm going off but then it stopped; I knew it was (R1's) alarm because he had a distinctive ring set to his alarm; E7 CNA told me she had turned off (R1's) alarm; and the pressure pad was not under (R1) when he was in bed because it was in his recliner. 6/30/17 at 10:57am, E9 CNA stated the following: I was in with another resident when I heard (R1's) alarm going off; I know it was (R1's) alarm because it had a specific alarm; I went in to check on (R1) when I was done with my other resident and (R1) was on the floor; E7 CNA told me she had silenced (R1's) alarm; and (R1) transferred himself from his chair to his bed and then fell because the alarm wasn't under him on the bed.

Based on interview, observation and record review, the facility to provide supervision to one of four residents (R1) reviewed for falls in the sample of 24. This failure resulted in R1 sustaining a left forehead laceration from a fall that required the placement of 9 sutures at a local hospital. Findings include: 1. R1's Fall Risk Assessments dated 2/15/15, 2/19/15 and 4/3/15 document that R1 is at high risk for falls. R1's Accident/Incident Report dated 2/15/15 documents that R1 fell from R1's wheelchair and obtained a right forearm skin tear. This same report documents the following intervention was initiated: "Keep in visibility when up in wheelchair..." R1's current fall care plan has this same intervention documented. R1's Accident/Incident Report dated 4/3/15 documents that R1 had an unwitnessed fall and was observed face down on the floor at the bottom of the facility's 800 hall ramp. This same report documents that R1 sustained a laceration to R1's left forehead, and was sent to a local hospital, where R1 had sutures placed to repair the laceration. R1's local hospital emergency room records dated 4/3/15 document the following: "...presents to the emergency department with complaint of fall and forehead laceration...(R1) was in (R1's) wheelchair and fell face first out of the wheelchair...(R1) with pain to head...pain has been constant since the injury...3.5 centimeter laceration to left forehead T-shaped...nine 5-0 Nylon sutures required to close laceration..." On 4/20/15 at 9:56 a.m., 4/21/15 at 10:15 a.m., and 4/22/15 at 10:17 a.m. and 12:00 p.m., R1 was sitting alone up in R1's wheelchair in R1's room. On 4/22/15 at 10:35 a.m., E8, Restorative Nurse, verified that R1's fall on 4/3/15 was unwitnessed and therefore R1 was not in staff visibility at the time of R1's fall. E8 also stated that facility staff should not be leaving R1 sitting up in R1's wheelchair alone in R1's room. On 4/23/15 at 12:30 p.m., E1, Administrator, stated that R1's fall on 4/3/15 occurred at approximately 7:00 p.m. E1 then stated, "At this time of the evening, staff may be busy toileting or providing cares to others, so (R1) may have been out of facility staff's visibility.