Every finding on record at Pine View Manor Inc

Based on interview and record review, the facility failed to ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegation was made when the facilities administrator failed to report to the state survey agency and the local police department that Nursing Assistant (NA) A took a nude photo of Resident #25 without his/her knowledge and sent it to Certified Nurse Aide (CNA) D. This affected one of one sampled residents. The facility census was 53. Review of the facility policy titled Pine View Manor Abuse and Neglect Protocol, dated 05/06/26, showed:-It is the purpose of this facility to report to the State Agency and appropriate law enforcement entity, any reasonable suspicion of a crime against any individual who is a resident or receiving care from the facility;-The facility shall report not later than two hours after forming the suspicion if the suspicion resulted in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 1.Review of Resident #24's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 06/22/26, showed:-The resident was cognitively intact;-The resident was dependent on staff to carry out activities of daily living;-Diagnoses included: Stroke, anxiety, and depression. Review of the facilities investigation, dated 06/16/26, showed:-The Administrator received messages from CNA D regarding a picture that was sent to CNA D by NA A via social media; -NA A thought that he/she had taken a picture over his/her shoulder of the wall and it was an accident that the resident was in the picture;-NA A told the Administrator that he/she knew he/she could not take pictures of resident's, especially if they were not clothed;-The picture sent by NA A to CNA D showed the resident's feet, legs, and underside of his/her bottom while the resident was layed in bed with his/her knees towards the wall in the resident's room. During an interview on 07/08/26 at 8:23 A.M. CNA E said:-CNA D had showed him/her a picture that CNA D received from NA A of the resident's bottom;-He/She told CNA D to report to the Administrator. During an interview on 07/08/26 at 8:32 A.M. CNA D said: -NA A sent him/her a picture that showed the resident's bottom;-He/She could tell that it was the resident from the picture since he/she took care of the resident frequently;-He/She saved the picture to show to the Administrator;-He/She thought that the Administrator would report the picture being taken of the resident to the state agency. During an interview on 07/08/26 at 9:00 A.M. the Administrator said:-NA A told her he/she took a picture of the resident accidently; he/she thought he/she took a picture of the wall and not the resident;-She could not tell who the resident was in the picture and there was nothing to identify the resident in the background of the picture either;-She did not report NA A taking a picture of the resident to the state agency or to the local police department since it was not an inappropriate picture and there was nothing to identify the resident in the picture; -NA A told the Administrator that the picture was of the resident. During an interview on 07/08/26 at 10:21 A.M. NA A said:-He/She took a picture over his/her shoulder of what was supposed to be the wall in the resident's room;-He/She did not mean to take a picture of the resident and he/she did not look at the picture before sending it to CNA D;-If the picture of the resident was something that should have been reported to the state agency the Administrator would have reported it. Intake 3062871

Based on observation, interview and record review the facility failed to ensure Resident #24 right to be free from abuse when Nursing Assistant (NA) A took a photo of Resident #25 without his/her knowledge and sent it to Certified Nurse Aide (CNA) D using a social media messaging service. The photo showed the resident lying in bed on/his her side with his/her unclothed hip, buttocks, legs and feet exposed. The facility census was 53. Review of the facilities policy Abuse and Neglect Protocol, dated 05/06/26, showed: Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of the facilities policy Cell Phone Use, not dated, showed:-The facility prohibits the use of cell phones while on duty;-The expectation is that staff will not use their cell phones except at break or meal times;-All staff members signed a form when in orientation regarding the appropriate use of cell phones. Review of the facilities investigation, dated 06/16/26, showed:-The Administrator had received messages from NA A and CNA D regarding a picture that was sent to CNA D by NA A;-NA A thought that he/she had taken a picture over his/her shoulder of the wall and it was an accident the resident was in the picture;-NA A told the Administrator that he/she knew he/she could not take pictures of resident's, especially if they were not clothed;-The picture sent by NA A to CNA D showed the resident's feet, legs, and underside of his/her bottom while the resident was laying in bed with his/her knees towards the wall in the resident's room. 1.Review of Resident #24's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 06/22/26, showed:-The resident was cognitively intact;-The resident was dependent on staff to carry out activities of daily living;-Diagnoses included: Stroke, anxiety, and depression. During an interview on 07/08/26 at 8:23 A.M., CNA E said: -CNA D had showed him/her an inappropriate picture that CNA D had received from NA A of the resident's bottom;-He/She told CNA D to make sure to report this to the Administrator. During an interview on 07/08/26 at 8:32 A.M., CNA D said-NA A sent him/her a picture of the resident that showed the resident's bottom;-He/She could tell that it was the resident from the picture since he/she took care of the resident frequently;-He/She was upset that a coworker would take an inappropriate picture of a resident;-He/She saved the picture to show to the Administrator then deleted it after the Administrator was notified. During an interview on 07/08/26 at 9:00 A.M., the Administrator said:-NA A had told her that it was an accident, he/she thought that they were taking a picture of the wall and not the resident to quickly reply to CNA A via social media private messaging service;- She expected all staff to follow the facilities cell phone use policy; -She could not identify the resident in the picture;-NA A told the Administrator it was the resident in the picture; -She explained to NA A the seriousness of the situation and that staff were not allowed to be on their phones in resident rooms. -She did not complete abuse education with all staff since the picture taken of the resident was an isolated incident; -She did not consider the picture of the resident to be abuse since the picture was not inappropriate and there was nothing in the picture to identify the resident; During an interview on 07/08/26 at 10:21 A.M., NA A said:-He/She was taking a picture over his/her shoulder of what was supposed to be the wall in the resident's room;-He/She did not mean to take a picture of the resident and he/she did not look at the picture before sending it to CNA D;-He/She knew he/she should not have taken any pictures in the resident's room; -He/She received training on the facilities abuse policy, resident privacy, and the no cell phone policy after she took the picture. During an interview on 07/08/26 at 1:28 P.M., the resident said:-He/She had not seen any staff members on their phones in his/her room;-He/She was not aware that any staff member had taken a picture of him/her. Intake 3062871

Based on observation, interview, and record review the facility failed to protect one of three sampled residents right to be free from abuse when staff observed Resident #1 and Resident #2 get into a verbal argument, and a short while later, Resident #2 went into Resident #1s room and a physical altercation occurred where both residents were found on the floor. The nurse assessed Resident #1 and found he/she was upset and with physical injuries including a scraped left knee and left elbow and a red mark on the left side of his/her ribs. This affected one of three sampled residents. The facility census was 55. Review of the facilities Abuse and Neglect Protocol policy, dated 2/15/22, showed: -It was the purpose of the facility to prohibit and prevent abuse and to assist the facility staff members in recognizing incidents of abuse; -Abuse was defined as the willful infliction of injury, intimidation or punishment with resulting physical harm or pain. Review of the facilities Resident-to-Resident Altercations policy, dated 1/1/26, showed: -Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents; -Review the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; -Document in the resident's clinical record all interventions and their effectiveness.Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 3/23/26, showed: -The resident was cognitively intact; -The resident was independent with activities of daily living; Review of Resident #2's Comprehensive MDS, dated [DATE], showed: -The resident was cognitively intact; -The resident required minimal assistance with activities of daily living; -The resident had diagnoses of major depressive disorder, osteoarthritis (a chronic joint disease-causing breakdown of cartilage causing bones to rub together leading to pain and reduced mobility), and hypertension. Review of Resident #1's emergency room discharge instructions, dated [DATE], showed: -The resident had pain to his/her left ribs and left knee; -The resident had a contusion (bruising) of the left chest wall, contusion of the left rib, and a skin tear to the left elbow.Observation on 04/13/2026 at 1:40 P.M. showed Resident #1 with a grapefruit sized bruise to his/her left rib area. During an Interview on 04/13/2026 at 1:36 P.M. Resident #1 said: -Resident #2 had said some rude things to one of the staff members so he/she had told Resident #2 not to speak that way to staff, Resident #2 got angry and yelled at Resident #1 since he/she was angry that Resident #2 had told him/her to not speak like that; -Resident #1 went back to his/her room after Resident #2 had yelled at Resident #1; -Resident #1 told Resident #2 not to come to his/her room but Resident #2 did. -When Resident #2 went into Resident #1's room, he/she lunged at Resident #1 and both residents got into a physical altercation ended up on the floor; -Resident #1 could not remember any specific details of the physical altercation; -Resident #1 had pain to the left side of his/her ribs and was sent to the emergency room to get x-rays. During an interview on 04/13/2026 at 2:03 P.M. Resident #2 said: -Resident #1 liked to interrupt his/her conversations; -Resident #2 replied to Resident #1 in an aggressive tone; -Resident #1 went back to his/her room after the verbal argument; -Resident #2 went by Resident #1's room to get to his/her own room when Resident #1 had made a rude remark to Resident #2, Resident #2 then turned around in his/her wheelchair and went into Resident #1's room; -Resident #1 had reached toward Resident #2 and both resident's had shoved each other, Resident #2 fell forward and Resident #1 fell on his/her back; -Resident #2 was not injured during this altercation; -Resident #2 has had anger issues in the past and that was something he/she was working on improving; -Resident #2 made sure to stay away from Resident #2 after the altercation. During an interview on 04/13/2026 at 1:36 P.M. Resident #2 said: -Resident #1 had said some rude things to one of the staff members so he/she had told Resident #1 not to speak that way to staff, Resident #1 got angry and yelled at Resident #2 since he/she was angry that Resident #2 had told him/her to not speak like that; -Resident #2 went back to his/her room after Resident #1 had yelled him/her; -Resident #1 came into Resident #2's room, Resident #2 had told Resident #1 not to come into his/her room but Resident #1 went into Resident #2's room anyway and lunged at Resident #2 and both resident's ended up on the floor; -Resident #2 could not remember any specific details of the physical altercation; -Resident #2 had pain to the left side of his/her ribs During an interview on 04/13/2026 at 10:45 A.M. Certified Nursing Assistant (CNA) A said he/she was sitting by Resident #2 when Resident #2 was told by Dietary Aide A that the facility was out of grapes. -The resident told dietary aide A that he/she could shove the grapes up his/her ass. -CNA A said that it sounded like Resident #2 was joking since he/she was smiling and dietary aide A was also smiling; -Resident #1 had heard what Resident #2 had said to dietary aide A and told Resident #2 that he/she should not speak to staff that way; -Resident #2 told Resident #1 that he/she was going to hit him/her one of these days. -Licensed Practical Nurse (LPN) A had Resident #1 return to his/her room and CNA A continued to sit by Resident #2 near the nurses station for approximately 10 minutes before CNA A went outside on break; -CNA A was outside when dietary aide A came outside and had said that Resident #1 and Resident #2 had gotten into a fight; -CNA A did not witness the physical altercation between Resident #1 and Resident #2; -The physical altercation happened approximately ten minutes after the verbal altercation; -After the physical altercation the residents were separated, and Resident #1 was sent to the hospital approximately one hour after the physical altercation occurred; -Resident #2 stayed in his/her room the rest of the night after the physical altercation with Resident #1; -Neither residents were placed on one-on-one observation or 15-minute checks after the physical altercation. During an interview on 04/13/2026 at 11:14 A.M. LPN A said: - On 4/11/26 Resident #1 and Resident #2 got into a verbal argument at the nurses station, Resident #1 was assisted back to his/her room and Resident #2 continued to sit by the nurse's station with staff nearby; -A little bit later that evening LPN A was down the hallway that both residents reside on caring for another resident when he/she saw Resident #2 go by Resident #1's room in his/her wheelchair, Resident #2 then turned around and went into Resident #1's room; -LPN A had told Resident #2 to not go into Resident #1's room; -When LPN A had arrived at Resident #1's room both residents were on the floor; -Resident #1 had a red mark on his/her left ribs and he/she said that the area felt sore, LPN A had called the resident's provider who gave an order for the resident to be sent to the emergency room for x-rays to determine if the resident had any broken ribs; -Resident #2 had a scrape to his/her left knee; -Typically, 15-minute checks were done after a resident-to-resident physical altercation, 15-minute checks were not officially done after Resident #1 and Resident #2 after their physical altercation; -Resident to resident physical altercations were considered abuse. During an interview on 04/13/2026 at 2:58 P.M. CNA B said: -He/she was not working the day the altercation between Resident #1 and Resident #2 occurred but was notified of the altercation when he/she received report; -He/she was instructed to watch and listen to Resident #1 and Resident #2 and separate the two residents if there were any signs of an argument beginning; -Resident #1 and Resident #2 were not on any form of official observation; -Resident to resident physical altercations were considered abuse. During an interview on 04/13/2026 at 3:15 P.M. Registered Nurse (RN) A said he/she was not working when the altercation between Resident #1 and Resident #2 occurred but he/she was notified of the altercation when he/she received report; -He/she was instructed to keep a close watch on Resident's #1 and #2; -Resident's #1 and #2 were not on 15-minute checks or any other form of increased observation; -Resident to resident physical altercations are considered abuse. During an interview on 04/13/2026 at 3:20 P.M. the Administrator said she had spoken with Resident #1 and Resident #2 and both residents had said that they would stay away from each other and neither of them wanted any issues; -Staff were instructed to keep a close eye on Resident #1 and Resident #2; -There was not a formal protocol of how often Resident #1 and Resident #2 should have been monitored by staff and no form for staff to fill out to show they monitored the residents. Review of the facilities investigation, dated 4/11/26, showed: -Resident #1 and Resident #2 got into a verbal argument at the nurses station on 4/11/26, facility staff intervened and ensured the residents were separated, later that evening Licensed Practical Nurse (LPN) A witnessed Resident #2 go into Resident #1's room, when LPN A entered Resident #1's room both residents were on the floor; -Resident #1 had a scraped left knee and left elbow and a red mark on the left side of his/her ribs; -Resident #1 was upset that the incident had happened but denied any distress; -Resident #1 and Resident #2 reside on the same hallway, both residents were offered to move to a different room and both resident's declined the room move; -Both residents were educated that physical altercations cannot occur and both residents were in agreement that any physical altercation would not happen again.Intake 2980674

2. Review of the Resident #40's Significant Change in Status MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Upper extremity and lower extremity impaired on both sides; - Dependent on the assistance of staff for toilet use; - Had a Foley catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - The resident had seven antibiotics in the last seven days; - Diagnoses included traumatic brain injury, seizure, dementia and depression. Review of resident's Urinalysis (UA, a test to analyze urine contents) and urine culture and sensitivity ( C & S, at test that identifies the amount and type of bacteria and medications to treat the infection), dated 10/11/24 showed: - The presence of bacteria indicative of a possible urinary tract infection (UTI); - The C & S showed the presence of organisms indicative of a UTI; - The resident was started on Cipro 250 mg (Antibiotic medication) twice daily for seven days, for a UTI. Review of the resident's urine culture showed: - 10/16/24 - The presence of bacteria indicative of a possible UTI; - 10/16/24 - The resident was admitted to the hospital with a seizure; - 10/18/24 - the urine culture was finalized; - 10/20/24 - Amoxicillin-Potassium Clavulanate oral suspension, 10.9 milliliters (mls.) via peg tube (a tube placed in the stomach to provide a route to deliver nutrition, fluids and medications) twice daily for UTI for seven days. Review of the resident's Urine culture, dated 12/6/24 showed: - The presence of bacteria indicative of a possible UTI; - 12/9/24 - Bactrim DS twice daily for five days for a UTI. Review of the resident's urine culture, dated 4/10/25 showed: - The presence of bacteria indicative of a possible UTI; - Bactrim DS oral tablet 800-160 milligrams (mgs.) one tablet via peg tube twice daily for seven days for a UTI. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed: - Foley catheter for urinary retention. Review of the resident's undated care plan, showed: - The resident had an indwelling Foley catheter for bladder retention; - The resident had a Foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks on every shift. Monitor, record, report to physician for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; - The resident is not toileted. The resident has a Foley catheter and is incontinent of bowel. Observation on 5/19/25 at 2:30 P.M., showed the facility did not have an isolation cart outside the resident's room and no isolation signage was posted. Observations on 5/19/25 at 2:34 P.M., showed: - The resident's drainage bag hung on the side of the resident's bed and was resting directly on the floor and did not have a dignity cover; - The facility did not have an isolation cart outside the resident's room. Observation on 5/20/25 at 9:09 A.M., showed: - There was an isolation cart outside the resident's room but no signage was posted; - CNA D and CNA E did not wash his/her hands and applied gloves; - CNA D and CNA E did not don a gown; - CNA D wiped down each side of the groin with a different wipe each time; - CNA D used the same area of the wipe to clean different areas of the perineal folds; - CNA D used the same area of the wipe and wiped back and forth multiple times on the resident's leg; - CNA D used a new wipe and wiped from where the catheter was attached to the drainage bag back up to the insertion site; - CNA D and CNA E turned the resident on his/her side; - CNA D cleaned fecal material from the rectal area; - CNA D removed gloves, did not wash his/her hands and applied new gloves; - The resident did not have a leg strap to secure the catheter tubing; - CNA D placed the graduate (a clear plastic container with markings used to collect and measure fluids) directly on the resident's fall mat; - CNA D cleaned the spout with wipe and emptied the urine into the graduate; - CNA D and CNA E removed gloves and washed his/her hands. During an interview on 5/21/25 at 3:11 P.M., CNA D said: - The residents do not have to have a leg strap. That's what the nurses have told him/her; - The graduate should be placed on a clean barrier; - He/She should have cleaned the drainage spout with an alcohol wipe; - He/She should have anchored the catheter tubing at the insertion site and wiped down the tubing. He/she should not have wiped from where the catheter tubing attached to the drainage bag back up to the insertion site; - He/She should have separated and cleaned all areas of the skin; - He/She did not have to wear PPE because the resident had a catheter. 3. Review of Resident #12's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Dependent on the assistance of staff for transfers; - Had a Foley catheter; - Frequently incontinent of bowel; - The resident had seven doses of antibiotics in the last seven days; - Diagnoses included urinary tract infection, anxiety and senile degeneration of the brain. Review of the resident's POS, dated May 2025 showed: - Foley catheter - change as needed related to retention of urine; - Check leg strap is in place for Foley catheter every day and evening shift. Check tubing is in place with leg strap for prevention of wound. Review of the resident's undated care plan, showed: - The resident had a Foley catheter due to UTIs and retention. Empty the Foley bag every shift and report any abnormalities tot he charge nurse. Keep the Foley catheter in a bag away from sight and off the floor. Observation on 5/19/25 at 11:32 A.M., showed the facility did not have an isolation cart outside the resident's room and no signage was posted. Observation on 5/20/25 at 9:31 A.M., showed: - The resident had an isolation cart outside his/her room; - CNA A and CNA E used the mechanical lift and transferred the resident from his/her wheelchair to the bed; - The resident did not have a leg strap to secure the catheter tubing; - CNA A wiped down each side of the resident's groin and used a different wipe each time; - CNA A used the same area of the wipe to clean different areas of the perineal fold; - CNA A used a new wipe and wiped from back to front and with the same area of the wipe and cleaned different areas of the perineal folds; - CNA A and CNA E turned the resident on his/her side and cleaned the resident's buttocks and rectal area with fecal material noted; - CNA A removed his/her gloves, did not wash his/her hands and applied new gloves; - CNA A and CNA E placed a clean incontinent brief under the resident and fastened it; - CNA A placed a paper towel on the floor and placed the graduate on it; - CNA A did not clean the drainage spout and emptied the urine in it; - CNA A and CNA E dressed the resident and used the mechanical lift and transferred him/her from the bed to his/her wheelchair. During an interview on 5/21/25 at 1:45 P.M., the Training and Development Coordinator said: - Staff should anchor the catheter tubing at the insertion site and wipe down toward where the tubing attached to the drainage bag, not the other direction; - Staff should not use the same area of the wipe to clean different areas of the skin; - Staff should separate and clean all areas of the skin; - Staff should place a barrier on the floor and place the graduate on it; - Staff should make sure the tip of the spout did not touch the inside of the graduate and should clean the spout with an alcohol wipe; - The resident should have a leg strap if he/she had a catheter; - EBP, PPE is only worn when the resident had a chronic wound dressing change, during feeding tube dressing changes and only when the nurse is inserting a new catheter or changing the catheter. During an interview on 5/21/25 at 2:07 P.M., CNA A said: - In his/her opinion, the residents should have a leg strap to secure the catheter tubing, but some of the residents do not; - He/She should wipe from the front to the back; - He/She should have cleaned the drainage spout with an alcohol wipe; - Should place a paper towel or some kind of barrier under the graduate when the drainage bag is emptied; - PPE is only worn when the Foley catheter is being changed; - He/She should make sure to separate and clean all areas of the skin and should not use the same area of the wipe to clean different areas of the skin; - The catheter tubing should be anchored at the insertion site and wipe down it about four inches. During an interview on 5/21/25 at 2:36 P.M., CNA E said: - The resident should have had a leg strap to secure the catheter tubing; - When cleaning the catheter tubing, should wipe away from the insertion site; - There should have been a clean barrier under the graduate; - The spout should have been cleaned with an alcohol wipe; - Should separate and clean all areas of the skin; - Should not use the same area of the wipe to clean different areas of the skin; - The isolation carts are for when the nurses do the wound care. During an interview on 5/22/25 at 11:30 A.M., the DON said: - Some of the residents do not like to wear the leg straps and pull them off. Unsure if the policy states the resident has to have a leg strap; - The staff should clean the catheter tubing with a wipe. Staff should wipe from the insertion site down towards where it is connected to the drainage bag. It is not appropriate to wipe from where it's connected back to the insertion site; - Staff should place a barrier under the graduate; - Staff should clean the drainage spout with an alcohol wipe; - Staff should not use the same area of the wipe to clean different areas of the skin. Staff should separate and clean all areas of the skin. Based on observation, interviews, and record review the facility failed to ensure staff provided appropriate treatment and services to prevent urinary tract infections to the extent possible when the facility staff failed to ensure proper foley catheter (a flexible tube inserted through the urethra into the bladder to drain urine) care to three of the 12 sampled residents (Residents #7, #40, and #12). The facility census was 48. Review of the facility's policy Urinary Catheter Care, dated 08/23/23, showed: - Use standard precautions when handling or manipulating the drainage system; - Maintain clean technique when handling or manipulating the drainage system; - Be sure the catheter tubing and drainage bag are kept off the floor; - Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site; - Catheter tubing should be strapped to the resident's inner thigh; - The following equipment and supplies will be necessary when performing this procedure * Personal Protective Equipment (PPE) (e.g., gowns, gloves, mask, etc., as needed); * Wipes; * Trash bags; - Arrange the supplies so they can be easily reached; - Wash and dry your hands thoroughly or hand sanitize; - Set aside wipes and other clean supplies in a clean trash bag. Set aside an additional trash bag for dirty supplies; - Put on gloves; - Place bed protector under resident; - Wash resident's genitalia and perineum thoroughly with wipes; - Remove the gloves and discard into the designated container. Wash and dry your hands thoroughly or hand sanitize; - Put on clean gloves; - Change the wipe with each cleansing stroke; - Use a clean wipe to cleanse the catheter from insertion site to approximately three inches outward; - Remove gloves, hand sanitize, apply new gloves; - Secure catheter utilizing a leg band; - Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Sanitize. 1. Review of Resident #7's Significant Change Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 02/06/25, showed: - Cognitive skills severely impaired; - Substantial assistance required with activities of daily living (ADL's); - The resident had a Indwelling foley catheter; - Diagnoses included: dementia, cancer, schizophrenia; Review of the resident's Comprehensive Care Plan, dated 05/14/25, showed: - The resident had an indwelling foley catheter for bladder retention; - Nursing staff to position catheter bag and tubing below the level of the bladder. Check tubing for kinks on every shift. Monitor, record, report to physician signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no urinary output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; - The resident was totally dependent on staff for all cares; - The resident was incontinent of both bowel and bladder; Review of the resident's Physician Order Sheet (POS), dated 05/22/25, showed: - An order for new insertion of a foley catheter for urinary retention; - An order prescribed for antibiotics of Bactrim DS oral tablet 800/160 mg, one tablet by mouth two times a day for urinary tract infection (UTI) starting 05/20/25. Review of resident's Nurse's Note, dated, 01/21/25, showed the Resident was admitted to hospital for UTI with sepsis. Observation on 05/19/25 at 10:57 A.M., showed: - Catheter bag, with no protective dignity cover, hanging on the lower frame of the bed and contained urine; - The facility did not have an isolation cart outside the resident's room and no EBP signage was posted. Observation on 05/20/25 at 10:46 A.M., showed: - There was no isolation cart outside the resident's room and no signage was posted; - Certified Nursing Assistant (CNA) D entered room to change the resident's catheter bag, sanitized hands and put on gloves; - CNA D used gloved hand to open dresser drawer, reached in, and dug around to get supplies; - CNA D kinked catheter tubing using same gloved hand to stop urine flow and removed collection bag from protective dignity cover then held catheter tube dripping urine with left hand; - CNA D grabbed new replacement catheter bag with right hand and plugged it directly into the catheter tube with same gloved hands placed into dignity cover; - CNA D removed gloves and left room to get assistance. Did not wash hands; - CNA C arrived with CNA D, both washed hands and put on gloves; - CNA D and CNA C rolled the undressed resident; - CNA D removed his/her gloves, then without washing or sanitizing hands. During an interview on 05/20/25 at 11:00 A.M., CNA D stated: - Staff should have two people for catheter bag changes; - He/She should have washed hands between glove changes; - He/She is aware of using PPE for infection prevention. During an interview on 05/20/25 at 11:23 A.M., CNA A stated: - CNA's are able to change catheter bags, not the entire catheter; - Nursing staff should wash hands, apply gloves, pinch catheter at end of tubing and separate. Use alcohol to clean both ends then connect new bag; During an interview on 05/20/25 at 12:08 P.M., Licensed Practical Nurse (LPN) B stated: - Nursing staff should have their supplies laid out prior to procedure, then wash hands and apply gloves and shouldn't reach into drawers and grab other items with gloved hands; - When changing catheter bags nursing staff should clean both ends with alcohol; - When emptying catheter bags nursing staff should wipe spigot with alcohol wipe after emptying and place a barrier between floor and graduate used to collect urine; - Nursing staff don't need gowns for catheter care, but the nurse wears a gown when changing actual catheter. During an interview on 05/20/25 a 03:20 PM, LPN C stated: - Nursing staff should locate and gather all equipment first then wash hands, put on gloves so they are not digging around with gloves on for the items they need; - Nursing staff should wash/sanitize hands between glove changes and if gloves get dirty, wash and then re-apply new gloves; - The process for changing catheter bags out includes, setting up supplies, washing hands, applying gloves, then taking off old bag (draining first) and throwing it away. Then, removing gloves, wash hands, and applying new gloves; - Best to use two people for changing catheter bags; - Clean ports or connections with alcohol or betadine; - To empty catheter bag nursing staff will set up supplies, wash hands and apply gloves, put paper towels down then set the graduate on the paper towels, drain into the graduate, wipe spigot with alcohol wipe and put back. Then chart output. During an interview on 05/21/25 at 02:10 P.M. CNA F stated: - To drain a catheter bag we wash up and put on gloves, He/She wears a mask, place a towel/barrier on the floor, then place the graduate and drain urine into the graduate. Measuring while sitting flat on the ground. Check for kinks in the tubing. Take gloves off then wash hands; - At this facility he/she is told gowns are for those with chronic wounds or if there will be contact with blood; - Nursing staff can get gowns from the isolation carts which are usually outside of the rooms with chronic wounds; - Nursing staff shouldn't keep gloves in scrub pockets, it's not hygienic; - Nursing staff shouldn't put gloved hands in pockets or drawers. During an interview by phone on 05/22/25 at 08:29 A.M., the Infection Control Nurse stated: - He/She was aware that last year CMS expanded the high contact activities to include peri-care and linen changes and anyone with catheter should have a PPE box; - He/She read the CMS guidelines over and over and tried to find something that is ethical, the goal is to protect ourselves; - He/She doesn't want staff to approach patients, only with gowns and gloves on, as that did not seem like compassionate care; - Our proposal identified very specific high risk episodes and which ones would have transmission risk, and tried to keep it a family setting and where the facility doesn't have a lot of signage; - PPE totes in hall ways create a high risk for falls; - No PPE signs are up because it puts us back into COVID and this is the resident's home; - He/she was not aware of PPE options that hangs on doors; - This was policy that we came up and did not want to write a policy that was not going to be enforced; - Currently there are isolation carts for specific residents, one with a chronic wound and one with a feeding tube; - He/She has not made changing catheter bag a high risk care and nursing staff doesn't need to wear a gown. Only a full catheter change requires a gown; During an interview on 05/22/25 at 11:30 A.M., the Director of Nursing (DON) stated: - He/She expects staff to wear gloves for catheter bag changes or emptying catheter bags but does not expect isolation gowns to be worn; - After washing hands and applying gloves, staff cannot search through resident drawers for supplies, they have to re-wash hands or sanitize and apply new gloves; - Staff should wipe connecting ends of catheter bags with alcohol wipe when changing.

Based on observation, record review, and interviews, the facility failed check bed rails regularly to make sure they were still installed correctly as rails may shift or loosen over time. The facility failed to inspect and regularly check the mattress and bed rails for areas of possible entrapment, and failed to include an evaluation of attempted alternatives prior to the installation or use of a bed rail on resident beds. This included three of 12 residents sampled (Resident #1, #33, and #34). The facility census was 48. Review of facility policy, side rail policy/ grab bars, revised 5/21/25, showed: -Facility would strive to provide a safe sleeping environment for all residents. -If resident wanted or needed side rails the MDS Coordinator or Nursing would contact the physical therapy department. The original side rail assessment was completed by physical therapy department for proper use and safety. -If deemed appropriate the entrapment assessment would be done by maintenance staff to ensure the safety by using the bed system measurement device. -The MDS Coordinator designee would inform resident and/or family/guardian about risk factors. -Staff should obtain consent for the use of side rails from the resident or the resident's legal representative prior to use. -Staff would obtain an order from the attending physician for side rails. -Quarterly assessments were done to ensure side rails continued to be appropriate in electronic medical record; -Side rails would be care planned. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/6/25, showed: -Cognition intact; -He/She had no impairment to upper or lower extremity range of motion; -He/She was dependent on a walker for mobility; -He/She was independent with rolling left and right, sitting on side of bed, lying to sitting on side of bed; -He/She required partial to moderate assistance with mobility from sitting to standing and chair to bed transfers. -He/She used no physical restraints including no side rails on bed; -Diagnoses included: glaucoma, osteoarthritis, and tremors. Review of care plan, revised 3/17/25, showed: -He/She used side rails on the bed due to injury and decreased mobility; -Physical Therapy to discuss and record with resident/responsible party, the risks and benefits of the side rails, when the side rails should/will be applied, and any concerns or issues regarding side rail use. -Ensure valid consent on chart prior to initiating side rails; -Physical Therapy to evaluate side rail use quarterly: Evaluate /record continuing risks/benefits of side rail, alternatives to side rails, need for ongoing use, and reason for side rail use. Review of physician's orders, dated 5/20/25, showed on 7/28/22, side rails for mobility were ordered. During an interview on 5/19/25 at 2:26 P.M., the Resident said: -He/She used the side rails to pull self out of bed and to hang on to, for support. Observation on 5/19/25 at 2:26 P.M. showed two U- shaped side rails on both sides of the resident's bed. Review of resident's medical record, 5/20/25, showed: -On 7/21/22, the Physical Therapist completed the initial side rail assessment: -Recommendation included bilateral side rails; -Alternatives to side rails were tried; -Side rails were indicated and served as an enabler to promote independence; -The resident requested to have side rails while in bed; -On 7/22/22 a consent for side rails was signed by resident; -On 7/22/22 a physician orders for side rails was signed; -On 11/18/23, a bed system entrapment measurement test was completed and zones 1-4 passed the test; -Quarterly side rail assessments were completed 9/6/24, 6/5/24, 3/6/24, and 12/7/23. -Quarterly side rail assessment was completed on 12/5/24 -No alternative to side rails were attempted. -No additional entrapment assessments were completed. During an interview on 5/21/25 at 1:48 P.M., Certified Nurse Aide (CNA) A said: -The resident used side rails to pull up out of bed and reposition while laying in the bed. During an interview on 5/22/25 at 9:41 A.M., CNA B said: -The resident used side rails to push up out of bed or reposition self in the bed. 2. Review of Resident #33's Quarterly MDS, dated [DATE], showed: -Cognition moderately impaired; -He/She had no impairment to upper or lower extremity range of motion; -He/She was dependent on a walker for mobility; -He/She was independent with all mobility and personal hygiene; -He/She used no physical restraints including no side rail; -Diagnoses included muscle wasting and atrophy, diabetes, and high blood pressure. Review of the resident's care plan, revised 4/2/25, showed: -Resident used side rails on the bed for mobility due to weakness and decreased mobility; -Discuss and record with resident and responsible party, the risks and benefits of the side rails, when the side rails should/will be applied, and any concerns or issues regarding side rail use. -Ensure valid consent obtained prior to initiating restraint; -Evaluate resident's restraint use, quarterly: evaluate/record continuing risks/benefits of restraint, alternatives to side rails, need for ongoing use, reason for side rail use. Review of physician's orders, dated 5/20/25, showed side rails were ordered 8/5/22, for mobility. During an interview on 5/19/25 at 2:57 P.M. the Resident said: -He/She used the side rails to get in and out of bed and for repositioning while in the bed. Review of resident's medical record, dated 5/20/25, showed: -On 8/3/22 a consent for use on side rails was found signed by the resident; -On 8/4/22 a physician order was signed for side rails; -On 8/26/22 a bed system entrapment zone measurement device test was completed and zones 1-4 passed the test; -On 12/23/24, 7/31/24, 6/29/24, and 3/27/24 quarterly side rail assessments were completed; -On 3/26/25 a quarterly side rail assessment was completed and showed: -An alternative to side rails was not attempted prior to installation of side rails. During an interview on 5/21/25 at 1:48 P.M, CNA A said the resident used side rails to help pull up, roll, and get in and out of the bed. 3. Review of Resident #34's Quarterly MDS, dated [DATE], showed: -Cognition intact; -He/She had no impairment to upper or lower extremity range of motion; -He/She was independent with mobility with use of walker or wheelchair; -He/She used no physical restraints including side rail; -Diagnoses included: scoliosis, kyphosis (curvature of upper back), low back pain, presence of right artificial hip joint, and repeated falls. Review of the resident's revised care plan, dated 3/6/25, showed: -Used grab bars on bed due to hip fracture and balance. -Discuss and record with resident/responsible party, the risks and benefits of the restraint, when the restraints should will be applied, routines while restrained and any concerns or issues regarding restraint use; -Ensure valid consent obtained prior to initiating restraint; -Evaluate resident's restraint use quarterly: evaluate/record continuing risks/benefits of restraint, alternatives to restraint, need for ongoing use, reason use of restraint use. Review of physician's orders, dated 5/20/25, showed on 7/28/22, side rails were ordered bed for mobility. Observation on 5/19/25 at 11:00 A.M. showed resident had U-shaped side rails on both sides of his/her bed. During an interview on 5/19/25 at 11:00 A.M. the resident said the side rails were used to turn self over in bed. Review of resident's medical record, dated 5/20/25, showed: -On 7/21/22, consent for side rail use was signed by the resident; -On 7/25/22, a Physician order was obtained and signed for side rails; -On 9/27/23, Bed system entrapment zone measurement device test was completed which showed zones 1-4 passed the test; -On 11/24/23, 2/26/24, 5/24/24, 8/23/24, and 11/22/24 prior quarterly side rail assessments were completed. -On 2/20/25, quarterly side rail assessment was last completed and showed: -There were no alternative to side rails that had been tried; During an interview on 5/21/25 at 1:48 P.M., CNA A said the resident used side rails to get out of bed and to reposition self. During an interview on 5/22/25 at 9:41 A.M., CNA B said the resident used side rails to independently scoot up in bed or to move by grabbing onto the side rails. 4. Observation on 5/20/25 at 3:09 P.M. showed facility maintenance staff members used the bed system (A measurement device to provide clear pass or fail indicators when assessing the four critical entrapment zones of a hospital bed system.) This bed system is used to test entrapment zones. During an interview on 5/20/25 at 10:12 A.M., Licensed Practical Nurse (LPN) A said: -Sometimes residents or their families would request side rails; -The facility did not offer full side rails; -Residents who had side rails on the beds used the side rails to help them turn, reposition, or move in and out of the bed; -The MDS Coordinator would be notified if a resident requested side rails; -The Director of Rehabilitation determined if side rails were needed; -A consent for use of side rails was obtained from the resident or the resident's representative; -Side rails were care planned; -The Housekeeping Supervisor or Maintenance Supervisor installed the side rails once the side rails were approved; -Side rail assessments were completed quarterly in the electronic medical record. During an interview on 5/20/25 at 10:39 A.M., the MDS Coordinator said: -The facility provided U-shaped side rails for residents who met the criteria; -When residents requested side rails, the facility obtained a physician's order, and consent from resident or their representative; -The Housekeeping Supervisor completed entrapment zone measurements with the measuring tool the facility purchased and kept record of those measurements; -Therapy completed each resident's initial side rail assessment; -Quarterly side rail assessments were completed in the electronic medical record; -Side rails then care planned; During an interview on 5/20/25 at 10:45 A.M., the Housekeeping Supervisor said: -He had an entrapment zone measuring device that he used to do measurements on the mattress to be sure there was no place for the head or arms to get stuck in the entrapment zones; -He kept a book of completed entrapment zone bed system measurement tests; -The maintenance supervisor maintained the bed measurements; -The entrapment zone bed system measurement device was used when the side rails were placed on the bed or when the mattress on the resident's bed was changed. During an interview on 5/20/25 at 3:09 P.M., the Maintenance Supervisor said: -He measured the entrapment zones on the beds in the facility using the entrapment zone bed system measuring device, and only one time when the side rails were initially installed on the bed; -He did not measure the bed zones again, unless the mattress on the bed was changed; -The side rails on the bed could work their way loose; -He did not do routine checks on the beds to ensure the side rails were properly attached to the resident's bed; -Staff notified him if the side rails became loose; -The facility had multiple types of beds and side rails that are used throughout the facility; During an interview on 5/20/25 at 3:18 P.M., the MDS Coordinator said: -Alternatives to side rails were not attempted prior to placement of the side rails on resident beds; -Residents would notify the facility when side rails were wanted for bed mobility assistance; -Many times residents chose the side rails because someone else has them on their beds. During an interview on 5/20/25 at 3:46 P.M., the Administrator said the Director of Therapy handled alternatives to side rails for residents. During an interview on 5/21/25 at 1:33 P.M., the Director of Rehabilitation said: -Facility staff notified him when a resident requested side rails; -He completed the initial assessment for the side rails; -Most residents in the facility had side rails for mobility and not for positioning; -He would attempt putting a walker beside resident's bed or wheelchair beside bed for alternatives to side rails; -Maintenance installed the side rails or grab bars and completed the entrapment assessment. During an interview on 5/22/25 at 7:44 A.M., the Administrator said: -She did not have any residents who had side rails that were considered a restraint; -Bed mobility was primary purpose for residents with side rails; -The Director of Therapy completed the resident's initial side rail assessments -Maintenance installed side rails and used an entrapment zone bed system measuring device; -Facility obtained consent from resident or the resident's representative; -She did not know how often the entrapment zone bed system measurements were checked; -She did not think the entrapment zones were checked regularly; -Staff notified maintenance of needed side rail repairs via the maintenance book. During an interview on 5/22/25 at 11:30 A.M., the Director of Nursing said: -She expected resident's with side rails to be assessed for risks of entrapment -She expected resident's with side rails to be checked regularly for proper installation and maintenance for resident safety. -She expected alternatives to side rails to be attempted and documented prior to installation of the side rails. During an interview on 5/22/25 at 11:30 A.M., the Administrator said: -She expected resident's with side rails to be assessed for risks of entrapment. -She expected resident's with side rails to be checked regularly for proper installation and maintenance for resident safety. -She expected alternatives to side rails to be attempted and documented prior to installation of the grab bars or side rails.

3. Review of Resident #40's Significant Change in Status MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Upper extremity and lower extremity impaired on both sides; - Dependent on the assistance of staff for toilet use; - Had a Foley catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - The resident had seven antibiotics in the last seven days; - Diagnoses included traumatic brain injury, seizure, dementia and depression. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed: - Foley catheter for urinary retention. Review of the resident's undated care plan, showed: - The resident had an indwelling Foley catheter for bladder retention; - The resident had a Foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks on every shift. Monitor, record, report to physician for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, shills, altered mental status, change in behavior, change in eating patterns; - The resident is not toileted. The resident had a Foley catheter and was incontinent of bowel. Observation on 5/19/25 at 2:30 P.M., showed the facility did not have an isolation cart outside the resident's room and no EBP signage was posted. Observations on 5/19/25 at 2:34 P.M., showed: - The resident's drainage bag hung on the side of the resident's bed and was resting directly on the floor and did not have a dignity cover; - The facility did not have an isolation cart outside the resident's room. Observation on 5/20/25 at 9:09 A.M., showed: - There was an isolation cart outside the resident's room but no EBP signage was posted; - CNA D and CNA E did not wash his/her hands and applied gloves; - CNA D and CNA E did not don a gown; - CNA D and CNA E provided catheter care to the resident. - CNA D cleaned fecal material from the rectal area; - CNA D removed gloves, did not wash his/her hands and applied new gloves; - The resident did not have a leg strap to secure the catheter tubing; - CNA D placed the graduate (a clear plastic container with markings used to collect and measure fluids) directly on the resident's fall mat; - CNA D cleaned the spout with wipe and emptied the urine into the graduate; - CNA D and CNA E removed gloves and washed his/her hands. During an interview on 5/21/25 at 3:11 P.M., CNA D said: - The residents do not have to have a leg strap. That's what the nurses have told him/her; - The graduate should be placed on a clean barrier; - He/She should have cleaned the drainage spout with an alcohol wipe; - He/She should have washed his/her hands or sanitized when entering the resident's room, between glove changes and after cleaning fecal material; - He/She did not have to wear PPE because the resident had a catheter. 4. Review of Resident #12's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Dependent on the assistance of staff for transfers; - Had a Foley catheter; - Frequently incontinent of bowel; - The resident had seven antibiotics in the last seven days; - Diagnoses included urinary tract infection, anxiety and senile degeneration of the brain. Review of the resident's POS, dated May 2025 showed: - Foley catheter and change as needed related to retention of urine; - Check leg strap is in place for Foley catheter every day and evening shift. Check tubing is in place with leg strap for prevention of wound. Review of the resident's undated care plan, showed: - The resident had a Foley catheter due to UTIs and retention. Empty the Foley bag every shift and report any abnormalities to the charge nurse. Keep the Foley catheter in a bag away from sight and off the floor. Observation on 5/19/25 at 11:32 A.M., showed the facility did not have an isolation cart outside the resident's room and no EBP signage was posted. Observation on 5/20/25 at 9:31 A.M., showed: - The resident had an isolation cart outside his/her room; - CNA A and CNA E used the mechanical lift and transferred the resident from his/her wheelchair to the bed; - The resident did not have a leg strap to secure the catheter tubing; - CNA A and CNA E provided catheter care to the resident; - CNA A and CNA E turned the resident on his/her side and cleaned the resident's buttocks and rectal area with fecal material noted; - CNA A removed his/her gloves, did not wash his/her hands and applied new gloves; - CNA A and CNA E placed a clean incontinent brief under the resident and fastened it; - CNA A placed a paper towel on the floor and placed the graduate on it; - CNA A did not clean the drainage spout and emptied the urine in it; - CNA A and CNA E dressed the resident and used the mechanical lift and transferred him/her from the bed to the wheelchair. During an interview on 5/21/25 at 1:45 P.M., the Training and Development Coordinator said: - Staff should anchor the catheter tubing at the insertion site and wipe down toward where the tubing attached to the drainage bag, not the other direction; - Staff should place a barrier on the floor and place the graduate on it; - Staff should make sure the tip of the spout did not touch the inside of the graduate and should clean the spout with an alcohol wipe; - The resident should have a leg strap if he/she had a catheter; - Staff should wash their hands before and after contact with a resident, between dirty and clean tasks and between glove changes. If hands are visibly soiled, staff should wash them, otherwise staff should use hand sanitizer. When staff are cleaning fecal material, staff should removed their gloves, wash their hands and apply new gloves; - EBP is only worn when the resident had a chronic wound dressing change, during feeding tube dressing changes and only when the nurse is inserting a new catheter or changing the catheter. During an interview on 5/21/25 at 2:07 P.M., CNA A said: - The residents should have a leg strap to secure the catheter tubing, but some of the residents do not; - He/She should have cleaned the drainage spout with an alcohol wipe; - Should place a paper towel or some kind of barrier under the graduate when the drainage bag is emptied; - PPE is only worn when the Foley catheter is being changed. During an interview on 5/21/25 at 2:36 P.M., CNA E said: - The resident should have had a leg strap to secure the catheter tubing; - When cleaning the catheter tubing, should wipe away from the insertion site; - There should have been a clean barrier under the graduate; - The spout should have been cleaned with an alcohol wipe; - The isolation carts are for when the nurses do the wound care. During an interview on 5/22/25 at 11:30 A.M., the DON said: - Some of the residents do not like to wear the leg straps and pull them off. Unsure if the policy states the resident has to have a leg strap; - The staff should clean the catheter tubing with a wipe. Staff should wipe from the insertion site down towards where it is connected to the drainage bag. It is not appropriate to wipe from where it's connected back to the insertion site; - Staff should place a barrier under the graduate; - Staff should clean the drainage spout with an alcohol wipe.5. Review of Resident #9's Quarterly MDS, dated [DATE], showed: -Cognition severely impaired; -He/She was dependent for toileting hygiene; -He/She had an indwelling catheter; -Diagnoses included renal failure and neurogenic bladder. Review of care plan, revised 3/5/25, showed: -He/She had an indwelling Foley catheter: neurogenic bladder; -Position catheter bag and tubing below the level of the bladder and away from entrance room door; -Check tubing for kinks each shift; -Monitor and document intake and output as per facility policy; -Monitor, record, report to medical doctor for signs and symptoms of urinary tract infection. Review of physician's orders, dated 5/21/25, showed: -Started 12/9/24, diagnosis neurogenic bladder for Foley catheter; -Started 12/11/24, check that leg strap was in place for Foley catheter, every day and evening shift for Foley catheter Observation on 5/19/25 at 10:34 A.M. showed the resident had a catheter in place and there was no enhanced barrier precautions in place and no enhanced barrier precaution signage on resident's door. Observation on 5/20/25 at 4:15 P.M. showed the resident had an indwelling catheter and no enhanced barrier precautions were in place for resident and no enhanced barrier precaution signage on resident's door. Observation on 5/19/25 at 12:04 P.M. showed indwelling catheter remained in place. The residents room had no enhanced barrier precautions signage or PPE. Observation on 5/21/25 at 6:41 A.M. showed indwelling catheter remained in place. The residents room had no enhanced barrier precautions signage or PPE. Observation on 5/21/25 at 1:43 P.M. showed catheter was in place hanging from resident's recliner. No enhanced barrier precautions in place and no enhanced barrier precaution signage on resident's room. During an interview on 5/21/25 at 1:48 P.M., CNA A said: -He/She did not know what enhanced barrier precautions was; -When resident had a wound he/she would put on personal protective equipment (PPE) to include gown, gloves, mask, hand sanitizer; -He/She did not put on full PPE if resident had a catheter; -He/She would only apply gloves only when handling a resident's catheter; -He/She did not put on a gown when emptying resident's catheter. During an interview on 5/21/25 at 2:02 P.M., Nurse Aide (NA) A said: -He/She did not know what enhanced barrier precautions meant and thought it might be use of barrier cream; -Residents that he/she would use PPE for would be residents who had a wound, covid, influenza, or MRSA; -He/She would apply full PPE to include gown, gloves, and masks while providing cares to residents with wounds, covid, influenza, or MRSA; -Residents who had catheters and he/she provided care to, would apply gloves only and not apply full PPE; -If he/she transferred a resident with a catheter he/she would put a towel between him/her and resident while doing the transfer. During an interview on 5/22/25 at 8:29 A.M., the Infection Control Nurse said: -She was aware that last year CMS expanded their precautions for transmission based precautions; -The facility team read the new CMS guidelines over and over and tried to find something methodical to implement to protect themselves and drafted something that was reasonable, practical, and doable and not just something to be implemented when the state survey team was in the facility; -The facility did not feel that approaching patients with gowns and gloves was providing compassionate care, especially residents who were nearing the end of life; -The facility did not use enhanced barrier precaution signage; -The facility was aware the CMS guidelines required PPE for residents with catheters; -Facility felt signage for Enhanced Barrier Precautions was not homelike; -Isolation carts with PPE were used only for specific patients with chronic wounds, feeding tubes, or specific cases; -Enhanced barrier precautions was used for chronic medical issues which was defined as a condition occurring three months or longer. During an interview on 5/22/25 at 9:41 A.M., the CNA B said: -He/She did not know what enhanced barrier precautions was; -He/She would apply PPE when resident had illnesses such as MRSA, influenza, and COVID; -There would be a sign on a resident's door to contact the nurse before entry on resident's rooms when contact precautions should be in place. During an interview on 5/22/25 at 11:30 A.M., Director of Nursing (DON) said: -She expected staff to use gloves when providing catheter care to residents with indwelling catheters but did not expect full personal protective equipment; -She expected enhanced barrier precautions to be used when changing out the catheter bag only. 6. Review of Resident #19's Quarterly MDS, dated [DATE], showed; -Cognitively intact; -He/She was independent with most cares and mobility; -He/She required partial to moderate assistance with putting on and taking off footwear; -He/She was at risk of pressure ulcers but had no unhealed pressure ulcers; -Diagnoses included chronic kidney disease, venous insufficiency (condition when veins in the legs are unable to return blood back to heart effectively leading to a buildup of pressure and fluid in lower extremities), and lymphedema. Review of care plan, revised 3/6/25, showed: -Resident had potential or actual impairment to skin integrity due to edema; -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; -Resident had renal insufficiency due to kidney disease; -Elevate feet when sitting up in chair to prevent dependent edema. Review of physician's orders, dated 5/22/25, showed: -Ordered 5/15/25, started 5/19/25, left side leg treatment: skin prep peri wound, apply gentamycin, apply hydrotherablue, then wrap with URgo2 leg wraps. Do on Mondays and Thursday. every day shift every Monday and Thursday for wound and edema; -Ordered 5/15/25, started 5/19/25, right side leg treatment: apply collagen powder, hydrotherablue, skin prep peri wound, and wrap with Urgok2 wrap. every day shift every Monday, Thursday for wound; -Ordered 5/19/25, started 5/19/25, Clindamycin HCl Oral Capsule 300 Mg, give 300 capsule by mouth two times a day for wound to legs until 5/25/25. Review of Medication Administration Record (MARS), dated 5/1/25-5/31/25, showed: -Started 5/1/25, Clindamycin HCL oral capsule 300 MG, give 300 mg by mouth two times a day for infection wound for 10 days, ended 5/11/25; -Received first dose 5/1/25 at 5:00 P.M.; -Received last dose 5/11/25 at 8:00 A.M.; -Started 5/15/25, Clindamycin HCL oral capsule 300 MG, give 300 capsule by mouth two times a day for wound to legs, ended 5/19/25; -Received first dose 5/15/25 at 5:00 P.M.; -Received last dose 5/19/25 at 8:00 A.M.; -Started 5/19/25, Clindamycin HCL oral capsule 300 MG, give 300 capsule by mouth two times a day for wound to lets until 5/25/25; -Received first dose 5/19/25 at 5:00 P.M.; During an interview on 5/19/25 at 4:22 P.M. resident said had edema and the left leg had a hole in skin that was starting to heal but itched like crazy. Observation on 5/19/25 at 4:22 P.M. showed resident had the legs wrapped. No enhanced barrier precautions were in place in resident's room and no enhanced barrier precautions signs were on resident's room. Observation on 5/20/25 at 4:12 P.M. showed the resident who had open wounds and had no enhanced barrier precautions were in place or signage on resident's door. Observation on 5/21/25 at 6:38 A.M. showed the resident with wounds had no enhanced barrier precautions in place in resident's room or signage on the door. Observation on 5/21/25 at 1:40 P.M. showed resident with wounds had no enhanced barrier precautions in place and no enhanced barrier precaution signage on resident's room. During an interview on 5/22/25 at 11:30 A.M., the DON said: -Enhanced barrier precautions were implemented only after chronic wounds were in place after three months; -Enhanced barrier precautions were not in place for Resident #19 because facility had just started wrapping resident's venous legs again; -Resident's on enhanced barrier precautions should have a PPE cart near their room During an interview on 5/22/25 at 11:30 A.M., the Administrator said: -Their should be signage in place near a resident's room to alert staff when resident required enhanced barrier precautions; -Signage is not homelike so staff did not not have enhanced barrier precaution signage in place; -New infection control standards showed that just because a resident had a catheter in place staff would need to glove up, gown up, and utilize enhanced barrier precautions when a resident may or may not have any sort infection; -Resident's on enhanced barrier precautions should have a PPE cart near their room. Based on observation, interview, and record review, the facility failed to ensure staff established and followed infection control practices regarding urinary catheters (a flexible tube inserted through the urethra or suprapubically, through a small incision in the abdomen, into the bladder to drain urine) resulting in increased urinary tract infection (UTI) risk for four residents (Residents #7, #9, #12, and #40) and pressure ulcers (a wound that develops due to prolonged pressure on the skin and underlying tissue, often occurring over bony prominences like the hips, heels, and tailbone) for two residents (Residents #13 and #19) when proper standard precautions and Enhanced Barrier Precautions (EBP) were not utilized by staff. This affected six of the 12 sampled residents. The facility census was 48. Review of the facility's policy, Urinary Catheter Care, dated 08/23/23, showed: - Use standard precautions when handling or manipulating the drainage system; - Maintain clean technique when handling or manipulating the drainage system; - Be sure the catheter tubing and drainage bag are kept off the floor; - Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site; - Catheter tubing should be strapped to the resident's inner thigh; - The following equipment and supplies will be necessary when performing this procedure * Personal Protective Equipment (PPE) (e.g., gowns, gloves, mask, etc., as needed); * Wipes; * Trash bags; - Arrange the supplies so they can be easily reached; - Wash and dry your hands thoroughly or hand sanitize; - Set aside wipes and other clean supplies in a clean trash bag. Set aside an additional trash bag for dirty supplies; - Put on gloves; - Place bed protector under resident; - Wash resident's genitalia and perineum thoroughly with wipes; - Remove the gloves and discard into the designated container. Wash and dry your hands thoroughly or hand sanitize; - Put on clean gloves; - Change the wipe with each cleansing stroke; - Use a clean wipe to cleanse the catheter from insertion site to approximately three inches outward; - Remove gloves, hand sanitize, apply new gloves; - Secure catheter utilizing a leg band; - Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Sanitize. Review of the facility's policy, Wound Care, dated 08/23/23, showed: - Assemble the equipment and supplies needed; - Personal protective equipment (gloves, gowns, etc, as indicated); - Use disposable cloth or paper towel to establish a clean field. Place all the items to be used during the procedure on the clean field. Arrange the supplies so they can be easily reached; - Wash and dry your hands thoroughly; - Position resident. Place disposable cloth next to resident (under wound) to serve as a barrier to protect the bed linen and other body sites as necessary; - Put on exam glove and loosen tape and remove dressing; - Pull glove over dressing and discard into appropriate receptacle. Wash and dry hand thoroughly; - Put on gloves. Gown if chronic wound or soiling of your skin or clothing with body fluids is likely. Review of the facility's policy, Enhanced Barrier Precautions (EBP), dated 08/06/24, showed: - EBP employs gown and glove use during targeted high contact resident care activities; - EBP are indicated for resident with infection or colonization with Centers for Disease Control (CDC) targeted Multi-Drug Resistant Organism (MDRO) when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices are present, even if the resident is not known to be infected or colonized with MDRO; - Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies; - High risk patient care activities includes; * Foley catheter insertion/change; * Dressing change for chronic wounds, tracheostomy and feeding tube; * When patient has excretions or secretions that are unable to be contained; - EBP must be implemented for any resident who has a chronic wound or indwelling medical device or secretions/excretions that are unable to be covered or contained, during high risk activities regardless if the are infected or colonized with CDC-targeted MDRO; - Use of EBP should remain in place until resolution of the wound or discontinuation of the indwelling device; - Employees will be aware of the use of EBP by signage on the residents' door and PPE stationed outside the residents door. 1. Review of Resident #7's Significant Change Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 02/06/25, showed: - Cognitive skills severely impaired; - Substantial assistance required with activities of daily living (ADL's); - Indwelling urinary catheter; - Diagnoses included: dementia, cancer, schizophrenia. Review of the resident's Comprehensive Care Plan, dated 05/14/25, showed: - The resident had an indwelling Foley catheter for bladder retention; - The resident had a Foley catheter. Nursing staff to position the catheter bag and tubing below the level of the bladder. Check catheter tubing for kinks on every shift. Monitor, record, report to physician signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no urinary output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; - The resident was dependent on nursing staff for care and all ADLs, including positioning and mobility. Review of the resident's Physician Order Sheet (POS), dated 05/22/25, showed: - Order for re-insertion of Foley catheter for urinary retention; - An order for anitiobic medication of Bactrim DS oral tablet 800-160 mg one tablet by mouth two times a day for urinary tract infection (UTI) starting on 05/20/25. Review of the resident's Nurse's Note, dated, 01/21/25, showed the resident was admitted to the hospital for UTI. Observation on 05/19/25 at 10:57 A.M., showed: - Urinary catheter bag, did not have a dignity cover, attached on the middle of the lower frame on the bed and contained urine; - The facility did not have an isolation cart outside the resident's room and no EBP signage was posted. Observation on 05/20/25 at 10:46 A.M., showed: - There was no isolation cart outside the resident's room and no EBP signage was posted; - Certified Nursing Assistant (CNA) D entered the room to change the resident's catheter bag, sanitized hands and put on gloves; - CNA D used gloved hand to open dresser drawer, reached in, and dug around to get supplies; then with gloved and CNA D kinked catheter tubing to stop urine flow and removed bag, held catheter tube with urine dripping from left hand; - CNA D grabbed new replacement collection bag with right hand and plugged new collection bag directly into catheter tube with same gloved hands then placed into the dignity bag; - CNA D removed gloves and left room to get assistance. Did not wash hands; - CNA D removed his/her gloves then, without washing or sanitizing hands. During an interview on 05/20/25 at 11:00 A.M., CNA D stated: - Staff should have two people for catheter bag changes; - He/She should wash hands between glove changes; - He/She is aware of using PPE for infections but had not heard about using gowns with catheters or wounds. During an interview on 05/20/25 at 11:05 A.M., CNA C stated: - The facility had gone over EBP with him/her called PPE training; - That if the facility had infections like airborne or blood borne, urine, covid, or the flu EBP PPE would be worn; - He/She had never heard about wearing gowns for cares with residents having catheters or wounds. 2. Review of Resident #13's Quarterly MDS, dated [DATE], showed: - Cognitively intact; - Substantial assistance required with ADL's; - Diagnoses included: high blood pressure, heart failure, and UTI. Review of the resident's Comprehensive Care Plan, dated 05/05/25, showed: - The resident had stress, functional, and mixed bladder incontinence related to impaired mobility; - The resident had potential for pressure ulcer development related to immobility; - Required pressure relieving device on wheelchair; - Staff will follow facility policies/protocols for the prevention/treatment of skin breakdown; - Required skin inspection weekly by the charge nurse. Observing for redness, open areas, scratches, cuts, bruises and report changes to the nurse. -Required assistance of nursing staff for all ADLS regarding peri/incontinent care, and positioning and mobility. Review of the resident's POS, dated 05/22/25, showed-Wound care order to right inner ankle area. Order to cleanse wound with hypochlorous acid, apply skin prep to peri wound area, then apply santyl medicated ointment, nickel thick, cover with border gauze dressing to wound daily and as needed. Observation on 05/19/25 at 04:36 P.M., showed the facility did not have any PPE isolation cart outside the resident's room and no EBP signage was posted. Observation on 05/21/25 at 09:11 A.M., showed: - Training and Development Coordinator gathered supplies for dressing change and read the wound care order. Sanitized his/her hands and applied gloves in the hallway. Collected a disposable clean field cloth from top of the treatment cart to use as a barrier - Placed barrier beneath resident's right foot and placed a red biohazard (infected or contaminated waste) trash bag next to resident; - Removed old dressing and placed it in red bag without changing gloves prior to cleaning; - Cleaned with hypochlorous acid and applied skin prep to peri wound area; - Removed gloves, sanitized, and reached into his/her scrub shirt pocket retrieving a set of gloves and applied them; - Applied santyl medicated ointment nickel thick to wound bed then covered with border gauze applied over wound and placed the rest of items and dirty gloves into red biohazard bag; - Washed hands, then helped put a sock back on residents foot During an interview on 05/21/25 at 09:28 A.M., the Training and Development Coordinator stated: - Nursing staff use EBP when it is a chronic wound and when changing dressings with a feeding tube or tracheostomy, this resident's stage III wound isn't chronic so PPE is not used; - Nursing staff only use EBP with residents with catheters and only when changing the catheter itself; - He/She would not put on clean gloves and then put gloved hands into pockets because it would contaminate the gloves. During an interview on 05/20/25 at 11:23 A.M., CNA A stated: - CNA's are able to change catheter bags, not the entire catheter; - Nursing staff should wash hands, apply gloves, pinch catheter at end of tubing and separate. Use alcohol to clean both ends then connect new catheter bag; - EBP is like PPE. We use it for wounds longer than three months or if a resident has flu or covid; - He/She didn't think EBP was used with catheters. He/She hadn't been trained about that; During an interview on 05/20/25 at 12:08 P.M., Licensed Practical Nurse (LPN) B stated: - Nursing staff should have treatment supplies laid out prior to procedure, then wash hands and apply gloves and shouldn't touch other items or areas in the room with gloved hands; - When changing catheter bags nursing staff should clean both ends with alcohol; - When emptying catheter bags nursing staff should wipe spigot with alcohol wipe after emptying and place a barrier between floor and use a graduate used to collect urine; - Nursing staff should wear EBP-PPE if someone has an infection and chronic wounds. Staff do not need isolation gowns for catheter care, but the nurse wears a gown when changing actual catheter. During an interview on 05/20/25 a 03:20 PM, LPN C stated: - Nursing staff should locate and gather all equipment first then wash hands, then put on gloves; - Nursing staff should wash/sanitize hands between glove changes and if gloves get dirty, wash and then apply new gloves; - The process for changing catheter bags out includes setting up supplies, washing hands, applying gloves, then taking off old bag (draining first) and throw away. Then removing gloves, wash hands, and applying new gloves; - It is best to use two people for changing catheter bags; - Clean ports or connections with alcohol or betadine; - EBP is used if resident has flu or covid, or wound dressings but supposed to use EBP for catheter care according to new policy; - To empty catheter bag nursing staff will set up supplies, wash hands and apply gloves, put paper towels down then set the graduate on the paper towels, drain into the graduate, wipe spigot with alcohol wipe and put back. Then chart output. Observations on 05/22/25 at 08:55 A.M., showed: - The facility did not have an isolation cart outside resident #19's room and no EBP signage was posted; - The facility did not have an isolation cart outside resident #7's room and no EBP signage was posted; - The facility did not have an isolation cart outside resident #13's room and no EBP signage was posted; - The facility did have an isolation cart outside resident #40's room but no EBP signage was posted; - The facility did have an isolation cart outside resident #12's room but no EBP signage was posted. During an interview by phone on 05/22/25 at 08:29 A.M., the Infection Control Nurse stated: - She was aware that last year CMS expanded the high contact activities to include peri-care and linen changes and anyone with catheter should have a PPE box; - She read the CMS guidelines over and over and believed the new guidance was not ethical; - By using EBP staff are treating all residents as if they have bacteria; - She doesn't want staff to approach patients, only with gowns and gloves on, and stated that did not seem like compassionate care; - The facility's policy identified very specific high risk residents and which ones would have transmission risk. Identified the high risk things which needed EBP and when there was a high risk of transmission,tried to keep a family setting and where the facility doesn't have a lot of signage; - EBP-PPE totes in hall ways are high risk for resident falls; - No isolation signs are up because it puts us back into COVID and this is the resident's home; - She was not aware of PPE storage options that hang on doors; - This was a policy that the facility came up and did not want to write a policy that was not going to be enforced; - Currently there are isolation carts for specific residents, one with a chronic wound and one with a feeding tube; - She has not made changing catheter bag a high risk care and nursing staff doesn't need to wear a gown. Only a full catheter change requires a gown; - The facility uses the medical definition of chronic wound being present three months or longer. During an interview on 05/22/25 at 11:30 A.M., the Director of Nursing (DON) stated: - She expects staff to wear gloves for catheter bag changes or emptying catheter bags but does not expect EBP to be worn; - After washing hands and applying gloves, staff cannot search through resident drawers for supplies, they have to re-wash their hands or sanitize and apply new gloves; - When performin

Based on observation, interview, and record review, and the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep all hair contained in hair restraints, failed to label and date food when it was opened, and failed to complete temperature checks on the refrigerator and freezers. This had the potential to impact all residents in the facility. The facility census was 48. 1. Review of facility policy, Hair Restraints, dated 5/29/24, showed: -Hair restraints shall be worn by all dietary staff when in food production areas, dishwashing areas, or serving food. -Staff shall wear hair restraints in all food production, dishwashing, and serving areas. -Hair restraints, such as hairnets, hats, hair bonnets, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair was discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production, serving, and dishwashing areas. -Hair bonnets are to be one shift use and washed. Observation on 5/21/25 at 8:52 A.M. showed Dietary Aide A wore a hair net with long strands of his/her hair hanging out of the hairnet and down past the ear and neckline. Observation on 5/21/25 at 11:11 A.M. showed [NAME] B entered the kitchen and wore a baseball cap backwards over his/her hair. Two inches of hair from [NAME] B's bangs were observed sticking out of the opening of the back of the hat and long strands of hair 3-4 inches in length stuck out the sides and back of the hat. Observation on 5/21/25 at 11:28 A.M. showed Dietary Aide A had 3-4 strands of hair hanging down to neck line out of the back and sides of the hairnet. During an interview on 5/21/25 at 11:50 A.M., [NAME] B said: -He/She did not wear hair nets; -Dietary manager approved for the hat to be worn; -Beard coverings should be worn with any facial hair; During an interview on 5/22/25 at 8:47 A.M. Dietary Aide A said: -Hairnets should be worn at all times while working in the kitchen; -No hair should hang out of the hairnet; -The Dietary Manager provided a reminder that morning that no hair should hang out of the hairnet; -The hairnet worn yesterday did not cover his/her hair as it should have. During an interview on 5/22/25 at 8:53 A.M. [NAME] C said: -While working in the dietary department hairnets or hats were to be worn with all strands of hair pulled tight into the hairnet or hat; -Hair was not allowed to hang out of the hairnet or hat. During an interview on 5/22/25 at 8:59 A.M., [NAME] A said: -Staff in the dietary department had to keep hair covered at all times; -Hair could not hang out of hairnet or a hat while working in the dietary department; -Beard coverings were to be worn to cover facial hair while working in the dietary department; During an interview on 5/22/25 at 9:05 A.M., the Dietary Manager said: -She expected dietary staff to wear hair restraints; -She expected dietary staff to have all hair covered, controlled, and fastened so it was not hanging out of a hairnet or hat; -Staff with beards had to wear beard covers; -Cook B's hair on 5/21/25 did not meet her expectations of appropriate hair restraint due to [NAME] B's hair was sticking out of the hat; -She had observed Dietary Aide A's hair sticking out of the hairnet and advised Dietary Aide A that the hair was not appropriate and provided a hair tie for the Dietary Aide A secure the hair. During an interview on 5/22/25 at 11:30 A.M., the Administrator said: -She expected staff working in the dietary department to have all hair covered and restrained. 2. Review of facility policy, Refrigerator and Freezer Temperatures, dated 2020, showed -To ensure all perishable foods stay fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use, including unit refrigerators located in the nourishment rooms. -Dining services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers and recording temperatures on the temperature report logs daily during each shift. -The temperature of each refrigeration and freezer unit is checked by the staff member who was closing the department for the day. Review of facility policy, Food Receiving and Storage, Revised December 2008, showed: -Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements. Observation on 5/19/25 at 9:17 A.M. showed during the initial tour of the kitchen the refrigerator and freezer temperature log by entry of walk-in cooler had no entries during the evening PM shift columns on 5/5, 5/7, 5/8, 5/14, 5/15, 5/19 for the refrigerator and no entries on Freezer log for PM on 5/5, 5/7, 5/8, 5/14, 5/15, 5/19. During an interview on 5/22/25 a5 8:47 A.M., Dietary Aide A said the cook was responsible for checking refrigerator and freezer temperatures during each shift. During an interview on 5/22/25 at 8:53 A.M., [NAME] C said the refrigerator and freezer temperatures were checked and logged by the cook three times a day. During an interview on 5/22/25 at 8:59 A.M., [NAME] A said temperature checks were the responsibility of the cook and freezer checks done one time during each shift. During an interview on 5/22/25 at 9:05 A.M., the Dietary Manager said: -She expected staff to check the refrigerator and freezer temperatures every day on day shift and on night shift; -She had one employee who struggled to check and record the refrigerator and freezer temperatures. During an interview on 5/22/25 at 11:30 A.M., the Administrator said: -She expected the refrigerator and freezer temperatures to be checked for proper holding temperature each shift; -She expected the temperature checks to be documented. 3. Review of facility policy, Food Receiving and Storage, revised December 2008, showed: -All foods stored in the refrigerator or freezer would be covered, labeled, and dated with 'use by' date. -Beverages must be dated when opened and discarded after twenty-four hours. Observation on 5/19/25 at 9:17 A.M. during initial tour showed: -Opened and undated 16 count hamburger buns; -Opened and undated hot dog buns; In the walk-in refrigerator: -Opened and undated 1-gallon whole milk; -Opened and undated 1 gallon orange juice; -Opened and undated 46 oz juice; -Opened and undated 14 oz prune juice; -Opened and undated 24 oz chocolate syrup; -Opened mandarin oranges and no used by date; -Unlabeled and undated container of chopped lettuce. During an interview on 5/22/25 at 8:47 A.M., Dietary Aide A said: -Food should be dated as soon as it was opened or placed in a container; -All food and beverages should have an opened by date. During an interview on 5/22/25 at 8:53 A.M., [NAME] C said: -Food should be dated as soon as it was placed in a container; -Cooked food could be maintained for 7 days; -All foods should have a date on it of when it was opened. During an interview on 5/22/25 at 8:59 A.M., [NAME] A said: -All foods and beverages should have date of when it was opened on; -Cooked food could be maintained for 7 days counting the day it was prepared; -Spices could be maintained for one year from opening; -Containers of dressing could be maintained for one month from opening; -All staff were expected to date and label anything they placed in the refrigerator. During an interview on 5/22/25 at 9:05 A.M., the Dietary Manager said she expected all food and beverages to be dated when opened. During an interview on 5/22/25 at 11:30 A.M., the Administrator said he expected all food to be dated and labeled.

Based on observation, interview, and facility policy review, the facility failed to maintain professional standards in the kitchen. Specifically, the facility failed to ensure dented canned foods were not in circulation in 1 of 1 dry storage area observed. This had the potential to affect all 55 residents who resided in the facility and received meals from the kitchen. Findings included: A facility policy titled, Food Receiving and Storage, revised 05/29/2024, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. The policy also indicated, When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. During an interview on 05/29/2024 at 2:56 PM, the Administrator stated the facility had no specific policy regarding dented canned food. Observations of the facility's dry storage area on 05/28/2024 at 10:08 AM revealed compromised canned foods in the facility storage rack, specifically: - One unlabeled 6-pound can of food had dents along the rim, - One dented 46 ounce (oz.) can of V8, - One unlabeled 3-pound can was in with other 3 pound cans of cream of mushroom soup, and - One dented rim of a 55 oz can of olives. Further observation revealed no designated dented can area was seen in the dry storage area. During an interview on 05/29/2024 at 10:29 AM, the Certified Dietary Manager (CDM) stated canned foods could be put away by anyone, but she preferred to put away the deliveries. She stated some of the dietary staff would take initiative and put things away on their own. She stated she would come in to find things everywhere at times. During an interview on 05/29/2024 at 11:38 AM, [NAME] #8 stated that when putting deliveries away she would make sure items received were not open or dented. She stated damaged items were put aside so the facility could get credit from the distributor. She stated that when she found damaged items she took a picture and sent it to the CDM. She stated she would then remove the damaged item and write on it that it was damaged and to not be used. Follow-up observations of the facility's dry storage area on 05/29/2024 at 11:44 AM revealed compromised canned goods in the facility storage rack, specifically: - Two dented 6-pound cans of sweet potatoes, both had dented rims, and - One dented 6.5-pound can of pinto beans. During an interview on 05/29/2024 at 11:55 AM, the CDM stated dented cans could allow oxygen into the canned food, causing microbe and bacteria growth and making the food unsafe and could cause illness. During an interview on 05/29/2024 at 12:22 PM, Dietary Aide (DA) #7 stated all dietary staff were to help unload the deliveries. He stated he would put deliveries away, and canned goods that were damaged or unlabeled should be thrown away. He stated if the distributor was alerted of the damaged product in the allotted timeframe the facility would get a credit. During an interview on 05/29/2024 at 12:30 PM, [NAME] #9 stated she had worked in the facility kitchen for a year and a half. She stated she was told by the CDM that they were going to be putting away the deliveries. She stated she had not help put away dry goods recently. She stated canned goods should be inspected for dents around the lid to make sure the food was not open and possibly contaminated. She stated if a can was dented it should be removed to the CMD's office. Observations in the CDM's office on 05/29/2024 at 12:40 PM after the CDM had gone through the dry storage can rack revealed that 36 compromised cans of food had been removed in total from the dry storage can rack, this included the compromised cans observed on 05/28/2024 at 10:08 AM and 05/29/2024 at 11:44 AM. Two cans were unlabeled and the other 34 were dented. The removed cans were all either 6-pounds or 46 oz of various foods. During an interview on 05/29/2024 at 1:00 PM, the Administrator stated if canned goods were delivered dented, they should be sent back and not used. She stated if dented cans of food were found after delivery they should be labeled and removed from storage. During an interview on 05/31/2024 at 1:06 PM, the Director of Nursing Services (DNS) stated dented cans of food should not be on the rack in dry storage. She stated she was unaware of the risks regarding compromised canned foods.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Certified Medication Technicians [CMT] #4) of 4 staff observed during medication administration wore gloves while performing fingerstick blood sugar checks and washed hands between residents for 2 (Resident #47 and Resident #41) of 6 residents observed during medication pass observations. In addition, the facility failed to ensure oxygen supplies were labeled and stored in a manner to prevent the development or spread of infection for 1 (Resident #3) of 3 residents reviewed for respiratory care. Findings included: 1. A facility policy titled, Obtaining a Fingerstick Glucose Level, revised 06/26/2017, indicated, The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. The policy The policy revealed the Steps in the Procedure included, 6. Wear clean gloves and 19. Wash hands or hand sanitize. A facility policy titled, Personal Protective Equipment - Gloves, reviewed on 05/30/2024, revealed Gloves must be worn when handling blood, body fluids, secretions, mucous membranes, and/or non-intact skin. The policy further revealed, 8. Wash your hands after removing gloves. An Admission Record revealed the facility admitted Resident #47 on 11/21/2023. According to the Admission Record, Resident #47 had a medical history that included a diagnosis of type one diabetes mellitus without complications. Resident #47's Order Summary Report, listing active orders as of 05/31/2024, contained an order, dated 01/24/2024, to complete fingerstick blood sugar checks four times a day. An Admission Record revealed the facility admitted Resident #41 on 06/29/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with unspecified complications. Resident #41's Order Summary Report, listing active orders as of 05/31/2024, contained an order, dated 12/21/2023, to complete fingerstick blood sugar checks three times a day before meals. During medication pass observations on 05/30/2024 at 11:36 AM, CMT #4 entered Resident #47's room and completed a fingerstick blood sugar check without donning gloves. After completing Resident #47's fingerstick blood sugar check, CMT #4 did not wash her hands, and proceeded to complete a fingerstick blood sugar check for Resident #41 at 11:45 AM, again without donning gloves. CMT #4 was interviewed on 05/30/2024 at 11:59 AM. CMT #4 stated she had no explanation for not washing her hands between the residents. CMT #4 further stated it was the facility's policy to wear gloves when there was a potential for contact with blood, such as fingerstick blood sugar checks. Per CMT #4, she forgot to wear gloves when completing the residents' blood sugar checks. The Director of Nursing Services (DNS) was interviewed on 05/31/2024 at 1:32 PM. The DNS stated staff were expected to wash or sanitize their hands after patient care, any time the hands were soiled, and after completing a fingerstick blood sugar check. The DNS stated staff were also expected to wear gloves when performing blood sugar checks. The Administrator was interviewed on 05/31/2024 at 1:22 PM. The Administrator stated she expected staff to wash or sanitize their hands between resident care, including fingerstick blood sugar checks. She further stated she expected staff to use gloves when performing blood sugar checks due to potential contact with blood. 39714 2. A facility policy titled, Oxygen Administration, revised in 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration; however, the policy did not address infection control measures for labeling or storage of oxygen equipment/supplies. During an interview on 05/31/2024 at 12:20 PM, the Director of Nursing Services (DNS) stated that night shift staff should change oxygen tubing once per week. The DNS stated the tubing should be labeled and stored in a blue bag. An Admission Record revealed the facility admitted Resident #3 on 06/19/2023. According to the Admission Record, the resident had a medical history that included diagnoses of pneumonia and heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #3's Order Summary Report, listing active orders as of 05/31/2024, contained an order, started on 06/19/2023, for two liters of supplemental oxygen via nasal cannula as needed for shortness of air. The Order Summary Report also contained an order, started on 06/19/2023, for two liters of supplemental oxygen via NC at bedtime for hypoxia (low blood oxygen levels). On 05/28/2024 at 8:34 AM, an observation of Resident #3 revealed the resident's oxygen tubing and nasal cannula were lying on the resident's bed. The nasal cannula was not stored in a bag and the tubing was not dated. During an interview on 05/28/2024 at 8:35 AM, Resident #3 stated that they had been utilizing supplemental oxygen since returning from the hospital. Resident #3 stated they only used supplemental oxygen at night. An observation on 05/29/2024 at 2:12 PM, revealed Resident #3's nasal cannula and oxygen tubing were hanging on the resident's bed rail. The tubing was dated 05/29/2024 but was not stored in a bag. During an interview on 05/29/2024 at 2:12 PM, Resident #3 stated staff put a date on the tubing during the morning on 05/29/2024. An observation on 05/30/2204 at 9:45 AM, revealed Resident #3's nasal cannula and oxygen tubing were hanging on the resident's bed rail, and the tubing was not dated and was not stored in a bag. During an interview on 05/30/2024 at 2:02 PM, Certified Nurse Aide (CNA) #1 revealed Resident #3 only used oxygen at night when in bed and staff shut off the oxygen machine during the day. CNA #1 stated that the oxygen tubing normally just hung on the bed rail, and no one really put it in a bag. During an interview on 05/31/2024 at 8:54 AM, Certified Medication Technician (CMT) #14 stated night shift staff was responsible for changing oxygen tubing every week, and the day shift staff were responsible for monitoring to ensure the tubing stayed clean. The CMT stated Resident #3 only utilized oxygen at night, and when not in use, the tubing should be stored in a bag and dated. During an interview on 05/31/2024 at 9:20 AM, Registered Nurse (RN) #5 stated night shift staff were responsible for changing and dating oxygen tubing. During an interview on 05/31/2024 at 11:32 AM, the MDS Coordinator stated Resident #3 only used oxygen at night. She stated typically, the night shift charge nurse dated and stored the tubing when the tubing was changed. An interview with the Administrator on 05/31/2024 at 2:05 PM revealed their expectation was for oxygen tubing to be dated and stored in a bag.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure only licensed personnel adjusted the flow rate on an oxygen concentrator for 1 (Resident #45) of 3 residents reviewed for supplemental oxygen use. Findings included: A facility policy titled, Administering Medications, reviewed 05/12/2017, revealed, Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. An Admission Record revealed the facility admitted Resident #45 on 03/19/2024. According to the admission record, Resident #45 had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #45 had an active diagnosis of asthma, COPD, or chronic lung disease. The MDS indicated Resident #45 received oxygen therapy while a resident. Resident #45's care plan revealed a focus area initiated 04/02/2024, that indicated Resident #45 had diagnoses of emphysema and COPD. Interventions directed staff to give oxygen therapy as ordered by the physician (initiated 04/02/2024). Resident #45's Order Summary Report, with active physician's orders as of 05/29/2024, revealed an order for supplemental oxygen to be delivered at 2 to 3 liters by nasal cannula (NC) to maintain blood oxygen saturation levels above 91 percent (%) each shift, with a start date of 03/19/2024. An observation on 05/29/2024 at 1:52 PM revealed Resident #45's oxygen concentrator was set to deliver 2.5 liters per minute by NC. During an interview at the time of the observation, Resident #45 stated they had just finished walking with therapy staff and was short of breath. Resident #45 activated their call light at 2:55 PM. At 3:05 PM Certified Nurse Aide (CNA) #1 entered the room and adjusted the resident's oxygen concentrator to deliver 3 liters of supplemental oxygen per minute. CNA #1 was interviewed on 05/30/2024 at 12:53 PM. CNA #1 stated she had not completed a Certified Medication Technician (CMT) course and was not allowed to administer medication. CNA #1 stated she had been taught that supplemental oxygen was a medication, and she was not allowed to change the setting on an oxygen concentrator. CNA #1 acknowledged she had adjusted Resident #45's supplemental oxygen on 05/29/2024 and stated she did not know why and added that she was not thinking and just wanted to give Resident #45 supplemental oxygen. CNA #1 sated she realized afterwards that she should not have altered the resident's oxygen concentrator and should have reported Resident #45's shortness of breath to the Director of Nursing Services (DNS). CMT #4 was interviewed on 05/31/2024 at 9:23 AM. CMT #4 stated either a nurse or a CMT could change the setting on an oxygen concentrator. CMT #4 stated supplemental oxygen was considered a medication and a CNA was not able to change an oxygen concentrator's setting. Registered Nurse (RN) #5 was interviewed on 05/31/2024 at 10:43 AM. RN #5 stated nurses were responsible for adjusting oxygen concentrators and added that she did not think the CMTs were allowed to adjust the oxygen concentrators and stated that CNAs were not allowed to adjust oxygen concentrators. RN #5 stated that she considered supplemental oxygen a medication and if a CNA adjusted an oxygen concentrator, it may cause under oxygenation or over oxygenation of a resident. The DNS was interviewed on 05/31/2024 at 12:55 PM. The DNS stated she did not consider supplemental oxygen a medication. The DNS stated the CNAs had completed an oxygen safety course that included instruction on setting up portable oxygen tanks and making sure the tanks had no oxygen leaks. The DNS stated the CNAs were shown how to know if a resident was receiving the correct dosage of supplemental oxygen. The DNS stated prior to adjusting the supplemental oxygen flow rate, she expected the CNAs to check with the nurse. The DNS stated she was the nurse on duty when CNA #1 adjusted the supplemental oxygen flow rate for Resident #45 and added that the CNA had not reported that Resident #45 was short of breath or that she had adjusted the resident's supplemental oxygen flow rate on the concentrator. The DNS stated it was not unusual for Resident #45 to become short of breath with activity, but the shortness of breath resolved when the resident rested. The Administrator was interviewed on 05/31/2024 at 1:22 PM. The Administrator stated a physician's order was needed for supplemental oxygen but added that she was not sure if supplemental oxygen was considered a medication but stated that it probably was. The Administrator stated the CNAs were not expected to adjust a resident's oxygen concentrator.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #5) of 1 sampled resident reviewed for self-administration of medications was assessed to determine if they were clinically appropriate to do so after the resident expressed a desire to self-administer one of their medications. Findings included: A facility policy titled, Self-Administration of Medications, revised in 12/2016, indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. An Admission Record revealed the facility readmitted Resident #5 on 07/11/2022. According to the Admission Record, Resident #5 had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/10/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had an active diagnosis of non-Alzheimer's dementia. Resident #5's care plan included a focus area, revised 01/24/2024, that indicated the resident had an activities of daily living self-care performance limitation related to limited mobility from a left shoulder fracture and spinal stenosis. Resident #5's care plan did not address self-administration of any medications. Resident #5's physician's orders contained an order, dated 05/23/2024, for Flonase allergy relief nasal suspension, two puffs to each nostril every 12 hours as needed for allergies. The order indicated Resident #5 was able to keep the medication at their bedside. Nursing Progress Notes dated 05/23/2024 at 12:46 PM indicated the MDS Coordinator documented that a provider was at the facility for rounds and ordered Flonase to be kept at Resident #5's bedside. There was no documented evidence the facility determined whether self-administration of medications was clinically appropriate for Resident #5. Resident #5's electronic medical record Standard Assessments beginning 10/11/2023 revealed no documented evidence the facility assessed the resident for self-administration of medication. During an interview on 05/31/2024 at 11:24 AM. Resident #5 stated they had asked the physician to write an order that allowed them to keep their Flonase in their room to use when needed. Resident #5 stated they had used Flonase for years and administered two sprays into each nostril once a day; however, Resident #5 stated staff had not completed an assessment for self-administration and no staff had watched the resident self-administer their Flonase. A telephone interview on 05/31/2024 at 1:10 PM with the MDS Coordinator, the nurse who documented Flonase was ordered to be kept at the resident's bedside, revealed she believed the only thing required for a resident to keep a medication at the bedside was a physician's order. The MDS nurse confirmed an assessment for self-administration of medication was not completed for Resident #5. Registered Nurse (RN) #5 was interviewed on 05/31/2024 at 10:51 AM. RN #5 stated that prior to a resident self-administering medication, the physician had to write an order for the medication to be kept at bedside. RN #5 stated she was unaware residents needed to be assessed for self-administration of medications. The Director of Nursing Services (DNS) was interviewed on 05/31/2024 at 1:00 PM. The DNS stated that prior to a resident self-administering a medication, the staff had to make sure the resident was capable of self-administering the medication. The DNS stated if a resident was going to self-administer their medication, staff educated the resident and then observed a return demonstration of self-administration. The DNS stated documentation of the education and assessment findings should be found in the electronic medical record progress notes. An interview with the Administrator on 05/31/2024 at 1:22 PM revealed that before a resident could self-administer medication, she expected the resident to be assessed and the assessment documented in their progress notes.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of as needed, supplemental oxygen for 1 (Resident #3) of 3 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, Oxygen Administration, revised in 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy further indicated, 2. Review the resident's care plan to assess for any special needs of the resident. An Admission Record revealed the facility admitted Resident #3 on 06/19/2023. According to the Admission Record, the resident had a medical history that included diagnoses of pneumonia and heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #3's Order Summary Report, listing active orders as of 05/31/2024, contained an order, started on 06/19/2023, for two liters of supplemental oxygen via nasal cannula as needed for shortness of air. The Order Summary Report also contained an order, started on 06/19/2023, for two liters of supplemental oxygen via NC at bedtime for hypoxia (low blood oxygen levels). Resident #3's care plan did not address the resident's supplemental oxygen usage prior to 05/31/2024 (during the survey). During an interview on 05/31/2024 at 9:20 AM, Registered Nurse (RN) #5 stated care plans should address a resident's use of oxygen. RN #5 said the care plan should reflect the ordered flow rate, whether the oxygen was used continuously or as needed, and any parameters set by the physician. During an interview on 05/31/2024 at 2:05 PM, the Administrator stated she expected care plans to address the use of oxygen.

Based on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #50) of 5 residents reviewed for unnecessary medications was free of significant medication errors. Specifically, staff administered metoprolol tartrate (a medication used for high blood pressure) to Resident #50 despite the resident's blood pressure being below the ordered parameters for administration and without monitoring the resident's pulse. Findings included: A facility policy titled, Administering Medications revised 12/2012, indicated, 3. Medications must be administered in accordance with orders, including any required time frame. The policy revealed, 8. The following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. An Admission Record revealed the facility admitted Resident #50 on 04/24/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of essential (primary) hypertension. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2024, revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident had an active diagnosis of hypertension. Resident #50's 05/2024 Medication Administration Record [MAR] revealed a transcription of a physician's order dated 04/24/2024 for metoprolol tartrate 25 milligrams (mg) twice daily for hypertension, with instructions to hold the medication if the resident's systolic blood pressure (the top number of the blood pressure reading) was below 120 millimeters of mercury (mmHg), the diastolic blood pressure (the bottom number of the blood pressure reading) was less than 60 mmHg or if the resident's heart rate was less than 60 beats per minute. The 05/2024 MAR revealed no documented evidence staff checked the resident's heart rate prior to administering metoprolol tartrate. The MAR revealed staff documented that they administered metoprolol tartrate 25 mg to Resident #50 on the following dates and times despite the resident's blood pressure reading that required the medication be held: - 05/01/2024 at 5:00 PM with a blood pressure of 110/60 mmHg, - 05/02/2024 at 8:00 AM with a blood pressure of 110/60 mmHg, - 05/02/2024 at 5:00 PM with a blood pressure of 108/60 mmHg, - 05/03/2024 at 8:00 AM with a blood pressure of 108/60 mmHg, - 05/03/2024 at 5:00 PM with a blood pressure of 112/62 mmHg, - 05/06/2024 at 5:00 PM with a blood pressure of 159/51 mmHg, - 05/08/2024 at 5:00 PM with a blood pressure of 104/66 mmHg, - 05/12/2024 at 5:00 PM with a blood pressure of 112/67 mmHg, - 05/14/2024 at 8:00 AM with a blood pressure of 110/62 mmHg, - 05/14/2024 at 5:00 PM with a blood pressure of 96/64 mmHg, - 05/15/2024 at 8:00 AM with a blood pressure of 101/60 mmHg, - 05/15/2024 at 5:00 PM with a blood pressure of 106/59 mmHg, - 05/16/2024 at 8:00 AM with a blood pressure of 112/63 mmHg, - 05/16/2024 at 5:00 PM with a blood pressure of 124/58 mmHg, - 05/18/2024 at 8:00 AM with a blood pressure of 113/65 mmHg, - 05/19/2024 at 5:00 PM with a blood pressure of 110/70 mmHg, - 05/20/2024 at 8:00 AM with a blood pressure of 119/60 mmHg, - 05/21/2024 at 5:00 PM with a blood pressure of 110/60 mmHg, - 05/22/2024 at 5:00 PM with a blood pressure of 112/58 mmHg, - 05/23/2024 at 8:00 AM with a blood pressure of 110/64 mmHg, - 05/23/2024 at 5:00 PM with a blood pressure of 110/70 mmHg, - 05/26/2023 at 8:00 AM with a blood pressure of 116/64 mmHg, - 05/26/2023 at 5:00 PM with a blood pressure of 114/68 mmHg. Certified Medication Technician (CMT) #4 was interviewed on 05/31/2024 at 9:25 AM. CMT #4 stated if vital signs, such as a blood pressure or pulse, were required to meet certain parameters, then the vital signs were required to be recorded on the MAR. CMT #4 reviewed the 05/2024 MAR for Resident #50 and stated the resident's pulse was not documented on the MAR. She also reviewed Resident #50's recorded blood pressures and stated there were several that did not meet the physician's parameters and the medication should not have been given. CMT #10 was interviewed on 05/31/2024 at 9:50 AM. CMT #10 stated if a medication was not given due to not meeting vital sign parameters, she chose either a code 4 (indicating vitals outside of parameters) or code 9 (indicating other/see nurse notes) and entered the code on the MAR. CMT #10 reviewed the MAR for Resident #50 and identified her initials indicated she gave metoprolol to Resident #50 when the blood pressure parameters were not met for the blood pressure medication. CMT #10 reviewed the MAR and stated Resident #50's heart rate was not recorded daily as directed. CMT #10 stated she did not follow the physician's orders for administering Resident #50's blood pressure medication and gave the medication when it should have been held. During an interview on 05/31/2024 at 3:59 PM, CMT #11 stated she gave Resident #50 metoprolol when the resident's blood pressure did not meet the parameters and acknowledged she should have held the medication. CMT #11 stated she had not taken the resident's pulse and overlooked the blood pressure parameters. Registered Nurse (RN) #5 was interviewed on 05/31/2024 at 10:48 AM. RN #5 stated she had worked each Thursday in 05/2024 and no one had reported Resident #50's blood pressure had not met the parameters for giving metoprolol. RN #5 reviewed Resident #50's MAR and stated the days the systolic blood pressure was less than 120 mmHg the medication should not have been given and stated she would have liked for the CMT to have reported the low blood pressure to her. RN #5 reviewed the MAR and stated Resident #50's heart rate had not been documented and stated the CMTs that had given the medication to Resident #50 had not followed the physician's order. RN #5 stated the danger of giving the medication would be Resident #50's blood pressure drooping even lower, and the resident could faint. A telephone interview was held with the Consultant Pharmacist (CP) on 05/31/2024 at 11:29 AM. The CP stated giving metoprolol to Resident #50 when the resident's blood pressure had not met the physician's parameters would make the blood pressure drop even more. The CP stated the medication should have been held. The Director of Nursing Services (DNS) was interviewed on 05/31/2024 at 12:48 PM. The DNS stated if Resident #50 had parameters for blood pressure and heart rate they should have been documented on the MAR. The DNS stated if the resident's blood pressure had not met the parameters, then the metoprolol should have been held and if the medication was held frequently the staff should have notified the physician. The DNS stated she was unaware the mediation was administered even though the resident's blood pressure parameters were not met. The DNS stated she was also unaware that Resident #50's heart rate had not been added to the MAR. The DNS stated staff did not follow the physician's orders. The Administrator was interviewed on 05/31/2024 at 1:22 PM and stated she expected physician's orders to be followed, and if the order was not to give blood pressure medications if the parameters were not met, the medication should not have been administered and she expected the physician to be notified.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication was safely stored for 1 (Resident #5) of 1 sampled resident reviewed for self-administration of medication. Specifically, Resident #5 had an order to keep their Flonase nasal spray at the bedside; however, the facility failed to ensure the medication was stored in a safe and secure place, not accessible to other residents, as directed by the facility's policy. Findings included: A facility policy titled, Self-Administration of Medications, revised in 12/2016, indicated 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. An Admission Record revealed the facility admitted Resident #5 on 07/11/2022. According to the Admission Record, Resident #5 had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/10/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had an active diagnosis of non-Alzheimer's dementia. The MDS revealed the resident was independent with chair/bed to chair transfers and sitting to standing. Resident #5's physician's orders contained an order, dated 05/23/2024, for Flonase allergy relief nasal suspension, two puffs to each nostril every 12 hours as needed for allergies. The order indicated Resident #5 was able to keep the medication at their bedside. An observation and interview on 05/28/2024 at 9:49 AM, revealed a bottle of Flonase was on Resident #5's dresser. Resident #5 stated the physician told staff to leave the medication in the resident's room for the resident to use when needed. An observation on 05/29/2024 at 1:39 PM, revealed Resident #5 and the resident's roommate were in the room. The Flonase bottle remained on the resident's dresser and was visible from the open doorway. Resident #5 was interviewed on 05/31/2024 at 11:24 AM. Resident #5 stated they had asked the physician to write an order that allowed them to keep their Flonase in their room. Resident #5 stated that on 05/28/2024 and 05/29/2024 the resident kept the Flonase on top of the dresser. Afterward, the resident's family member put the medication in a dresser drawer so no other resident could get the medication. Resident #5 stated facility staff had not provided any instructions on how to store their Flonase. Certified Nurse Aide (CNA) #1 was interviewed on 05/30/2024 at 12:48 PM. CNA #1 stated Resident #5 had nasal spray in their room that was kept on top of their dresser. CNA #1 stated the medication had been in the resident's room for the last couple of months and the CNA had been told the resident was able to have the medication at bedside. Certified Medication Technician (CMT) #3 was interviewed on 05/30/2024 at 2:01 PM. CMT #3 stated Resident #5 had an order to keep their Flonase at bedside. CMT #3 stated she thought Resident #5 left the Flonase on the table. Registered Nurse (RN) #5 was interviewed on 05/31/2024 at 10:51 AM. RN #5 stated medications kept at bedside were kept on top of the resident's bedside table or in the bedside table drawer. The Director of Nursing Services (DNS) was interviewed on 05/31/2024 at 1:00 PM. The DNS stated medications that were kept in a resident's room were expected to be stored in a bathroom cabinet. The Administrator was interviewed on 5/31/2024 at 1:22 PM. The Administrator stated she expected medications to be stored out of sight.

Based on interview, record review, and review of the Facility Assessment Tool, the facility failed to ensure nurse aides received 12 hours of required in-service training per year for 2 (Certified Medication Technician [CMT] #3 and CMT #10) of 5 nurse aide employee files reviewed. Findings included: The Facility Assessment Tool, reviewed by the Quality Assurance and Performance Improvement (QAPI) Committee on 08/23/2023, revealed, Required in-service training for nurse aides. In-service training must: - Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. - Include dementia management training and resident abuse prevention training. CMT #3's Orientation Checklist revealed she was hired as a CMT on 06/28/2018. CMT #3's Employee Inservice Attendance Record revealed that for the timeframe from 06/18/2022 to 06/18/2023 (most recent full year based on her hire date of 06/28/2018), CMT #3 attended only four in-services, none of which pertained to dementia management. The Employee Inservice Attendance Record did not reflect the number of in-service hours awarded for each in-service CMT #10 attended. CMT #10's Orientation Checklist revealed she was hired as a CMT on 12/03/2019. CMT #10's Employee Inservice Attendance Record revealed that for the timeframe from 12/03/2022 to 12/03/2023 (most recent full year based on her hire date of 12/03/2019), CMT #10 attended only four in-services, none of which pertained to dementia management. The Employee Inservice Attendance Record did not reflect the number of in-service hours awarded for each in-service CMT #10 attended. The Administrator (ADM) was interviewed on 05/30/2024 at 12:05 PM. The ADM acknowledged that there may have been missing in-service training records and stated that the facility recently hired a full-time Staff Development Director (DSD); however, per the ADM, the DSD had not yet started working at the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to specify dose parameters for 1 (Resident #7) of 3 residents reviewed for supplemental oxygen use. Specifically, the facility failed to ensure Resident #7's supplemental oxygen orders specified liters per minute (L/min) parameters. Findings included: A facility policy titled, Oxygen Administration, revised October 2010, indicated under the section titled Preparation to Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. The policy also indicated, Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Resident #7's Admission Record revealed the facility admitted the resident on 09/15/2022. According to the Admission Record, the resident had a medical history that included diagnoses of hypoxemia (low blood oxygen levels) dystonia (involuntary muscle movements causing twisting and contorting), torticollis (involuntary muscle movements causing twisting and contorting of the neck), and pneumonia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received oxygen therapy during the assessment period. Resident #7's Care Plan, included a focus area revised on 03/25/2024, that indicated the resident had oxygen therapy related to ineffective gas exchange from dystonia. Interventions directed staff to monitor for signs and symptoms of respiratory distress and report to the medical doctor as needed, humidified supplemental oxygen setting via nasal prongs at 2 liters continuously at night and as needed during the day, and to promote lung expansion and improve air exchange by positioning with proper body alignment and if tolerated, position the head of bed above 45 degrees. Resident #7's Order Summary Report revealed an order dated 12/24/2023 for supplemental oxygen by way of nasal cannula (NC) to maintain above 91 percent (%) blood oxygen saturation level every shift and to keep on at night. Resident #7's Treatment Administration Record [TAR], dated March 2024, April 2024, and for the timeframe from 05/01/2024 through 05/28/2024, revealed the staff had documented the resident had blood oxygen saturation levels over 90% every day on all three shifts. During an observation and interview on 05/28/2024 at 11:20 AM, Resident #7 was in their room. The resident's NC was askew on their nostrils and the supplemental oxygen concentrator was set at 2 L/min. Resident #7 stated they had no concerns about staff treatment or care provisions. During an interview on 05/30/2024 at 8:45 AM, Certified Nurse Aide (CNA) #1 stated she assisted residents with their supplemental oxygen. She stated she would enter the resident's room and make sure the supplemental oxygen was on. She stated supplemental oxygen use was in the resident's care plan. She stated she would make sure the cannula was correctly placed on the resident and would check the L/min, but she did not adjust the settings. She stated any concerns noticed were reported to the nurse and she would follow any directive given to assist the resident. She stated she would monitor the resident's blood oxygen saturation using the pulse oximeter. She stated the supplemental oxygen orders were relayed to her by the nurse. She stated Resident #7 was to have their supplemental oxygen on while in bed but could wear it while up at their discretion. She stated if the resident's blood oxygen saturation level was below 95%, she would reapply the NC for the resident. She stated the resident was compliant with their oxygen therapy when their blood oxygen saturation levels were outside the parameters. During an interview on 05/30/2024 at 12:41 PM, Registered Nurse (RN) #5 stated that as the RN she would check oxygen saturation readings for residents who required monitoring and make sure their blood oxygen saturation levels were good. She stated that when residents were in their rooms, they were connected to an oxygen concentrator and when they were out of bed they were connected to a portable tank, which was checked before application and refilled as needed. She stated supplemental oxygen orders should include as needed or continuous use, L/min, and any titration guidelines. She stated that when she received orders from physicians, she would review them and enter them into the resident's record, before placing them in the orders basket for the night nurses to verify. She stated if she found a discrepancy with the orders, she would call the Director of Nursing Services (DNS) and physician to verify. She stated if there was a supplemental oxygen order without parameters for L/min she would start off with 2 L/min and monitor per the resident's condition. RN #5 stated she worked with Resident #7 and double checked their NC placement frequently as it tended to become askew. She stated the resident's blood oxygen saturation levels were regularly between 90% and 92%. She stated she monitored the L/min setting and would reposition the resident if the resident's blood oxygen saturation levels were low. She stated Resident #7 was on 3 L/min supplemental oxygen flow. She stated if the resident's blood oxygen saturation levels read below 91%, she would call the physician. Review of Resident #7's medical record on 05/30/2024 at 12:56 PM with RN #7 revealed the resident's supplemental oxygen order indicated oxygen by way of NC to maintain above 91% sat [saturation] every shift keep on at night. After reviewing the order, RN #7 stated the only parameter was to maintain blood oxygen saturation levels above 91% and she did not see any L/min indication on the order to start from. She stated supplemental oxygen orders should be accompanied by L/min. During an interview on 05/30/2024 at 3:57 PM, Licensed Practical Nurse (LPN) #15 stated supplemental oxygen orders typically started at 2 L/min and titration was attempted from there to achieve blood oxygen saturation levels. She stated the resident's blood oxygen saturation levels were checked at least once a shift, so three times a day. She stated supplemental oxygen orders should be accompanied by L/min parameters, so the nurses had a starting point and was unsure why there was no L/min associated with the order. During an interview on 05/31/2024 at 1:06 PM the DNS stated any order for supplemental oxygen should be accompanied by L/min parameters. She stated she was made aware of the concern regarding Resident #7 on 05/30/2024 and the facility was awaiting a call back from the physician with L/min parameters to update the order. She stated the original order should have been accompanied by L/min parameters. During an interview on 05/31/2024 at 1:58 PM, the Administrator stated supplemental oxygen orders should be accompanied by L/min parameters, so the nurses knew where to start oxygen flow. During an interview on 05/31/2024 at 4:04 PM, Medical Doctor (MD) #17 stated supplemental oxygen orders should be accompanied by L/min parameters and there was no situation where that would not be the case. She stated the L/min was the dosage information.

Based on interview and record review, the facility staff failed to report to Department of Health and Senior Services (DHSS) an injury of unknown origin when the facility staff became aware on 12/14/23 that one resident (Resident #1) had a broken femur and did not know the source of the fracture. The facility census was 54. Review of facility policy, Abuse and Neglect Protocol, dated 2/15/22, showed: -Response and Reporting: It is the purpose of this facility to report to the state agency and appropriate law enforcement entity, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility. The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours. Serious bodily injury would be classified as a fracture. The facility will report the results of all investigations to the Administrator or designee, DHSS and to other officials in accordance with State law, and within five working days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken. -Indicators of abuse, neglect, or misappropriation of resident's property to be investigated include, but not limited to the following: injuries of unknown origin. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/25/23, showed: -A Brief Interview Mental Status (BIMS), an assessment tool used in long term care facilities to monitor cognition, score of 14, showed cognitively intact; -He/She used a manual wheelchair and mechanical lift; -He/She was dependent for mobility in sitting to lying, chair to bed transfers, toilet transfers, lower body dressing, showers, and toileting hygiene; -He/She required substantial/maximal assistance for upper body dressing and rolling left to right; -Diagnoses included: Dystonia (a condition causing involuntary muscle contractions that cause repetitive or twisting movements), edema, torticollis (rare condition in which neck muscles contract, causing the head to twist to one side), low back pain, and a fracture. Review of care plan, dated 12/18/23, showed: -He/She was at risk for falls due to gait and balance problems and disease process of dystonia; -He/She had pain due to dystonia, osteoarthritis, and right femur fracture; -He/She required two staff participation with transfers using the mechanical lift; -He/She required leg brace to right leg when transferred; Review of electronic medical record, dated 12/13/24 to 12/18/23, showed: -12/13/23 at 11:00 P.M., Licensed Practical Nurse (LPN) A wrote Resident complained of right knee pain. He/She did not rate pain but stated it hurt really bad. The resident's knee appeared to be swollen. He/She told the nurse he/she did not know what happened but his/her knee started hurting during the night. -12/14/23 at 9:09 A.M., MDS Coordinator wrote the nurse practitioner was in the facility for rounds. The resident was complaining of pain in right knee, hurts worse with movement. Magnetic resonance imaging (MRI) scheduled at the hospital. Will send to hospital today and the hospital will give resident Toradol (pain medication) intramuscularly (IM) injection. -12/14/23 at 1:50 P.M., Call received from nurse practitioner stating resident being sent to emergency room for further evaluation due to imaging showed a fracture of the femur; -12/14/23 at 2:43 P.M. Resident had dystonia and was chair bound and transferred with a sit to stand lift. -12/18/23 at 7:04 P.M., LPN B wrote the resident arrived back to facility at 3:22 P.M. with diagnosis of femur fracture. Resident was supposed to be transferred by the mechanical lift. Review of facility investigation showed investigation was started on 12/14/23 by the Administrator. During an interview on 1/29/24 at 9:01 A.M., the Administrator said: -On 12/14/23 discovered Resident #1 had a broken femur; -He/She completed investigation and interviews with staff; -Resident was seen by the nurse practitioner and was sent to the hospital to have a MRI done to rule out blood clots; -Daughter was notified of the fracture; -She did not know how the fracture occurred; -Resident was not dropped, never screamed out in pain; -Resident was using sit to stand which required two people for all his/her transfers; -Resident did not want to start using the mechanical lift, he/she was assessed by therapy that he/she was still appropriate to use sit to stand lift a few weeks prior. During an interview on 1/29/24 at 10:53 A.M., the Administrator said she did not report the resident's fractured femur to DHSS because it was an injury of an unknown origin. During an interview on 1/29/24 at 11:37 A.M., the Administrator said: -He/She reviewed emails and he/she had not contacted DHSS; -He/She never suspected abuse of the injury of unknown origin. -He/She was responsible for reporting and should have reported the injury of unknown origin. MO228795

Based on observation, record review and interviews, the facility staff failed to assure Resident #1's safety when the facility staff allowed the resident to remain outside in full sun the afternoon of 9/19/22 from approximately 1:30 P.M. to 3:40 P.M. The high temperature was 94 degrees Fahrenheit. The resident was found outside not responding and sustained a sunburn to the top of his/her head and required hospitalization . This affected one of three sampled resident's. The facility census was 57. Review of the outdoor temperature policy dated 9/28/22 showed: - When the heat index is 100 degrees or above or if the wind chill is 0 degrees or below the staff are supposed to encourage the residents to stay inside. If the resident refuses to stay indoors, the staff are supposed to check on the resident every 15 minutes. - The staff do not recommend that resident's go outside for longer than 15 minutes. - The charge nurse will ensure that staff members check on residents that are outside every 15 minutes. 1. Review of Resident #1's Annual Minimum Data Set (MDS, a federally mandated assessment tool that the facility staff fill out) dated 8/12/22 showed: - He/she was admitted to the facility on [DATE]. - Brief interview for mental status (BIMS) score of 9, indicating moderate cognitive deficit. - Diagnoses include: Chronic obstructive pulmonary disease (COPD, a disease of the lungs making breathing difficult), chronic fatigue, and heat stroke (A condition that include fever and often unconsciousness caused by exposure to excessively high heat) and sunstroke (heat stroke brought about by excessive exposure to the sun). - He/she was independent with most cares requiring assistance of one staff for personal hygiene and meal set up. - He/she was continent of bowel and bladder. Review of the resident's facility medical record showed the following: - 9/20/22 at 1:14 A.M. The Director of Nursing (DON) documented: On 9/19/22 the resident wheeled him/herself outside and was checked on by an aide. - The resident was asleep, the aide awakened the resident to see if he/she was ready to go back inside the facility and the resident declined. - Another staff member went outside and saw the resident who did not look normal and would not respond. - The resident's breathing was labored and the resident did not respond to sternal rubs (a procedure in which the person rubs the sternum, of the resident to elicit a response). - The resident's oxygen saturation was 80% on room air (below normal), blood pressure was 151/76 (elevated), and his/her temperate was 104 degrees Fahrenheit. - Oxygen was put on the resident at 15 liters, the resident was gurgling. - The DON suctioned white frothy sputum from the resident's throat. - Emergency Medical Services (EMS) were called, the resident had a red sunburn on top of his/her head and a red rash to his/her trunk. - Cool cloths were placed on the resident's head, neck and face. - The resident was sent to the hospital. - The undated activity care plan showed that he/she enjoyed sitting outside when the weather permits. - The undated Activities of Daily Living (ADL) care plan showed that the resident propels him/herself throughout the facility in his/her wheelchair. - The care plan did not address the resident's heat stroke and sunstroke sustained on 9/19/22. Observations of the resident on 10/5/22 showed: - 9:23 A.M. He/she was in his/her wheelchair in the hallway, propelled self a few feet and then stopped and placed chin to his/her chest and appeared to be asleep. - 10:02 A.M. the resident was in his/her room awake. - His/her hat was off and dark red scabbed area that appeared inflamed was on top of the resident's head. - The scabbed area was in the shape of a horseshoe and covered most of the top of his/her head. - There was no hair on top of the resident's head. During an interview on 10/5/22 at 11:39 A.M. Nurse Aide (NA) A said: - He/she works the 2:00 P.M. to 10 P.M. shift. - The resident was outside when he/she first reported to duty at 2:00 P.M. - He/she went outside and checked on the resident a short time after he/she began his/her shift. - The resident was in full sun outside the back courtyard and sleeping. - The resident's ball cap fell off of his/her head and NA A placed it back on the resident's head because his/her head was sunburned. - He/she woke the resident up and asked him/her if he/she was ready to go inside and the resident said no. - He/she left the resident sitting in the full sun. - He/she went outside and checked on the resident 30 minutes later, the resident was asleep again and he/she woke the resident up and asked him/her if he/she was ready to go inside. The resident said no. - He/she left the resident in the full sun. - He/she was concerned about the resident because the temperature was hot outside. - He/she next saw the resident at 3:40 P.M. being pushed inside, he/she was not responding and the DON grabbed the crash cart. During an interview on 10/5/22 at 11:45 A.M. Certified Nurse Aide (CNA) A said: - He/she saw the resident outside under the canopy at 1:30 P.M. - The resident was able to open the door by him/herself and went outside often. - He/she spoke with the resident while he/she was outside at 2:00 P.M., he/she was in full sun. - He/she asked the resident if he/she was ready to go inside and the resident said no. - He/she left the resident outside. - He/she reported to the oncoming staff, CNA B, that he/she was outside. During an interview on 10/5/22 at 204 P.M. CNA B said: - The resident often sat outside under the tree in the afternoons. - He/she saw the resident sitting outside at 3:00 P.M. but unable to recall if the resident was sitting in the sun. - The resident was asleep and he/she did not awaken the resident because he/she knew if he/she asked the resident to go inside, the resident would have said no. - The resident was wearing his/her hat. - The outdoor temperature was hot. - The Business Office Manager (BOM) went outside with another resident at 3:40 P.M. and the resident would not respond. - The DON went outside and he/she brought the resident inside. - The resident was hot and he/she placed cold rags on the resident's face, neck and under arms. - He/she helped the DON get the resident in bed and then left the room. During an interview on 10/5/22 at 12:46 P.M. the BOM said: - He/she saw the resident outside while he/she was taking a break at 3:10 P.M. - The resident was asleep in his/her wheelchair parked on the sidewalk 3k, he/she was sitting in the sun. - NA A went outside and said something to the resident then NA A sat at the porch taking a break. - The BOM then went back inside the facility. - 3:40 P.M. he/she then took another resident for an outdoor outing in his/her wheelchair. - The resident was sitting on the sidewalk in his/her wheelchair in the same spot as earlier - The BOM then tried to shake the resident awake and could not get him/her to awaken. - The resident's feet were touching the cement and his/her head was resting on his/her hand with his/her elbow on the arm rest. - He/she pushed the resident under the shade of the canopy. - The DON and Certified Medication Technician (CMT) A went outside and pushed the resident's wheelchair to his/her room. During an interview on 10/5/22 at 2:13 P.M. CMT A said: - He/she was sitting outside taking a break at 3:40 P.M. and saw the resident was sitting in the sun asleep. - The BOM tried to awaken the resident so that he/she and another resident could pass on the sidewalk. - The BOM could not get the resident awake. - He/she and the BOM moved the resident to the shade, tried to shake the resident and could not get him/her awake. - The resident's hands were hot. - He/she helped the DON place the resident in bed. - The resident's body was limp and he/she would not wake up. - The DON suctioned the resident, he/she coughed a little with the suctioning, but he/she did not wake up. During an interview on 10/5/22 at 12:22 P.M. the DON said: - 2:30 P.M. NA A reported to him/her that the resident was sitting outside and he/she instructed NA A to check on the resident again. - A little later that same afternoon, the BOM told me that he/she was outside and saw that the resident was not waking up and did not look well. - He/she went outside to assess the resident and attempted to rub the resident's sternum, he/she opened his/her eyes momentarily. The resident was under the canopy at that time. The staff had already moved the resident from the sun. - It was hot outside that day. - He/she took the resident inside, the resident's skin was hot and face was normal coloration. - He/she applied cool cloths to the resident's face, neck, and abdomen to cool him/her. - He/she suctioned white, frothy sputum from the resident's throat, the resident coughed during the suctioning but did not wake up - He/she expected the staff to check on the resident every 15 minutes while outside. - If the resident refuses to go inside, he/she expects the staff to alert the charge nurse. - He/she did not initiate an investigation of the incident. - He/she should have initiated an investigation. Review of the hospital record dated 9/19/22 showed: - He/she presented to the Emergency Department (ED) on 9/19/22 unresponsive due to being outside in the hot sun from 2:00 P.M. to 3:40 P.M. - The resident's oxygen saturation was in the 70's % (very low oxygen in the blood stream), temperature was 102 degrees Fahrenheit, heart rate 114 (elevated) and respirations 32 (elevated). - The resident was found to have heat stroke and sunstroke. - The resident was returned to the facility on [DATE]. During an interview on 10/5/22 at 12:55 P.M. the Administrator said: - He/she expected the staff to check on the resident every 15 minutes while outside. - He/she expected if the resident refused to come inside, the staff would report that the charge nurse. - The facility staff encourage residents to not go outdoors when the heat index is 100 degrees or above and the wind chill 0 degrees and below. - He/she did not initiate an investigation and collect staff statements and he/she should have done that. MO207907

Based on observation, record review and interviews, the facility staff failed to maintain Resident #1's dignity by not emptying his/her urinal's (bottle that captures urine so the resident does not have to go to the toilet), and leaving the urinals half full sitting in the garbage can for approximately 4 hours spanning across two shifts. This affected one of three sampled resident's. The facility census was 57. Review of the urinal removing policy dated May 2013 showed: - Residents that keep their urinal at the bedside are to be checked by the staff frequently. - Facility staff are supposed to empty the urinal and clean when it has urine in it. 1. Review of Resident #1's Annual Minimum Data Set (MDS, a federally mandated assessment tool that the facility staff fill out) dated 8/12/22 showed: - He/she was admitted to the facility on [DATE]. - Brief interview for mental status (BIMS) score of 9, indicating moderate cognitive deficit. - Diagnoses include: Chronic obstructive pulmonary disease (COPD, a disease of the lungs making breathing difficult) and chronic fatigue. - He/she was independent with most cares requiring assistance of one staff for personal hygiene and meal set up. - He/she was continent of bowel and bladder. Observations on 10/5/22 showed: - 9:50 A.M. two urinals are in the resident's trash can each half full of yellow urine and the trash can is half full of trash. - 10:02 A.M. CMT A entered the resident's room, the resident was sitting in his/her wheel chair, CMT A applied a nebulizer treatment using a mask over the resident's nose and mouth. CMT A did not empty the urinals. - 1:00 and 2:00 P.M. Both urinals remain in the resident's trash can half full of urine. During an interview on 10/4/22 at 2:04 P.M. CNA B said: - The CNA's are supposed to empty and clean the urinals after the resident uses them and each shift. - He/she starts his/her shift at 2:00 P.M. and often the resident's urinals are full of urine from the previous shift. Observation on 10/5/22 at 2:10 P.M. showed: - Both urinals were emptied and placed back in the residents trash can. During an interview on 10/4/22 at 2:13 P.M. CMT A said: - He/she saw the resident's urinals that morning half full of urine and should have emptied them at that time. During an interview on 10/5/22 at 3:24 P.M. the Director of Nursing (DON) said: - He/she expected the CNA's to empty the resident's urinals every shift and when full. - He/she expected the resident's urinal to be emptied prior to 2:00 P.M. During an interview on 10/5/22 at 3:40 P.M. the Administrator said: - She expected the staff to empty and clean the resident's urinals every shift and as needed. MO207907

Based on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental psychosocial needs identified in the comprehensive assessment for of three of 13 sampled residents (Residents #2, #22 and #30). The facility census was 51. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, showed the following: - A comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - The compressive, person-centered care plan will (included): o Include measurable objectives and timeframes; o Describe the serves that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; o Describes the services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; o Incorporate identified problem areas; o Incorporate risk factors associated with identified problems - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan; - Identifying problem areas and their causes, and developing interventions that are targets and meaningful to the resident, are the endpoint of an interdisciplinary process; - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The IDT must review and update the care plan when there has been a significant change in the resident's condition; At least quartering, in conjunction with the required quarterly assessment. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/24/22, showed the following: - Date admitted [DATE]; - Severe cognitive impairment; - Had one fall with injury since the previous assessment and two or more non-injury falls; - Received antipsychotic (used to treat mental disorders) and antianxiety medications in the last seven days of the assessment. Review of the resident's care plan dated 6/3/22 showed the following: - The resident was at risk for falls. The interventions included: o Conduct fall assessment on admit and every quarter and as needed; o Ensure that the resident has his/her call light close at hand and remind him/her to use it for needs; o Frequently check in on the resident to ensure he/she is safe; o The resident required a two-person assist with all transfers; - It did not include fall mats or the use of bolster sides; - The care plan did not include information regarding the use of [CONDITION(S)] medications. Review of the resident's physician orders sheet (POS), dated 6/8/22, showed the following: - [MEDICATION(S)] concentrate (an anti-psychotic, used to treat mental/mood disorders), give 0.5 milliliter (mL) by mouth three times a day for restlessness, start date 5/19/22; - [MEDICATION(S)] concentrate ([CONDITION(S)], used to treat anxiety), give 0.5 milliliters (mL) by mouth every two hours as needed (PRN) for anxiety/restlessness. Start date 5/7/22; - [MEDICATION(S)] [MEDICATION(S)] concentrate, give 0.5 mL mouth four times per day for anxiety. Start date 4/29/22; - [MEDICATION(S)] (antipsychotic, used to treat mental/mood conditions) 25 milligrams (mg), give half a tablet by mouth one time per day for anxiety. Start date 2/8/22; - [MEDICATION(S)] 25 mg, give 1.5 tablet by mouth at bedtime for anxiety. Start date 2/8/22. Review of the resident's medical records showed the following: - A nurse note, dated 4/5/22, showed the staff heard a thump and found the resident on the fall mat next to his/her bed. The resident complained of hitting his/her right eye. Noted a red spot above the right eye and light redness on his/her back; - Fall assessment dated [DATE] showed the resident was a moderate fall risk. During an interview on 6/8/22 at 2:34 P.M., the resident's spouse said: - Facility staff used fall mats during evenings for safety and they also used bolster sides. Observation on 6/6/22 at 3:29 P.M. showed the resident had fall mats stacked against the wall behind the resident's bed and bolster sides were on the resident's bed. Observation on 6/9/22 at 12:41 P.M. showed: - Fall mats were placed next to the resident's floor and the resident was laying in bed. During an interview on 6/08/22 at 2:36 P.M. Licensed Practical Nurse (LPN) A said: - Fall preventions for the resident included bolsters on the side of the resident's bed and they moved him/her to a room closer to the nurse station. 2. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/13/22, showed the following: - Date admitted [DATE]; - Cognitively intact; - Was independent with bed mobility; - Was independent with transfers including to and from bed, chair, wheelchair, and standing position (excluding to and from the bath/toilet); - Bed rail was not indicated as used. Review of the resident's care plan dated 4/21/22 did not show any information about the use of rails. Observation on 6/7/22 at 9:28 A.M., showed the resident had grab bars During an interview on 6/7/22 at 9:28 A.M. the resident said the bars were for positioning in bed. 3. Review of Resident #30's MDS dated [DATE], showed: - A Brief Interview of Mental Status (BIMS) of 15 which indicated no cognitive impairment; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -Has had two falls with no injuries; -Requires limited assistance of one staff member for Activities of Daily Living (ADL's); -Is not steady with walking or movements; -Impairment on one side of the body; -Uses a wheelchair or walker for mobility. Review of resident's electronic health record showed fall events on : - 1/1/2022 at 6:04 P.M. - 1/22/2022 at 1:00 P.M. - 2/3/2022 at 5:10 P.M. - 2/10/2022 at 1:19 P.M. - 2/18/2022 at 11:22 P.M. - 4/28/2022 at 1:00 P.M. - 5/6/2022 at 11:51 P.M. - 5/8/2022 at 2:14 P.M. - 5/17/2022 at 9 :15 P.M. - 6/1/2022 at 4:30 A.M. - 6/4/2022 at 11:06 P.M. Review of a radiology report dated 5/18/22 showed: -2nd proximal phalanx shaft fracture without malalignment. (the small bone closest to the hand in the pointer finger has a fracture); - Soft tissues (tendons,ligaments, and blood vessels) appear swollen. Review of the resident's undated care plan showed: - He/she participates in restorative therapy. - Physical therapy to evaluate and treat as needed. - Heavy duty grab bar in bathroom and outside bathroom. - He/she needs assist of one staff with a gait belt for transfers. - He/she will transfer him/herself independently at times. -The care plan did not address the history of falls, cause of the falls or interventions to prevent further falls. -No care plan to address behaviors. During an interview on 6/9/22 at 9:48 A.M., the resident said: - He/she falls a lot. - He/she does not want to fall. - He/she turns on the call light , staff do not always come so he/she tries to get up him/herself. - He/she broke this finger (indicating left first finger) when he/she fell . During an interview on 6/9/22 at 9:16 A.M., Certified Nurse Aide (CNA) A said: - He/she believes the resident places him/herself on the floor for attention. - He/she has not seen the resident place him/herself on the floor. - Fall interventions should be in the care plan. During an interview on 6/9/22 at 9:23 A.M., Registered Nurse (RN) A said: - Every fall is written on the care plan. - New interventions are put in place with each fall. During an interview on 6/9/22 at 9:55 A.M., Licensed Practical Nurse (LPN) A said: - Each fall is not care planned unless there are changes in approach. - New approaches should be tried with each fall. During an interview on 6/9/22 at 12:20 P.M., the Administrator said: - He/she expected fall interventions to be care planned. - He/she believes Resident #30's falls are behavioral. 4. During an interview on 6/09/22 at 12:35 P.M. Certified Nurse Aide (CNA) A said: - Care plans were kept behind nurse station. CNA's have access to them to review; - The more falls a resident has, the more interventions were in the care plans; - Wounds were addressed that they are at risk for the wounds; - Grab bars were addressed on the care plan. During an interview on 6/9/22 at 11:19 A.M., the MDS Coordinator said: - She was responsible for updating care plans. Care plans were updated quarterly on the computer and hand written updates were made as needed; - Changes were discussed during weekly risk meetings; - Fall mats, and bolster sides should be addressed on the care plan; - If a resident is prescribed [CONDITION(S)] medication, it should be addressed on the care plan; - If a resident comes in and the bed had grab bars on them and the resident does not need them, it would not necessarily be on the care plan and they do not take them off the bed because they were not a restraint. During an interview on 6/09/22 at 12:41 P.M. the Director of Nursing (DON) said: - The use of grab bars should be on the care plan; - The use of fall mats and bolster sides should be on the care plan. 6. During an interview on 6/9/22 at 12:41 P.M., the Administrator said: - Anyone could update the care plan. The MDS Coordinator was responsible to make sure updates are accurate. Risk management met weekly for needed updates. - The use of grab bars should be on the care plan.