Every finding on record at Peak Resources - Alamance, Inc

Based on record reviews, observations, and resident, Nurse Practitioner (NP), and staff interviews, the facility failed to provide a safe transfer for 1 of 3 residents reviewed for preventing avoidable accidents (Resident #1). On 06/19/2026 (exact time unknown), Resident #1 was in her room with Nurse Aide (NA) #1 and NA #2. NA #2 stood at the side of her bed preparing to assist with transferring. Resident #1 reported that she tried to tell NA #2 that she did not have strength in her back, that she would need the arm rail to assist with getting up, and that she could not lift her arms above her shoulders. NA #2 assured her, then wrapped her arms around Resident #1's torso and lifted her off the bed. Resident #1 stated that her feet were not touching the floor, and she told NA #2 that the action was hurting her. NA #2 reassured her again and placed her in the wheelchair. Resident #1 stated that her right arm hit the arm of the wheelchair during the transfer and was forced straight upward. Resident #1 reported feeling pain and hearing a popping sound in her arm when it was hit. She attempted to tell NA #2 what had happened but became dizzy and lightheaded and could not communicate. Resident #1 was evaluated by Nurse #1, who ordered an X ray of Resident #1's shoulder. The X ray revealed that Resident #1 had a potential fracture in her shoulder, which was confirmed during an emergency room visit on 06/20/2026. She was admitted back to the facility on [DATE] with her right arm in a sling and a prescription for hydrocodone as needed for five days.The findings included:Resident #1 was admitted to the facility on [DATE] with acute chronic diastolic congestive heart failure (a condition where the heart has difficulty relaxing and filling with blood). She also had chronic respiratory failure with hypoxia (long term trouble breathing with low oxygen levels). Her medical history included a personal history of pulmonary embolism (blood clots in the lungs), obesity, and unspecified pain. She also had polyneuropathy (nerve damage causing weakness or numbness).On 06/05/2026, a Physical Therapy Treatment Order was written for Resident #1. The order required physical therapy five times weekly for four weeks to work on therapeutic exercises, therapeutic activities, neuromuscular reeducation (helping improve balance, coordination, and movement), group or concurrent treatment, gait training (improving walking patterns, speed, and safety), and discharge planning.A review of the physical therapy evaluation and plan of treatment for the certification period 06/05/2026 through 07/04/2026 showed Resident #1 had a short term goal to improve her ability to safely transfer from lying on her back to sitting on the side of the bed with no back support, supervision, or touching assistance. At that time, she required partial to moderate assistance for lying to sitting transfers. A second short term goal stated Resident #1 would improve her ability to safely transfer to a standing position from sitting in a chair, wheelchair, or on the side of the bed, with no supervision or touching assistance and without abnormal changes in vital signs. She required partial to moderate assistance for sit to stand transfers. Resident #1's functional mobility assessment indicated she required partial to moderate assistance for sit to stand transfers. The clinical impression stated, based on examination of Resident #1's body regions, systems, and structures, she had balance deficits, decreased dynamic and static balance (difficulty maintaining balance while moving and while still), decreased functional capacity, muscle disuse atrophy (loss of muscle from inactivity), impaired postural alignment control (difficulty sitting or standing upright), proximal instability (weakness in the hips, pelvis, or trunk), and strength impairments. Considering her history, personal factors, and functional limitations, the therapist determined Resident #1 required skilled physical therapy services to analyze her gait (walking) patterns, assess functional abilities, plan discharge needs, improve independence with mobility, improve dynamic balance, increase activity tolerance, increase range of motion and strength in her left arm and leg, reduce fall risk, and improve safety awareness. Resident #1 experienced oxygen desaturation (drop in oxygen levels) during movement and needed increased recovery time afterward, even with encouragement to breathe through her nose. She was functioning below her usual baseline and would benefit from physical therapy to improve strength, mobility, and activity tolerance. A Care Plan dated 06/08/2026 identified a problem titled Plan of Care Resident Profile. The goal stated Resident #1 would have access to necessary care and services to support her quality of life and overall well being. The plan stated she required one person assistance for bed mobility, two person assistance for stand pivot transfers, and one person assistance for wheelchair mobility. This information appeared in her resident profile.Resident #1's profile in the electronic medical record (EMR) was updated on 06/08/2026 to reflect that she required one person assistance for bed mobility and two person assistance for stand pivot transfers.The admission Minimum Data Set (MDS), completed on 06/10/2026, showed Resident #1 was cognitively intact and was working with Speech Therapy, Occupational Therapy, and Physical Therapy.On 09/30/2028 at 10:51 AM, Resident #1 was interviewed and stated that, when prompted, her regular nursing assistant (NA #1) and another nursing assistant she did not know (NA #2) came to get her up for therapy. She stated that NA #2 stood at the side of her bed while NA #1 stood at the end of the bed. She reported that she tried to tell NA #2 that she did not have strength in her back, that she would need the arm rail to assist with getting up, and that she could not lift her arms above her shoulders. NA #2 told her, I've been doing this for 16 years, and I'll get you up, then wrapped her arms around Resident #1's torso and lifted her off the bed. Resident #1 stated that her feet were not touching the floor, and she told NA #2 that the action was hurting her. NA #2 told her to hang on and placed her in the wheelchair. Resident #1 stated that her right arm hit the arm of the wheelchair during the transfer and was forced straight upward. Resident #1 reported feeling pain and hearing a popping sound in her arm when it was hit. She attempted to tell NA #2 what had happened but became dizzy and lightheaded and could not communicate. Resident #1 stated the next thing she knew, she was back in bed with NA #1 and Nurse #1 next to her, and NA #2 standing at the end of the bed.On 06/30/2026 at 2:04 PM, Nurse #1 was contacted by phone but the attempt to speak with him was unsuccessful.On 06/30/2026 at 2:05 PM, NA #2 was contacted by phone but the attempt to speak with her was unsuccessful.On 07/01/2026 at 1:30 PM, NA #1 was interviewed in person and reported that she kept a coded notebook for her assignments, transfer information, and other important details. Without prompting, she began discussing Resident #1. She stated that before she could act, NA #2 had transferred Resident #1 improperly. NA #1 explained that she normally worked at Nursing Station 3, so she allowed NA #2 to take the back half of the hallway because those residents were more cognitively intact. She stated that she was assisting because Resident #1 required a two person assist. Resident #1 insisted on getting up, and NA #1 tried to persuade her to wait until it was safer; however, when the resident continued to insist, NA #1 moved to the left side of the bed to lower the mattress. As she was about to do this, NA #2 told the resident to lift her arms and wrap them around her neck. Resident #1 informed NA #2 that her arms did not lift above her shoulders. NA #2 insisted, and when the resident attempted to comply, NA #2 wrapped her arms under the resident's underarms and pulled her off the bed. NA #1 reported hearing several popping sounds and hearing the resident express pain. Once the resident was placed in her wheelchair, NA #1 went to get the nurse (Nurse #1), who assessed the resident and reported that she did not immediately send her to the hospital but ordered an X ray. NA #1 stated that she reported the incident to the Director of Nursing (DON) and Administration and wrote a statement. She added that NA #2 was terminated following the incident.A progress note written by Nurse #1 on 06/19/2026 at 3:56 PM stated Resident #1 was awake and alert in bed with no signs of acute distress. She denied any needs or complaints. She became short of breath with exertion but recovered quickly and had no shortness of breath at rest. She required one person assistance for activities of daily living (ADLs) and two person assistance for bed mobility. At 4:00 PM, another note written by Nurse #1 stated Resident #1 was in bed with a family member present and reported pain in her right shoulder and elbow. Staff noted no swelling, discoloration, or open areas. She could not perform range of motion of her right shoulder because of pain. Her family member reported she had bone fusions and very brittle bones. The family member requested X rays, and Resident #1 agreed. Staff obtained the order and notified the mobile X ray service.An Event Report written by Nurse #1 at 6:09 PM on 06/19/2026 stated Resident #1 reported unusual pain in her right shoulder and elbow. Staff administered as needed Tylenol and ordered X rays. Staff notified the Attending Physician and Resident #1's representative at 9:57 PM.A Medical Doctor (MD) progress note on 06/20/2026 at 2:00 PM stated that Resident #1 complained of severe right shoulder pain with limited range of motion (ROM), meaning she could not move her shoulder normally. She had chronic limited ROM in her right shoulder. She reported that the previous day she was moved from her bed to her wheelchair, and afterward she began experiencing pain in the right shoulder area, which was worse the next morning. An X ray was completed and showed an abnormality in her right shoulder joint with malalignment (the bones not lining up correctly) of the right humerus (the upper arm bone), which could indicate a fracture. The on call medical provider stated Resident #1 needed to be seen by orthopedics (a medical specialty that treats bone, joint, and muscle problems). The diagnostic assessment and plan stated that Resident #1 had right shoulder pain as her primary issue. The X ray showed malalignment of the right shoulder and humerus. The provider documented this as an acute new problem and noted that her condition was worsening. The provider ordered Resident #1 to be taken to the Emergency Department (ED). At 2:56 PM, a progress note stated that the X rays were completed because of her pain. The on call medical provider viewed the X rays while the technician was still in the room. The on call medical provider stated that the images showed a fracture and ordered Resident #1 to be sent to the emergency room (ER) for an orthopedic evaluation. Resident #1's family member was notified and stated she would meet Resident #1 at the ER. Emergency Medical Services (EMS) left the facility with Resident #1 at 2:45 PM.Emergency Department records dated 06/20/2026 at 3:15 PM stated Resident #1, an 89 year old woman with chronic respiratory failure, congestive heart failure, prior deep vein thrombosis (DVT), chronic kidney disease, hypertension, and high cholesterol, arrived with a suspected shoulder injury. She reported that two days earlier, during physical therapy, she had been treated roughly and then developed shoulder pain. EMS reported earlier imaging showed a shoulder fracture. Her exam showed tenderness, decreased movement, chronic bruising, and intact circulation and sensation. A new X ray showed a proximal humerus fracture. Orthopedics recommended a sling and outpatient follow up and did not feel surgery was appropriate. Resident #1 understood the plan and received pain medication.A progress note written by Nurse #1 on 06/20/2026 at 6:01 PM stated that Resident #1 returned from the Emergency Department (ED) after being evaluated for a right shoulder fracture. Resident #1 came back with her right arm in a sling and was instructed to wear it at all times. The provider also wrote an order for Hydrocodone as needed (PRN) for five days. Resident #1 received an emergency dose from the facility's emergency supply.On 07/01/2026 at 8:48 AM, the Director of Rehabilitation was interviewed in person and stated that Resident #1 was recommended to receive two person assistance with pivot turns for safety. She explained that Resident #1's biggest challenge was activity intolerance, as the resident needed a break after completing one step of a multi step task. The Director of Rehabilitation described the process for informing direct care staff of a resident's transfer status: first, an order was obtained and the resident was assessed; next, a verbal recommendation was given to the staff assigned to that resident; and finally, the information was provided to the Minimum Data Set (MDS) Nurse so the resident's profile could be updated in the electronic medical record (EMR). She added that part of direct care staff training required staff to check the resident's profile before completing any transfers.On 07/01/2026 at 2:51 PM, NP #1 was interviewed in person and stated that she was not sure what had happened because she was not in the building at the time and the on call provider had been contacted. However, she reported that she spoke with Resident #1 when the resident returned from the hospital. NP #1 stated that Resident #1 reported that NA #2 had been rough with her during a transfer. NP #1 added that she informed the Director of Nursing and the Administrator of the concern after receiving the report.On 07/01/2026 at 2:40 PM, the Administrator was interviewed and reported that the expectation for NAs was to review the resident profile in the EMR system before completing a transfer and before reporting to the floor for their shift. She stated that, after discussing the incident with NA #2, she believed the event was an accident and that NA #2 felt rushed by Resident #1, who was pressing for a transfer. The Administrator reported that NA #2 was terminated following the incident.On 07/01/2026 at 2:52 PM, the Director of Nursing was interviewed and stated that the expectation was for nursing assistants to review the resident profile prior to performing a transfer and to follow the instructions exactly as documented. She reported that NA #2 had completed the orientation process, was aware of the resident profile and transfer status, and nonetheless performed an inappropriate transfer that resulted in Resident #1 being hurt. She added that NA #2 had a brief lapse in judgment and felt pressured by the resident to complete the transfer. The facility provided the following Corrective Action Plan:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.The resident involved in the incident on 6/19/2026 was immediately assessed following the transfer after reporting shoulder pain. The physician and responsible party were notified, and the resident was transferred for further medical evaluation, which confirmed a fracture. Upon return to the facility, the resident's condition was monitored, appropriate treatment was implemented, and the resident's care plan and transfer interventions were reviewed and revised as indicated to accurately reflect the resident's current needs.The staff member involved was removed from resident care responsibilities pending investigation and was subsequently terminated for failure to follow the resident's established transfer interventions in accordance with facility policy.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 6/22/2026, the Director of Nursing (DON) and Nurse Supervisors completed a 30-day retrospective review of resident injuries requiring physician notification or hospital evaluation to determine whether any injuries may have been associated with resident transfers or failure to follow established transfer interventions. No additional injuries related to improper transfer techniques were identified.Also on 6/22/2026, the Director of Nursing (DON) and Nurse Supervisors reviewed the care plans, resident care guides, and transfer interventions for all residents requiring transfer assistance to verify that transfer requirements accurately reflected each resident's current needs. Any discrepancies identified during the review were corrected immediately.3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.The Director of Nursing and Staff Development Coordinator initiated re-education of all licensed nurses, nursing assistants, and other direct care staff on 6/20/2026. Education was completed by 6/22/2026 and included:Following each resident's individualized transfer interventions as outlined in the resident care guide and care plan.Safe transfer techniques and the importance of using the required equipment and level of assistance.Location of resident-specific transfer requirements, in the Matrix electronic medical recordThe expectation that staff review and follow resident-specific transfer interventions before providing transfer assistance.Any employee who had not completed the required education by 6/22/2026 was removed from the work schedule until the education was completed by the Staff Development Coordinator or Director of Nursing.4.Indicate how the facility plans to monitor its performance to make sure that solutions are sustainedOn 6/22/2026, the facility determined that the following monitoring process would be implemented.The Director of Nursing /designee will complete observations of resident transfers on all shifts to verify that resident-specific transfer interventions are being followed and that appropriate assistance and equipment are being utilized.Five resident transfer observations will be completed weekly for four weeks, then five resident transfer observations monthly for two months. Audit findings will be reviewed by the Director of Nursing, and any identified concerns will be addressed through immediate corrective action and additional education as needed.The results of the audits and corrective actions will be presented to the facility's quarterly Quality Assurance and Performance Improvement (QAPI) Committee meeting. Additional corrective action will be implemented immediately if concerns are identified. The committee will determine whether additional monitoring or interventions are necessary to ensure sustained compliance.The facility's alleged date of compliance is 6/23/2026.The Responsible person is Director of Nursing. The facility's corrective action plan was validated on 07/01/2026 through staff interviews and transfer observations with nurse aides and nursing staff. All observed staff were able to correctly perform safe transfers using the appropriate level of assistance and equipment. Staff demonstrated knowledge of where and how to review resident specific transfer requirements in the resident profile and were able to verbalize the expectation to review these requirements prior to assisting with any transfer. Staff also accurately described and demonstrated proper steps involved in safe transfers.Audit and monitoring tools included verification of each active resident's profile to ensure transfer status was accurate and up to date. Staff who completed the required education signed attestations for the in services delivered on 06/20/2026. Staff reported they had received the required training prior to beginning their next scheduled shift. Newly hired staff after 06/22/2026 received education during orientation regarding reviewing the resident profile prior to transfer and safe transfer practices, which was confirmed through orientation documentation and trainer verification.On 06/25/2026, Resident #1's electronic medical record (EMR) profile was updated to reflect accurate transfer requirements, including one person assist for bed mobility, two person assist with transfers using the mechanical lift, and one person assist for wheelchair mobility. On 07/01/2026, three observations of safe transfers, including a transfer involving Resident #1, were completed. Nurse Aides demonstrated understanding of Resident #1's transfer needs and followed all specified interventions correctly, safely operating the mechanical lift and performing stand pivot transfers using proper technique. All observed transfers were completed safely without causing harm.The facility was determined to be back in compliance 06/23/26.

Based on observations and staff interviews, the facility failed to discard expired medications stored in 1 of 2 medication storerooms (Station 1 Medication Storeroom), store medications in accordance with the manufacturer's instructions in 1 of 2 medication storerooms (Station 1 Medication Storeroom), and date medications as to when they were opened to allow for the determination of the shortened expiration date in 1 of 2 medication storerooms (Station 3 Medication Storeroom).The findings included:1. An observation was conducted on 3/4/26 at 11:15 AM of the Station 1 Medication Storeroom. The observation revealed the following medications were stored in the medication storeroom:a. An unopened box of Allegra D (an over-the-counter antihistamine and decongestant) containing 15 tablets was stored on the shelf of the medication storeroom. The manufacturer's expiration date of November 2025 was printed on the box containing the tablets, indicating this medication was expired.b. An opened box containing six (6) 14 milligram (mg) Nicotine Transdermal System Patches was stored on the shelf of the medication storeroom. The manufacturer's expiration date of January 2026 was printed on both the box and packaging of the individual patches, indicating the patches were expired.c. An unopened plastic case containing a 1 mg glucagon pen (an injectable medication used to treat low blood sugar) dispensed from the pharmacy on 2/11/26 for Resident #43 was observed in the medication storeroom's refrigerator. The temperature of the refrigerator was 40 degrees Fahrenheit at the time of the observation. The manufacturer's storage instructions on the label of the glucagon pen read in part, Store at controlled room temperature 20 to 25 degrees Celsius (68 to 77 degrees Fahrenheit).On 3/4/26 at 11:30 AM, the Station 1 Unit Manager reviewed the medications identified with a concern in the Station 1 Medication Storeroom. When asked, the Unit Manager reported it was her responsibility to check the storeroom to ensure the medications were not expired and stored properly. The Unit Manager was observed as she collected the identified medications for removal from the medication storeroom.An interview was conducted on 3/5/26 at 1:00 PM with the facility's Director of Nursing (DON) in the presence of the Regional Nurse Consultant. During the interview, the medication storage concerns were discussed. When asked, the DON reported that everyone (including the supervisors) was responsible for checking the medication storeroom to ensure all medications were properly stored and within date. The DON also confirmed that glucagon should not be stored in the refrigerator.2. Accompanied by Nurse #1, an observation was conducted on 3/4/26 at 11:35 AM of the Station 3 Medication Storeroom. The observation revealed the following:One (1) opened, multi-dose vial of Tuberculin PPD (Purified Protein Derivative) injectable solution (used for skin testing in the diagnosis of tuberculosis) dispensed from the pharmacy on 1/28/26 was stored in the medication storeroom refrigerator. Neither the vial nor the manufacturer box it was stored in were labeled as to when the vial had been opened to allow for the determination of its shortened expiration date.The manufacturer's storage instructions for a multi-dose vial of Tuberculin PPD (Purified Protein Derivative) injectable solution (used for skin testing in the diagnosis of tuberculosis) indicated that once opened, the product should be discarded after 30 days. When asked, Nurse #1 reported the vial of PPD solution would need to be discarded.An interview was conducted on 3/5/26 at 1:00 PM with the facility's Director of Nursing (DON) in the presence of the Regional Nurse Consultant. During the interview, the medication storage concerns were discussed. When asked, the DON reported that everyone (including the supervisors) was responsible to check the medication storeroom to ensure all medications were properly stored and within date. The DON also stated she would expect the nurse who opened a medication to date the medication on the label as to when it had been opened.

Based on record review and interviews with home health, resident, and staff, the facility failed to implement an effective discharge planning process that ensured the resident was referred for home health services prior to discharge to the community to ensure services were not delayed for 1 of 3 residents (Resident #148) reviewed for discharge.The findings included:Resident #148 was most recently readmitted to the facility on [DATE] with diagnoses that included a displaced fracture of the second right metatarsal bone [a break in the second metatarsal (the longest metatarsal or bone in the foot] where the bone fragments are misaligned), cerebral palsy (a brain disorder that permanently affects body movement and muscle coordination), and muscle weakness.A review of Resident 148's Care Plan dated 01/10/2025 revealed no information related to discharge planning.The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #148 was cognitively intact. Her Activities of Daily Living abilities were as follows: independent with eating, oral hygiene, and personal hygiene; supervision for toileting and transfers; partial to moderate assistance for bathing, lower body dressing, and footwear; and setup assistance for upper body dressing. Resident #148 was receiving physical therapy and occupational therapy services. Her overall discharge goal was to return to the community and active discharge planning was noted to already be occurring.A review of the Notice of Medicare Non-Coverage (NOMNC) form for Resident #148 revealed her last covered day in the facility was 01/25/2025. The paperwork included instructions on how to appeal the decision and what happened after an appeal. Resident #148 signed the form on 01/23/2025.The Business Office Manager was interviewed on 03/04/2026 at 8:40 AM. She reported she and her two assistants handled the provision of NOMNC forms. She explained that the business office staff spoke with the residents/responsible parties and provided written and verbal information about the last day of Medicare coverage and the appeal process. She indicated that she did not recall working with Resident #148, but reviewed the record and the NOMNC was provided to Resident #148 on 01/23/2025, with the last day of coverage being 01/25/2025. Resident #148 appealed to the discharge and remained in the facility until her appeal was declined, after which she discharged on01/31/2025. The Business Office Manager reported that the resident was responsible for charges from 01/26/2025 through 01/31/2025.A review of Resident #148's orders revealed an order dated 01/28/2025 stating Discharge Home with Home Health: physical therapy, occupational therapy, and case management services.The Occupational Therapy (OT) Discharge summary dated [DATE] for OT services from 01/08/2025 through 01/25/2025 indicated Resident #148 was admitted to the facility on [DATE] with plans to eventually return home. Prior to admission, Resident #148 lived alone in a private two-level home with one step to enter. Resident #148 participated fairly in therapy and demonstrated fair carryover of education; however, Resident #148 exhausted therapy benefits. Resident #148 would require home health occupational therapy.The Physical Therapy (PT) Discharge summary dated [DATE] for PT services from 01/08/2025 through 01/25/2025 revealed Resident #148 independently used a manual wheelchair for mobility and managed wheelchair propulsion independently. Therapists educated Resident #148 on a supportive home setup, including converting the first floor into a temporary living space, but Resident #148 declined these recommendations. Resident #148 exhausted therapy benefits and declined further treatment, and the interdisciplinary team was to coordinate a discharge that included home health physical therapy.A Nurse Practitioner (NP) note (electronically signed on 02/02/2025) documented that on 01/30/2025 the NP certified that Resident #148 was homebound and required health services due to a nondisplaced fracture of the right second metatarsal and cerebral palsy with right-sided weakness. The NP indicated follow-up with podiatry and neurology was arranged and physical therapy for gait training and occupational therapy for assistance with daily activities were ordered. The note indicated a face-to-face encounter with Resident #148 was conducted on 01/30/2025, she reviewed required home health documentation, and communicated with the home health agency.A review of progress notes from 01/07/2025 through 01/31/2025 revealed no information related to discharge planning for Resident #148.A progress note dated 01/31/2025 written by Nurse #8 indicated that Resident #148 was discharged from the facility on 01/31/2025 at 4:45PM.A review of the Discharge/Transfer Plan of Care dated 01/31/2025 completed by Previous Social Services #1 revealed Resident #148 discharged from the facility on 01/31/2025 at 2:00 PM. The discharge status was to home, and she was transported by car with a friend. Resident #148 was to be set up with home health services for occupational therapy, physical therapy, and casework management with Home Health prior to discharge.A review of a fax confirmation to Home Health from the facility revealed the referral information had been faxed on 02/01/2025, after Resident #148 was discharged from the facility. There was no evidence of a referral being sent to Home Health for Resident #148 prior to 02/01/2025.Resident #148 was interviewed by phone on 03/03/2026 at 3:16 PM. Resident #148 reported she had received a discharge notification from the facility on 01/25/2025 and appealed the decision but lost the case. She reported that she remained in the facility while the appeal was pending. Resident #148 indicated it was her decision to discharge home when the appeal was lost because she did not want to remain in the facility and accrue additional costs. She stated that the Social Worker at the facility had informed her that home health services would be arranged before she discharged home; however she didn't hear from Home Health until a few days after discharge. She explained that she was receiving home health services now. She indicated she also had friends who came over to help her with her needs at home.Previous Social Services #1 was interviewed on 03/05/2026 at 9:06 AM. She stated that the discharge planning process happened when a resident entered the facility and continued until they were discharged . Prior to discharge, services were supposed to be set up for a safe discharge and at the time of Resident #148's discharge she (Previous Social Services #1) was responsible for discharge planning. Previous Social Services #1 reported that she recalled Resident #148 and stated that it was her impression that Resident #148 was anxious but eager to return home when she was discharged . She was unable to recall specific details about this resident's discharge but reported that resident was supposed to go home with home health services.Home Health Nurse #2 was interviewed by phone on 03/04/2026 at 10:09 AM and 10:30 AM. Home Health Nurse #2 reported that the referral paperwork for Resident #148 included a home health order dated 01/28/2025. She stated that she first received the referral paperwork regarding the resident on 02/01/2025. Home Health Nurse #2 indicated that normally referrals were received prior to the resident's discharge, so they were able to obtain authorization for services. She explained that it typically took 2 days to obtain authorization. Home Health Nurse #2 reported that she first contacted Resident #148 regarding admission to services on 02/01/2025 and the authorization for care was received on 02/03/2025. She stated that on 02/04/2025, she attempted to contact the resident, but no one answered the phone, and she was unable to leave a voicemail. She further stated that on 02/05/2025, she successfully reached Resident #148, who consented to services, and she completed an introduction to services call and services were initiated.The Director of Nursing (DON) was interviewed on 03/05/2026 at 1:25 PM. She reported that she had not been the DON at that time, but she stated that she would have expected Social Services to arrange for required home health services before a resident left the facility, not afterward.The Administrator was interviewed on 03/05/2025 at 11:35 PM. She reported that she had not been the Administrator at the time, but based on her review of the record Resident #148 lost an appeal after being served a NOMNC and discharged quickly at the resident's request to avoid accruing additional care costs. The Administrator stated that it was a Friday (01/31/2025) when Resident #148 was discharged and based on her experience, Home Health services would not start until 02/03/2025 at the earliest. She provided an email showing that a referral had been sent to Home Health on Saturday 02/01/2025 around 8:30 AM.

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of urinary catheter (Resident #157) and medications (Resident #64) for 2 of 29 residents whose MDS assessments were reviewed . The findings included: 1. Resident #157 was admitted to the facility on [DATE] with diagnoses which included flaccid neuropathic (underactive) bladder. Review of the physician orders for Resident #157 revealed an order dated 7/6/25 for an indwelling urinary catheter and to provide urinary catheter care every shift. Review of the physician orders, dated 8/13/25, revealed an order for Resident #157 to discontinue use of the indwelling urinary catheter. Review of the physician orders, dated 8/13/25, revealed an order for Resident #157 to use intermittent urinary catheter as needed. Review of Resident #157's July and August 2025 Medication Administration Records (MAR) revealed nurses documented urinary catheter care every shift from 7/6/25 through 8/13/25. The quarterly MDS assessment dated [DATE] revealed Resident #157 was coded as having an indwelling urinary catheter. The quarterly MDS assessment dated [DATE], revealed Resident #157 was coded as having an indwelling urinary catheter. During an interview with MDS Coordinator #2 on 3/5/26 at 8:45 AM, she indicated that she had completed the 11/7/25 and 1/30/26 MDS assessments for Resident #157 and had coded them incorrectly. She explained at the time of the assessments, Resident #157 no longer had an indwelling urinary catheter and was receiving intermittent urinary catheterizations instead. She stated the MDS should have been coded to reflect intermittent catheterization use. During an interview on 3/5/26 at 12:30 PM the Administrator indicated the expectation was for MDS assessments to be coded accurately for each resident. 2. Resident #64 was admitted to the facility on [DATE] with a diagnosis of mood disorder, major depressive disorder and pain. The diagnosis of localized edema was added on 8/29/24. Resident #64's physician orders dated 4/8/25 included: Risperdal (an antipsychotic medication) 1 milligram (mg) one tablet by mouth once daily for mood disorder Duloxetine (an antidepressant medication) 30 mg one capsule by mouth once daily for major depressive disorder Furosemide (a diuretic medication) 20 mg tablet once daily for localized edema No orders for opioid (narcotic pain medication) medications were observed. A review of Resident #64's medication administration record (MAR) for December 2025 revealed: Risperdal 1 mg once daily for treatment of mood disorder, Duloxetine 30 mg once daily for treatment of major depressive disorder, and Lasix 20 mg once daily for treatment of localized edema had been received daily as ordered. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] completed by MDS Nurse #2 noted Resident #64 was taking medication from the drug classifications of antipsychotic, antidepressant, diuretic, and opioid. The MDS assessment did not include documented indications (identified, documented clinical rationale for administering a medication) for the use of any of these medications. During an interview with MDS Nurse #2 on 3/5/26 at 12:59PM she revealed not including the medication indications for use on Resident #64's MDS assessment dated [DATE] was an oversite. MDS Nurse #2 confirmed Resident #64 had diagnoses related to the use of antipsychotic, antidepressant, and diuretic medications and acknowledged the resident did not receive any opioid medications. MDS Nurse #2 explained that coding Resident #64 as taking an opioid medication was a mistake. The Director of Nursing was interviewed on 5/5/25 at 1:14PM, she stated she expected the MDS assessments to be coded accurately.

Based on record review and staff interview the facility's Quality Assessment Performance Improvement committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the complaint investigation completed 9/19/2023. This was a repeat deficiency in the area of supervision to prevent accidents that was originally cited on 9/19/2023. The continued failure of the facility with a repeat deficiency showed a pattern of the facility's inability to sustain an effective Quality Assessment Performance Improvement program. The findings included: This citation is cross referred to: F689: During the complaint investigation of 4/24/2024 the facility failed to prevent a fall from a mechanical lift for one of three residents reviewed for supervision to prevent accidents. During the complaint investigation of 09/19/2023 the facility failed to provide incontinent care safely for one of three residents reviewed for accidents. The Administrator was interviewed on 4/24/2024 at 11:07 AM. The Administrator stated the Quality Assessment Performance Improvement (QAPI) committee members were made up of the Administrator, Director of Nursing, Medical Director, Dietary Manager, Maintenance Director, Social Workers, Activities Director, Housekeeping Manager, Nursing Unit Managers, Infection Preventionist, Staff Development Coordinator, and the Medical Records Manager. The Administrator stated it was mandatory for all department heads to attend the QAPI meetings. The Administrator revealed she was reeducated by the Corporate Compliance Officer on the QAPI process after the fall of Resident #1 from the mechanical lift during care because the corporate office identified non-compliance with the QAPI process for accidents.

Based on record review and staff interview the facility failed to prevent a fall from a mechanical lift for one (Resident #1) of three residents reviewed for supervision to prevent accidents. Findings included: Resident #1 was admitted on [DATE] with multiple diagnoses some of which included a birth defect resulting in a cognitive and developmental disability and spinal stenosis. Documentation in a nutrition note dated 2/20/2024 revealed Resident #1 was 5 feet tall and weighed 193 pounds. Documentation in a nursing progress note for Resident #1 dated 2/20/2024 at 3:20 PM revealed, Writer notified by [Medication Aide] that resident was on floor. The Writer immediately assessed resident for injury. Resident denies pain. No [signs or symptoms] of pain. PACE (Program of All-Inclusive Care for the Elderly) notified, and order received by the Doctor. Transferred to [emergency room ]. Resident was not moved until EMS (emergency medical services) arrived and EMS transferred resident via [mechanical lift] from floor to stretcher. An interview was conducted simultaneously with the Nurse Aides (NA) #1 and NA #2 on 4/19/2024 at 11:19 AM. NA #1 explained she was the assigned nurse aide to Resident #1 on 2/20/2024 for the 7:00 AM to 3:00 PM shift. NA #1 further explained she gave Resident #1 a bath and then put a lift pad underneath her so she could be put into her wheelchair via the mechanical lift. NA #1 relayed she then asked NA #2 to come into the room to assist her in moving Resident #1 via the lift into the wheelchair. NA #2 confirmed she came into the room and assisted NA #1 to attach the straps of the lift pad to the wheelchair. NA #2 and NA #1 confirmed they put the same-colored straps on the hooks of the mechanical lift crossing the straps between the legs of Resident #1 to keep her secure. NA #1 recalled that the lift pad underneath Resident #1 was a blue pad, but she could not specifically recall the size pad she used. NA #1 stated she used the lift controls to lift Resident #1 off the bed and into the air. NA #2 stated she was holding onto the hand holds on the lift pad at the side of Resident #1 as she was being lifted into the air. NA #1 stated her hands were on the lift machine as Resident #1 was suspended in the air and kept the mechanical lift stationary. NA #2 explained she removed her hands from the hand holds on the lift pad and turned to move the wheelchair into position. NA #1 stated that Resident #1 slid to her side very quickly and slipped out of the top of the lift pad while suspended in the air. NA #1 relayed that she thought Resident #1 slid out of the top of the lift pad because she had a slippery shirt and Resident #1 was top heavy, with most of her weight on the top portion of her body. Both NA #1 and NA #2 confirmed they were retrained on all the steps in using a mechanical lift and specifically that a nurse aide needed to always be holding onto the hand holds while a resident was suspended in the air. Documentation in an emergency room discharge summary dated 2/20/2024 revealed, [Resident #1] here with pain after being dropped from lift chair. No apparent major trauma on exam. She is at her mental baseline and moving all extremities. CT (computed tomography) head/[cervical] spine reviewed and are negative. Hip (x-ray) negative. Discussed with [patient's] provider at PACE, will [discharge] with return precautions including any weakness, grip strength changes or signs of occult cord injury despite normal CT. No apparent pain on exam. Resident #1 was diagnosed with a scalp soft tissue injury or a hematoma of the scalp without any underlying skull fracture on the discharge summary. Documentation in a primary care provider assessment for an emergency room visit dated 2/20/2024 revealed Resident #1 was assessed by her physician in the emergency room after her fall from the mechanical lift. An addendum to the assessment was added by her physician on 2/22/2024 revealing Resident #1 was found to have no evident new arm motor weakness or functional change out of concern for a neck injury. Documentation in the Resident #1's care plan, dated as last reviewed on 2/22/2024 revealed the focus area for a risk for falling relative to poor balance, decreased mobility, and weakness. One of the interventions was to ensure proper position of the lift pad prior to transfer. An interview was conducted with the Director of Nursing (DON) on 4/19/2024 at 12:00 PM. The DON stated on 2/20/2024 she was not the DON at the time, but she participated in the investigation and determination of the root cause analysis of how Resident #1 fell out of the mechanical lift. The DON stated the nurse aides did a recreation of what happened after Resident #1 was assessed and sent to the emergency room . The DON revealed NA #1 and NA #2 recreated their actions using herself in the place of Resident #1. The DON stated NA #1 and NA #2 used the proper size lift pad and used appropriate techniques in using the mechanical lift except for not always keeping hold of the lift pad with the hand holds. The DON revealed NA #1 and NA #2 were reeducated on the entire process of how to transfer a resident using a mechanical lift. The DON further revealed the education was provided to not only NA #1 and NA #2 but to the entire nursing staff to include agency on the use of a mechanical lift. The DON explained the focus of the training was on how to access the resident profile for choosing the correct lift pad, making sure wheelchairs are in position before starting the process of moving the resident, obtaining a third nurse aide if needed, and always making sure at least one nurse aide was holding on to the hand holds at all times while the resident was in the air. The DON explained that a return demonstration of the use of a mechanical lift was performed by all the nursing staff after the training. The DON indicated that all the mechanical lifts and the lift pads were checked for functionality by the Maintenance Director on 2/20/2024 in addition to the training and skill demonstrations by the nursing staff by the DON. The DON revealed the staff development coordinator had been doing audits on all the units to confirm the nurse aides were using proper technique in using the mechanical lifts. An interview was conducted with the Administrator on 4/19/2024 at 12:26 PM. The Administrator stated after the fall of Resident #1 from the mechanical lift she was very concerned for Resident #1 and she spoke with the physician for Resident #1, who called her from the emergency roiagnom on [DATE]. The Administrator stated Resident #1 had a hematoma on her head but was otherwise not injured or in any pain. The facility provided the following corrective action plan with a completion date of 2/21/2024. A Plan of Correction was instituted on 2/20/2024. A root cause analysis was completed by the leadership team at Peak Resources, Alamance. The root cause analysis revealed the lift pad was positioned incorrectly during the transfer and a nurse aide let go of the hand holds on the lift pad while the resident was in the air. Resident was assessed for injury by the nursing staff, and EMS (emergency medical services) was notified, and resident was sent to the hospital for further intervention, but no significant injuries were noted. Nursing Unit Managers and SDC (Staff Development Coordinator) performed additional lift training and competency checks with CNAs (Certified Nursing Assistants) involved, signed copy of their competency check was provided by SDC. Nursing Staff Education regarding use of mechanical lift was initiated on 2/20/2024 and SDC and unit managers provided one on one training with lectures and demonstration to all nursing staff regarding proper use of the mechanical lift technique. The Maintenance staff inspected all mechanical lifts. No defects were identified. All residents that use a mechanical lift are at risk. Unit managers and SDC reviewed those resident's care profile in the electronic medical record to reassure each transfer status and correct sling color were listed. Those resident care plans were reviewed on 2/20/24 to ensure transfer status and sling colors (indicating the size) were listed correctly. Staff education was provided on a written staff education form and nursing staff meetings. Lift training/ lift safety was also completed by the SDC or designee for all new staff working in the nursing department during new hire orientation. New hires must be checked off on using the lifts correctly before being assigned to the halls. Any employee that did not receive the education will be removed from the schedule until education is completed. SDC will conduct random audits on all three shifts weekly for four weeks, monthly for four months, and then quarterly for two quarters. SDC will audit staff using mechanical lifts to ensure staff are transferring residents using proper mechanical lift technique as listed in the care plan. The findings will be reviewed at the quarterly Quality Assurance/Performance Improvement (QAPI) meetings monthly x 4 months. The QAPI team will also determine if the plan of correction needs to be continued or modified. Alleged date of compliance February 21, 2024 The Plan of Correction was validated on 4/19/2024 for the alleged date of compliance of 2/21/2024. The Quality Assessment and Performance Improvement Plan was reviewed, each intervention had corresponding documentation to support the actions taken by the facility. The facility nursing staff were educated on how to access the resident profile in the electronic record, selection of appropriate lift pad per recommended height and weight guidelines, positioning residents in the lift, and procedures for safe transfers via the mechanical lift. Nursing staff were interviewed for retention of the information provided in the training on 2/20/2024. The Nursing staff interviewed also confirmed that a return demonstration of use of a mechanical lift with a skill check off was completed in groups of three on 2/20/2024. Review of the documentation revealed mechanical lift competency checks were completed for each nurse aide and dated 2/20/2024. Quality Assurance/Performance Improvement audits were initiated the week of 2/20/2024 with observations of mechanical lift transfers for 5 residents for 4 weeks with no concerns identified. The monthly audits were ongoing. Review of Quality Assessment Performance Improvement committee meeting minutes dated 2/29/2024 revealed the audits of the mechanical lift transfers were brought to the committee meeting for review by the interdisciplinary team noting that staff education and monitoring was to continue.

Based on record review and staff and Nurse Practitioner interviews, the facility failed to provide incontinent care safely for 1 of 3 residents reviewed for accidents (Resident #1). During incontinent care provided by Nurse Aide (NA) #1, Resident #1 rolled off the bed and landed on her knees with no injuries. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses which included vascular dementia with behavioral disturbance and difficulty in walking. A physician order dated 08/19/23 indicated Resident #1 was prescribed Apixaban (a medication to prevent blood clots) 2.5 milligrams twice a day for atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had moderate cognitive impairment, required extensive assistance of one with bed mobility, toilet use, and personal hygiene. Resident #1 was coded as not having behavioral symptoms or refusal of care. The MDS indicated the resident was always incontinent of bowel and bladder. The MDS further indicated the resident had a fall in the last month, the last 2 to 6 months, and had a fracture related to a fall in the last 6 months. Review of NA #1's telephone interview transcript dated 09/01/23 revealed NA #1 asked Resident #1 to roll over, and when she started to roll, Resident #1 did not stop rolling. NA #1 was on the right side of the bottom of the bed. Resident #1 was turning to the left side of the bed. As NA #1 was walking to the left side, Resident #1 was still in the bed, but the resident kept rolling. She grabbed the resident's brief and pad and held onto her to keep her from falling out of the bed. Resident #1 slowly lowered herself to the floor with NA #1's assistance. Resident #1 was on her knees facing the bed with her chest on the bed. NA #1 stood behind her while she assisted the resident onto her back with her head resting on the wall between the bed and nightstand. During a phone interview on 09/18/23 at 1:05 PM, NA #1 reported she was in the resident's room providing care on 09/01/23. During the interview, NA #1 described the following, Resident #1 was in a good mood and was not exhibiting negative behaviors. Resident #1 needed to be changed due to having a urinary incontinence episode. NA #1 had the bed raised up to her waist height when she had just finished cleaning the resident and had put a clean brief on her while the resident was lying on her right side. While NA #1 was walking to the left side of the resident's bed, she instructed Resident #1 to roll over to the other side. Resident #1 rolled over but did not stop. She stated she lunged over the bed and held onto the resident's waist. She assisted Resident #1 onto her knees. Resident #1 was resting on her knees with her body leaning against the bed. She assisted Resident #1 onto her back because she could not stay on her knees. She called for the nurse to help assist Resident #1 back into her bed. Resident #1 did not hit her head or complain of pain. She indicated she had been in-serviced on how to properly turn and reposition the residents at the facility. A nurse progress note completed by Nurse #1 dated 09/01/23 indicated she was called into Resident #1's room by NA #1. Resident #1 was noted to be on her back on the floor beside the bed. NA #1 stated she was changing the resident and her rolling over. The resident kept on rolling out of bed onto the floor. Resident #1 was assisted back to bed. The on-call Nurse Practitioner was notified and was instructed to continue to monitor. Resident #1's Responsible Party was also notified. The investigation report of the incident dated 09/01/23 completed by Nurse #1 indicated she was called into Resident #1's room by NA #1. Resident #1 was noted to be on her back on the floor beside her bed. NA #1 stated she was changing the resident and had her roll over. Resident #1 kept on rolling out of bed onto the floor. Resident #1 was assisted back to bed by Nurse #1 and NA #1. The report indicated behaviors and medication were factors that may have contributed to the event. Review of Nurse #1's telephone interview transcript dated 09/01/23 she was notified by NA #1 at approximately 6:15 AM she needed assistance in Resident #1's room due to an assisted fall. She went into the room and found Resident #1 on the floor. NA #1 and Nurse #1 assisted the resident back into bed. During a phone interview on 09/19/23 at 9:38 AM, Nurse #1 stated she was walking down the hallway when NA #1 came to her and informed her Resident #1 was on the floor. When she went into the room, she noticed Resident #1 was lying flat on her back with her head against the wall. She stated NA #1 told her she was on the other side of the bed when Resident #1 rolled off the bed. NA #1 told her Resident #1 was on her knees and because she could not stay in the position, NA #1 assisted her to her back. She assessed Resident #1 and Resident #1 did not complain of any pain. There were no injuries noted and she assisted Resident #1 back to bed with the help of NA #1. A progress note dated 09/01/23 completed by the Nurse Practitioner indicated Resident #1 was seen due to a witnessed fall. Per report, NA #1 turned the resident to provide peri-care and the resident slid off the bed onto her knees and then leaned against the wall. NA #1 stated the resident did not hit her head. There were no injuries observed by nursing staff at the time of the fall. The resident later complained of headache and neuro checks were initiated. On exam, the resident stated she did hit her head and pointed to her forehead. There was no swelling or bruising noted to her face or changes to her range of motion. Further, there was no bruising or wounds on her body. The resident's vital signs were stable. The resident was on a blood thinning medication. Resident #1 was sent to the ER for an assessment due to the fall, headache, and being on blood thinning medication. During an interview with the Nurse Practitioner on 09/19/23 at 9:47 AM, she stated she was informed by staff Resident #1 rolled out of bed while NA #1 was providing personal care. NA #1 stated the resident did not hit her head; however, when she spoke with Resident #1, she informed her she did hit her head. She stated the resident was sent to the hospital because of Resident #1's Responsible Party's request and the resident complaining of a headache. Resident #1 returned from the hospital the same day because there were no injuries. She stated Resident #1 has schizophrenia and dementia, which caused resident to have behaviors. She stated the cause of the fall was related to the resident's behavior. Review of the emergency room Physician Note dated 09/01/23 revealed Resident #1 presented to the emergency room after sustaining a fall. She was reportedly bedbound and while she was being changed, she rolled out of bed. There was no loss of consciousness or head strike. Resident #1 reported to the triage nurse that she had a headache, but denied this complaint to the physician, instead stating that her back was hurting since her fall. The resident reported no other medical complaints. The note indicated even though there was an actively low mechanism for injury she was admitted for observation due to her age and use of anticoagulants (medications used to prevent blood clots). Computerized Tomography (CT) scans were performed on her head, chest, abdomen, pelvis, and spine. There were no acute findings of injury. She was discharged on [DATE] because she was in stable condition throughout her emergency room stay and there were no acute traumatic injuries noted on the imaging. Resident #1's care plan was updated on 09/01/23 after her return from the hospital to reflect a new intervention of Resident #1 was to have 2-person assistance with all Activities of Daily Living (ADL) care, bed mobility, and repositioning. Resident #1's care plan which was last reviewed on 09/07/23 indicated Resident #1 had a focus area of behavioral symptom in which resident's actions characterized by ineffective coping, verbal/physical aggression or combativeness related to cognition, impairment, anger, inability to perform tasks, and sundown. The goal included staff would ensure safety for resident(s) and staff. Interventions included approaching resident slowly when entering room; be cognizant of not invading resident's personal space; and help resident cope using past successful coping mechanisms. During an interview with the Director of Nursing (DON) on 09/19/23 at 3:01 PM, indicated NA #1 was aware of how to turn and reposition residents. She stated when NA #1 was providing care to Resident #1, she rolled and fell from bed to floor due to the resident's behaviors. She stated NA #1 was re-educated on safe turning and repositioning while providing care to residents. Resident #1's care plan was also changed to reflect the resident needed 2 staff members for personal care. The Administrator was interviewed on 09/19/23 at 3:39 PM. She stated they had completed an investigation on how the resident fell from the bed to the floor, and they determined that the resident rolled out of bed due to the resident rolling over prematurely. The resident was sent to the hospital out of precaution and per the resident's Responsible Party's request. The resident returned the same day because there were no injuries. NA #1 was educated on ensuring she was standing in front of the resident when the residents were being rolled.

Based on observations, staff interviews, and record review the facility failed to: 1) keep the floors of the walk-in refrigerator and walk-in freezer clean; 2) label foods in the walk-in refrigerator, reach-in refrigerator and in three of three nourishment room refrigerators; 3) ensure the food in walk-in freezer was free of ice; 4) ensure the divided plates used for the upcoming meal were clean; 5) utilize clean dollies to store cups and glasses; and 6) ensure male dietary staff (dietary cook, dietary aide #2 and # 3) had all facial hair contained in a face covering. These practices had the potential to affect food being served to residents. Finding included: 1a) An observation of the walk-in refrigerator on 8/7/23 at 6:12 AM revealed light brown colored crust on the floor under the racks containing milk. [NAME] colored fluid was observed on the floor. There were pieces of brown paper and plastic cling wrap on the floor. The floor was dirty and sticky. During an interview on 8/7/23 at 6:15 AM, the Dietary Aide #1 stated she was unsure what the brown colored crust was. She further stated the white colored fluid was milk and someone should have cleaned the floors of the refrigerator. b) An observation of the walk-in freezer on 8/7/23 at 6:18 AM revealed brown colored liquid stains on the floor. The floor was very sticky and dirty. During an interview on 8/7/23 at 6:20 AM, the Dietary Aide #1 stated she was unsure what the brown colored stains were and why the floor was sticky. During an interview on 8/9/23 at 12:10 PM, the District Dietary Manager indicated all the Dietary Aides were responsible for cleaning the walk-in refrigerator and walk-in freezer prior to the end of the shift. 2a) An observation of the reach-in refrigerator on 8/7/23 at 6:22 AM revealed an opened 46 fluid ounce (fl. oz.) carton nectar thick water with no date, two opened 32-ounce cartons Honey thick milk with no date, and two opened 46 fl. oz. carton honey thick water with no date. The reach-in refrigerator also contained a tray with 5 sandwiches wrapped in clear plastic wrap with no date. During an interview on 8/7/23 at 6:25 AM, the Dietary Aide#1 stated the thickened liquid cartons when opened should be dated with open by date. She stated she was unsure why the staff had not dated them. The Dietary Aide further stated the sandwiches were peanut butter jelly sandwiches, but unsure when they were prepared. During an interview on 8/9/23 at 3:30 PM, the District Dietary Manager stated opened thickened liquids cartons should be labeled with an open date and the carton should be discarded 7 days after opening. Review of the manufacturer's recommendations revealed thickened water can be stored in the refrigerator for 10 days and thickened milk can be stored in the refrigerator for 3 days after opening. b) An observation of the walk-in refrigerator on 8/7/23 at 6:12AM, revealed an opened plastic container containing light orange food labeled Pimento cheese- 5 pounds (5 lbs.), with no date on it. Observation also revealed a white plastic bucket, one fourth filled with strawberries and pink fluid, wrapped with cling wrap on top and dated July 4. During an interview with the Dietary Aide #1 on 8/7/23 at 6:12 AM, she stated the strawberries were frozen strawberries and usually used when pancakes were on the menu. She stated the date July 4 must be incorrect. c) Observations of three of three nourishment room refrigerators/ freezer were as follows: - On 8/7/23 at 12:52 PM observation of Nourishment room freezer at Station #3 revealed a 24-ounce Styrofoam take out cup with pink colored frozen liquid with no label or date. During an interview on 8/7/23 at 12:53 PM, Nurse #1 stated any food placed in the nourishment refrigerator/freezer should be labelled and dated. She indicated the cup was from a fast-food restaurant and must belong to a staff member. - On 8/9/23 at 2:49 PM observation of the nourishment room refrigerator at Station #1 revealed a white grocery plastic bag containing an opened 12 oz. plastic soda bottle, 2 unopened soda bottles and a white Styrofoam take out box with no label or date. The freezer contained two plastic 16 oz. cups. One contained light pink semi solid liquid (similar to a milk shake), and another contained brownish white semi solid liquid. There was no label or date on them. During the observation a staff member walked in and took the 2 cups indicating that were his and walked out of the room. During an interview on 8/9/23 at 2:52 PM, the District Dietary Manager indicated any food brought in by the resident's family members should be labeled with resident's name, room number and the date when the food was placed in the refrigerator. He further indicated facility staff should not be storing their personal food in the nourishment refrigerator. - On 8/9/23 at 2:55 PM, an observation of the nourishment room refrigerator at Station #2 revealed two plastic takeout containers containing cut fruit with resident's name and room number but no date. One plastic takeout container contained watermelon chunks, and another contained cantaloupe chunks. The containers were half filled with fruit. During an interview on 8/9/23 at 2:58 PM, the District Dietary Manager indicated any food brought in by the resident's family members should be labeled with resident's name, room number and the date when the food was placed in the refrigerator. He further indicated the food should be discarded within 7 days since placed in the refrigerator. He indicated the Dietary Manager did daily nourishment refrigerator checks to ensure the nourishment refrigerators were clean and food was label and dated. The Dietary Manager was unavailable to be interviewed. 3) An observation of the walk-in freezer on 8/7/23 at 6:18 AM revealed a brown cardboard box, half filled with nutrition supplement Magic Cup with ice cubes on them. The cups were attached to each other with large chunks of ice. Two black crates filled with nutrition supplement Magic Cup with ice on them. The cups were attached to each other with large chunk of ice. During an interview on 8/7/23 at 6:20 AM, the Dietary Aide #1 stated the nutritional supplements Magic Cups were stuck together to form a huge ice chunk and unsure why that had accumulated so much ice. The Dietary Aide #1 indicated these must have been used during the previous meal on the tray line. During an interview on 8/9/23 at 12:05 AM, the District Dietary Manager stated the ice cream cups were nutritional supplements that were used during the tray line. The nutritional supplements were stored on ice during tray line service and the staff had not removed the cups from the ice before they restored them in the walk-in freezer resulting in a huge ice block. He indicated all the nutritional supplements that formed an ice block had been discarded. The District Dietary Manager stated the staff should remove any leftover nutritional supplements from the ice and place them in a clean crate before placing them back in the freezer. 4) During the tray line observation on 8/9/23 at 12:15 PM, seven of the eleven divided plates to be used at the upcoming meal had dried food stains and black spots on them. These plates were immediately removed from the tray line and were rewashed. During an interview on 8/9/23 at 12:20 PM, the District Dietary Manager indicated Dietary Cook usually checked the plates prior to plating the food and will not serve food if the plate was not cleaned well. The District Dietary Manager stated the Dietary Aides should ensure the divided plates were clean and free of any food particles/debris prior to placing them on tray line for upcoming meals. 5) During an observation of the dishwasher on 8/9/23 at 2:20 PM, clean crates of cups and glasses were stored on dollies that were not clean. There were three dollies that had dirt and food particles on the base on which the clean crates were stored. During an interview on 8/9/23 at 2:25 PM, the District Dietary Manager stated the staff assigned for dishwashing duty should ensure the dollies were cleaned before placing any clean dishes on them. The District Dietary Manager removed the crates containing cleaned cups and glasses and ensured the staff rewashed all the dishes in the dishwasher and the dollies were cleaned prior to the clean dishes been placed on them. 6. a) An observation on 8/7/23 at 6:08 AM revealed a male Dietary Aide #2 filling coffee in carafe. The Dietary Aide had a beard and was not wearing a beard guard. During an interview on 8/7/23 at 6:10 AM, Dietary Aide #2 stated he usually wore a beard guard and not worn it today. b) An observation on 8/7/3 at 6:10 AM, revealed a male Dietary Cook, cooking residents' breakfast. The cook had a beard and was not wearing a beard guard. During an interview on 8/7/23 at 6:12 AM, the Dietary Cook stated all male staff with beard usually wore a beard guard while in kitchen. He indicated he had not worn one today. c) During the tray line observation on 8/9/23 at 12:15 PM, observed a male Dietary Aide #3 assisting on the tray line. The male aide had facial hair and was not wearing a beard guard. The District Dietary Manager who also observed it requested the male Dietary Aide #3 to wear a beard guard to cover his facial hair. Dietary Aide #3 indicated he had forgotten to wear one. During an interview on 8/9/23 at 12:15 PM, the District Dietary Manager indicated all male dietary staff should ensure their facial hair was covered with beard guards and hair covered with hair nets while working in the kitchen and assisting in meal service for the residents. During an interview on 08/10/23 03:27 PM, the Administrator indicated the refrigerator and freezer should be cleaned as scheduled. The cleaning schedule should be monitored by the Dietary Manager or designee to ensure all equipment was cleaned. All foods when opened should be labeled and dated. Foods should be discarded with in use by date on the label. The Administrator indicated the dietary staff should check the plates, cups and glasses used to serve food and used in meal service for residents prior to tray line service to ensure all of them were clean. The Administrator stated Nourishments refrigerators were to be used for resident food only and staff should not be using them for their personal food. All foods should be labeled with resident name and room number and dated. Related to the use of beard guard to cover facial hair the Administrator indicated all hair should be appropriately covered when working in the dietary department especially facial hair.

Based on record review and staff interview, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours a day for 1 out of 121 days reviewed for staffing (2/4/2023). Findings included: The daily assignment sheets were reviewed from January1, 2023 through March 31,2023 and July 7, 2023, through August 8, 2023, it revealed that on 2/4/23 there was no RN assigned to work in the facility. Record review of the daily nurse staffing hours from February 1 to February 28, 2023 revealed that 8 RN hours were assigned on 2/4/23; this did not match the daily assignment sheet provided. An interview and record review of the 2/4/23 staff assignment sheet and the daily nursing department staffing form with the Director of Nursing (DON) on 08/09/23 at 2:56 PM revealed that a RN was documented on the daily staffing hours and there was no RN assigned on the staff assignment sheet. She stated in the past the scheduler was responsible to confirm an RN was assigned 8 hours each day. There was currently no scheduler, and she was responsible for nursing staff assignments. The scheduler was not available by phone. On 8/10/23 at 1:30 PM the Administrator stated that there was no RN coverage for 2/4/23. The scheduler had made an error and it was an oversight. Since that time another RN was hired and there was RN coverage daily. An interview on 8/11/23 at 10:50AM the Staff Development Coordinator indicated that she was a new employee and setting up her office on 2/4/23 and had no idea how to supervise in the facility.

Based on staff interviews and record reviews, the facility failed to develop a comprehensive person-centered activity care plan that included individualized goals and approaches for 5 of 5 cognitively impaired residents that needed assistance with activities (Resident #30, #55, #66, #67 and #99). The findings included: 1. Resident #30 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Review of the activity assessment dated [DATE], revealed resident preference in group activities with interest in exercise/sports, music, trips, shopping, outdoor activities, current events, movies, plays/theatre and dining out. The quarterly Minimum Data Set ((MDS) dated [DATE], coded Resident #30's cognition was impaired and needed assistance with activities. Review of the activity assessment dated [DATE], revealed resident preference in group activities with interest in exercise/sports, music, trips, shopping, outdoor activities, current events, movies, plays/theatre and dining out. Review of the care plan dated 1/10/19, identified the problem as Resident #30 at times would disrupt activities by talking loudly, demands things, or becomes anxious/aggravated. The goal included resident would sit through an activity without any outburst once weekly. The approaches included offer 1:1 assistance to resident to help keep resident calm. Praise resident when resident has sat through an activity without an outburst and stop activities if resident seems to get aggravated. During an interview on 2/7/19 at 11:33 AM, the Minimum Data Set (MDS) Nurse stated the expectation was for all departments to ensure residents care plan were resident specific /person center to resident needs with measurable goals and approaches. The care plan should be updated quarterly and annually to represent resident changes/progress and discontinued when appropriate. Resident #30's activity care plan with the MDS nurse she stated the resident's care plan was a standard plan for all residents and it was not person-center or resident specific based on resident assessment or activities of interest. During an interview on 2/7/19 at 11:45 AM, the Administrator stated the expectation was to review the entire care plans for current resident issues with measurable goals and approaches to include resident specific areas and person centered. The care plans should be updated quarterly/annually for accuracy of service needed and/or discontinued. Review of the activities care plans revealed the goals did not reflect the resident assessments nor did they have measurable goals or approaches. 2. Resident #55 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Review of the activity assessment dated [DATE], revealed resident preference in small group activities with interest in crafts, art, music, spiritual, religious activities, gardening/plants, animals/pets, current events, drawing/painting, movies, poetry and radio. Focused activities included 1:1 activity, creative/expressive activities, community outings, intellectually stimulating activities, religious/relaxation activities, talk-orientation activities and social interaction activities. The quarterly Minimum Data Set ((MDS) dated [DATE], coded Resident #55's cognition was impaired and needed assistance with activities. Review of the resident's care plan dated 1/10/19, included a problem that specified Resident #55 required extensive assistance in activities related to memory related to dementia. The goal included resident would be able to remember and complete a simple activity task three times a week. The approaches included encourage resident to participate in activities of interest such as watching others dance, watching television, socializing, eat out, current events and dance/music, modify approaches according to residents' ability and response to levels during activities, remind and assist resident to/from and during activities and simplify and breakdown task to encourage resident participation in activities. During an interview on 2/7/19 at 11:33 AM, the Minimum Data Set (MDS) Nurse stated the expectation was for all departments to ensure resident care plans were resident specific /person center to resident needs with measurable goals and approaches. The care plan should be updated quarterly and annually to represent resident changes/progress and discontinued when appropriate. When Resident #55's activity care plan was reviewed with the MDS nurse she stated the resident's care plan was a standard plan for all residents and it was not person-center or resident specific based on resident assessment or activities of interest. During an interview on 2/7/19 at 11:45 AM, the Administrator stated the expectation was to review the entire care plans for current resident issues with measurable goals and approaches to include resident specific areas and person centered. The care plans should be updated quarterly/annually for accuracy of service needed and/or discontinued. Review of the activities care plans revealed the goals did not reflect the resident assessments nor did they have measurable goals or approaches. 3. Resident #66 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the activity assessment dated [DATE], revealed resident preference in small group activities and 1:1, with interest in exercise, sports, music, reading/writing, spiritual, religious activities, gardening/plants, animals/pets, current events, drawing/painting, movies, woodworking and outdoor games. Focused activities included 1:1 activity, creative/expressive activities, community outings, intellectually stimulating activities, religious/relaxation activities, talk-orientation activities and social interaction activities. The annual Minimum Data Set ((MDS) dated [DATE], coded Resident #66's cognition was impaired and needed assistance with activities. Review of the resident's care plan dated 1/25/19, included a problem that specified Resident #66 required extensive assistance in activities related to memory related to dementia. The goal included resident would be able to remember and complete a simple activity task three times a week. The approaches included encourage resident to participate in activities of interest such as watching others dance, watching television, socializing, eat out, current events and dance/music, modify approaches according to residents ' ability and response to levels during activities, remind and assist resident to/from and during activities and simplify and breakdown task to encourage resident participation in activities. During an interview on 2/7/19 at 11:33 AM, the Minimum Data Set (MDS) Nurse stated the expectation was for all departments to ensure resident care plans were resident specific /person center to resident needs with measurable goals and approaches. The care plan should be updated quarterly and annually to represent resident changes/progress and discontinued when appropriate. When Resident #55's activity care plan was reviewed with the MDS nurse she stated the resident's care plan was a standard plan for all residents and it was not person-center or resident specific based on resident assessment or activities of interest. During an interview on 2/7/19 at 11:45 AM, the Administrator stated the expectation was to review the entire care plans for current resident issues with measurable goals and approaches to include resident specific areas and person centered. The care plans should be updated quarterly/annually for accuracy of service needed and/or discontinued. Review of the activities care plans revealed the goals did not reflect the resident assessments nor did they have measurable goals or approaches. 4. Resident #67 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], specified Resident #67's cognition was impaired and needed assistance with activities. Review of the activity assessment dated [DATE], revealed resident preference in small group activities with interest in crafts, art, music, spiritual, religious activities, gardening/plants, animals/pets, current events, drawing/painting, movies, poetry, wood working, word games and radio. Focused activities included 1:1 activity, creative/expressive activities, community outings, intellectually stimulating activities, religious/relaxation activities, talk-orientation activities and social interaction activities. Review of the resident's care plan dated 1/28/19, included a problem that specified Resident #67 required extensive assistance in activities related to memory related to dementia. The goal included resident would be able to remember and complete a simple activity task three times a week. The approaches included encourage resident to participate in activities of interest such as watching others dance, watching television, socializing, eat out, current events and dance/music, modify approaches according to residents' ability and response to levels during activities, remind and assist resident to/from and during activities and simplify and breakdown task to encourage resident participation in activities. During an interview on 2/7/19 at 11:33 AM, the Minimum Data Set (MDS) Nurse stated the expectation was for all departments to ensure resident care plans were resident specific /person center to resident needs with measurable goals and approaches. The care plan should be updated quarterly and annually to represent resident changes/progress and discontinued when appropriate. When Resident #55's activity care plan was reviewed with the MDS nurse she stated the resident's care plan was a standard plan for all residents and it was not person-center or resident specific based on resident assessment or activities of interest. During an interview on 2/7/19 at 11:45 AM, the Administrator stated the expectation was to review the entire care plans for current resident issues with measurable goals and approaches to include resident specific areas and person centered. The care plans should be updated quarterly/annually for accuracy of service needed and/or discontinued. Review of the activities care plans revealed the goals did not reflect the resident assessments nor did they have measurable goals or approaches. 5. Resident #99 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], coded Resident #99's cognition was impaired and needed assistance with activities. Review of the activity assessment dated [DATE], revealed resident preference in small group activities and 1:1 with interest in card/board/games music, spiritual, religious activities, gardening/plants, animals/pets, current events, drawing/painting, movies, plays/theatre and coloring. Focused activities included 1:1 activity, creative/expressive activities, community outings, intellectually stimulating activities, religious/relaxation activities, talk-orientation activities and social interaction activities. Review of the resident's care plan dated 1/28/19, included a problem that specified Resident #99 required extensive assistance in activities. Resident enjoys bingo and music. The goal included resident would be able to remember and complete a simple activity task three times a week. The approaches included encourage resident to participate in activities of interest such as watching others dance, watching television, socializing, eat out, current events and dance/music, modify approaches according to residents' ability and response to levels during activities, remind and assist resident to/from and during activities and simplify and breakdown task to encourage resident participation in activities. During an interview on 2/7/19 at 11:33 AM, the Minimum Data Set (MDS) Nurse stated the expectation was for all departments to ensure resident care plans were resident specific /person center to resident needs with measurable goals and approaches. The care plan should be updated quarterly and annually to represent resident changes/progress and discontinued when appropriate. When Resident #55's activity care plan was reviewed with the MDS nurse she stated the resident's care plan was a standard plan for all residents and it was not person-center or resident specific based on resident assessment or activities of interest. During an interview on 2/7/19 at 11:45 AM, the Administrator stated the expectation was to review the entire care plans for current resident issues with measurable goals and approaches to include resident specific areas and person centered. The care plans should be updated quarterly/annually for accuracy of service needed and/or discontinued. Review of the activities care plans revealed the goals did not reflect the resident assessments nor did they have measurable goals or approaches.

Based on observations, staff interview and record review, the facility failed to provide an on-going activity program as scheduled and that met the individual interest and needs to enhance the quality of life for 5 of 5 cognitively impaired residents reviewed for activities (Residents #30, #55, #66, #67 and #99). The findings included: 1. Resident #30 was admitted to the facility on [DATE] and resided on the facility's 200 hallway. The resident's [DIAGNOSES REDACTED]. Resident #30 was coded on the quarterly Minimum Data Set ((MDS) dated [DATE], as having impaired cognition and he needed assistance with activities. Review of the activity assessment dated [DATE], revealed resident preference in group activities with interest in exercise/sports, music, trips, shopping, outdoor activities, current events, movies, plays/theatre and dining out. Review of Resident #30's care plan dated 1/10/19, specified the resident would at times would disrupt activities by talking loudly, demanding things, or becoming anxious/aggravated. The goal included resident would sit through an activity without any outburst once weekly without any outburst. The approaches included offer 1:1 assistance to resident to help keep resident calm. Praise resident when resident has sat through an activity without an outburst and stop activities if resident seems to get aggravated. During an interview with Resident #30 on 2/4/19 at 10:00 AM he reported being interested in music, sports, bingo, church and fun stuff. Review of the facility's activity calendar revealed the following activities were scheduled for 02/04/19: 10:00 AM coffee club, 3:00 PM Bingo and in room visits (no designated time frame) Observations of Resident #30 on 2/4/19 at 10:00 AM and at 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. Review of the facility's activity calendar revealed the following activities were scheduled for 02/05/19: 10:00 AM coffee club, 10:30 AM fancy fingers, 2:00 PM kingdom Hall and 3:00 PM volunteer's name (no description). Observations of Resident #30 on 2/5/19 at 10:00 AM, 10:30 AM, 2:00 PM and 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. During an interview on 2/6/19 at 11:27 AM, Nursing Assistant (NA) #2, who worked on the facility's 200 hallway, stated the expectation was for staff to get all residents up, ready for the activities and to take them to the scheduled activity and/or the main dining room if there were schedule activities. NA #2 indicated she had not taken any of the residents from the 200 hall to any of the scheduled activities that were scheduled to take place off the 200 hallway. During an interview on 2/6/19 at 11:29 AM, NA#3, who worked on the facility's 200 hallway, stated once the residents were bathed and dressed they were to be taken to the activity room on the 200 hallway for coffee and then to other activities. NA#3 stated she had taken residents to the activity room, but she was uncertain whether the activity took place and she had not taken any residents to any other activities that were scheduled. NA #3 stated the activities staff was responsible for doing the activity and NAs were responsible to assist with taking residents to the activities when available. During an interview on 2/6/19 at 11:40 AM, NA #4, who worked on the facility's 200 hallway, stated once residents were groomed and dressed in the morning they were to be taken to the 200 hallway activity room to watch television. NA #4 further stated the activities staff were expected to provide the scheduled activities and the NA staff were expected to assist with taking residents to the activities when we can. During an interview on 2/6/19 at 11:43 AM, NA #5, who worked on the facility's 200 hallway, stated the expectation of the NA staff was to ensure in the mornings the residents on the 200 hallway were up, dressed and ready for activities. NA #5 further explained the NA staff was expected to take residents to the 200 hallway activity room by 10:00 AM, for the scheduled coffee club activity and aides were to assist with taking residents to other activities in the facility when available. NA #5 stated the activity staff were expected to run the activities that was scheduled. During an interview on 2/6/19 at 11:07 AM, the Activities Director (AD) indicated she was unaware the activities scheduled for the 200 hallway on 2/4/19 and 2/5/19 did not occur as scheduled and residents on the 200-hall area were not encouraged or offered participation in the scheduled activities that took place off the facility's 200 hallway. She further stated she did not have a system in place to ensure the cognitively impaired residents, including Resident #30, received or attended activities. The AD added the expectation was for the nurse aides to assist and bring residents to the activities. The AD reviewed several months of the scheduled activities and stated the current activities program does not incorporate residents with cognitive impairments. The AD stated the expectation was for her to document quarterly on resident participation and progress. The AD stated she did not have a system in place to ensure participation records and documentation were current. During an interview on 2/7/19 at 8:17 AM, the Administrator stated the expectation was for the activities staff to run the activities program as planned. In addition, all staff was expected to encourage resident participation and assist with taking residents to the activities. Review of the facility's activities calendar with the administrator revealed the scheduled daily activities did not always address the needs of residents with dementia or cognitive impairments. Additional, review of the activities progress notes revealed insufficient documentation of resident participation was incomplete for at least a year or more. The Administrator stated the expectation would be for the activities staff to document resident participation and document quarterly. 2. Resident #55 was admitted to the facility on [DATE] and resided on the facility's 200 hallway. The resident's [DIAGNOSES REDACTED]. Resident #55's quarterly Minimum Data Set ((MDS) dated [DATE], coded the resident's cognition as impaired and needed assistance with activities. Review of the resident's care plan dated 1/10/19, included a problem that specified Resident #55 required extensive assistance in activities related to memory related to dementia. The goal included resident would be able to remember and complete a simple activity task three times a week. The approaches included encourage resident to participate in activities of interest such as watching others dance, watching television, socializing, eat out, current events and dance/music, modify approaches according to residents' ability and response to levels during activities, remind and assist resident to/from and during activities and simplify and breakdown task to encourage resident participation in activities. During an interview with Resident #55 on 2/4/19 at 10:05 AM the resident reported interest in music, flowers, art and dancing. Review of the facility's activity calendar revealed the following activities were scheduled for 02/04/19: 10:00 AM coffee club, 3:00 PM Bingo and in room visits (no designated time frame). Observations of Resident #55 on 2/4/19 at 10:00 AM and at 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. Review of the facility's activity calendar revealed the following activities were scheduled for 02/05/19: 10:00 AM coffee club, 10:30 AM fancy fingers, 2:00 PM kingdom Hall and 3:00 PM volunteer's name (no description). Observations of Resident #55 on 2/5/19 at 10:00 AM, 10:30 AM, 2:00 PM and 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. During an interview on 2/6/19 at 11:27 AM, Nursing Assistant (NA) #2, who worked on the facility's 200 hallway, stated the expectation was for staff to get all residents up, ready for the activities and to take them to the scheduled activity and/or the main dining room if there were schedule activities. NA #2 indicated she had not taken any of the residents from the 200 hall to any of the scheduled activities that were scheduled to take place off the 200 hallway. During an interview on 2/6/19 at 11:29 AM, NA#3, who worked on the facility's 200 hallway, stated once the residents were bathed and dressed they were to be taken to the activity room on the 200 hallway for coffee and then to other activities. NA#3 stated she had taken residents to the activity room, but she was uncertain whether the activity took place and she had not taken any residents to any other activities that were scheduled. NA #3 stated the activities staff was responsible for doing the activity and NAs were responsible to assist with taking residents to the activities when available. During an interview on 2/6/19 at 11:40 AM, NA #4, who worked on the facility's 200 hallway, stated once residents were groomed and dressed in the morning they were to be taken to the 200 hallway activity room to watch television. NA #4 further stated the activities staff were expected to provide the scheduled activities and the NA staff were expected to assist with taking residents to the activities when we can. During an interview on 2/6/19 at 11:43 AM, NA #5, who worked on the facility's 200 hallway, stated the expectation of the NA staff was to ensure in the mornings the residents on the 200 hallway were up, dressed and ready for activities. NA #5 further explained the NA staff was expected to take residents to the 200 hallway activity room by 10:00 AM, for the scheduled coffee club activity and aides were to assist with taking residents to other activities in the facility when available. NA #5 stated the activity staff were expected to run the activities that was scheduled. During an interview on 2/6/19 at 11:07 AM, the Activities Director (AD) indicated she was unaware the activities scheduled for the 200 hallway on 2/4/19 and 2/5/19 did not occur as scheduled and residents on the 200 hall area were not encouraged or offered participation in the scheduled activities that took place off the facility's 200 hallway. She further stated she did not have a system in place to ensure the cognitively impaired residents, including Resident #55, received or attended activities. The AD added the expectation was for the nurse aides to assist and bring residents to the activities. The AD reviewed several months of the scheduled activities and stated the current activities program does not incorporate residents with cognitive impairments. The AD stated the expectation was for her to document quarterly on resident participation and progress. The AD stated she did not have a system in place to ensure participation records and documentation were current. During an interview on 2/7/19 at 8:17 AM, the Administrator stated the expectation was for the activities staff to run the activities program as planned. In addition, all staff was expected to encourage resident participation and assist with taking residents to the activities. Review of the facility's activities calendar with the administrator revealed the scheduled daily activities did not always address the needs of residents with dementia or cognitive impairments. Additional, review of the activities progress notes revealed insufficient documentation of resident participation was incomplete for at least a year or more. The Administrator stated the expectation would be for the activities staff to document resident participation and document quarterly. 3. Resident #66 was admitted to the facility on [DATE] and resided on the facility's 200 hallway. The resident's [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], coded Resident #66's cognition as impaired and needed assistance with activities. Review of the resident's care plan dated 1/25/19, included a problem that specified Resident #66 required extensive assistance in activities related to memory related to dementia. The goal included resident would be able to remember and complete a simple activity task three times a week. The approaches included encourage resident to participate in activities of interest such as watching others dance, watching television, socializing, eat out, current events and dance/music, modify approaches according to residents' ability and response to levels during activities, remind and assist resident to/from and during activities and simplify and breakdown task to encourage resident participation in activities. During an interview with Resident #66 on 2/4/19 at 10:00 AM, he reported interest in music, church, writing and woodwork. Review of the facility's activity calendar revealed the following activities were scheduled for 02/04/19: 10:00 AM coffee club, 3:00 PM Bingo and in room visits (no designated time frame). Observations of Resident #66 on 2/4/19 at 10:00 AM and at 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. Review of the facility's activity calendar revealed the following activities were scheduled for 02/05/19: 10:00 AM coffee club, 10:30 AM fancy fingers, 2:00 PM kingdom Hall and 3:00 PM volunteer's name (no description). Observations of Resident #66 on 2/5/19 at 10:00 AM, 10:30 AM, 2:00 PM and 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. During an interview on 2/6/19 at 11:27 AM, Nursing Assistant (NA) #2, who worked on the facility's 200 hallway, stated the expectation was for staff to get all residents up, ready for the activities and to take them to the scheduled activity and/or the main dining room if there were schedule activities. NA #2 indicated she had not taken any of the residents from the 200 hall to any of the scheduled activities that were scheduled to take place off the 200 hallway. During an interview on 2/6/19 at 11:29 AM, NA#3, who worked on the facility's 200 hallway, stated once the residents were bathed and dressed they were to be taken to the activity room on the 200 hallway for coffee and then to other activities. NA#3 stated she had taken residents to the activity room, but she was uncertain whether the activity took place and she had not taken any residents to any other activities that were scheduled. NA #3 stated the activities staff was responsible for doing the activity and NAs were responsible to assist with taking residents to the activities when available. During an interview on 2/6/19 at 11:40 AM, NA #4, who worked on the facility's 200 hallway, stated once residents were groomed and dressed in the morning they were to be taken to the 200 hallway activity room to watch television. NA #4 further stated the activities staff were expected to provide the scheduled activities and the NA staff were expected to assist with taking residents to the activities when we can. During an interview on 2/6/19 at 11:43 AM, NA #5, who worked on the facility's 200 hallway, stated the expectation of the NA staff was to ensure in the mornings the residents on the 200 hallway were up, dressed and ready for activities. NA #5 further explained the NA staff was expected to take residents to the 200 hallway activity room by 10:00 AM, for the scheduled coffee club activity and aides were to assist with taking residents to other activities in the facility when available. NA #5 stated the activity staff were expected to run the activities that was scheduled. During an interview on 2/6/19 at 11:07 AM, the Activities Director (AD) indicated she was unaware the activities scheduled for the 200 hallway on 2/4/19 and 2/5/19 did not occur as scheduled and residents on the 200-hall area were not encouraged or offered participation in the scheduled activities that took place off the facility's 200 hallway. She further stated she did not have a system in place to ensure the cognitively impaired residents, including Resident #66, received or attended activities. The AD added the expectation was for the nurse aides to assist and bring residents to the activities. The AD reviewed several months of the scheduled activities and stated the current activities program does not incorporate residents with cognitive impairments. The AD stated the expectation was for her to document quarterly on resident participation and progress. The AD stated she did not have a system in place to ensure participation records and documentation were current. During an interview on 2/7/19 at 8:17 AM, the Administrator stated the expectation was for the activities staff to run the activities program as planned. In addition, all staff was expected to encourage resident participation and assist with taking residents to the activities. Review of the facility's activities calendar with the administrator revealed the scheduled daily activities did not always address the needs of residents with dementia or cognitive impairments. Additional, review of the activities progress notes revealed insufficient documentation of resident participation was incomplete for at least a year or more. The Administrator stated the expectation would be for the activities staff to document resident participation and document quarterly. 4. Resident #67 was admitted to the facility on [DATE] and resided on the facility's 200 hallway. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], coded Resident #67's cognition as impaired and needed assistance with activities. Review of the resident's care plan dated 1/28/19, included a problem that specified Resident #67 required extensive assistance in activities related to memory related to dementia. The goal included resident would be able to remember and complete a simple activity task three times a week. The approaches included encourage resident to participate in activities of interest such as watching others dance, watching television, socializing, eat out, current events and dance/music, modify approaches according to residents' ability and response to levels during activities, remind and assist resident to/from and during activities and simplify and breakdown task to encourage resident participation in activities. Review of the facility's activity calendar revealed the following activities were scheduled for 02/04/19: 10:00 AM coffee club, 3:00 PM Bingo and in room visits (no designated time frame). Observations of Resident #67 on 2/4/19 at 10:00 AM and at 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. Review of the facility's activity calendar revealed the following activities were scheduled for 02/05/19: 10:00 AM coffee club, 10:30 AM fancy fingers, 2:00 PM kingdom Hall and 3:00 PM volunteer's name (no description). Observations of Resident #67 on 2/5/19 at 10:00 AM, 10:30 AM, 2:00 PM and 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. During an interview on 2/6/19 at 11:27 AM, Nursing Assistant (NA) #2, who worked on the facility's 200 hallway, stated the expectation was for staff to get all residents up, ready for the activities and to take them to the scheduled activity and/or the main dining room if there were schedule activities. NA #2 indicated she had not taken any of the residents from the 200 hall to any of the scheduled activities that were scheduled to take place off the 200 hallway. During an interview on 2/6/19 at 11:29 AM, NA#3, who worked on the facility's 200 hallway, stated once the residents were bathed and dressed they were to be taken to the activity room on the 200 hallway for coffee and then to other activities. NA#3 stated she had taken residents to the activity room, but she was uncertain whether the activity took place and she had not taken any residents to any other activities that were scheduled. NA #3 stated the activities staff was responsible for doing the activity and NAs were responsible to assist with taking residents to the activities when available. During an interview on 2/6/19 at 11:40 AM, NA #4, who worked on the facility's 200 hallway, stated once residents were groomed and dressed in the morning they were to be taken to the 200 hallway activity room to watch television. NA #4 further stated the activities staff were expected to provide the scheduled activities and the NA staff were expected to assist with taking residents to the activities when we can. During an interview on 2/6/19 at 11:43 AM, NA #5, who worked on the facility's 200 hallway, stated the expectation of the NA staff was to ensure in the mornings the residents on the 200 hallway were up, dressed and ready for activities. NA #5 further explained the NA staff was expected to take residents to the 200 hallway activity room by 10:00 AM, for the scheduled coffee club activity and aides were to assist with taking residents to other activities in the facility when available. NA #5 stated the activity staff were expected to run the activities that was scheduled. During an interview on 2/6/19 at 11:07 AM, the Activities Director (AD) indicated she was unaware the activities scheduled for the 200 hallway on 2/4/19 and 2/5/19 did not occur as scheduled and residents on the 200-hall area were not encouraged or offered participation in the scheduled activities that took place off the facility's 200 hallway. She further stated she did not have a system in place to ensure the cognitively impaired residents, including Resident #67, received or attended activities. The AD added the expectation was for the nurse aides to assist and bring residents to the activities. The AD reviewed several months of the scheduled activities and stated the current activities program does not incorporate residents with cognitive impairments. The AD stated the expectation was for her to document quarterly on resident participation and progress. The AD stated she did not have a system in place to ensure participation records and documentation were current. During an interview on 2/7/19 at 8:17 AM, the Administrator stated the expectation was for the activities staff to run the activities program as planned. In addition, all staff was expected to encourage resident participation and assist with taking residents to the activities. Review of the facility's activities calendar with the administrator revealed the scheduled daily activities did not always address the needs of residents with dementia or cognitive impairments. Additional, review of the activities progress notes revealed insufficient documentation of resident participation was incomplete for at least a year or more. The Administrator stated the expectation would be for the activities staff to document resident participation and document quarterly. 5. Resident #99 was admitted to the facility on [DATE] and resided on the facility's 200 hallway. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], coded Resident #99's cognition as impaired and needed assistance with activities. Review of the resident's care plan dated 1/28/19, included a problem that specified Resident #99 required extensive assistance in activities. Resident enjoys bingo and music. The care plan goal included resident would be able to remember and complete a simple activity task three times a week. The approaches included encourage resident to participate in activities of interest such as watching others dance, watching television, socializing, eat out, current events and dance/music, modify approaches according to residents' ability and response to levels during activities, remind and assist resident to/from and during activities and simplify and breakdown task to encourage resident participation in activities. Review of the facility's activity calendar revealed the following activities were scheduled for 02/04/19: 10:00 AM coffee club, 3:00 PM Bingo and in room visits (no designated time frame). Observations of Resident #99 on 2/4/19 at 10:00 AM and at 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. Review of the facility's activity calendar revealed the following activities were scheduled for 02/05/19: 10:00 AM coffee club, 10:30 AM fancy fingers, 2:00 PM kingdom Hall and 3:00 PM volunteer's name (no description). Observations of Resident #99 on 2/5/19 at 10:00 AM, 10:30 AM, 2:00 PM and 3:00 PM revealed he was in the 200 hallway activity room not engaged in any activity and not participating in the activities that were scheduled at these times on the activity calendar. During an interview on 2/6/19 at 11:27 AM, Nursing Assistant (NA) #2, who worked on the facility's 200 hallway, stated the expectation was for staff to get all residents up, ready for the activities and to take them to the scheduled activity and/or the main dining room if there were schedule activities. NA #2 indicated she had not taken any of the residents from the 200 hall to any of the scheduled activities that were scheduled to take place off the 200 hallway. During an interview on 2/6/19 at 11:29 AM, NA#3, who worked on the facility's 200 hallway, stated once the residents were bathed and dressed they were to be taken to the activity room on the 200 hallway for coffee and then to other activities. NA#3 stated she had taken residents to the activity room, but she was uncertain whether the activity took place and she had not taken any residents to any other activities that were scheduled. NA #3 stated the activities staff was responsible for doing the activity and NAs were responsible to assist with taking residents to the activities when available. During an interview on 2/6/19 at 11:40 AM, NA #4, who worked on the facility's 200 hallway, stated once residents were groomed and dressed in the morning they were to be taken to the 200 hallway activity room to watch television. NA #4 further stated the activities staff were expected to provide the scheduled activities and the NA staff were expected to assist with taking residents to the activities when we can. During an interview on 2/6/19 at 11:43 AM, NA #5, who worked on the facility's 200 hallway, stated the expectation of the NA staff was to ensure in the mornings the residents on the 200 hallway were up, dressed and ready for activities. NA #5 further explained the NA staff was expected to take residents to the 200 hallway activity room by 10:00 AM, for the scheduled coffee club activity and aides were to assist with taking residents to other activities in the facility when available. NA #5 stated the activity staff were expected to run the activities that was scheduled. During an interview on 2/6/19 at 11:07 AM, the Activities Director (AD) indicated she was unaware the activities scheduled for the 200 hallway on 2/4/19 and 2/5/19 did not occur as scheduled and residents on the 200-hall area were not encouraged or offered participation in the scheduled activities that took place off the facility's 200 hallway. She further stated she did not have a system in place to ensure the cognitively impaired residents, including Resident #99, received or attended activities. The AD added the expectation was for the nurse aides to assist and bring residents to the activities. The AD reviewed several months of the scheduled activities and stated the current activities program does not incorporate residents with cognitive impairments. The AD stated the expectation was for her to document quarterly on resident participation and progress. The AD stated she did not have a system in place to ensure participation records and documentation were current. During an interview on 2/7/19 at 8:17 AM, the Administrator stated the expectation was for the activities staff to run the activities program as planned. In addition, all staff was expected to encourage resident participation and assist with taking residents to the activities. Review of the facility's activities calendar with the administrator revealed the scheduled daily activities did not always address the needs of residents with dementia or cognitive impairments. Additional, review of the activities progress notes revealed insufficient documentation of resident participation was incomplete for at least a year or more. The Administrator stated the expectation would be for the activities staff to document resident participation and document quarterly.

Based on observations, staff interviews and record reviews, the facility failed to keep a resident's urinary catheter drainage bag from touching the floor for 1 of 1 sampled residents with an indwelling urinary catheter (Resident #55). The findings included: Resident #55 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED].#55 had cognitive impairments and required total assistance with activities of daily living. Review of the care plan dated 1/10/19 identified the problem as Resident #55 has potential for urinary tract infection [MEDICAL CONDITION] related to the history of urinary tract infection, and the use of an indwelling urinary catheter. The [DIAGNOSES REDACTED]. The goal included Resident #55 would not exhibit signs of urinary tract infection. The approaches included Administer medications as ordered and evaluate and document and report effectiveness and any adverse side effects. Assess for UTI (burning, pain w/urination, urgency, frequency, bladder cramps/spasms, low back pain, flank pain, malaise, nausea, vomiting, pain/tenderness over the bladder, chills, fever, foul odor of urine, concentrated urine, blood in urine, confusion, unexplained change in mental status) and report to physician. During a continuous observation on 02/06/19 from 8:10 AM to 10:38 AM, Resident #55 was lying in bed sleep with the bed was in the lowest position on the floor. The urinary drainage bag was detached from the bed lying on the floor. The drainage bag was not secured to Resident #55. Several staff entered the room to provide care for the roommate. Staff did not check Resident #55's drainage bag that was lying on the floor. On 02/06/19 at 10:38 AM Nurse #2 enter room and picked the drainage bag off the floor and reposition the bag onto the bed frame. During an interview on 2/6/19 at 10:38 AM, Nurse #2 was asked what the required position of the drainage bag and she stated the drainage bag should be secured and below the bladder. The expectation would be for all staff to ensure the drainage bag was properly placed and secured. During an interview on 2/6/19 at 11:35 AM, the Director of Nursing stated the expectation was for the drainage bag should not to be lying on the floor. The bed should be positioned at proper level to ensure the drainage bag was secured to resident leg and/or bed. The nurse, charge nurse and unit manager should be checking to make sure all of the catheter drainage bags were secured properly and not on the floor. During an interview on 2/6/19 at 2:30 PM, Nurse Manager stated the expectation was for the aides and nursing to check proper positioning and anchoring of the drainage bag to ensure it was secured either to resident or bed. During an interview on 2/7/19 at 8:17 AM, the Administrator stated the expectation was for nursing to ensure the drainage bags were secured properly and positioned correctly. The catheter should not be on the floor at any time.

Based on observation and staff interviews, the facility failed to store 91 tablets and capsules in labeled packaging to identify the medication name, strength and expiration date in four of five medication carts inspected. Findings included: 1. During an inspection of Station 3 ' s medication cart 3-A on 01/04/18 at 9:30 a.m., five loose white tablets and one loose colored tablet were found in the bottom of the second drawer on the right-hand side. In an interview on 01/04/18 at 9:30 a.m., Nurse # 1 could not identify the unpackaged medications and she wasted them. She acknowledged they were not labeled or stored correctly. 2. During an inspection of Station 4 ' s medication cart on 01/04/18 at 9:50 a.m., a total of 16 loose tablets were found in the bottom of two drawers. Two white tablets, one colored tablet and six partial tablets were loose in the second drawer on the right-hand side. Three white tablets, two colored tablets and two partial tablets were loose in the third drawer on the right-hand side. In an interview with Nurse #6 on 01/04/18 at 9:50 a.m., she indicated that had she seen the unpackaged pills she would have thrown them away in a secured container. Nurse #6 was observed discarding the medications after they were retrieved from the drawers. 3. During an inspection of Station 1 ' s medication cart 1-A on 01/04/18 at 10:05 a.m., a total of 64 loose pills and three capsules were found in the bottom of four drawers. Eighteen white tablets, 13 colored tablets, one capsule and seven partial tablets were loose in the second drawer on the right-hand side. Eight white tablets, seven colored tablets and two capsules were loose in the third drawer on the right-hand side. Three white tablets, three colored tablets and four partial tablets were loose in the fourth drawer on the right-hand side. One loose white tablet was found in the first drawer on the left-hand side. In an interview with Nurse #5 on 01/04/18 at 10:05 a.m., she indicated that the loose medications must have been released from the blister packs when the drawer was packed full and the cards were pressed against each other. Nurse #5 was observed discarding the medications in a secured container. 4. In an inspection of Station 1 ' s medication cart 1-B on 01/04/18 at 10:35 a.m., one white tablet was found loose in the bottom of the fourth drawer on the right-hand side and one colored tablet was loose in the first drawer on the left-hand side. In an interview with Nurse #7 on 01/04/18 at 10:35 a.m., she identified the medications as not being labeled and discarded them in a secured container. In an interview on 01/08/18 at 4:00 p.m., the Director of Nursing acknowledged that the medications discovered on inspection of the medication carts were not stored correctly. She offered that the pills may have broken free from the pharmacy blister packs when they were moved against each another in the drawer, or that the pills had unintentionally fallen in the drawers when nurses popped them from the packs during administration. She shared her expectation that medications be stored in appropriately labeled containers or other packaging to include the medication name.

Based on observations and staff interviews, the facility failed label opened food in the walk in freezer, dietary staff failed use gloves during the dish washing process and also failed to maintain a clean ice scoop and ice scoop holder for the ice machine in the nourishment room. Facility also failed to prevent staff from bring personal food into the kitchen. Findings included: 1. Observation of the walk in freezer on 1/2/18 at 9: 15 AM revealed an opened, half-filled transparent bag containing food that looked like cut cauliflower not labeled and an opened bag containing three (3) frozen pieces of meat in a box labeled Beef Salisbury steak not labeled and dated. 2. Observation on 1/2/18 at 9:30 AM revealed staff entered into the kitchen with a brown bag with a restaurant label and 2 cold beverages in a clear plastic cup with straws. Staff was observed placing the brown bag and beverages on the clean steam table and sipping beverage from the one of the cups. Dietary Manager was made aware and he requested staff to remove the food and take it to their break room. During an interview with the Dietary Manager (DM) on 1/2/18 at 9:35 AM, DM indicated that any opened bag of food should be labeled and dated appropriately. He also stated that staff should not be bringing in their personal food to the kitchen as no eating or drinking was allowed inside the kitchen. He further stated that staff should put their personal food in the break room. During an interview with the dietary staff # 2 on 1/9/18 at 11:00 AM , dietary staff indicated that she had brought in food for another staff member and not noticed the surveyor and placed the food where it should not be placed. She stated that all personal food should be placed in the break room and not brought into the kitchen. 3. Observation of ice machine in the nourishment room near the nursing station 1 hallway on 1/8/18 at 12:32 PM revealed the ice scoop was placed inside the ice scoop holder that was not clean. The ice scoop holder had brown colored bottom that looked like dried dirt. Interview with DM on 1/8/18 at 12:35 PM revealed that the ice scoops and holder were washed by dietary on a regular basis. He indicated he was not sure why it was not washed. 4. During dish washing observation on 1/8/18 at 2:09 PM, observed staff who was handling clean dishes not wearing gloves and using a white colored cloth that was placed near the clean stack of plates to wipe his hands frequently. The Dietary Manager made the observation too and asked the staff to remove the white colored cloth and wash his hands. The staff discarded the white colored cloth, but did not wash his hands and use gloves, and he returned to complete the task assigned. During an interview with the dietary Staff #1 on 1/8/18 at 2:13 PM, staff indicated that he was using the white colored cloth to wipe his wet hands. The staff also indicated that he had forgotten to wash his hands and use gloves before returning to the task. The staff then went back and washed hands and wore gloves. Dishes were sent back through the dish washing cycle. During an interview with the DM on 1/8/18 at 2:15 PM, DM indicated that dietary staff should not be using a napkin during dish washing and should be washing his hands and use gloves appropriately. During an interview with DM on 1/9/18 at 1:00 PM, DM stated that it was his expectation that staff follow proper hand hygiene, appropriately label and date all food and use break room for their personal food. He further stated that all ice scoops and ice scoop holders should be washed and replaced daily in the nourishment rooms.

Based on observation, record review and interviews, the facility failed to revise care plans to include discontinuation of electronic monitoring devices and use of a mechanical lift for 2 of 27 sampled residents (Residents #33 and #253). Findings included: 1. Resident #33 was admitted [DATE] with [DIAGNOSES REDACTED]. a. The care plan dated 12/09/17 identified Resident #33 as an elopement risk with a Problem Start Date of 03/02/16. One of the interventions entered was to equip resident with a device that alarms when (she) wanders. The most recent Minimum Data Set ((MDS) dated [DATE] recorded severe cognitive impairment with behavioral symptoms. She required extensive assistance or total dependence for activities of daily living (ADLs) except for independent eating. No wandering was noted on the MDS during the seven-day look back period and the resident was not coded for use of a wander/elopement alarm. No electronic monitoring device was visible on Resident #33 ' s wrists or ankles during observations made throughout the survey, including 01/03/18 at 10:42 a.m., 01/08/18 at 12:30 p.m., 01/08/18 at 1:20 p.m., and 01/09/18 at 9:30 a.m. In an interview on 01/09/18 at 9:45 a.m., Nurse Aide #4 indicated that Resident #33 did not use a monitoring device. She denied any concern about the resident exiting the facility unattended. Although the resident ' s room was next to a facility exit door, Nurse Aide #4 had not seen her near the door in an attempt to leave when the door was opened. In an interview on 01/09/18 at 11:45 a.m., Nurse #8 confirmed that Resident #33 did not use an electronic monitoring device. She did not consider the resident at risk for elopement, stating that the resident was less mobile now than when first admitted . b. The care plan for Resident #33 included an entry for the use of a mechanical lift (Hoyer) for safe transfers as needed. The Approach Start Date was 09/15/16. The wheelchair of Resident #33 did not have a mechanical lift sling present during observations made throughout the survey, including 01/03/18 at 10:42 a.m., 01/08/18 at 12:30 p.m., 01/08/18 at 1:20 p.m., and 01/09/18 at 9:30 a.m. When asked, the resident was not able to provide any information about the use of the lift. She indicated that she was able to stand. In an interview on 01/08/18 at 12:50 p.m., Nurse Aide #3 confirmed that Resident #33 was able to stand and pivot. She stated that she did not use the mechanical lift with the resident because she believed the resident could transfer safely with one staff member assisting. In an interview on 01/09/18 at 1:45 p.m., the Occupational Therapy (OT) Manager stated that Resident #33 was not currently on their caseload. The resident was last seen by OT in December of 2016 and by Physical Therapy in February of 2017. She proposed that the use of the mechanical lift must have been initiated by Nursing based on the resident ' s readmission to the facility when she was in decline. She indicated that revisions to the care plan based on improvements in resident condition, i.e., discontinuing the mechanical lift, didn ' t need the approval of someone from Rehabilitation when nursing services initiated the care plan entry. In an interview on 01/09/18 at 10:00 a.m., the MDS Coordinator confirmed that wandering behaviors were not present for Resident #33 and there was no use of a monitoring device for wandering according to the latest MDS document. She stated she was not aware that the current care plan did not reflect the lowered elopement risk. She indicated she was not aware that nursing staff were not using a mechanical lift for Resident #33 and that the care plan needed an update for her improved ability to transfer. She indicated that she usually learned of needed revisions by attending the daily department meetings and daily stand-up clinical meeting on the units. Staff could also notify her directly of a change in the care plan. She further stated that any nurse can update care plans and point-of-care guides but only a registered nurse could initiate an issue. In an interview on 01/09/18 at 4:30 p.m., the Director of Nursing (DON) acknowledged that the care plan was not updated to reflect the lowered elopement risk for Residents #33. She stated that an elopement screen conducted in early October showed that a monitoring alarm was not needed. She explained that nursing staff were not using the mechanical lift for Resident #33 due to her improved ability to transfer safely. The DON shared her expectation that nursing staff followed interventions outlined in resident care plans and that revisions were done in a timely manner to keep the plans current. 2. Resident #253 was admitted [DATE] with [DIAGNOSES REDACTED]. Hospice care was initiated 01/02/17 for end-stage [MEDICAL CONDITION]. The quarterly MDS dated [DATE] recorded severe cognitive impairment. He required extensive assistance for ADLs with total dependence for bathing. No wandering was noted on the MDS during the seven-day look back period and the resident was not coded for use of a wander/elopement alarm. The care plan dated 01/05/18 identified Resident #253 as an elopement risk with a Problem Start Date of 01/26/15. One of the interventions entered was to equip resident with a device that alarms when (he) wanders. The nursing problem was last reviewed 01/03/18. No electronic monitoring device was visible on Resident #253 ' s wrists or ankles during observations made throughout the survey, including 01/03/18 at 11:25 a.m., 01/08/18 at 10:34 a.m., and 01/08/18 at 12:44 p.m. Resident #253 was not observed in his wheelchair stationary near any facility exit doors during the time of the survey. When asked, the resident was not able to provide information about the use of any device that alerted staff if he left the facility. In an interview on 01/08/18 at 12:20 p.m., Nurse Aide #3 indicated that the resident refused to wear a monitoring alarm and that the nurses were aware of this. She did not consider the resident an elopement risk because of his limited mobility and impaired cognition. In an interview on 01/08/18 at 12:44 p.m., Nurse #8 indicated that the alarm was discontinued because the resident was not at risk for elopement. In an interview on 01/09/18 at 10:00 a.m., the MDS Coordinator confirmed that wandering behaviors were not present for Resident #253 and there was no use of a monitoring device for wandering according to the latest MDS document. She stated she was not aware that the current care plan did not reflect the lowered elopement risk. She indicated that she usually learned of needed revisions by attending the daily department meetings and daily stand-up clinical meeting on the units. Staff could also notify her directly of a change in the care plan. She further stated that any nurse can update care plans and point-of-care guides but only a registered nurse could initiate an issue. In an interview on 01/09/18 at 4:30 p.m., the DON acknowledged that the care plan was not updated to reflect the lowered elopement risk for Resident #253. She stated that an elopement screen conducted in early October showed that a monitoring alarm was not needed. The DON shared her expectation that nursing staff followed interventions outlined in resident care plans and that revisions were done in a timely manner to keep the plans current.

Based on observations, record review and staff interviews, the facility failed to safely transfer a resident from the wheelchair to the bed using a mechanical lift resulting in a deep leg laceration that required surgical repair for one of three residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a BIMS (Brief Interview of Mental Status) score of 12 which indicated intact cognition. The resident needed extensive assistance from staff for bed mobility, dressing and hygiene. The resident did not walk on admission. Balance was not steady for sitting to standing position changes, turning around, and moving on and off the toilet. The resident was only able to stabilize with staff assistance. The resident used a wheelchair for mobility. Behavioral symptoms not directed toward others was noted during the look-back period. The resident was totally dependent on the assistance of two staff members for transfer, locomotion, bathing and toileting. The resident weighed 293 pounds (lb) on admission. The resident was coded as needing the use of mechanical lift for transfer. The resident's care plan did not have specific instructions regarding the use of mechanical lift to transfer the resident. The Weekly Skin Check dated 08/03/17 noted scars and pigment changes near antecubital regions (anterior region of the elbow) bilaterally. Skin remains intact. On 08/03/17 at 4:40 p.m. Nurse #1 entered a nursing progress note to indicate that Resident #1 was being transferred by nursing assistants (NA) and hit her leg against the wheelchair. The NAs called Nurse #1 to the room and the nurse observed a laceration to the left lower leg. The nurse applied pressure and notified the medical doctor (MD) and the supervisor. The supervisor advised the nurse to send the resident to the emergency room and notify the resident representative. A Skin Tear/Laceration Report of 8/3/17 was completed by Nurse #1 described the depth of the wound as deep with controlled bleeding. The pain on a 10-point scale with 10 being high was estimated as 6. Measurements of the wound were not documented. The resident was transferred to the Emergency Department of Hospital #1. The treating physician (Physician #1) conducted a physical exam of the resident that revealed large laceration to the left lower extremity with subcutaneous fat exposed. The physician documented the size of the wound as 25 cm (centimeters or 9.8 inches) long. On 08/03/17 at 10:07 p.m. the wound was sutured and there were no foreign bodies/material noted and no underlying fracture. The physician described the large wound defect with muscle exposure. An Orthopedist was consulted and recommended that the resident be transferred to another hospital for plastic surgery. The resident was accepted by another acute care facility on 08/03/17 at 11:02 p.m. Final [DIAGNOSES REDACTED]. Resident #1 was transferred to Hospital #2 and seen in the emergency department at 08/04/17 at 12:09 a.m. The clinician (Clinician #1) documented a patient with complicated and complex left lower leg laceration that does not violate through fascia (connective tissue) into bone. She exhibits no edema. A Trauma specialist was consulted for wound assessment. Devitalized tissues were resected, and subcutaneous tissues were approximated to cover the fascia. Wet-to-dry dressings was ordered twice a day. In an interview on 10/17/17 at 7:45 pm., NA #1 stated that Resident #1 had requested to go to bed on 08/03/17 and this required the use of the mechanical lift. The resident was cooperative with the procedure. She indicated that NA #2 was operating the lift and she was guiding the resident. She stated that the resident hit her leg against the armrest of her wheelchair. When asked if the resident was lifted high enough to achieve a smooth transfer, NA #1 did not provide an answer. She said she noticed that the resident was injured once she was in the bed. In an interview on 10/18/17 at 6:35 a.m., NA #2 stated that NA #1 was operating the lift and he was guiding Resident #1. He stated that the resident hit her leg against the arm of the wheelchair. The NA stated that the resident didn't hit her leg hard but it was enough to cause an injury. He was not aware of any sharp edges on the resident's wheelchair. On 10/19/17 at 10:09 a.m., an observation was conducted of NA #2 demonstrating how he transferred Resident #1. The NA was observed operating a mechanical lift to transfer a resident from the bed to her wheelchair. NA #3 assisted with the procedure. NA #2 demonstrated where the lift, wheelchair and bed were positioned on the day of Resident #1 injury. He showed how he had come from behind the wheelchair to the opposite side of the bed to guide the resident as the sling was lowered to bed. He stated that he felt the resident hit something as he was guiding her but couldn't tell what it was. On 10/17/17 at 4:16 pm, an interview was conducted with Nurse #1. The nurse indicated the incident happened around 4:00 pm around the time she was starting her medication pass. The nurse said that NA #1 came to her to get her to assess the resident. NA #2 stayed in the room with the resident. The nurse's understanding was that the resident was being transferred from the wheelchair to the bed, and the resident hit her leg on the wheelchair. The nurse said it must have been the armrest of the wheelchair, the bed side rail was lowered to accommodate the resident. The nurse said the layout of the room was such that the wheelchair was parallel to the bed and the mechanical lift was in front of the wheelchair. There was a lot of blood when she got to the room, more of it was fluid than blood. The left leg was open and bleeding, she dry dressed it. She could not give an estimate of the length or size of the wound. The nurse stated she called one of the nurse supervisors, and the supervisor notified the MD, and she phoned 911. The EMS arrived in maybe 10 minutes and the resident was sent to hospital emergency room . The nurse said the resident was sent to the hospital because of the extent of the injury. In an interview on 10/17/17 at 5:16 p.m., Nurse #1 estimated the time of the incident as 4:00 p.m. NA #1 came to her and asked her to come to the room to assess Resident #1. NA #2, who was also assisting with resident transfer, had stayed in the room with the injured resident. She stated that the resident was familiar with the mechanical lift. She described the layout of the room with the wheelchair parallel to the bed and the lift positioning in front of the wheelchair. She was unable to provide an estimate of the length or size of the wound. In an interview on 10/17/17 at 9:40 a.m., the Staff Development Coordinator (SDC) provided the Operator Instructions for the mechanical lift used for Resident #1. The mechanical lift had the capacity of 500, 600 or 1,000 lb. The manual revealed that the lift was designed to be operated safely by one person. However, with some patients it is best to use two people. The SDC stated that facility policy was to use two staff members to operate a mechanical lift: one to operate the mechanical lift and the other to stand near the resident and guide the sling to assist in repositioning. She confirmed that the lift used was the correct device for Resident #1. In an interview on 10/17/17 at 4:00 p.m., Nurse Supervisor #1 said she had come to the room of Resident #1 on 08/03/17 to assist the charge nurse in caring for the injury. She described the wound as a skin tear which needed evaluation for potential stitches or staples. She indicated that the wound was not bleeding profusely but there was a lot of serous drainage and white tissue. She could not give an estimate of the length of the skin tear or the size of the wound. She notified the facility physician who gave the order for transfer. Resident #1 did have behavioral issues but was not yelling when she arrived to the room. She did not appear to be in pain. In an interview on 10/19/17 at 4:00 p.m., the director of nursing (DON) stated that she had reviewed the incident on the day it occurred because she was present in the building. She went to the room and spoke with the two nursing assistants involved in transferring Resident #1. She observed as the NAs demonstrated their technique in lifting the resident. The DON was satisfied that NA #1 and #2 had followed facility policy on using the mechanical lift. She concluded that the resident's leg had not cleared the wheelchair but this was not due to inattention or failure to properly guide the occupied sling. She did not document her investigation or conclusions.

Based on observations, record review, and interviews with staff the facility failed to follow a physician-ordered diet stating " no green beans " for 1 of 1 resident (Resident #88). Findings included: Resident #88 was most recently admitted on [DATE] and had [DIAGNOSES REDACTED]. The resident's care plan dated 2/20/14 indicated he was at risk for alteration in nutrition status related to variable oral intake and requiring a mechanically altered diet. Interventions included: ? Feed resident all meals ? Provide diet as ordered: Mechanically soft with puree meats, double portion entrees, no straws, no bread, no mixed consistencies, no green beans, no broccoli stems, no hard fruit or vegetables. Record review of the current physician order [REDACTED]." The Minimum (MDS) data set [DATE] revealed Resident #88 was severely cognitively impaired, was on a mechanically-altered diet, and required extensive assistance with eating. The Nutritional assessment dated [DATE] revealed Resident #88's current diet order included no hard veggies or fruits, no bread, no mixed consistencies, no corn, no cabbage, no green beans, no rice, and no broccoli. During an observation of the dinner meal on 6/10/14 at 6:22 pm, Resident #88 was observed sitting in his bed. NA #2 set up his meal tray and fed the resident his meal which included pureed lasagna and whole green beans. Review of the resident's meal card indicated "alternate vegetable." During an interview with the Speech Therapist (ST) on 6/12/14 at10:30 am she indicated she had been the ST for a year, had never assessed Resident #88, and his food restrictions on the physician order [REDACTED]. assessment done by the previous ST. She stated, the assessment "must have noted (Resident #88) had trouble with the foods listed (on the physician order)." During an interview with the Dietary Manager (DM) on 6/12/14 at 4:00 pm she indicated that information about particular food restrictions are received from nursing and put in the dietary computer. She further indicated if a restricted vegetable is being served then the resident's ticket for that meal will state "alternate vegetable" and that is what the kitchen staff should put on his meal tray. During an interview with the District Dietary Manager on 6/12/14 at 4:05 pm the dinner ticket for 6/10/14 was reviewed. He indicated the ticket stated, "Alternate vegetable," that the vegetable for 6/10/14 was green beans, and Resident #88 should have received the alternate vegetable on his dinner tray. He stated, "The alternate (vegetable) for 6/10/14 dinner was carrots." During an interview with the Director of Nursing on 6/12/14 5:10 pm she indicated staff should follow the physician-ordered diet and the care plan.

Based on observations and staff interviews the facility failed to maintain sanitary conditions in the kitchen by not ensuring opened food items were sealed, dated and labeled; and, by not ensuring food service equipment and preparation areas were maintained clean and free from debris. Findings included: 1. During the initial tour of the kitchen on Monday, 1/30/12 at 10:42am, a large stack of empty cardboard boxes (some flattened) were observed on the floor in kitchen. During an interview, the Dietary Cook revealed food deliveries were received on Wednesdays and there were no deliveries that day. The Cook did not explain why the boxes were on the floor in the kitchen. There was a large pot with dirty, standing water on the floor beneath the 3-compartment sink. The Dietary Cook indicated the pot was left there by the evening staff. The filters in the hood over the stove were covered with greasy dark substances. The Dietary Cook stated the filters were cleaned weekly. The filters on each side of the ice machine contained greasy, grey lint. During a second observation of the kitchen on 2/1/12 at 1:50pm, the greasy, grey lint was still on the filters of the ice machine; and the filters in the hood over the stove were covered with dark grey substances. 2. During the tour of the kitchen on 1/30/12 at 10:42am, observations of the refrigeration units revealed food items that were not sealed, dated or labeled. The walk-in refrigerator contained 2-resealed packages of lunchmeat and a resealed container of sour cream that were not dated or labeled; 1-4" deep pan of uncovered, not labeled, thick, red substance; and, 1-half covered, plastic container of cooked grits that were not dated or labeled. The walk-in freezer contained 1-opened box of hamhocks in an opened bag. The reach-in refrigerator contained a 1/2 crate of 8 ounce milk containers with expiration dates of 1/23/12. As a result of these observations, the dietary staff removed the above items. The observation of the Dry Storage Room revealed 1-bag of opened grits and 1-bag of opened rice on the storage racks. There was also 1-large box containing packages of creamer stored on the same storage shelf with paper supplies (foil, plastic lids, sandwich bags and plastic wrap).

Based on observations, record reviews, and staff interviews the facility failed to provide maintenance services necessary to maintain a clean, orderly, and comfortable interior for 2 of 3 resident shower rooms and 1 of 54 resident rooms. Findings include: 1) On 01/30/2012 at 10:30 a.m. an initial tour of the facility was conducted. During the tour the following observations were made: a) On 01/30/2012 at 10:35 a.m. in the "A Hall" resident shower room's toilet area the grab bar on the wall next to the toilet was observed to have several screws in the brackets holding the bar to the wall partially backed out. When touched the grab bar was found to be loose and could be easily moved vertically up and down and not solid to support a resident's weight if needed. 01/31/2012 at 12:30 p.m. the A hall resident shower room ' s toilet grab bar was observed. No maintenance or repair was observed to have been conducted. The grab bar was observed to still be loose. On 02/01/2012 at 4:30 p.m. the A hall resident shower room ' s toilet grab bar was observed. No maintenance or repair was observed to have been conducted. The grab bar was observed to still be loose. On 02/01/2012 at 4:35 p.m. an interview was conducted with a A/B hall NA. The NA was asked if she ever gave resident baths/showers and if so which shower room (s) she used. The NA stated, "I use both the A hall and the B hall resident bathrooms to give the residents their showers." The NA then stated, "All of us (clarified - the NAs on the A and B halls) use both shower rooms." b) On 01/30/2012 at 10:40 a.m. on the A hall in resident room 114 a section of sheet rock measuring approximately 7" long 3" wide was observed to have been broken off the wall at the corner next to resident's wardrobe closets. Also observed were small pieces of sheet rock debris/dust on the floor directly under the area. On 01/31/2012 at 12:33 p.m. resident room 114 was observed. The wall still had the area of the broken/missing sheet rock. No maintenance or repair was observed to have been conducted. On 02/01/2012 at 4:37 p.m. resident room 114 was observed. The wall still had the area of the broken/missing sheet rock. No maintenance or repair was observed to have been conducted. c) On 01/30/2012 at 10:55 a.m. in the "B Hall" resident shower room the call light system button with pull string and metal cover plate were observed hanging from exposed wires coming out of the junction box in the wall. The shower area was noted to have been recently used as there was standing water on the floor and marks on the floor in the water where a shower chair/bed, also observed, appeared to have been moved. The shower chair/bed was observed directly under the hanging wires/call light. Also during the facility tour observations were made of both the A/B hall's and C/D hall's nurse's stations. At each nurse's station there were two plastic document organizers attached to the wall near the nurse's station entry way. Each of the nurse's station document organizers were labeled, one read "Maintenance Request Forms" and the other read "Maintenance Requested." Blank "Repair Requisition" forms were observed in each of the document organizers labeled Maintenance Request Forms. A review of a blank Repair Requisition form was made. The form had areas for information to be documented which included - Date, Location, Repair needed, Signed by, Approved by, Workman, and Date Completed. There were no filled out Repair Requisition forms observed in either nurse's station Maintenance Requested document organizers. On 01/31/2012 at 12:36 p.m. the B hall resident shower room was observed. The call light switch and wires were observed to still be hanging from the junction box. No maintenance or repair was observed to have been conducted. Each of the nurses station's Maintenance Requested document organizers were observed and found to be empty. On 02/01/2012 at 12:40 p.m. the B hall resident shower room was observed. The call light switch and wires were observed to still be hanging from the junction box. No maintenance or repair was observed to have been conducted. Each of the nurses station's Maintenance Requested document organizers were observed and found to be empty. An interview was conducted on 02/02/2012 at 8:10 a.m. with facility's maintenance manager about the facility's maintenance request procedures. The maintenance manager stated " There are two boxes on the walls at each nurse's station. One of the boxes has blank repair requisitions in it and when something is identified by a staff member, resident, or family member the issue is documented by the staff on a blank repair requisition. When they are finished filling it out they sign and date the form and place it in the other box. " The maintenance manager stated he would make two rounds daily to check for filled out forms in the boxes and take the forms to the maintenance office to file and prioritize the repairs or maintenance needing to be made. He stated, " I review the forms every day, I order the parts if needed and the issues are repaired in the priority needed. " The maintenance manager also stated, If the repair or maintenance issue needs immediate attention I may be called or talked to by the staff on the floor without a repair requisition form being filled out and the maintenance may be initiated right then or a form filled out and deferred. " A review of the facility's filled out and filed repair requisition forms was conducted with the facility's maintenance manager on 02/02/2012 at 8:15 a.m. The forms on file (located in two plastic document organizers on the maintenance office wall) covered the time period from 04/06/11 through 02/02/12. The maintenance manager stated, "I started keeping track of the maintenance requests when I was hired in April 2011." The documentation review revealed there were no repair requisition forms initiated/turned in for any of the three areas found during the initial tour needing maintenance and/or repair. The maintenance manager was asked if there were any other places that a filled out request form would be kept. The maintenance manager stated, "The forms are only kept at the nurses' stations and in my office, if I have to show them to someone else I return it to my file right after that is done." On 02/02/2012 at 8:32 a.m. observations were made with the facility's maintenance manager of the three areas found to be in need of repair. When asked if he knew about the areas in need of repair the maintenance manager stated he did not know and was not informed of the areas observed. The facility's maintenance manager stated all three areas needed repair. The maintenance manager also stated both shower rooms on the A and B halls were in full operation during the week of the survey and not closed for renovation as compared with the C hall renovation areas. An interview with an A hall nursing assistant (NA) was conducted on 02/02/2012 at 8:43 a.m. The NA was asked about her knowledge of how things needing repairs were identified, documented, and maintenance notified. The NA stated, "There is a box at each nurse's station which has blank repair requisition slips. When you find a problem that needs maintenance to fix, you fill out the slip, sign and date it then put it into the repair box for maintenance to pick up." When asked if she had noted any of the 3 items needing repair she stated, "No."

Based on observation, record review and staff interviews the facility failed to ensure that staff cleaned a resident ' s perineal area for 1 of 4 residents observed during incontinence care (Resident #7). The findings include: The facility policy dated May 2007 titled Perineal Care under Purpose read: " The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation. " Steps in the Procedure #9 read: " For a female resident: b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side and using downward [MEDICAL CONDITION]. (3) Rinse perineum thoroughly in same direction. (4) Gently dry perineum. c. Instruct or assist the resident to turn on her side with her top leg slightly bent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. F. Rinse thoroughly using the same technique as described in " e " above. g. Dry area thoroughly. " Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Care Area assessment dated [DATE] showed that the resident was frequently incontinent and required total assistance with toileting. The most recent Minimum Data Set (MDS) Assessment (quarterly) dated 10/25/11 showed that Resident #7 had short and long term memory loss and was severely cognitively impaired. The MDS showed that the resident required total assistance for personal hygiene and toileting. The MDS showed that the resident was totally incontinent of bowel and bladder. The resident ' s Care Plan dated 11/23/11 listed urinary incontinence as a problem and to provide incontinence care after each incontinent episode. Nursing Assistant (NA) #1 was observed to provide incontinence care for Resident #7 on 12/01/11 at 4:12 PM. Resident #7 was observed resting in bed. The NA was observed to remove the resident ' s incontinent brief and assist the resident to roll over to the left side. The resident was observed to have a wet diaper with a moderate amount of soft stool. The NA used a pre-moistened wipe to clean the resident cleaning front to back and cleaned the resident ' s buttocks with pre-moistened wipes and applied a dry brief. The NA did not wash the resident ' s perineal area. NA #1 stated in an interview on 12/01/11 at 4:25 PM that he cleaned the resident ' s perineal area front to back with one motion with the resident lying on her side. The Director of Nursing stated in an interview on 12/01/11 at 4:57 PM that the NA should have separated the resident ' s labia and cleaned down the middle (front to back) and then on either side and then turned the resident over to the side and cleaned the resident ' s buttocks and removed the stool.