Every finding on record at Pleasant View Nursing Home

Based on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the resident's size and weight for three of 13 sampled residents (Residents #11, #17 and #47). The facility census was 51. The facility did not provide the requested policy on entrapment assessments. 1. Review of Resident #11's Quarterly Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 02/26/25, showed: -Severe cognitive impairment; -Substantial assist for toileting and bathing; -Partial assistance for bed mobility; -Bed rails not used; -Diagnoses included, dementia, other fracture and high blood pressure. Review of the resident's care plan dated, 05/01/25, showed: -Assist of two staff for Activities of Daily Living (ADLs); -Half bed rails to assist with bed mobility; -At risk for falls due to a history of falls. Review of the resident's Physician's Orders Sheet (POS) dated May 2025, showed an order dated 05/08/25 for side rails. Review of the resident's quarterly side rail assessment dated , 11/27/24 showed: -History of falls; -Poor bed mobility; -No other side rail assessments were found; -Resident was not assessed for entrapment. Observation and interview on 05/19/25 at 02:18 P.M., showed: -The resident in bed with both side rails in the up position; -Fall mats on the floor on both sides of the bed; -A family member sat at the bedside of the resident; -The resident's family member said the resident had side rails due to a history of falls and for positioning; -The resident's family member did not know if an entrapment assessment had been completed; -The resident's family member said it was a good idea to check the dimensions of the bed to assess for potential entrapment. Observation and interview on 05/19/25 at 04:02 P.M., showed: -The resident in bed with eyes open; -Both side rails were in the up position on the resident's bed; -Fall mats on the floor on each side of the bed; -Certified Nurse's Aide (CNA) F said the resident used the side rails for turning over in bed: -CNA F said the resident had fall mats on the floor because he/she was a fall risk; -CNA F said the staff assisted the resident with incontinent care; -CNA F said he/she had not seen staff measure or inspect the bed; -CNA F said the maintenance department took care of that. Observation on 05/20/25 at 09:26 A.M., showed: -The resident in bed with eyes open; -Both side rails were in the up position on the resident's bed; -Fall mats on the floor on each side of the bed. During an interview on 05/20/25, at 09:45 A.M., CNA C said: -The resident used the side rails for turning over in bed: -The resident had fall mats on the floor because he/she was a fall risk; -The nurses took care of the assessments for side rails. -Maintenance took care of putting the beds together. Observation and interview on 05/21/25 at 11:32 A.M., showed: - The resident in bed with eyes open; - Both side rails were in the up position on the resident's bed; -Fall mats on the floor on each side of the bed; -Licensed Practical Nurse (LPN) A said the resident used the side rails for positioning. -LPN A said the therapy department takes care of the side rail assessments. -LPN A said If any bed inspections or measurements were done the maintenance department would do them. 2. Review of Resident #17's Quarterly MDS, dated [DATE], showed: -No cognitive impairment. -Substantial assist for toileting and bathing; -Partial assist for bed mobility; -Bed rails not used; -Diagnoses included, stroke, paraplegia and heart failure. Review of the resident's care plan dated, 03/25/25, showed: -Assist of two staff for ADLs; -Bed rails to assist with bed mobility. Review of the resident's POS dated May 2025, showed and order dated 05/20/25 for side rails on the reisdents bed. Review of the resident's quarterly side rail assessment dated , 12/04/24 showed: -Poor bed mobility; -Resident was assessed for entrapment; -No record of measurements found for entrapment assessment. -No other side rail assessments were found. Observation and interview on 05/19/25 at 02:01 P.M., showed: -The resident in bed with both side rails in the up position. -The resident said he/she used the side rails for positioning. -He/She said no staff had measured his/her bed. Observation on 05/19/25 at 03:52 P.M., showed: -The resident was in bed with eyes open; -Both side rails were in the up position on the resident's bed. During an interview on 05/19/25 at 04:12 P.M., CNA F said: -The resident used the side rails for turning over in bed: -He/She had not seen staff measure or inspect the bed; -The maintenance department did them. Observation on 05/20/25 at 09:34 A.M., showed: -The resident in bed with eyes open; -Both side rails were in the up position on the resident's bed. During an interview on 05/20/25, at 10:12 A.M., CNA C said: -The resident used the side rails for turning over in bed: -The nurses do the assessments for side rails. -Maintenance takes care of putting the beds together. Observation and interview on 05/21/25 at 11:40 A.M., showed: - The resident in bed with eyes open; - Both side rails were in the up position on the resident's bed; -LPN A said the resident used the side rails for positioning; -LPN A said therapy takes care of the side rail assessments; -If any bed inspections or measurements were to be done the maintenance department would do it. 3. Review of Resident #47's Admission MDS dated [DATE], showed: -Moderate cognitive impairment; -Substantial nursing assistance for bed mobility; -Bed rails not used; -Diagnoses included, cancer, stroke and depression. Review of the resident's care plan dated 04/30/25, showed: -Assist of two staff for bed mobility; -At risk for falls; -Bed rails to assist with bed mobility. Review of the resident's POS dated May 2025, showed an order dated 04/27/25 for side rails. Review of the resident's side rail assessment dated , 04/27/25 showed: -Poor bed mobility; -No other side rail assessments were found; -Resident was not assessed for entrapment. Observation on 05/19/25 at 01:05 P.M., showed: -The resident in bed with both side rails in the up position; -Fall mats on the floor on both sides of the bed. Observation on 05/19/25 at 02:17 P.M., showed: -The resident was in bed with eyes closed; -Both side rails were in the up position on the resident's bed; -Fall mats on the floor on each side of the bed. During an interview on 05/19/25 at 04:13 P.M., CNA F said: -The resident used the side rails for turning over in bed: -The resident had fall mats on the floor because he/she is a fall risk; -The staff assist the resident with incontinent care; -He/She had not seen staff measure or inspect the bed. Observation on 05/20/25 at 10:15 A.M., showed: -The resident in bed with eyes closed; -Both side rails were in the up position on the resident's bed; -Fall mats on the floor on each side of the bed. During an interview on 05/20/25, at 10:45 A.M., CNA C said: -The resident used the side rails for turning over in bed: -The resident had fall mats on the floor because he/she is a fall risk. Observation and interview on 05/21/25 at 11:48 A.M., showed: - The resident in bed with eyes open; - Both side rails were in the up position on the resident's bed; -Fall mats on the floor on each side of the bed; -LPN A said the resident used the side rails for positioning; -LPN A said the therapy department did the side rail assessments; -LPN A said he/she did not do any bed inspections or measurements. During an interview on 05/21/25, at 11:59 A.M. Restorative Aide A said: -Therapy did not do the assessments for the side rails. -Nursing did the assessments for the side rails. -She did not know who did entrapment assessments. During an interview on 5/21/25 at 12:14 P.M., the Maintenance Supervisor said: -He assembled the beds after getting a work order. -He put the side rails on after he gets a work order or if the administrator tells him to; -He did not inspect the beds after the initial set up unless staff reported a problem; -He did not do entrapment assessments or measure the beds on a routine basis; -He was not aware that the facility should have a system in place to routinely measure the beds and asses for entrapment. During an interview on 05/22/25 at 11:16 A.M. the Director of Nursing (DON) said: -Resident #11, #17 and #47 used side rails on the beds for positioning and not restraints; -She completed the side rail assessments; -There is a place on the side rail assessment form that says something about entrapment but she did not know that it had to be filled out; -She did not do an entrapment assessment on Resident #11, #17 and #47. During an interview on 05/22/25, at 11:30 A.M., the Administrator said: -The facility is not doing entrapment assessments or measurements; -Residents #11, #17 and #47 should have entrapment assessments completed each quarter, and their beds should be inspected on a regular basis; -The facility should have a process in place for entrapment assessments to be completed on all at risk residents.

Based on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made two medication errors out of 26 opportunities for error which resulted in a medication error rate of 8%, this affected 3 residents of the 13 sampled residents, ( Residents #101, #46, #22). The facility census was 51. Review of the facility's undated Glucose Finger Stick policy, showed: Alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. 1. Review of Resident #101's Quarterly MDS, dated [DATE] showed: -Cognition intact; -Requires nursing assistance with self care and mobility; -Diagnoses: Diabetes, high blood pressure, renal insufficiency, parkinsons. Review of the care plan revised on 10/3/24 showed staff are to complete accuchecks two times a day to monitor blood sugar. Observation on 05/20/25 at 11:40 A.M. showed CMT B performing an accucheck on resident Fingertip was cleansed with alcohol. The fingertip was not allowed to dry more than 4 seconds before the CMT B used a lancet to puncture fingertip. Accucheck reading was resulted. Record Review on 05/20/25 at 11:45 A.M., showed documentation of accucheck in chart. During an interview on 05/20/25 at 11:48 A.M, the Resident said: -I get my fingers stuck two times a day for my sugar level; -I dont pay attention to how they stick my finger. 2.Review of Resident #46's Quarterly MDS, dated [DATE] showed: -Cognition moderately impaired; -Needs nursing assistance with self care and mobility; -Diagnoses: Diabetes, dementia, thyroid disease, pneumonia, and urinary infection. Observation on 05/20/25 at 11:52 A.M. showed CMT B performing an accucheck on resident. The fingertip was cleansed with alcohol but it was not allowed to dry more than 3 seconds before he/she used a lancet to puncture the resident's fingertip. Accucheck reading was performed. Record Review on 05/20/25 at 11:55 A.M, showed: -CMT B Documented accucheck in chart. During an interview on 05/20/25 at 11:58 A.M,, the Resident said: -I have no problems getting my fingers stuck except my fingers get sore from them getting stuck; -I don't watch the nurses stick my fingers I just let them do it. 3. Review of Resident #22's Quarterly MDS, dated [DATE] showed: -Cognition moderately impaired; -Diagnoses: Anoxic brain injury, diabetes, dementia, and hypertension; -Requires partial assistance with ADLs (Activities of Daily Living). Review of the care plan revised on 01/30/24 showed: -Resident was receiving Diabetes management. -Resident will allow nursing staff to check his blood sugar as needed or if has signs and symptoms of low blood sugars. Observation on 05/21/25 at 11:30 A.M., CMT C performing an accucheck on resident. Fingertip was cleansed with alcohol but did not allow it to dry for more than 6 seconds before sticking the finger. CMT C wiped the first drop of blood with a cotton swab and used second drop of blood to check glucose. Accucheck reading was performed. Record Review on 05/21/25 at 11:37 A.M., showed accucheck documented by CMT C. During an interview on 05/21/25 at 11:41 A.M., CMT C said he/she should have allowed the finger to dry after use of alcohol swab, then stick the finger to obtain blood sample. During an interview on 05/22/25 at 09:25 A.M., CMT B said after swabbing the fingertip, wipe off the first drop of blood, then use the second drop for the accucheck, after it dries. During an interview on 05/22/25 at 09:30 A.M., LPN A said after use of alcohol swab to the fingerip, allow it to completely dry at least a few second before using the drop of blood for the accucheck. During an interview on 05/22/25 at 09:10 A.M., The Director of Nursing (DON) said accucheck steps are as follows: -Handwashing before gloving; -Each resident has their own device; -Place barrier down then gloves on; -Put supplies on the barrier; -Scrub the fingertip with alcohol, then dry it off with cotton; -Poke fingertip and get blood out; -Place blood on strip and insert into accucheck device; -Lancet goes into the sharps container; -Hand hygiene; -Clean device. During an interview on 05/22/25 at 01:10 P.M., the Administrator said that after a residents fingertip is swiped with alcohol, staff should wait to allow the residents finger to dry before the accucheck is done which is approximately 10 seconds. She said staff can use the first drop of blood but the second drop of blood is more accurate.

Based on interview and record review, the facility failed to ensure the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for residents (Resident #26 and Resident #47) were correct when the Durable Power of Attorney (DPOA)'s name was printed on the DNR instead of the name of the resident and when the facility failed to ensure the DNR orders for residents (Resident #46 and Resident #47) were not signed by the DPOA prior to the residents being declared incapacitated. This affected three of 13 sampled residents (Resident #26, Resident #46 and Resident #47) The facility census was 51. Review of the facility's policy titled, Advance Directives, dated December 2016, showed: -Advanced directives will be respected in accordance with the state and state law; -Upon admission the resident will be provided with written information concerning the right to refuse or accept treatment; -If a resident is incapacitated and unable to receive information about his/her rights to formulate an advanced directive the legal representative will be provided the information; The interdisciplinary team will review annually with the resident. 1. Review of Resident #26's Quarterly Minimum Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/21/25, showed: -Severe cognitive impairment; -Partial assist for Activities of Daily Living (ADLs); -Diagnoses included, dementia, seizures and depression. Review of the resident's care plan dated 04/17/25, showed: -The resident had a DNR in place; -Code status will be reviewed every quarter. Review of the resident's electronic medical record showed: - On 11/30/22 a physician's order for Do Not Resuscitate was obtained; - The DNR document showed the name of the resident's DPOA printed on the line reserved for the name of the resident; - The DNR document was signed by the resident's DPOA and the physician on 06/07/22. During an interview on 05/21/25 at 01:28 P.M., Certified Nurses Aide (CNA) C said: -The nurses or the Social Services Designee (SSD) take care of getting signatures for the DNR's; -The DPOA signs the DNR if the resident is incapacitated; -The name of the resident should be printed on the line designated for the resident; -The DPOA's name should not be printed on the line reserved for the resident. During an interview on 05/21/25, at 02:52 P.M., Licensed Practical Nurse (LPN) A said: -The resident does not make his/her own decisions; -The resident is a DNR code status; -The name of the resident should be printed on the line designated for the resident; -The DPOA's name should not be printed on the line reserved for the resident. 2. Review of Resident #46's Admission MDS dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included, dementia, high blood pressure and kidney disease. Review of the resident's care plan dated 04/11/25, showed: -The resident had a DNR in place; -Code status will be reviewed every quarter. Review of the resident's electronic medical record showed: -DPOA document signed by the DPOA on 11/28/2011; -Incapacitation letter, dated 04/16/25, that was signed by two physicians; -DNR signed by DPOA on 03/28/25 before the resident was deemed incapacitated. During an interview on 05/21/25, at 03:45 P.M., Certified Medication Technician (CMT) C said: -The resident is a DNR code status; -The name of the resident should be printed on the line designated for the resident; -The DPOA's name should not be printed on the line reserved for the resident; -SSD reviews the DNR forms. During an interview on 05/21/25, at 02:52 P.M., LPN A said: -The resident does not make his/her own decisions; -The resident is a DNR code status; -SSD oversees the completion of the DNR forms; -The name of the resident should be printed on the line designated for the resident; -The DPOA's name should not be printed on the line reserved for the resident. 3. Review of Resident #47's Admission MDS dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included, cancer, stroke and depression. Review of the resident's care plan dated 04/30/25, showed: -The resident had a DNR in place; -Code status will be reviewed every quarter. Review of the resident's medical record showed: -DPOA document signed by the DPOA on 04/24/25; -Incapacitation letter, dated 05/14/25, that was signed by two physicians; -DNR signed by DPOA on 04/21/25 before the resident was deemed incapacitated. During an interview on 05/21/25 at 01:28 P.M., CNA C said: -The nurses or the SSD take care of getting signatures for the DNR's; -The DPOA signs the DNR if the resident is incapacitated; -The name of the resident should be printed on the line designated for the resident; -The DPOA's name should not be printed on the line reserved for the resident. During an interview on 05/21/25, at 02:52 P.M., LPN A said: -The resident does not make his/her own decisions; -The resident is a DNR code status; -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident; -SSD reviews the DNR forms. During an interview on 05/22/25 at 09:18 A.M., the SSD said: -She reviews the resident DNRs every quarter; -Resident #26, #46 and #47 are DNR code status; -The DNR is not correct if the DPOA's name is printed where the resident's name is indicated; -The DPOA should not have signed Resident #46's DNR until the resident had been declared incapacitated; -The DPOA should not have signed Resident #47's DNR until the resident had been declared incapacitated. -The DNRs for Resident #26, #46 and #47 are not correct; -The DNRs for Resident #26, #46 and #47 should be correct. During an interview on 05/22/25 at 11:16 A.M. the Director of Nursing (DON) said: -The resident's name should be printed on their DNR not the name of the responsible party; -She expects the DNRs to be correct; -SSD is in charge of making sure the DNRs are correct; -The DPOA should not have signed Resident #46's DNR until the resident had been declared incapacitated; -The DPOA should not have signed Resident #47's DNR until the resident had been declared incapacitated. During an interview on 05/22/25, at 11:30 A.M., the Administrator said: - The name of the DPOA should not be printed on the line designated for the resident; -The DPOA should not have signed Resident #46's DNR until the resident had been declared incapacitated; -The DPOA should not have signed Resident #47's DNR until the resident had been declared incapacitated; -The DNRs for Resident #26, #46 and #47 are not correct; -She expects the DNRs for Resident #26, #46 and #47 to be correct.

Based on observations, interviews, and record reviews, the facility failed to ensure staff followed professional standards of care for four of 12 sampled residents (Resident #18, #22. #35 and #46) when staff failed to ensure blood sugars were checked 30 minutes prior to meals which affected two residents (Resident #18 and #35), and failed to obtain a physician's order to check blood sugars for one resident who was receiving insulin (Resident #46) and when staff failed to obtain physician's orders for the use of a Continuous Positive Airway Pressure (CPAP) machine (a machine that helps the resident breathe easier) and for changing the oxygen tubing one resident (Resident #22). The facilty census was 48. Review of the facilty's Medication Administration and Maintenance Policy, dated October 2017, showed: -No medication or treatment shall be given without an order from a person lawfully authorized to prescribe such and the order shall be followed; -No medications will be left unattended or unobserved by the CMT/Nurse administering medications; -Self administration of medication is permitted only if approved in writing by the resident's physician. Review of the facility's policy for blood glucose monitoring and cleaning, dated 12/12/17, showed it did not address how soon a resident should eat after the blood sugar was obtained. Review of the facility's undated policy for medication administration and maintenance showed it did not address how soon a resident should eat after the blood sugar was obtained. 1. Review of Resident #46's Admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/2/24, showed: -Severe cognitive impairment; -The resident received injections seven out of the last seven days; -The resident had an order for insulin seven out of the last seven days; -Diagnoses included weakness, Parkinson's disease (a disorder of central nervous system that affects movement often including tremors), disorientation, dependence on renal dialysis (process of removing extra fluid and waste products from the body when kidneys are not able to), diabetes (a disease in which the body does not process blood sugar properly). Review of the resident's Physician's Order Sheet (POS) dated March 2024, showed: -Order start date: 3/27/27, Glargine Max SoloStart (a long acting insulin) insulin 300 units/ milliliter (ml), inject 5 units one time daily; -No order to check the resident's accu check (a meter used by people with diabetes to monitor their blood sugar levels) was found. A review of the resident's Medication Administration Record (MAR) dated March 2024, showed: - Order start date: 3/27/24 Glargine Max SoloStart insulin 300 units/ milliliter (ml), inject 5 units one time daily showed: - 3/27/24 - the insulin was given at 8:25 A.M.; - 3/28/24 - the insulin was given at 6:50 A.M.; - 3/29/24 - the insulin was given at 8:29 A.M.; - 3/30/24 - the insulin was given at 7:37 A.M.; - 3/31/24 - the insulin was given at 7:32 A.M Review of the resident's POS dated April 2024, showed: -Order start date: 3/27/27, Glargine Max SoloStart insulin 300 units/ ml, inject 5 units one time daily; -No order to check the resident's blood sugar was found. Review of the resident's MAR, dated April 2024, showed: -Order start date: 3/26/27, Glargine Max SoloStart insulin 300 units/ ml, inject 5 units one time daily; -No order to check the resident's blood sugar was found. Observation and interview on 04/10/24, at 07:03 A.M., showed: -Licensed Practical Nurse (LPN) B gave the resident 5 units of Glargine Max SoloStart insulin in the lower right abdomen; -The nurse did not check the resident's blood sugar before giving the insulin; -The nurse said he/she uses nursing judgement to determine if the insulin is to be given or not because there is no order for an accu check yet; -The resident has been here for two weeks; -The resident can tell the staff giving medications if he/she wants the insulin or not based on how he/she feels; -The nurse said the facilty reached out to the physician for the accu check order when he/she was admitted but have not heard anything back; -The nurse said a physician's order for accu checks should be obtained if insulin is given. During an interview on 4/10/24 at 3:24 P.M., the Administrator and the Director of Nursing (DON) said: -There should been an order for blood sugar checks if there is an order for insulin; -The nursing staff needs to obtain an order for a blood sugar check from the physician if there is not one on the admitting orders; -Blood sugar checks should be obtained before insulin is given. 47195 2. Review of Resident #22's quarterly MDS dated [DATE], showed: -Intact cognition: -He/She had clear speech, was able to make self understood, and clear comprehension of others; -He/She was on oxygen therapy; -Diagnoses included sleep apnea (a condition in which the resident stops breathing during sleep). Review of care plan, 1/31/24, showed: -CPAP or oxygen was not addressed Review of physician's orders, dated 4/8/24, showed: -Ordered 11/29/22, adjust oxygen to keep oxygen saturations above 90%; -No orders for CPAP machine; -No orders to change oxygen tubing; -No orders to clean/change oxygen filter; -No orders for changing CPAP filter. -No orders for adding water to CPAP or oxygen concentrator. Review of Medication Administration Record, dated April 2024, showed: -No orders for oxygen tubing or filter changes. -No orders for CPAP machine or filter changes. Review of Treatment Administration Record, dated April 2024, showed: -No orders for oxygen tubing or filter changes. -No orders for CPAP machine or filter changes. During an interview on 4/7/24 at 11:42 A.M., resident said: -He/She wore oxygen at sleep; -He/She had a CPAP machine; -Oxygen tubing was changed maybe on time monthly, it did not get changed weekly. Observation showed on 4/7/24 that resident had an oxygen concentrator beside his/her bed and a CPAP machine with filter dated 3/14/24 sitting on ledge beside bed. During an interview on 4/10/24 at 3:18 P.M., the Administrator said: -He/She expected physician's orders to include changing of oxygen tubing and filters for oxygen concentrators and CPAP machines. 31102 3. Review of Resident #35's POS, dated April 2024 showed: - Order date: 11/22/22 - Accu checks before meals and at bedtime related to diabetes mellitus. Notify the physician if the blood sugar is below 70 or above 400. Review of the resident's medication administration record (MAR), dated April 2024 showed: - Accu checks before meals and at bedtime related to diabetes mellitus. Notify the physician if the blood sugar is below 70 or above 400. Observation on 4/9/24 at 10:09 A.M., showed: - LPN A obtained the resident's blood sugar which was 152; - The resident did not receive any insulin based on the resident's blood sugar. Observation on 4/9/24 at 11:59 A.M., showed: - Resident #35 was served his/her meal and staff assisted him/her to eat. During an interview on 4/10/24 at 11:07 A.M., LPN A said: - The blood sugars should be obtained an hour before the resident's meal. 4. Review of Resident #18's POS, dated April 2024 showed: - Start date: 1/20/23 - accu checks before meals. Notify the physician if the blood sugars are below 70 or greater than 400. Review of the resident's MAR, dated April 2024, showed:- Accu checks before meals. Notify the physician if the blood sugars are below 70 or greater than 400. Observation on 4/9/24 at 10:46 A.M., showed: - Certified Medication Technician (CMT) A obtained the resident's blood sugar which was 196; - The resident refused his/her insulin. Observation on 4/9/24 at 12:16 P.M., showed: - The resident was served his/her meal and started eating. During an interview on 4/9/24 at 12:20 P.M., CMT A said:- Should obtain the blood sugars an hour before the residents eat. During an interview on 4/10/24 at 3:22 P.M., the Administrator and the DON said: - Staff should obtain the blood sugars 30 minutes to an hour before the meal.

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect when they stood to feed residents who required assistance (Resident #34 and #35) and when they failed to serve residents sitting at the same table at the same time during meal service (Resident #28, #17, #8, and #39. This affected six of twelve sampled residents. The facility census was 48. Review of facility policy, quality of life - dignity, dated August 2009, showed: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. -Residents shall be treated with dignity and respect at all times. -'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 1. Review of Resident #34's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/4/24, showed: -He/She was cognitively intact. -He/She had clear speech; -He/She was able to make self-understood and understand others; -He/She required substantial to maximal assistance with eating, oral care. -Diagnoses included: Guillain-Barre syndrome (a condition in which the immune system attacks nerves) , high blood pressure, hyperlipidemia (high levels of fat in the blood), depression, hypokalemia (blood level is below normal in potassium which can cause fatigue, muscle cramps, and abnormal heart rhythms), restless leg syndrome, neuropathy, fusion of the cervical spine region, astigmatism, low back pain, and generalized muscle weakness. Review of care plan, dated 1/30/24, showed: -He/She required assistance of one staff member during meals due to tremors; -He/She had weighted silverware and brace for right arm to assist with feeding him/herself. He/She did not like to use that and felt it took too long and he/she would rather staff just assist him/her with eating; Observation on 4/9/24 at 12:13 P.M. showed the Administrator stood to feed the resident. 2. Review of Resident #35's Quarterly MDS, dated [DATE], showed: -Resident is rarely or never understood; -He/She had unclear speech; -He/She required substantial or maximal assistance with eating, oral care. -Diagnoses included stroke, high blood pressure, diabetes (too much sugar in the blood), aphasia, dementia, aphasia (disorder that affects a person's ability to communicate), hyperglycemia (high blood sugar levels), hypokalemia (a condition when blood level low in potassium), retention of urine, cognitive communication deficit (a condition causing difficulty with thinking and how someone uses language), need for assistance with personal care, cataract (a condition where there is clouding of the normally clear lens causing blurry vision). Review of care plan, dated 11/2/23, showed: -He/She was on a regular diet with thin liquids. He/She was placed at the feed feeding assistance table. -He/She required staff assistance and cuing with meals. -He/She was alert but unable to communicate effective due to aphasia following a stroke and communication deficit. He/She will make eye contact and he/she liked staff to explain what they are doing during his/her care. Observation on 4/9/24 at 12:13 P.M. showed Administrator stood to feed the resident. Observation on 4/10/24 at 7:30 A.M., showed Activity Director stood to feed the resident. 3. Review of Resident #28's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech and was able to make self-understood and understand others; -He/She required set up or clean up assistance with eating. -Diagnoses included: immunodeficiency (absence of elements of the immune system), cancer, high blood pressure, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), hyperglycemia (too much sugar in the blood), bone-marrow stem cell transplantation status, long term use of blood thinners, and history of pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). Review of care plan, dated 1/21/24, showed: -He/She was alert and orientated with person, place, and situation; -His/Her speech was clear and able to make his/her needs known; -He/She was independent of activities of daily living. During an interview on 4/8/24 at 12:37 P.M. resident said: -Meal service should go by tables not just giving someone a plate 4. Review of Resident #17's MDS, dated [DATE], showed: -He/she was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She required supervision or touching assistance with eating; -He/She required set up or clean up assistance with oral care; -He/She required partial to moderate assistance with upper body dressing; -Diagnoses included high blood pressure, renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), stroke (damage to the brain from interruption of its blood supply), paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), aortic valve disorder (a condition causing narrowing of the valve in the large blood vessel branching off the heart), respiratory failure (a condition making it difficult to breathe on your own), contracture of left knee. Review of care plan, dated 3/6/24, showed: -He/She used an electric wheelchair for mobility; -He/She required staff assistance with all activities of daily living -He/She was able to express his/her needs. Observation on 4/9/24 at 7:52 A.M. during breakfast showed Dietary Aide A serving one resident at each of first three tables, Table 1, 2, and 3 and Dietary Aide A returned at 7:55 A.M. and served second resident at table 2 . Resident #17 expressed frustration over way breakfast was served to multiple tables at once and he/she had to wait. During an interview on 4/8/24 at 12:37 P.M. resident said: -The whole table should be served at once during meal service and is not occurring. -Plates are being served to one person at one table then to another person at another table. 5. Review of Resident #8's MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had unclear speech with slurred or mumbled words; -He/She had clear comprehension; -He/She was dependent on a wheelchair; -He/She required set up or clean up assistance with eating. -Diagnoses included cancer, anemia, high blood pressure, peripheral vascular disease (a circulatory condition in which a narrowing of the blood vessels reduced blood flow to the limbs), malnutrition (a lack of sufficient nutrients in the body). Review of care plan, dated 3/27/24, showed: -He/She was alert and orientated and able to voice his/her own needs; -He/She was independent with oral cares. Observation on 4/9/24 at 7:52 A.M. during breakfast showed Dietary Aide A serving one resident at each of first three tables, Table 1, 2, and 3 and Dietary Aide A returned at 7:55 A.M. and served second resident at table 2 . During an interview on 4/8/24 at 12:37 P.M. resident said: -It was uncomfortable when your friends are served their meal and you are just sitting there. 6. Review of Resident #39's Quarterly MDS, dated [DATE], showed: -He/She had moderate cognitive impairment; -He/She had clear speech, made self-understood, and had clear comprehension of others; -He/She was independent with eating; -Diagnoses included: anemia, coronary artery disease, high blood pressure, dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety, and depression. Review of care plan, dated 3/6/24, showed: -He/She was able to communicate needs with a clear voices; -He/She had adequate vision During an interview on 4/8/24 at 12:37 P.M. resident said: -They skip around when they are trying to serve us meals; -Facility ought to feed one table at a time; -Facility staff skip around when they serve plates; Observation on 4/09/24 at 7:45 A.M. showed first breakfast plates being served in the dining room, one breakfast plate was served to table one, followed by one breakfast plate served to table two, and then one breakfast plate was served to table three. There was thirty-four residents waiting in dining room at their tables. Second cart came to dining room and Dietary Aide A served one plate to resident at table two, then served three plates to residents at table four. Observation on 4/9/24 at 7:55 A.M. showed Dietary Aide A served a breakfast plate to table two, the first plate was served to this table at 7:45 A.M. Observation on 4/9/24 at 12:23 P.M. showed Resident #200 was sitting at table with two other residents who had already been served their meals. He/She had not yet been served the noon meal. Observation on 4/10/24 at 7:10 A.M. showed Cook B brought out second set of breakfast trays and served table 5 which included three residents, two residents were served (Resident #39 and #6). Resident #46 was also at table 5 and was not served until 7:16 A.M. During an interview on 4/8/24 at 11:57 A.M., Dietary Aide B said: -He/She did not serve all residents at one table in the dining room at the same time; -He/She tried to make it fair when serving room trays; -He/She tried to look and see which resident was in the dining room the longest when he/she served meals; -He/She check marked resident names off of resident roster when resident was at their table so that he/she knew who to serve next. During an interview on 4/10/24 at 10:08 A.M., the Dietary Manager said: -Residents at the same table should be served their meals at the same time; -Facility had open dining. The kitchen serves residents as they come into the dining room; -Facility staff cannot serve residents as they enter dining room if they do not have a staff member out there; because they do not see when residents arrive. -The facility does try to serve everyone at the same table all at once. During an interview on 4/10/24 at 10:31 A.M., the Activities Director said: -He/She should not stand to feed residents; -He/She stood to feed resident as he/she cannot reach resident from sitting down. -He/She should be eye level resident when assisting resident to eat. During an interview on 4/10/24 at 10:33 A.M., the Administrator said: -He/She acknowledged when interviewed that he/she should not stand to feed resident due to dignity. -He/she should not stand to feed a resident; -He/she was standing as he/she was feeding two residents while staff member was gone. 31102 Observation on 4/7/24 at 11:58 P.M., showed: - Resident #17 was served his/her meal and was eating. Two other tablemate's, (Resident #18 and #8) sat at the table without a meal. At 12:15 P.M., Resident #18 was served his/her meal and started eating. At 12:17 P.M., Resident #8 was served his/her meal and started eating. Observation on 4/8/24 at 11:52 A.M., showed: - Residents #11, #35 and #37 were served their meal and started eating. Resident #34 sat at the same table and did not have a meal. At 11:56 A.M., Resident #34 was served his/her meal and started eating; - At 12:02 P.M., Resident #41 and #43 were served their meal and started eating. Resident #27 did not have his/her meal. At 12:15 P.M., Resident #27 was served his/her meal and started eating. Observation on 4/9/24 at 11:55 A.M., showed: - Resident #37 was served his/her meal. Two tablemate's (Resident #34 and #35) did not have a meal. At 11:59 A.M., Resident #35 was served his/her meal. At 12:09 P.M., Resident #34 was served his/her meal and started eating. During an interview on 4/10/24 at 3:22 P.M., the Administrator and Director of Nursing (DON) said: - Would expect all the residents to get their meals at the same time.

Based on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer, the location to which the resident is transferred or discharged , a statement of the resident's appeal rights, including he name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman, and for residents with a mental disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility must send a copy of the notice to a Representative of the Office of the State Long - Term Care Ombudsman. This affected three of 12 sampled residents, ( Resident #2, #39 and #46). The facility census was 48. The facility did not provide a policy for transfers, discharges or notifying the Ombudsman. 1. Review of Resident #2's progress notes, dated 11/8/23 showed: - At 5:00 A.M., the resident was sent to the hospital for surgery; - At 11:45 A.M., the resident returned from the hospital; - No documentation of the bed-hold letter sent with the resident when he/she was sent to the hospital for surgery; - Did not show a letter or reason for the transfer/discharge to the hospital sent to the responsible party. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 1/11/24 showed: - Cognitive skills intact; - Required set up and clean up with toilet use, dressing and personal hygiene; - Independent with transfers; - Diagnoses included diabetes mellitus, breast cancer, depression and abscess of left great toe. 2. Review of Resident #39's progress notes showed: - 2/12/24 at 1:39 P.M., the resident had redness and swelling to his/her right and left eyes from eyebrows to cheeks. Faxed the resident's physician with an order for Benadryl ( relieves symptoms of allergies, itchy skin and the common cold). After the resident received the dose of Benadryl, the resident complained of facial burning and itching with redness and swelling noted to jaw line. Physician notified with instructions to transfer the resident to the emergency room (ER). - No documentation of the bed-hold letter sent with the resident when he/she was sent to the emergency room ; - Did not show a letter or reason for the transfer/discharge to the hospital sent to the responsible party. Review of the resident's quarterly MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Independent with toilet use, personal hygiene and transfers; - Continent of bowel and bladder; - Diagnoses included dementia, anxiety, and depression. During an interview on 4/8/24 at 3:03 P.M., Licensed Practical Nurse (LPN) B said: - When they send a resident out to the hospital, they send a copy of the face sheet, physicians order sheet, advance directives and fill out a transfer form which just has the basic information on it (name, date of birth, insurance information, diagnoses and code status). At the bottom of the transfer form he/she would document a mini report about what was going on with the resident; - He/she would notify the physician, family or responsible party and call report to the hospital. During an interview on 4/8/24 at 3:14 P.M., the Social Services Designee said: - The staff typically print out the transfer form with the resident's information on it and the staff hand write information about what was going on with the resident at the bottom of the transfer form; - He/she did not think the staff fill out any forms with the resident's appeals rights on it. During an interview on 4/9/24 at 1:42 P.M., the Administrator said: - She did not think the Social Services Designee had notified the Ombudsman monthly of the transfers and discharges; - She was not aware the Ombudsman was supposed to be notified; - She did not think the transfer forms were always being sent with the residents when they were transferred out to the hospital; - The nurses should make a copy of the transfer form and give it to Social Services so that it can be scanned in and given to the family. 47195 3. Review of Resident #46's Admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/2/24, showed: -He/She was severely cognitively impaired; -He/She had clear speech, was able to make self-understood. -Diagnoses included weakness, Parkinson's disease (a disorder of central nervous system that affects movement often including tremors), disorientation, dependence on renal dialysis (process of removing extra fluid and waste products from the body when kidneys are not able to), diabetes. Review of progress notes, dated 4/8/24, showed: -LPN B wrote: Resident was sent to emergency room after resident was found to be weak, pulse was 45, and blood pressure was 88/55, and incoherent. Nurse notified emergency medical response and resident began to come around and became more coherent and had his/her comprehension back but after EMT's arrived began acting slower and weak again and left in ambulance at 7:12 A.M. During an interview on 4/8/24 at 8:13 A.M., LPN B said: -Resident was sent to hospital that morning; -He/She did not send transfer paperwork with resident; -He/She sent with resident a copy of their medication list, diagnosis and allergies, and the resident's code status.

Based on interviews and record review, the facility failed to ensure staff completed a Level I Preadmission Screen and Resident Review (indicated for any individual who may have an intellectual disability (ID), developmental disability (DD), or mental illness (MI). This affected two of 12 sampled residents, ( Resident #22 and #33). The facility census was 48. Review of the facility's undated policy for PASARR's (Preadmission Screening and Resident Review, a federal requirement to help ensure that individuals are inappropriately placed in nursing [NAME] for long term care) showed: - The Nursing Home Reform Act was passed as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA - 87), and amended by Public Law 100 -203 and 101 - 508, creating the Preadmission Screening and Resident Review ([NAME]) process; - The purpose of the PASARR is to ensure that individuals being considered for admission to a Medicaid certified nursing facility (NF) are evaluated for evidence of possible PASARR conditions (serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or a related condition (RC). PASARR grants special protections to individuals with SMI, ID/DD, or RC to ensure they receive services in the most integrated setting; - PASARR ensures that individuals being admitted to, or residing in a NF, receive services or supports that address their PASARR condition, including services linked to that condition; - The PASARR process consists of a LEVEL 1 Screening, a Level II evaluation (depending on the outcome of the Level I Screening), and a Determination. A Determination is defined as a decision made by the mental illness (MI) or ID state authority, delivered by a provider, that include placement and treatment recommendations that are most appropriate for an individual. 1. Review of Resident #33's medical record showed: - admitted - 8/17/22; - Payer source- private pay and Medicare; - Diagnoses included Alzheimer's Disease and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch and taste), or delusions (a belief that is clearly false and that indicates an abnormality in the affected person's content of thought), and mood disorder symptoms, such as depression or mania); - No Level I PASARR was located in the resident's medical record or made available. Review of the resident's care plan, revised 7/11/23 showed:- The resident had behaviors of paranoia (a mental disorder in which a person has an extreme fear and distrust of others), that has been reported by the resident's daughter, related to his/her schizoaffective disorder. The resident required reassurance in a calm, soft voice with light touches; - The resident was alert with periods of confusion related to the resident's Alzheimer's disease with early onset. He/she required reminders and reassurance; - The resident had episodes of paranoia related to his/her schizocarp disorder. Offer to assist the resident with calling his/her family to talk with them. Provide reassurance in a calm voice with soft touching. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 2/22/24, showed:- Cognitive skills severely impaired; - No behaviors; - Independent with toilet use, showers, personal hygiene and transfers; - Continent of bowel and bladder; - Diagnoses included Alzheimer's disease, Schizophrenia, and depression. During an interview on 4/8/24 at 4:42 P.M., the Social Services Designee said;- He/she was unable to locate the resident's PASARR in the resident's medical record. 47195 2. Review of Resident #22's Quarterly minimum data set (MDS), dated [DATE], showed: -He/She had moderate intact cognition. -He/She had clear speech, was able to make self understood, and clear comprehension of others; -He/She had hallucinations and delusions; -Diagnoses included dementia, depression, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), Review of the resident's care plan, dated 1/31/24, showed: -He/She had diagnosis of depression; - He/She has mental health needs and behavioral needs. -He/She took medications for depression and behavioral needs. Review of resident's medical record on 4/8/24, showed: -He/She did not have a PASARR available. The Requested PASARR was not provided by facility. During an interview on 4/10/24 at 3:18 P.M., Director of Nursing (DON) said: -The DON was responsible for completing PASARRS; -He/She completed them and printed out and placed in resident's medical record. During an interview on 4/10/24 at 3:18 P.M., Administrator said: -PASARR's are completed with all residents upon admission; -If resident had a change in status he/she would repeat the PASARR to see if resident triggered for a level two PASARR; -PASARR's should be available in all resident's medical records.

Based on observations, interviews and record review, the facility staff failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not ensure nail care was completed for one of 12 sampled residents, (Resident #33) and ensure shaving was completed for two sampled residents, (Resident #3 and #33). The facility census was 48. Review of the facility's undated policy on nail care showed it did not address when fingernail polish should be removed and reapplied. Review of the facility's shaving policy, revised October 2010, showed, in part: - The purpose of this procedure is to promote cleanliness and to provide skin care; - The policy did not address how often a female or male resident should be shaved. 1. Review of Resident #33's care plan, revised 7/1/23 showed: - It did not address how often the resident preferred to be shaved and did not address how often fingernail polish should be removed and reapplied. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/22/ 24 showed: - Cognitive skills severely impaired; - Independent with oral hygiene, toilet use, showers, personal hygiene, and transfers; - Required set up and clean up assistance with dressing; - Diagnoses included Alzheimer's disease, depression, schizophrenia ( a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions). Observation and interview on 4/7/24 at 9:58 A.M., showed: - The resident had 1/4 inch chin whiskers; - The polish on the resident's fingernails were coming off; - The resident said he/she would like for someone to take the polish off and apply new polish. He/she did not like how his/her fingernails looked; - The resident said he/she did not like the chin whiskers and would like for the staff to offer to do something about them. Observation on 4/9/24 at 8:14 A.M., showed the resident continued to have the chin whiskers and his/her fingernails still had partial nail polish on them. During an interview on 4/10/24 at 7:02 A.M., Nurse Aide (NA) A said: - Some of the residents had little shavers in their room and they either shave the residents or assist them. The staff do it every morning before the residents go to breakfast; - There's a Hospice (end of life care) group that comes in about once a week or every other week and does nail care for the residents. During an interview on 4/10/24 at 7:18 A.M., Licensed Practical Nurse (LPN) B said: - If a female resident had whiskers and wanted them removed, then the staff should shave them; - If the resident did not like the fingernail polish half on and half off, then the staff should remove it and apply new polish if they want it. During an interview on 4/10/24 at 11:07 A.M., LPN A said: - If a female had chin whiskers and did not want them, then staff should shave them or assist them; - If a resident had fingernail polish that was coming off and they were not happy about it, all they would need to do is ask the staff and the staff would redo them. He/she thought the residents got their nails done about once a week. During an interview on 4/10/24 at 3:22 P.M., the Administrator and Director of Nursing (DON) said: - The residents should be shaved if they do not like the chin whiskers; - If a resident was not alert and oriented, staff should talk to the family and see what they want done; - There's stuff in the activity department to remove the fingernail polish. Hospice comes in once or twice a month and does the resident's fingernails. 46706 2. Review of Resident #3's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/7/24, showed: -No cognitive impairment; -Substantial assistance with toileting; -Substantial assistance with personal hygiene; -Diagnoses included, coronary artery disease (CAD, a disease is caused by plaque buildup in the wall of the arteries that supply blood to the heart) and high blood pressure. Review of the resident's undated care plan showed: -The resident had a self care performance deficit related to multi-system degeneration of the autonomic nervous system; -The resident requires extensive assistance with showers; - The resident's care plan did not address shaving. Observation and interview on 04/07/24 09:57 A.M., showed: -The resident was in his/her room setting in a recliner; - The resident's hair was uncombed; - The resident had facial hair; - The resident said he/she could not remember the last time he/was shaved; - The resident said he/she would like to be shaved today. Observation on 04/08/24 09:14 A.M., showed: - The resident was in his/her room setting in a recliner; - The resident's hair was uncombed; - The resident had facial hair. During an interview on 4/8/24 at 11:12 A.M., NA B said: - The resident gets a shave on shower days; - He/She was not sure when the resident's shower days were; - Sometimes Hospice will shave the resident. During an interview on 4/10/24 at 9:17 A.M., LPN B said: - He/she would expect staff to assist the resident with shaving; - Shaving gets done on the shower days; - Hospice shaves the resident most of the time; - He/She would expect the resident to be cleanly shaved if that is what they want. During an interview on 4/10/24 at 3:22 P.M., the Administrator and DON said: - The residents should be shaved if they do not like the chin whiskers; - If a resident was not alert and oriented, staff should talk to the family and see what they want done; - There's stuff in the activity department to remove the fingernail polish. Hospice comes in once or twice a month and does the resident's fingernails.

Based on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the residents size and weight, failed to complete quarterly assessments, and failed to obtain a physician's order prior to installation for two of twelve sampled residents (Resident #22 and #39). The facility census was 48. Facility did not provide a policy on entrapment assessments. Review of facility policy, proper use of side rails, revised December 2016, showed: -Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. -An assessment will be made to determine the resident's symptoms, risk of entrpament and reason for usng side rails. When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility; -Ability to change positions, transfer to and from bed or chair, and to stand and toilet; -Risk of entrapment from the use of side rails; and -That the bed's dimensions are appropriate for the resident's size and weight. -The use of side rails as an assistive device will be addressed in the resident care plan. -Consent for using restrictive devices will be obtained fromt her esident or legal representative per facility protocol. -Documentation wil indicate if less restrictive approaches are not successful, prior to considering the use of side rails. -The risks and benefits of side rails will be considered for each resident. -Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risk. -Manufacturer instructions for the operation of side rails will be adhered to. -The resident will be checked periodically for safety relative to side rail use. -If side rail use is associated with symptoms of distress, such as screaming or agitation, the resident's needs and use of side rails will be reassessed. -When side rail use is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depneding on theype of bed and mattressing being used). -Side rails with padding may be used to prevent resident injury in stiuations of uncontrollable movement disroders, but are still restraints if they meet the definition of restraing. -Facility staff, in conjuction with the attending physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions. Review of facility policy, Accomodation of needs, dated August 2009, showed: -Resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. 1. Review of Resident #22's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/25/24, showed: Cognition intact; -He/She had clear speech, was able to make self understood, and clear comprehension of others; -He/She was dependent for toileting, putting on and taking off footwear, personal hygiene, sitting to lying, lying to sitting, sitting to standing, chair to bed transfers -He/She required substantial/maximal assistance with bathing, lower body dressing, rolling left and right, -He/She required partial/moderate assistance with upper body dressing; -He/She was always incontinent of bowel and bladder; -He/She had no falls since last assessment; -Diagnoses included cancer, hip fracture, dementia, spinal stenosis, osteoarthritis of left knee, weakness, artificial left hip, and aphakia (a condition in which you are missing the lens of one or both of your eyes). Review of care plan, dated 1/31/24, showed: -He/She had bilateral assist bars on his/her bed to be able to promote as much independence as possible with bed mobility and still required staff assistance. Review of physician's orders dated, April 2024, showed: -He/She had no orders for side rails. Review of medical record showed: -Bed Rail Assessment form signed 4/8/24 showed: -Resident had poor bed mobility; -Resident expressed desire to have side rails; -Side rails are indicated to serve as an enabler to promote independenc; -Side rail placement was bilateral -No other side rail assessments found, resident was admitted to facility on 11/29/22. During an interview on 4/7/24 at 11:58 A.M., resident said the rails were for positioning. Observation on 4/7/24 at 11:58 A.M. showed resident had two cane rails on both sides of bed. 31102 2. Review of Resident #39's care plan, revised 2/1/24, showed it did not address the use of cane rails (a device that enables a resident's mobility). Review of Resident #39's quarterly MDS, dated [DATE] showed: - Cognitive severely impaired; - Independent with toilet use, personal hygiene and transfers; - Diagnoses included coronary artery disease ( CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart), anemia (a condition in which the body does not have enough healthy red blood cells), dementia, anxiety and depression. Review of the resident's physician order sheet (POS) dated April 2024 showed: - No order for the use of cane rails. Review of the resident's medical records showed: - No entrapment assessment completed; - The only bed rail assessment was completed on 4/8/24 and unable to locate any previous assessments. Observation and interview on 4/7/24 at 11:07 A.M., showed: - A cane rail on each side of the resident's bed; - The resident said he/she used it very little. During an interview on 4/9/24 at 11:10 A.M., Maintenance Supervisor said: -Facility had wide and narrow bed rails that go on resident beds; -He/She assesses side rails to bed frames by looking to see if wide bed or narrow bed; -He/She checked side rails every week but did not document or track those checks anywhere; -There was a side rail that was unhooked and leaning to the left, and he/she just ensured it was hooked back in to the bed so it was straight; -He/She did not know what entrapment assessments were; -He/She did not measure the mattresses to bed frames or look for gaps in mattresses. During an interview on 4/10/24 at 3:18 P.M., Director of Nursing (DON) said: -He/She did not think physician's orders were needed for cane rails; -He/She expected entrapment assessments to be completed with changes of the side rails, the bed, or a change of mattress. During an interview on 4/10/24 at 3:18 P.M., Administrator said: -Resident's with side rails should probably have a physician's order; -Therapy completed side rail assessments quarterly; -Therapy should complete measurements of side rails; -He/She did not know the last time side rails were measured to the mattress and bed frame; -He/She expected the nurse aides to report if a bed rail was loose and then therapy would check the side rail; -Facility took of side rails unless therapy suggested side rails for the resident; -He/She expected therapy to complete entrapment assessments; -Entrapment assessments should be completed with resident's change of condition.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care to include measurable objectives and appropriate timeframe's for five of 12 sampled residents (Resident #3, #6, #22, #34 and #39), when the facilty failed to address Hospice care for one resident (Resident #3), and when the facilty failed to address a pressure ulcer for one resident (Resident #6), and failed to address the use of oxygen and a Continuous Positive Airway Pressure (CPAP, a machine that helps the resident breathe easier) machine for one resident (Resident #22). Additionally, the facilty failed to address the use of cane rails (a device that enables the residnet's mobility) for two residents (Resident #34 and #39). The facility census was 48. Review of the facility's Care Plans, Comprehensive Person-Centered, revised December 2016, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan will describe measurable objectives and time frames; -The care plant will describe the services that are to be furnished to or maintain the residents highest potential; -The care plan will describe specialized services; -The care plan will incorporate problem area; -The care plan will reflect currently recognized standards of practice; -Comphrensive care plans will be developed within seven days of the completion of the required comprehensive assessment. 1. Review of Resident #3's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/7/24, showed: -No cognitive impairment; -Substantial assistance with toileting; -substantial assistance with personal hygiene; -The resident had an indwelling catheter; -Diagnoses included, coronary artery disease (CAD, a disease is caused by plaque buildup in the wall of the arteries that supply blood to the heart) and high blood pressure. Review of the resident's undated care plan showed: -The resident had a self care performance deficit related to multi-system degeneration of the autonomic nervous system; - The care plan did not address hospice. Review of the resident's Physician's Order Sheet (POS) dated April 2024, showed: -Start date: 3/23/23, admit to facility with hospice services. During an interview on 4/07/24 at 9:22 A.M., Resident said: -Hospice gives him/her his showers several times a week; -Hospice changes his/her catheter when it needs it. During an interview on 4/10/24 at 9:44 A.M. the MDS Coordinator said: -If a resident is on hospice services it should be addressed on their care plan. 47195 2. Review of Resident #6's Admission MDS, dated [DATE], showed: -He/She was cognitively impaired; -He/She had unclear speech and had difficulty communicating some words or finishing thoughts. -He/She was dependent on a wheelchair for mobility; -He/She required partial/moderate assistance with eating, rolling left and right, sit to lying, lying to sitting on side of bed, transfers. -He/She was dependent for personal hygiene and activities of daily living; -HE/She was always incontinent of urine and bowel -Diagnoses included Shy [NAME] Syndrome (a movement disorder which is often referred to as a Parkinson plus syndrome or Multiple System Atrophy) pneumonia, high blood pressure, wound infection; -He/She had care area that was triggered included pressure ulcers. Review of care plan, dated 2/6/24 showed: -Staff to monitor his/her skin for breakdown during cares; -His/Her skin will remain intact; -Skin checks are performed by staff on his/her bath days. Any areas of concern noted are to be reported to charge nurse for assessment. Report on to his/her family and physician as needed; -Care plan did not address pressure ulcers. Review of physician's orders, dated 4/8/24, showed: -Ordered 3/14/24, area to bottom. Apply mepilex border flex dressing over area for added protection to promote healing, one time a day every three days; -Ordered 1/30/24, roho mattress to bed for added pressure relief; During an interview on 4/07/24 at 10:57 A.M., Resident said: -He/She had sore on his/her bottom that hurts; -Nursing staff are putting a salve and bandage on his/her sore and it was getting better;. Review of progress notes, dated 3/11/24 to 4/10/24 showed: -3/15/2024 at 10:55 A.M., he/she had mepilex on coccyx (lowest part to the back). -3/28/2024 at 8:33 A.M., Skin/Wound Note, Resident with sheering/pressure to bottom that writer has been doing weekly skin assessments. Areas are now formed to one large wound. Area measuring 5 cm x 2.5 cm. Wound bed noted to be red in color. No drainage noted. Irregular in shape. Top layer of skin noted to be involved. Area cleansed with NS and covered with mepilex as ordered. During an interview on 4/10/24 at 10:55 A.M., MDS Coordinator said: -He/She expected pressure ulcers to be care planned. During an interview on 4/10/24 at 3:18 P.M., the Director of Nursing (DON) said: -He/She expected pressure ulcers should be included in care plan if a resident had one. During an interview on 4/10/24 at 3:18 P.M., the Administrator said: -He/She expected pressure ulcers to be included in resident's care plan. 3. Review of Resident #22's Quarterly MDS dated [DATE], showed: -He/She had moderate intact cognition. -He/She had clear speech, was able to make self understood, and clear comprehension of others; -He/She required partial/moderate assistance with upper body Activities of Daily Living (ADL) assistance; -He/She was on oxygen therapy; -Diagnoses included sleep apnea (when the resident stops breathing when asleep). Review of care plan, 1/31/24, showed: -CPAP or oxygen was not addressed Review of physician's orders, dated 4/8/24, showed: -Ordered 11/29/22, Titrate oxygen to keep oxygen saturations above 90%; -No orders for CPAP machine; -No orders for oxygen tubing changing. During an interview on 4/7/24 at 11:42 A.M., resident said: -He/She wore oxygen at sleep; -He/She had a CPAP machine. Observation showed on 4/7/24 that resident had an oxygen concentrator beside his/her bed and a CPAP machine with filter dated 3/14/24 sitting on ledge beside bed. During an interview on 4/10/24 at 10:55 A.M., MDS Coordinator said: -He/She wrote care plans; -He/She expected oxygen and CPAP usage to be care planned. During an interview on 4/10/24 at 3:18 P.M., the Director of Nursing (DON) said: -He/She expected oxygen and CPAP usage to be care planned. During an interview on 4/10/24 at 3:18 P.M., the Administrator said: -He/She expected oxygen and CPAP usage to be included in care plans. 31102 4. Review of Resident #39's care plan, revised 2/1/24, showed it did not address the use of cane rails. Review of Resident #39's quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Independent with toilet use, personal hygiene, transfers and mobility; - Diagnoses included coronary artery disease ( CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart), anemia (a condition in which the body does not have enough healthy red blood cells), dementia, anxiety and depression. Review of the resident's physician order sheet (POS) dated April 2024 showed: - No order for the use of cane rails. Observation and interview on 4/7/24 at 11:07 A.M., showed: - A cane rail on each side of the resident's bed; - The resident said he/she used it very little. 5. Review of Resident #34's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required substantial to maximal assistance with toilet use, showers, lower body dressing, personal hygiene, and transfers; - Required partial to moderate assistance with upper body dressing; - Diagnoses included depression, Schizophrenia ( a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), Guillian - Barre Syndrome ( a rare condition in which the body's immune system attacks the nerves located outside the brain and spinal cord), and restless leg syndrome (RLS, a neurological disorder that causes an urge to move your legs). Review of the resident's care plan, revised 1/30/24 showed it did not address the use of cane rails. Review of the resident's POS, dated April 2024 showed: - No order for the use of cane rails. Observation and interview on 4/7/24 at 3:11 P.M., showed: - A cane rail on each side of the resident's bed; - The resident said he/she used them to hold onto when moving in bed. During an interview on 4/10/24 at 10:48 A.M., the MDS/Care Plan Coordinator said: - The care plans should include the used of side rails or assist rails. During an interview on 4/10/24 at 3:22 P.M., the Administrator and Director of Nursing (DON) said: - The care plans should address the use of cane rails, Hospice (end of life care), pressure ulcers, or if the resident was at risk for pressure ulcers.

Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent (5%). Facility staff made five medication errors out of 25 opportunities for error, resulting in a medication error rate of 20%. This affected four of 12 sampled residents, (Resident #21, #27, #33, and #43). The facility census was 48. Review of the facility's undated policy for medication administration and maintenance, showed, in part: - No medication or treatment shall be given without an order from a person lawfully authorized to prescribe such and the order shall be followed. Review of the facility's policy for eye drops/ointment administration, dated September, 2017 showed: - Eye drops and eye ointments will be administered according to physician orders and/or recommendations; - Have the resident tilt their head backwards and look up; - Using your finger, hold the eye lid down and apply the drops; - With your finger, apply pressure to the inside corner of the eye for one minute; - Wait five minutes before instilling another eye medication. The facility did not provide a policy for applying and removing Lidocaine patches. Review of the package directions for Lidocaine 4% patch showed: - Clean and dry the affected area; - Use one patch for up to 12 hours. 1. Review of Resident #21's physician order sheet (POS), dated April 2024 showed: - Start date: 2/15/23 - Aspercreme Lidocaine External Patch 4%, apply to lower back topically in the morning for lower back pain. On 12 hours and off 12 hours; - Start date: 2/22/23 - Systane Complete Ophthalmic Solution 0.06%, instill two drops in both eyes twice daily for seasonal allergies. Review of the resident's medication administration record (MAR), dated April 2024 showed: - Aspercreme Lidocaine External Patch 4%, apply to lower back topically in the morning for lower back pain. On 12 hours and off 12 hours; - Systane Complete Ophthalmic Solution 0.06%, instill two drops in both eyes twice daily for seasonal allergies. Observation and interview on 4/9/24 at 8:03 A.M., showed: - Licensed Practical Nurse (LPN) A administered two drops in the resident's right eye then two drops in the resident's left eye. LPN A did not apply lacrimal pressure (pressure applied to the inner corner of the eye by the nose) to either eye; - LPN A removed the Lidocaine patch dated 4/8/24, did not clean the resident's lower back and applied a new patch to the same area and dated it; - LPN A said the patch should have been removed last night. 2. Review of Resident #33's POS, dated April 2024 showed:- Start date: 3/20/24 - Levobunolol Hydrochloride solution 0.5%, instill one drop in left eye daily for glaucoma (increased pressure within the eyeball causing loss of sight). Review of the resident's MAR, dated April 2024 showed: - Levobunolol Hydrochloride solution 0.5%, instill one drop in left eye daily for glaucoma. Observation on 4/9/24 at 8:14 A.M., showed: - LPN A placed one drop in the resident's left eye and did not apply lacrimal pressure. During an interview on 4/10/24 at 11:07 A.M., LPN A said: - He/She should have applied lacrimal pressure. He/She thought it was for five seconds; - The Lidocaine patch should have been removed the night before. He/She has never cleaned an area before applying a new patch. 3. Review of the website https://www.drugs.com for Metoprolol Tartrate, (used to treat high blood pressure) showed: - Swallow whole and do not crush, chew or break it. Review of Resident #27's POS, dated April 2024 showed:- Start date: 10/18/23 - Metoprolol Tartrate 25 milligrams (mg.) by mouth in the morning for high blood pressure. Review of the resident's MAR, dated April, 2024 showed:- Metoprolol Tartrate 25 mg by mouth in the morning for high blood pressure. Observation and interview on 4/9/24 at 10:17 A.M., showed: - LPN A crushed the Metoprolol Tartrate 25 mg. with the resident's other morning medication and mixed it in a glass with carnation instant breakfast; - LPN A said that's the only way the resident would take his/her medication; - At 10:40 A.M., the resident still had approximately a swallow of the drink left with pill fragments in the bottom of the glass. During an interview on 4/10/24 at 11:07 A.M., LPN A said:- He/She was unsure if Metoprolol Tartrate could be crushed, he/she would have to look it up. He/She knew one kind could be crushed but was unable to remember which one it was. During an interview on 4/10/24 at 3:22 P.M., the Administrator and the Director of Nursing (DON) said: - The staff should have removed the Lidocaine patch at bedtime and should clean the skin before applying a new patch; - Staff should apply lacrimal pressure for one minute; - They thought Metoprolol Tartrate could be crushed. 46706 Review of the manufacturer's instructions for Dulera Inhaler dated 2021, showed: -Breathe out through the mouth; -Push out as much air from the lungs as possible; -Hold the inhaler in the upright position and place the mouthpiece into mouth; -Close lips around the mouthpiece; - After inhaling the medication rinse mouth with water and spit out the water; -Do not swallow the water. 4. Review of Resident #43's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -The resident requires supervision with Activities of Daily Living (ADL)s; -Diagnoses included, coronary artery disease (CAD, a condition that affects your heart), high blood pressure and respiratory failure. Review of the resident's POS dated April 2024, showed: -Order start date: 3/15/24, Dulera Inhaler 100-5 micrograms (mcg)/ actuations (act), inhale 2 puffs two times a day, rinse mouth after each use, do not swallow water. Review of the resident's MAR, dated April 2024, showed: -Order start date: 3/26/24, Dulera Inhaler 100-5 mcg/ act, inhale 2 puffs two times a day, rinse mouth after each use, do not swallow water. Observation and interview on 04/10/24, at 06:55 A.M., showed: -LPN B shook the Dulera inhaler and instructed the resident to exhale before each inhalation; -The resident exhaled before each inhalation of the medication; -The nursed gave the resident a cup of water with giving any instructions to swish and spit out the water; -The resident swished the water in his/her mouth and swallowed the water instead of spitting the water out as instructed in the physician's order. -The nurse said he/she should have instructed the resident to swish with the water and then spit the water back out into the cup instead of allowing the resident to swallow it. During an interview on 4/10/24 at 3:24 P.M., the Administrator and the DON said: -Physician's orders should be followed; -The staff should instruct the resident to swish and spit if that is what is ordered.

Based on observation, interview, and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, and when the medications were left in pill cups on the dining table for residents in the dining room (Resident #18, #20, and #39) and when the facility failed to discard an opened vial of tuberculin purified protein derivative (skin test used to help diagnose tuberculosis infection), failed to date an opened vial of tuberculin purified protein derivative, and failed to date an opened insulin pen for Resident #46. The facility census was 48. Facility policy, Medication Administration and Maintenance, undated, showed: -No medications will be left unattended or unobserved by Certified Medication Technician or nurse administering to residents. -Self-administration of medication is permitted only if approved in writing by the resident's physician, the resident has been assessed and educated on self-administration of medication. 1. Review of Resident #20's Annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed: - Cognitively intact; -He/She had clear speech, made self-understood, and had ability to understand others; -He/She required set up and clean up assistance with eating, oral hygiene -He/She required substantial/maximal assistance with toileting, bathing, lower body dressing, sit to stand, chair to bed transfers, toilet transfers, and tub transfers; -He/She required partial to moderate assistance with upper body dressing, personal hygiene, rolling left and right, sitting to lying, and lying to sitting mobility; -Diagnoses included: hypertension, gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), arthritis (condition causing swelling and tenderness in one or more joints causing joint pain or stiffness that gets worse with age), osteoporosis (a condition in which the bones become weak and brittle), hip fracture, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), paraplegia (paralysis of the legs and lower body), anxiety, depression, spinal stenosis (when the space inside the backbone is too small), chronic pain, muscle weakness, need for assistance with personal care, dyspnea (feeling you can't get enough air into your lungs), and headache. Review of care plan, dated 2/22/24, showed: -He/She had scheduled pain management of Tramadol 50 mg that he/she got twice daily due to chronic pain; -He/She had medications- Tylenol, ibuprofen and Tramadol that he/she can request as needed; -He/She took diazepam to help with muscle spasms related to cerebral palsy; -He/She took escitalopram 10 mg daily for diagnosis of depression; -He/She took medications whole with water; -His/Her medications will be administered as ordered by primary care physician. Review of physician's orders, dated April 2024, showed: -Resident had no orders for self-administration of medications. Review of medical record showed: -He/She had no self-administration of medication assessments. Observation on 4/9/24 at 7:54 A.M. showed resident had a cup of pills sitting in front of him/her at the dining room table. Resident said to tablemate that he/she had a whole thing of pills but he/she had to wait to eat something. He/She was last resident served at 8:20 A.M. and still had pills sitting in front of him/her. Observation on 4/10/24 at 7:08 A.M. showed LPN A delivered resident medications and resident stated he/she would not take them on an empty stomach. LPN A stayed to talk with resident as medications remained on table. At 7:14 A.M. LPN A left dining room and moved medication cart. LPN A observed assisting other residents with obtaining their glasses and moving about dining room and did not maintain observation of pill cups in front of resident. During an interview on 4/10/24 at 10:55 A.M., MDS Coordinator said: -Resident preferred to wait to take a medications after he/she had eaten some food. 2. Review of Resident #39 Quarterly MDS, dated [DATE], showed: -Cognitive impairment; -He/She had clear speech, made self-understood, and had clear comprehension of others; -Diagnoses included: anemia, coronary artery disease, high blood pressure, dementia, anxiety, depression, history of falling, low back pain, stroke, disorientation, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of right hip and of knee. Review of care plan, dated 3/6/24, showed: -He/She had unspecified dementia that caused him/her to have mild confusion at times; -He/She required reminders from staff at time. Review of physician's orders, dated April 2024, showed: -He/She had no orders to self-administer his/her medications. Review of medical record showed: -He/She had no assessments to self-administer his/her medications. Observation on 4/9/24 at 8:06 A.M. showed medications were left sitting in a cup on the breakfast table. Resident had six medications observed sitting in a pill cup. He/She was eating his/her breakfast. During an interview on 4/10/24 at 10:43 A.M., LPN A said: -Medications are especially not left at bedside they are with resident because he/she has a narcotic. During an interview on 4/10/24 at 10:55 A.M., MDS Coordinator said: -Resident is particular with his/her medications, staff should keep him/her in eyesight if they leave medications for him/her. 3. Review of Resident #40's Quarterly MDS, dated [DATE], showed: -Cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She was independent with most of all his/her cares; -Diagnoses included: intracranial injury with loss of consciousness, traumatic brain injury, depression, puncture wound without foreign body of unspecified part of head, alcohol abuse, constipation, gastro-esophageal reflux disease, need for assistance with personal care. Review of care plan, dated 4/10/24, showed: -He/She was independent with mobility without use of an assistive device. Review of physician's orders, dated April 2024, showed: -He/She had no orders to self-administer medications. Observation on 4/7/24 at 12:18 P.M. showed resident had pills left on his/her plate. He/She took independent. No staff was around during resident's self-administration. During an interview on 4/10/24 at 10:39 A.M., LPN B said: -On Sunday he/she did leave medications with resident as he/she had issues with control and was in a mood. If he/she would have stood over resident he/she would have escalated behaviors. He/she watched him/her the whole time from the hallway. During an interview on 4/10/24 at 10:39 A.M., LPN B said: -There are no residents that self-administer their medications; -Every person he/she administers medications to he/she would stand to watch them take their medications; -If medications were at bedside there would have to be a physician's order; -If someone were to self-administer medications they would have to have a self-administration of medications assessment completed; During an interview on 4/10/24 at 10:55 A.M., MDS Coordinator said: -Residents who self-administer medications should be care planned. During an interview on 4/10/24 at 3:18 P.M., Director of Nursing said: -He/She expected staff to ensure resident took their medications. During an interview on 4/10/24 at 3:18 P.M., Administrator said: -He/She did not expect staff to leave medications on dining room table for residents; -He/She expected resident to be evaluated for taking his/her medications safely before self-administration; -He/She would expect staff to ensure resident took his/her medications. 31102 4. Review of Resident #18's care plan, revised 1/31/24 showed it did not address self administration of medications. Review of the resident's annual MDS, dated [DATE], showed: - Cognitive skills intact; - Required set up and clean up with eating, toilet use and dressing; - Independent with oral hygiene and personal hygiene; - Required partial to moderate assistance with showers; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Always continent of bowel; - Diagnoses included cancer, renal insufficiency (decreased kidney function), neurogenic bladder (loss of bladder control due to nerve, brain, or spinal cord problems), thyroid disorder, depression and chronic obstruction pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's POS, dated April 2024 showed: - Did not have an order to self administer medications. Review of the resident's medical chart showed it did not contain any self administration assessments. Observation and interview on 4/9/24 showed:- Certified Medication Technician (CMT) A placed a medication cup in front of the resident at the dining room table and walked away; - The resident said the staff frequently leave their medications at the dining room table and do not wait to ensure they have been taken. 5. Review of the facility's undated policy medication administration and maintenance, showed, in part: - Any refrigerated liquid medications will be labeled with date opened. Observation and interview on 4/9/24 at 9:39 A.M., of the medication room showed: - An opened vial of Tuberculin (TB) Purified Protein Derivative (a skin test to help diagnose tuberculosis, (a potentially serious infectious bacterial disease that mainly affects the lungs) , 0.1 milliliters (ml.), did not have a date when it was opened; - An opened vial of Tuberculin Purified Protein Derivative 0.1 ml. dated 12.15/23. The label on the vial said to discard 30 days after opening; - Resident #46 had an opened Lantus (long acting) insulin pen without a date when it was opened; - The Administrator said the medication room is checked monthly by the charge nurses when they get time. The TB vial should have been dated when it was opened. The dated vial of TB should have been discarded. The Lantus insulin pen should have been dated when opened and should not have been used since it was not dated. During an interview on 4/1024 at 3:22 P.M., the DON said: - The TB vials should have been dated when opened and discarded 30 days after opened; - The insulin pens should be dated when opened and not used if it was not dated.

Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot and cold food was not served at an appetizing temperature and when pureed food was not made to proper consistency to three of twelve sampled residents (Resident #22, #39, and #34). The facility had a census of 48. Review of facility policy, general food preparation and handling, undated, showed: -Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. Review of facility policy, food temperatures, undated, showed: -All hot foods must be cooked to appropriate internal temperatures, held and served at temperature of at least 135 degrees Fahrenheit (F); -All cold food items must be stored and served at a temperature of 41 degrees F or below; -Temperatures should be taken periodically to assure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the holding and plating process until food leaves the service area. Review of facility policy, handling cold foods for tray line, undated, showed: -Proper cold food temperatures will be maintained during meal service. -Cold food items will be place din the refrigerator at least 3 to 4 hours before serving. -Cold food temperatures will be taken and recorded prior to and halfway through service to assure the foods are 41 degrees F or below. Review of facility policy, puree diet policy, undated, showed: -How to test pureed foods to check whether they're the right texture by conducting the two different tests-the fork drip test and the spoon tilt test. -For the fork drip test, scoop a sample of the food onto a fork. -The food should not dollop or drip continuously through the fork prongs. If it does, the food is too thin and needs to be thicker. -For the spoon tilt test, scoop a food sample onto a spoon. The food should hold its shape on the spoon. -Next tilt the spoon. -The food should fall off easily, leaving minimal residue on the spoon. -If the food doesn't fall off easily or leaves a lot behind, the food is too sticky and needs more liquid. -Each pureed food should pass both tests. -Food that doesn't pass both tests increase the risk for choking or aspiration, where food dangerously enters the lungs. Review of facility policy, taste testing, undated, showed: -All food will be taste-tested for quality prior to serving. -The cook will be responsible for tasting all food before it is served. The supervisor should also participate in procedure. -Proper tasting procedure should be used: one spoon will be used to serve food onto a dish or bowl ad new, clean spoon will be used to taste the food. -All food which does not pass the taste test due to seasoning, toughness, color, or other negative factors will not be served until the problem has been corrected. 1. Review of Resident #22's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/25/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 11, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident had moderate intact cognition. -He/She had clear speech, was able to make self understood, and clear comprehension of others; -He/She was dependent on a wheelchair for mobility; -He/She required set up or clean up assistance with eating and oral care; -Diagnoses included cancer, high blood pressure, diabetes (a condition resulting in to much sugar in the blood), hip fracture, and depression. During an interview on 4/7/24 at 11:46 A.M. the resident said: -Oatmeal comes out on hall trays cold. 2. Review of Resident #39 quarterly MDS, dated [DATE], showed: -He/She had a BIMS of 10, showed resident was moderate cognitive impairment; -He/She had clear speech, made self-understood, and had clear comprehension of others; -He/She was dependent on walker or wheelchair; -He/She was independent with eating, oral care, toileting, and personal hygiene, -He/She required set up and clean up assistance with upper and lower body dressing; -Diagnoses included: anemia, coronary artery disease, high blood pressure, dementia, anxiety, depression, history of falling, low back pain, stroke, disorientation, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of right hip and of knee. During an interview on 4/8/24 at 10:37 A.M., resident said: -Lot of times food was not warm when it was served, but rather cold; -Facility changed owners and the budget and supplier of the kitchen has changed; -Portions are sometimes really small; -Facility serves a lot of macaroni and noodles. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed: -He/She had a BIMS score of 15, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact. -He/She had clear speech; -He/She was able to make self-understood and understand others; -He/She was dependent on a wheelchair for mobility; -He/She required substantial to maximal assistance with eating. -He/She required partial to moderate assistance with upper body dressing; -Diagnoses included: Guillain-Barre syndrome (a condition in which the immune system attacks nerves) , high blood pressure, hyperlipidemia (high levels of fat in the blood), depression, hypokalemia (blood level is below normal in potassium which can cause fatigue, muscle cramps, and abnormal heart rhythms), restless leg syndrome, neuropathy, fusion of the cervical spine region, astigmatism, low back pain, and generalized muscle weakness. During an interview on 4/7/24 at 3:05 P.M. the resident said: -Would be nice to have different food options and not the same thing all the time; -Food is barely warm when served. 4. Observation on 4/8/24 at 11:03 A.M. showed foods being temperature checked on steam table by dietary manager. Pork loin temperature was 190.8 F, potatoes 168.4 F, green beans 194.1 F. Dietary manager advised Cook C he/she was turning down steam table because the steam table was keeping everything too hot. Observation on 4/8/24 at 11:45 A.M. showed steam table covers removed by Cook C and plating of first room tray completed. No food temperature were obtained. Observation on 4/8/24 at 11:52 A.M. showed first dining room tray was served. Food had not been temperature checked since 11:03 A.M. Observation on 4/8/24 at 12:14 P.M. of regular test tray showed pork loin was below serving temperature at 113.1 degrees. Observation on 4/9/24 at 12:33 P.M. of puree test tray showed pineapple was above cold food serving temperature at 47.9 degrees F. The pureed pineapple was liquid in consistency running through the prongs of fork and off of the spoon. The pureed corn had no taste and ran off of the spoon and through the prongs of the fork. During an interview on 4/07/24 at 10:13 A.M., Dietary Manager said: -He/She expected food to be temperature checked while it was cooked, on steam table, and those temperature checks are documented; During an interview on 4/10/24 at 10:08 A.M., Dietary manager said: -Puree food should be thick as pudding but not as thin as a liquid; -Food should be temperature checked when it had completed being cooked and before it was served on the line; -Food is usually temperature checked before the kitchen starts serving; -He/She completed dietary preferences for residents upon admission then every three months. During an interview on 4/10/24 at 3:18 P.M., Administrator said: -He/She expected food to be temperature checked before serving and during meal service; -He/She expected hot food to be served hot and cold food to be served cold.

Based on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to clean and sanitize all areas of the kitchen, maintain a thermometer in the chest freezer, compete proper hand washing techniques, maintain a lid on trash cans, utilize and ensure proper parts per million (PPM) of sanitizer solution, discard expired food, ensure all employees wear hair and beard nets, invert clean pitchers for storage, label and date all foods. This had the potential to impact all residents in the facility. The facility census was 48 residents. 1. Review of facility policy, general food preparation and handling, undated, showed: -The kitchen will be kept neat and orderly; -Kitchen surfaces and equipment will be cleaned and sanitized as appropriate; -All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. Review of facility policy, food storage, undated, showed: -Food will be stored in an area that is clean, dry and free from contaminants. Observation on [DATE] at 9:39 A.M. during initial tour showed: -Grease trap by the griddle was full of grease and food; -Stove top was covered with dried on food particles on each of the burners; -Cooked noodle observed draped over wire shelving in walk in cooler; -Fried food crumbs on outer layers of the deep fat fryer; -Caked on layer of food was on bottom layer of oven; -Stove door and handles had food caked on them; -Microwave has food particles spilt inside and layer of crumbs inside; -Bottom shelf of steam table had food crumbs laying on it; -Countertops throughout kitchen were covered in food particles; -Fan in walk in fridge had dust covering coils; -Food particles in plastic utensil container on shelf under food preparation table; -Trash can in kitchen did not have lid down, lid was stuck in the up position. Observation on [DATE] at 11:23 showed the trash can lid was stuck in up position and paper towel and gloves were on floor beside trash can. Trash was overflowing from its receptacle. During an interview on [DATE] at 10:13 A.M., the Dietary Manager said: -He/She had a cleaning routine schedule posted for the staff; -He/She did not have a sign off sheet for cleaning items. During an interview on [DATE] at 11:33 A.M., Dietary Aide B said: -The kitchen had no cleaning sign off sheet or checklist; During an interview on [DATE] at 10:00 A.M., Cook D said: -Cleaning routines in kitchen included wiping everything down and sweeping and mopping the floors after breakfast and lunch. 2. Review of facility policy, food storage, undated, showed: -Food will be stored in an area that is clean, dry and free from contaminants. -Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. -Food should be dated as it is placed on the shelves as required by state regulation. -Date marking will be visible on all high-risk food to indicate the date by which a ready to eat. -Plastic containers with tight-fitting covers must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. -Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within seven days or discarded. Review of facility policy, use of leftovers, undated, showed: -Leftovers will be properly handled and used or discarded as appropriate. Review of facility policy, general food preparation and handling, undated, showed: -Foods will be received, checked, and stored properly as soon as they are delivered. -Food will be covered for storage. -Leftovers must be dated, labeled, covered, and cooled and stored in a refrigerator. Use leftovers within seven days. Review of facility, food storage chart-food storage guidelines, undated, showed: -Pastries to be stored at room temperature and best used within one to three days. -Angel food and sponge cakes, store in refrigerator up to three days. -Juices in cartons, fruit drinks, punch store seven to 10 days opened. -Meat left overs, can be stored three to four days in the refrigerator. Observation on [DATE] at 9:39 A.M. during initial tour showed: Walk-in cooler: -Box of prepared cupcakes dated [DATE]; -Prepared tray of water glasses sat on top of a three tiered cart were uncovered; -Sugar pie in container dated [DATE]; -Cooked goulash dated [DATE]; -Cooked creamed corn dated [DATE]; -Opened and undated 16 oz thousand island dressing; Spice shelf above microwave: -Undated and opened 20 oz onion powder; -Undated and opened 26 oz iodized salt; -Undated 10 oz parsley; -Undated and opened 12 oz wheat germ; -Opened can tomato soup with the lid resting inside the soup; Free standing refrigerator in kitchen: -Had four trays filled with prepared drinks covered in undated foil with resident names written on top of them; -Opened and undated prune juice 64 oz; -Opened and undated gallon white vitamin D milk . During an interview on [DATE] at 10:13 A.M., Dietary Manager said: -He/She expected food to be labeled and dated when it was opened; -He/She expected juice to be labeled for five days then thrown out; -He/She expected drinks to be covered with lids; -He/She expected leftovers to be labeled with the cooked date on it, if he/she could reuse food he/she will freeze it with the cooked date and reheat it for supper. During an interview on [DATE] at 11:33 A.M., Dietary Aide B said: -He/She did not date foil coverings on drinks because he/she knew who drinks were made for; -Leftovers should be thrown out in a couple of days; -All staff are responsible for getting rid of left overs. During an interview on [DATE] at 11:43 A.M., Dietary Aide A said: -Food should be dated anytime it went into cooler or freezer or when he/she was finished making it, and when it came off truck; -Leftovers should be thrown out after five days or when past their expiration dates. During an interview on [DATE] at 10:00 A.M., Cook D said: -Food should be dated and labeled right away before put in the walk in cooler; -Food should be thrown out in three days. During an interview on [DATE] at 10:04 A.M., Cook B said: -Food should be labeled and dated right after they get done serving it; -Leftovers should be thrown out after three days; -Cooks are responsible for throwing out leftovers. During an interview on [DATE] at 3:18 P.M., the Administrator said: -Food should be dated when it was opened and if putting something in the cooler; -Leftovers should be dated with the date it was served; -Leftovers should be thrown out after three days. 3. Review of facility policy, food safety: ice, undated, showed: -Ice will be produced and handled in a manner to keep it free from contamination; -Ice machines will be maintained in a clean and sanitary condition to prevent contamination; -Ice machines and containers will be cleaned and sanitized on a regular basis. Observation on [DATE] at 9:39 A.M. during initial tour showed: -Ice machine had a blank cleaning log posted on side of ice machine dated February 2024; -Ice machine had dust residue laying on top of outside surfaces and edges; -Air filters on ice machine were caked with dust. Observation on [DATE] at 11:39 A.M. showed the ice machine filter was dirty with layers of dirt and dust clinging to filter. Sticker above filter showed clean air filter twice a month. During an interview on [DATE] at 10:13 A.M., Dietary Manager said: -He/She cleaned ice machine monthly; -He/She had new crew of staff and had not trained them on cleaning ice machine; -He/She last cleaned ice machine on [DATE]. During an interview on [DATE] at 10:08 A.M., Dietary Manager said: -Outside company comes in and services the ice machine; -Facility staff clean it and sanitize machine; -The ice machine filters are cleaned one time a week. 4. Review of facility policy, bare hand contact with food and use of plastic gloves, undated, showed: -Hands are to be washed when entering the kitchen and before putting on the single -use gloves and after removing single use gloves. Continuous observation on [DATE] of kitchen and dining room showed: -10:56 A.M., food on steam table covered with foil, dietary manager removed foil; -11:03 A.M., showed Dietary Manager food temperature checking on steam table: pork loin 190.8 degrees F, potatoes tested at 168.4 degrees F, and green beans tested at 194.1 degrees. He/She advised Cook C that he/she was turning down steam table because it was keeping everything above temperature; -11:08 A.M., Dietary Manager temperature checked sanitizer bucket; -11:45 A.M., Steam table covers removed by Cook C, plating of first room tray started; -11:52 A.M., first tray left kitchen for dining room, food temperatures had not been checked since 11:03 A.M.; -11:53 A.M., Dietary Aide A returned to kitchen from serving in dining room, he/she did not sanitize his/her hands; -11:54 A.M., Dietary Aide B took plate to dining room using a plate cover, returned to dining room and reused plate cover. 11:54 A.M.; -11:55 A.M. -11:59 A.M. Dietary Aide A and B go in and out of kitchen multiple times serving resident's plates in dining room and did not wash hands; -12:01 P.M., Dietary Aide A re-entered kitchen, grabbed plate, did not wash his/her hands; -12:05 P.M. showed Dietary Aide A and B served more chocolate frosted cake out of dessert pans and plating additional desserts. Neither washed his/her hands since entering kitchen; -12:08 P.M., Dietary Aide A obtained lemon concentrate from the walk in cooler for resident and exits the kitchen with drinks. He/She returned to the kitchen and did not wash his/her hands; -12:12 P.M., Dietary Aide A washed hands for first time since meal service began; -12:14 P.M., Plate covers were being reused after each resident by being sat on a cart by the door or placed on steam table when Dietary Aide A or B returned to kitchen for next plated meal to serve. Continuous observation on [DATE] of kitchen showed: -11:48 A.M., Cook D serving first plate; -11:54 A.M., Dietary Aide B wheeled hall tray cart out of kitchen; -11:56 A.M., Dietary Aide B returned to kitchen, served first plate, he/she did and was holding the same plate cover had just used to serve a resident's meal with. He/She obtained next the plate and utilized same plate cover. -11:57 A.M., Dietary Aide A served first plate to dining room, returned to the kitchen. He/She did not wash his/her hands and returned to the kitchen with the same plate cover and used it to cover the next plate he/she served to a resident; -11:58 A.M., Dietary Aide B returned to kitchen with same plate cover, he/she did not sanitize, and reused same plate cover to serve next plate; -11:59 A.M. Dietary aide B and A returned to kitchen with same plate cover in their hands, did not sanitize, and reused plate covers to serve next plate to the dining rooms; -12:00 P.M., Dietary Aide B continued using same lid cover returned to kitchen with to serve next plate to dining room; -12:01 P.M., Dietary Aide B returned to kitchen with plate cover, set plate cover on steam table's empty bin and accepted new tray from Cook B; -12:02 P.M., Dietary Aide A returned with plate cover in his/her hands, set the plate cover down on top of the stack of lid covers on steam table for reuse. He/She did not sanitize; -12:05 P.M., Dietary Aide A returned to kitchen and washed his/her hands for first time during meal service; -12:06 P.M., Dietary Aide A grabbed used plate cover from top of stack on steam table and reused plate cover to serve next plate to dining room; -12:06 P.M., Dietary Aide B returned to kitchen with plate cover in hands, he/she did not sanitize, used same plate cover to cover next plated food handed to him/her from cook D; -12:06 P.M., Dietary Aide A returned to kitchen, he/she did not sanitize, then used same plate cover from in his/her hands to cover next plate that was handed to him/her from Cook D; -12:07 P.M., Dietary Aide B returned to kitchen with same plate cover in his/her hands, and served next plate with same plate cover; -12:07 P.M., Dietary Aide A returned to kitchen with same plate cover, used same plate cover to cover new plate, he/she did not sanitize; -12:09 P.M., Dietary Aide A returned to kitchen with same plate cover, he/she did not sanitize, and served next plate to residing in dining room using same plate cover. During an interview on [DATE] at 10:13 A.M., Dietary Manager said: -He/She completed hand washing training with his/her staff; -He/She expected staff to wash their hands thoroughly and frequently. During an interview on [DATE] at 11:33 A.M., Dietary Aide B said: -He/She should wash hands all the time, when he/she is in and out of kitchen. During an interview on [DATE] at 10:08 A.M., Dietary Manager said: -He/She did not feel staff needed to wash hands during food service unless there was something on their hands; -He/She expected staff serving food in dining rooms to sanitize between residents; -He/She did not expect the cooks serving food to sanitize; -He/She felt that using the same plate cover to serve multiple residents their meal plates was not sanitary. During an interview on [DATE] at 11:43 A.M., Dietary Aide A said: -He/She should wash his/her hands every time like as soon as he arrives to kitchen, if he/she went outside, if he/she went out of kitchen; -He/She did not wash his/her hands between each resident plate service, he/she has never washed his/her between residents as long as he/she had worked in kitchen; -He/She did not wash his/her hands every time he/she takes a plate out of kitchen to resident. During an interview on [DATE] at 10:00 A.M., Cook D said: -Hand washing should be completed when entering kitchen, after use of bathroom, after utilizing sanitizer water, or get hands soiled. During an interview on [DATE] at 10:04 A.M., Cook B said: -He/She did reuse plate covers while serving residents meals in dining room. -Plate lid covers were washed after meal service. During an interview on [DATE] at 3:18 P.M., the Administrator said: -He/She expected a new plate cover to be used for each resident served; -He/She did not think reuse of plate covers was sanitary. 5. Review of facility policy, menus, undated, showed: -Menus will be posted in at least two resident areas in positions and in print large enough for residents to read them. Observation on [DATE] at 10:45 A.M. showed there was no breakfast or supper menu posted, lunch menu was only item posted. Observation on [DATE] at 12:16 P.M. showed alternative menu posted in small print outside dining room door in hall way. Menu was not visible to someone in seated wheelchair position. Observation on [DATE] at 7:40 A.M. showed breakfast was not yet posted, lunch menu posted. Observation on [DATE] at 8:05 A.M. showed breakfast was now added to menu board and date was added. Observation on [DATE] at 7:43 A.M. showed the same menu that was posted yesterday was visible on the menu board with date [DATE]. Observation on [DATE] at 12:00 P.M. showed the supper menu had not yet been posted. During an interview on [DATE] at 10:08 A.M., Dietary Manager said: -The alternative menu is available on the bulletin board outside kitchen, menu was not visible to residents sitting in a wheelchair. -He/She expected menus to be posted the night before and if not completed the night before should be posted before breakfast was served. During an interview on [DATE] at 10:13 A.M., Dietary Manager said: -Facility had open dining policy, meal times are Breakfast 7:00 A.M.-9:00 A.M., lunch 11:30 A.M.-1:00 P.M., and supper 4:30 P.M.-7:00 P.M.; -Food is posted on special out on the menu board -The Certified Nurses Aide (CNA) or Care partner will go around to resident rooms and see what residents wants for his/her meals; -Substitutes include chicken strips, onion rings, french fries; -He/She served room trays first; -The second cook is responsible for preparing special orders. -Most if his/her residents are on regular diets; -Alternative menu would not be readable for someone in a wheelchair. During an interview on [DATE] at 3:18 P.M., the Administrator said: -Menus should be posted for the week; -Menus should be posted on the menu board at the beginning of the day before breakfast. 7. Review of facility policy, general food preparation and handling showed: -Kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Facility did not provide a policy on three compartment sink or sanitizer logs. Observation on [DATE] at 9:45 A.M. showed of sanitation log at three compartment sink -Had not been filled out since [DATE] breakfast -Blank on ,d+[DATE] lunch and supper -Blank on ,d+[DATE] lunch supper -Blank ,d+[DATE] breakfast, lunch, and supper -Blank ,d+[DATE] breakfast, lunch, and supper -Blank [DATE] breakfast During an interview on [DATE] at 10:13 A.M., Dietary Manager said: -The three compartment sink should be tested every time it is used and refilled; -He/She expected staff to be documenting the three compartment sink checks on the log; -Staff do sanitizer check and log the three compartment sink, he/she expected staff to write that on the log; 8. Observation on [DATE] at 10:56 A.M. showed dietary manager changed sanitizer solution after Cook C said he/she had last changed it forty-five minutes prior. The sanitizer bucket was tested with a strip that read dark green, indicated 300 parts per million (PPM). During an interview on [DATE] at 11:33 A.M., Dietary Aide B said: -He/She did not test sanitizer buckets; -He/She had no training on sanitation buckets. Observation on [DATE] 11:40 A.M. of sanitizer bucket in kitchen showed a test strip completed and read green, showed 200 PPM. During an interview on [DATE] at 10:13 A.M., Dietary Manager said: -He/She expected sanitizer buckets to be changed every hour-two hours; -He/She did not test sanitizer buckets During an interview on [DATE] at 11:43 A.M., Dietary Aide A said: -He/She test strips sanitation water but did not record readings; During an interview on [DATE] at 3:18 P.M., the Administrator said: -He/She expected sanitation logs to be completed on three compartment sink with every change of sanitation water; -He/She expected sanitation buckets to be changed at beginning of every shift and in between and logged.

Based on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to replace trim missing from the base of the nurses station, replace damaged drywall on the side of nurses station, repair the medication cart that had several pieces of black duct tape on top left side, failed to repair a pillar near the left entrance of the dining room which had a 3-4 inch and 1 to 11/2 inch gouges of paint removed and missing paint. The facility failed to keep oxygen concentrators and Continuous Positive Airway Pressure (CPAP) machine dust free when a layer of dust was on Resident #22's oxygen concentrator and CPAP machine. The facility failed to keep Resident #200's dry wall seam was peeling from the ceiling. Additionally the facilty failed to repair a wall at the head of the bed in room [ROOM NUMBER] A that had scuff marks and gouges with the paint missing and white plaster showing. The facility census was 48. Review of facility policy, Quality of Life - Homelike Environment, dated May 2017, showed: -Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: -Clean, sanitary, and orderly environment; -Inviting colors and decor; -The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalize, institutional setting. These characteristics include: medication carts. 1. Observation on 4/08/24 at 10:33 AM showed the nurses station had trim missing from base of station, with drywall patches on the side of nurses station with gouges out of the front of it. The medication cart had several pieces of black duct tape on top left side. 2. Observation on 4/9/24 at 12:33 P.M. showed a pillar near left entrance of the resident's dining room had a 3-4 inch and 1 to 1 1/2 inch gouges of paint removed from pillar with paint missing. 3. Review of Resident #22's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/25/24, showed: -He/She had moderate intact cognition. -He/She had clear speech, and was able to make self understood, and clear comprehension of others; -He/She was on oxygen therapy; -Diagnoses included: Sleep apnea. Observation on 4/7/24 at 11:42 A.M. showed oxygen concentrator and CPAP machine were not clean and had a layer of dust on them. 3. Review of face sheet, dated 4/8/24, Resident #200 showed: -He/She admitted to facility on 4/3/24; -Diagnoses included Guillain-Barre Syndrome (a condition in which a person's immune system attacks the peripheral nerves ), strokes, cardiomyopathy (disease where walls of the heart muscle have become stretched), fractures to right side ribs, generalized muscle weakness, unsteadiness on feet, and cognitive communication deficit (a condition where person has difficulty with thinking and how someone uses language), and history of falling. Review of baseline care plan, dated 4/3/24, showed: -He/She communicates easily with staff; -He/She was cognitively intact. Observation on 4/7/24, at 4:29 P.M. showed the seam of drywall was peeling off on the ceiling of resident #200's room. 31102 4. Observation on 4/6/24 at 8:55 A.M., showed: - The wall at the head of the bed in room [ROOM NUMBER] A had scuff marks and gouges with the paint missing and white plaster showing. 5. Observation and interview on 4/9/24 at 10:49 A.M., showed: - The left side of the medication cart was broken and someone used black tape to hold it into place; - Certified Medication Technician (CMT) A said it has been like that for a while. They try not to pull on it; - The chair at the nurse's station showed the leather was missing on both arms, where their head rested and half of it missing from the seat and the tan material was showing. During an interview on 4/10/24 at 3:22 P.M., the Administrator and the Director of Nursing (DON) said: - The medication cart should not be secured with black tape and they should probably have a new chair at the nurse's station; - The walls should not have scuff marks or gouges on them and the paint should not be missing and the ceiling should not be peeling.

Based on the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected five of six sampled staff (RN A, Cook A, NA A, Maintenance Supervisor, and Care Partner A). The facility census was 48. Review of facility Policy, Abuse and Neglect, dated January 2017, showed: -It is policy to not employe 1) Individuals who have been found guilty by a court of law of abuse, neglect, exploitation, misapprorpiation of property or mistreatment 2) individuals with ahistory of certain criminal offenses 3) individuals on the Employee Disqualification List or who are listed on the state CNA registry as having been found to have committed abuse, neglect, exploitation, or misappropriation of funds, or mistreatment 4) individuals whoa re listed as being (excluded' by the federal DHSS Office of Inspector General or 5) have a disciplinary action in effect against his or her professional icense by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. -Prior to hiring any person for a full-time, part time or temporary position, the facility shall request a criminal background check as provided in section 660-317, RSMo. -Prior to hiring of employees, the facility will make inquiry into the Nurse Aide Registry through the DHSS. The facility will also prior to hiring check the Federal OIG fraud and abuse exclusion list. Documentation of checking these sites and the outcomes of the check will be printed off and maintained in the employee file. -Facility will prior to hiring and prior to any patient contact by a new employee send the request for a criminal record check to MHCA for the request to be processed by the Missouri Highway patrol or a background check may be processed by ADP screening and selection services. Once the CBC has been submitted the EDL check is negative, the facility may hire the employee and allow patient contact. -Records received back will be maintained in the employee's personnel file. 1. Review of Registered Nurse (RN) A employee file showed: -Hired 10/2/2023; -No Certified Nurse Aide (CNA) registry check found. 2. Review of Cook A , employee file showed: -Hired 10/23/23; -No Family Care Registry check; -No record of criminal background check; -No CNA registry check found. 3. Review of Nurse Aide (NA) A employee file showed: -Hired on 3/6/24; -No CNA Registry check found. 4. Review of Maintenance Supervisor's employee file showed: -Hired on 9/14/23; -No CNA Registry check found. 5. Review of Care Partner A employee file showed: -Hired on 12/2/23; -No CNA Registry check found. During an interview on 4/9/24 at 1:20 P.M., Business Office Manager said: -He/She could not find Cook A's family care registry or background check anywhere; -He/She had to upload all employee documents and background checks into an online system; -He/She believed the system may have saved an item over Cook A's background checks and that is why he/she could not locate them; -Facility policy was that facility no longer maintained hard copy personnel files on site, everything was uploaded into online system; -He/She checked the nurse aide registry for any nurse aides that come in and say they are or were certified; -He/She did not check nurse aide registry for non nurse aide or nursing employees; During an interview on 4/10/24 at 3:18 P.M., the Director of Nursing said: -He/She did not think the nurse aide registry should be checked for non-nursing employees. During an interview on 4/10/24 at 3:18 P.M., the Administrator said: -Background checks should be completed prior to hire before an employee starts working; -He/She did not know if the nurse aide registry should be checked on all employees.

Based on observation and interview the facility failed to assist one resident (Resident #6) to maintain hydration status when they failed to provide resident water in his/her room. The facility census was 48. Facility did not provide policy on hydration. 1. Review of Resident #6's Admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/5/24, showed: -He/She admitted on [DATE]; -Cognition severely Impaired. -He/She required partial/moderate assistance with eating, upper body dressing, rolling left and right, sit to lying, lying to sitting on side of bed -He/She required supervision or touching assistance for oral care; -Diagnoses included pneumonia, high blood pressure, wound infection, thyroid disorder, arthritis, anxiety, and depression. -He/she had mechanically altered diet Review of care plan, dated 2/6/24, showed: -He/She was on a pureed diet with thickened liquids related to decline due to shy draggers syndrome; -He/She would have a water jug handy in his/her room at all times. Staff will change his/her water/jug out three times daily. Fluids are encouraged due to his/her multi-system degeneration of the autonomic nervous system and the effects it has on his/her blood pressure. Review of physician's orders, dated 4/8/24, showed: -Resident had no fluid restriction; -Ordered 2/15/24, Pureed texture, Nectar/mildly thick consistency, may have pleasure feedings per resident request. During an interview on 4/7/24 at 10:55 A.M., resident said: -He/She was so thirsty, he/she could hardly talk; -Sometimes staff forget to bring him/her water; -He/She had to remind staff; -His/Her skin got dry and scaly if he/she did not have water; -He/She had to have water; -His/Her lips are chapped bad all the time, staff never see that his/her lips were dry; -He/She had to ask for lip balm; -He/She used cream for his/her face on his/her lips because that was all he/she could find. Observation on 4/7/24 at 10:55 A.M. showed resident had no water in his/her room. Resident was observed to have dry, flaky skin on tops of his/her arms and on his/her forehead. His/Her lips were dry and peeling. Observation on 4/8/24 at 9:11 A.M. showed resident was red in face and pacing halls in his/her wheelchair. Licensed Practical Nurse (LPN) B asked resident if he/she had a headache and resident said he/she did. LPN B offered resident a pain reliever for headache. Resident had skin that was flaking around his/her face. Observation on 4/08/24 09:23 A.M., showed resident did not have any water in his/her room. Observation on 4/09/24 11:05 A.M. showed resident had no water in his/her room. During an interview on 4/09/24 at 11:04 A.M., Nurse Aide (NA) A said the resident was not on fluid restriction. During an interview on 4/9/24 at 11:07 A.M., Certified Medication Technician (CMT) A said: -Resident was always so thirsty; -Staff keep a water glass at nurses station because staff have to add thickner to the cup; -He/She did not think there was currently a glass available at the nurses station for resident because the kitchen picked up the old cups. Observation on 4/9/24 at 11:12 A.M. showed no cup for resident at nurses station. During an interview on 4/10/24 at 3:18 P.M., the Director of Nursing said the residents should have access to fluids unless they had a physician's order for fluid restriction. During an interview on 4/10/24 at 3:18 P.M., the Administrator said: -Residents should have access to fluids; -He/She expected staff to offer fluids throughout the day.

Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 48. Review of facility policy, Director of Food and Nutrition Services, undated, showed: -The director of food and nutrition services will be responsible for all aspects of the food and nutrition services department including but not limited to food safety, staff safety, cost management, and meeting nutritional needs of patients/residents served. -The Director of food and nutrition services will be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. A facility that did not have a full time dietician or must designate a person to serve as director of food and nutrition service. During an interview on 4/07/24 at 10:13 A.M., Dietary Manager said: -He/She did not have any dietary certification; -He/She was currently enrolled in college out of state; -He/She did not have any completed training certificates; -There was nobody currently in facility that was certified in dietary; -The facility dietician was contracted to come in one time a month; During an interview on 4/10/24 at 1:04 P.M., Facility dietician said: -He/She came to facility once time a month; -He/She had not provided any training's to the facility. During an interview on 4/10/24 at 3:18 P.M., Administrator said: -Dietary manager was enrolled in school working on his/her certification; -He/She did not have anyone in building that is currently a certified dietary manager; -A consulting dietician comes to building monthly; -Facility had regional support who was certified that comes to building on a quarterly basis; -Dietary managers meet over phone every other week for corporate training.

Based on observation, record review and interview the facility failed to follow infection control standards and guidelines for catheter care when staff failed to ensure the urinary catheter drainage bag was not touching the floor for one of 12 sampled residents (Resident #3). The facility census was 48. Review of the facility's Urinary Catheter Care Policy, dated September 2014, showed: -The purpose of this procedure is to prevent catheter-associated urinary tract infections; -Use standard precautions when handling the drainage system; -Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facilty's Infection Prevention and Control Policy dated September 2023, showed: - The facilty will establish a safe, sanitary and comfortable environment to help prevent the development and transmission of infections for all residents; -Standard precautions will be used for all resident care; -Staff will properly handle and clean and disinfect resident equipment. 1. Review of Resident #3's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/7/24, showed: -No cognitive impairment; -Substantial assistance with toileting; -Substantial assistance with personal hygiene; -The resident had an indwelling catheter; -Diagnoses included, coronary artery disease (CAD, a disease is caused by plaque buildup in the wall of the arteries that supply blood to the heart) and high blood pressure. Review of the resident's undated care plan showed: -The resident had a self care performance deficit related to multi-system degeneration of the autonomic nervous system (nervous system that controls bodily functions); -The resident had an indwelling catheter. Review of the resident's Physician's Order Sheet (POS) dated April 2024, showed: -Start date: 9/18/23, indwelling catheter, change monthly and as needed. -Observation on 04/07/24 at 10:52 A.M. showed: -The resident was in his/her room setting in a recliner; -The resident's catheter drainage bag was hooked on the edge of the trash can and touching the floor. -Observation and interview on 04/08/24 at 09:14 A.M. showed: -The resident was in his/her room setting in a recliner; - The resident's catheter drainage bag was hooked on the edge of the trash can and touching the floor; - The resident said staff changes and cleans the catheter; During an interview on 4/8/24, at 11:12 A.M., Nurses Aide B said; -The resident's catheter drainage bag should not being hanging on the edge of the trash can; - The resident's catheter drainage bag should not be touching the floor; - Staff assist the resident with getting out of the chair and getting in his/her wheel chair; - Staff should ensure the drainage bag is off the floor and not on the trash can before they leave the room. During an interview on 4/10/24, at 11:12 A.M., Licensed Practical Nurse (LPN) B said; -- The resident's catheter drainage bag should not be touching the floor or hanging on the trash can; - Staff assist the resident with transfers and toileting; - If he/she notices a catheter drainage bag touching an unclean surface he/she moves it; - Staff should ensure the drainage bag is up off the floor. During an interview on 4/10/24, at 3:22 P.M., the Administrator and Director of Nursing (DON) said: -Indwelling urinary catheter drainage bags should not be touching the floor; -Indwelling urinary catheter drainage bags should not be setting or hanging on a contaminated surface. 47195

Based on observations, record review, and interviews, the facility failed to prepare and serve food under sanitary conditions when staff failed to change gloves between dirty and clean tasks, failed to date opened food products and failed to store clean dishes in a manner to protect them from possible contamination from food and dust. This had the potential to affect all the residents who ate in the facility. The facility census was 42. Review of the undated general food preparation and handling policy showed: - Disposable gloves are a single use item and should be discarded after each use; - Employees should wash hands prior to putting gloves on and after removing gloves; - Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: *After coughing or sneezing into hands, using a handkerchief or tissue, using tobacco or touching hair or face; *After handling garbage or garbage cans; *After handling soiled trays or dishes; *After handling anything soiled; *After handling boxes, crates or packages; *After picking up any item from the floor; *During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; *When switching between working with raw food and working with ready-to-eat food; *After engaging in other activities that may possibly contaminate the hands with bodily fluids; *After using the rest room; *After caring for or handling service animals or aquatic animals; *Any time a contaminated surface is touched; *Wash hands after removing gloves. Review of the undated Bare Hand Contact with Food and Use of Plastic Gloves showed: - Staff will use clean barriers such as single-use gloves, tongs, deli paper, and spatulas when handling food; - Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation; - Clean barriers such as single-use gloves are to be used when: a. Handling ready-to-eat foods; b. Handling raw meat, poultry, raw eggs, fish and shellfish; c. Preparing foods such as meatloaf or meat salads; d. Hand tossing salad, mixing coleslaw, potato or macaroni salad; e. Bagging bread or cookies; f. Anytime hands would otherwise touch food DIRECTLY; - During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks. Review of the undated Handling Clean Equipment and Utensils policy showed: - Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination. - Stationary equipment will also be protected from contamination. Review of the undated food storage policy showed food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. The policy directed the following: - All stock must be rotated with each new order received; rotating stock is essential to assure the freshness and highest quality of all foods; - Old stock is always used first (first in - first out method); - Food should be dated as it is placed on the shelves if required by state regulation; - Foods will be stored and handled to maintain the integrity of the packaging unit ready for use; - Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated; - The policy and procedure did not direct staff on when to discard condiments, spices, and seasonings after opening. - The policy did not give staff any direction for the storage of spices, condiments, or seasonings. 1. Observation on 2/2/23 at 11:16 A.M. showed Cook B did the following: - Sanitized the food preparation table with gloves on; - Wearing the same gloves, he/she walked into the cooler, gathered salad materials and proceeded to cut vegetables for the salad. During an interview on 2/2/23 at 2:20 P.M. Cook B said he/she changed his/her gloves all the time. Staff should change their gloves anytime they touched raw foods, when leaving a task, or touching a clean surface. During an interview on 2/2/23 at 3:33 P.M. the Dietary Manager (DM) said the staff should change gloves quite a bit, when touching something different, or touching the trash can. During an interview on 2/3/23 at 3:33 P.M. the Administrator said gloves should be changed often between different tasks like changing trash, chopping foods then to writing menus. Gloves need changed when staff change job duties for example when the table gets washed down, staff go into the cooler, or even vegetables are chopped. 2. Observation on 1/31/23 at 9:38 A.M. showed: - Vanilla was open without an open and use by date on it; - Worcestershire sauce, mayonnaise, sweet chili sauce, and mild picante sauce were open without an open and use by date on them. Observation on 2/2/23 at 8:40 A.M. showed: - The garlic powder, garlic herb, season salt, black pepper, onion powder, thyme, rosemary, and pumpkin pie seasoning were open without open and use by dates; - A jar of bacon grease was on the prep shelf without an open and use by date. During an interview on 2/2/23 at 8:48 A.M. Cook A said staff that opened the seasonings should put the open and use by dates on them as soon as they are opened. During an interview on 2/2/23 at 8:48 A.M. the DM said once food items are opened, all open and use by dates are put on those products. 3. Observation on 2/2/23 at 8:40 A.M. showed: - The shelf in front of the vegetable sink held dry metal baking pans stored facing up; - Metal bowls on the same shelf as the metal baking pans were stored dry, facing up; - Stand mixer cart had plastic rectangular salad bowls stored facing up. Observation on 2/2/23 at 8:43 A.M. showed: - Stand mixer cart was dirty with crumbs and dust on and around it; - Shelf with metal cooking pans on it was dirty with crumbs and dust; - Round plastic bowls were faced up on the bowl shelf. During an interview on 2/2/23 at 8:48 A.M., Cook A said staff should store clean dry dishes faced down so dirt does not get in. During an interview on 2/2/23 at 8:48 A.M. the DM said he/she knew dry dishes were to be faced down, but had not realized they were not.

Based on interview and record review the facility failed to notify one resident's physician of a change in condition and promptly intervene when the resident was in distress. This affected on resident (Resident #1). The facility census was 27. 1. Review of the undated facility policy on change in condition showed: - The purpose of the policy was to ensure staff promptly notified the resident's physician when the resident experienced a change in condition. - Staff should notify the resident's physician when a resident experienced a deterioration in health. Review of the facility policy, dated [DATE], on physician notification, showed: - Staff should notify a resident's physician anytime a resident experienced a significant change in the resident's physical status. - Staff should notify a resident's physician as soon as possible. 2. Review of Resident #1's physician order sheet (POS) showed an order dated [DATE] for staff to monitor and chart the resident's respiratory status and oxygen saturation (saO2) twice a day (BID). Review of the resident's care plan, dated [DATE] showed: - The resident was alert and oriented. - The resident was able to make his/her wishes and needs known. - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - Staff will monitor the resident's oxygen saturation (saO2) twice a day. - Staff will notify the resident's physician of any changes from baseline. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: - A brief interview for mental status (BIMS) showed the resident had moderate cognitive impairment; - Required extensive staff assistance for transfers, dressing, toileting, and hygiene; - Frequent bladder incontinence and occasional bowel incontinence; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's saO2 (normal range ,d+[DATE]%) showed: - [DATE] at 11:11 A.M. 86% and at 3:20 P.M. 90%; - [DATE] at 8:00 A.M. 88% and at 2:55 P.M. 89%; - [DATE] at 8:55 A.M. 85%. During an interview on [DATE] at 1:14 P.M. RN A said: - He/she provided care for the resident on [DATE] from 6:00 A.M. through 6:00 P.M. - He/she checked the resident's saO2 the morning of [DATE] and found the resident's saO2 was 85%. - He/she told the resident to take several deep breaths and the resident's saO2 went up to 90% after the deep breaths. - He/she did not reassess the resident. - He/she did not chart the incident. - He/she did not notify the resident's physician regarding the resident's saO2 85%. - Staff got the resident up for breakfast. - The resident as usual went back to bed after breakfast. - The resident usually requested to stay in bed most of the day. - On [DATE] around 12:00 P.M. the resident requested Oxycodone for pain and [MEDICATION(S)] for nausea. - RN A provided the requested medications. - The resident later reported the medications relieved his/her pain and nausea. - Staff got the resident up for supper. - The resident complained of nausea. - Staff took the resident to the dining room. - The resident had dry heaves and wanted to go back to bed. - Staff placed the resident in the hall outside the dining room so they could watch the resident. - LPN A, the evening nurse, walked by the resident and the resident said he/she wanted to go to bed. - LPN A put the resident back to bed. - RN A checked on the resident after the supper medication pass. - The resident said he/she was short of breath. - RN A repositioned the resident. - The resident sat on the side of the bed. - The resident laid down and said he/she was short of breath. - The resident was a Do Not Resuscitate (DNR) status (if the resident stopped breathing and/or heart stopped beating staff would not attempt resuscitative measures). - He/she called 911 to get assistance. During an interview on [DATE] at 1:37 P.M. LPN A said: - He/she arrived for his/her 6:00 P.M. through 6:00 A.M. shift on [DATE] at 5:45 P.M. - He/she saw the resident outside the dining room. - The resident told LPN A that he/she did not feel good and wanted to go back to bed. - The resident was dry heaving. - LPN A took the resident back to bed. - The resident requested medication for pain and nausea. - LPN A administered both medications. - The resident told LPN A he/she felt like he/she was dying (the resident frequently said this). - Certified Nurse Assistant (CNA) came out of the resident's room and said the resident was short of breath. - LPN A went to the resident's room and noted the resident was having difficulty breathing. - LPN A went to get a blood pressure cuff. - LPN A could not obtain the resident's blood pressure. - LPN A called RN A. - LPN A went to get the resident some supplemental oxygen. - Before LPN A could bring in the supplemental oxygen, the resident stopped breathing. Review of the resident's nurses' note, dated [DATE] at 2:20 A.M. by Licensed Practical Nurse (LPN) A showed: - No times or dates were given for any of the following. - The resident presented this shift in distress. - The resident was dry heaving and LPN A escorted the resident to his/her room. - LPN A assisted the resident to bed. - LPN A was summoned to the resident's room (did not indicate what staff) and found the resident sitting in a chair. - The resident requested and received [MEDICATION(S)] (used to treat nausea) and [MEDICATION(S)] (used to treat pain). - The resident requested to return to bed. - LPN A assisted the resident to bed. - As the resident was lying down the resident began to have labored breathing. - Without calling for help, LPN A left the resident's room to obtain a machine to obtain vital signs. - LPN A could not obtain any vital signs using the vital sign machine. - Registered Nurse (RN) a came into the room. - The resident had no pulse or respirations. - At 7:10 P.M. (no date given) LPN A and RN A notified the resident's physician and pronounced the resident deceased at 7:10 P.M. Review of the resident's nurses' notes, dated [DATE] at 6:44 A.M. by RN A showed RN A notified the resident's physician of the resident's death at 7:10 P.M. (no date of death given). During an interview on [DATE] at 1:55 P.M. CNA A said: - He/she was working the 2:00 P.M. to 10:00 P.M. shift on [DATE]. - The resident had no issues prior to getting up for supper. - He/she assisted the resident getting up for supper. - The resident started throwing up. - He/she informed RN A that the resident was throwing up. - RN A took about 15 minutes to check on the resident. - RN A checked on the resident and left. - The resident went to bed and then insisted on getting up. - The resident said he/she was short of breath. - He/she told RN A and LPN A that the resident was short of breath. - The charge nurse took about 15 minutes before he/she checked on the resident. During an interview on [DATE] at 2:36 P.M. CNA B said: - He/she worked the 2:00 P.M. to 10:00 P.M. shift on [DATE]. - He/she helped the resident get up for supper around 4:30 P.M. - At that time the resident did not seem any different than usual. - RN A was in the dining room and noticed the resident threw up mucous. - He/she did not know if the resident ate or not. - He/she placed the resident in the hall by the dining room so staff could observe the resident . - The resident continued to have dry heaves. - LPN A walked by the resident and took the resident back to bed. - LPN A laid the resident in bed and left. - The resident's call light went on. - The resident wanted to go back to bed. - The resident was moaning help me. - He/she straightened the resident in bed and told RN A and LPN A that the resident was short of breath. - He/she felt it took RN A and LPN A about 15 minutes to check on the resident. Review of Resident #2's medical records showed the resident was recently admitted and did not have an MDS assessment or a care plan. During an interview on [DATE] at 3:10 P.M. the DON said Resident #2 was cognitively intact. During an interview on [DATE] at 3:00 P.M. Resident #2 said: - He/she was Resident #1's roommate. - Resident #1 slept a lot. - Resident #1 got sick at supper. - When Resident #1 said he/she was short of breath, he/she called for help. - Resident #2 felt it took staff a long time to check on the resident. - When RN A and LPN A came to the room, they did not bring any equipment to check to Resident #1's vital signs or supplemental oxygen. - Resident #1 kept saying he/she could not breathe. - RN A came to the room and asked the resident what was going on? - Resident A sounded like he/she was choking and then quit breathing. During an interview on [DATE] at 1:44 P.M. the Director of Nursing (DON) said: - Staff should have notified the resident's physician when the resident's saO2 was 85%. - Staff should have reassessed the resident. - Staff should have charted any interventions. - Staff should have given the resident supplemental oxygen when the resident was short of breath. - Staff should have attempted to suction when the resident was short of breath. MO 3

Based on observation, record review and interview, the facility failed to provide timely care for one of ten sampled residents (Resident #6) who exhibited loose stools, pain and four falls in one week when the facility failed to assess and put interventions into place to address the resident's pain and failed to timely notify the physician of the resident's increased pain and loose stools. The facility census was 43. 1. Review of the facility's undated pain assessment and management policy and procedures showed: - Each resident will have a formal pain assessment done at admission and will be reassessed on each re-admission, quarterly and with any change of condition by the MDS coordinator. Informal assessments are done by the nursing staff throughout the day as needed. Based on the pain assessment, appropriate management will be initiated and then re-evaluated for effectiveness. Pain management will be care planned for the resident. - The purpose of pain management is to address individual needs regarding pain, initiate appropriate interventions, provide learning opportunities for staff, residents and families and to monitor and evaluate resident outcome. - The MDS coordinator will conduct and document a pain assessment as stated above for formal assessments. Indicate what the resident considers an acceptable level of pain. - Document assessment and develop a management plan including pharmacological and /or non-pharmacological modalities. Initiate treatment and monitor for effectiveness. If no effective, adjust treatment. - All residents that are on a pain management program will have a Care Plan addressing the plan of treatment. - Care plan will be updated as changes are made. - For new pain or intermittent pain: Develop and discuss a treatment plan with the resident/family. Consider pharmacological and nonpharmacological interventions; Check for PRN (as needed) [MEDICATION NAME] order and administer PRN; Document the pain scale on the MAR before and one hour after pain medication is administered. Monitor routine and PRN [MEDICATION NAME] use monthly to see if medication is effective. - Refer to the pain treatment algorithm for possible treatment options. The algorithm uses the pain scale number and severity of pain to make suggestions for treatment. - Try non-pharmacological management: list included items such as hot/cold therapy, message, acupuncture, relaxation and imagery, distraction, psychotherapy, etc. - Provide routine care: Positioning, frequent oral care, toileting and peri care, proper nutrition and hydration, prevention of pressure ulcers and contractions and emotional support. Review of Resident #6's transfer records, dated 12/1/14, Medical Facility A, showed they dismissed the resident with the following instructions: - [DIAGNOSES REDACTED]. blood pressure and chronic diarrhea; - Peg tube placement (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation). - Allergy to [MEDICATION NAME] (a muscle relaxant), iodine, milk products and seafood. - Orders for [MEDICATION NAME] 1.2 at 60 ML(milliliters) per hour continuous, water 400 milliliters every six hours. (feeding solution dripped into the tube at a rate of 60 ml per hour and staff were to administer into the tub an additional 400 ml of water every six hours). - Did not list any pain medication. Review of resident's admission POS, dated 12/2/14, showed Physician A ordered the following: - Admit to skilled services; - NPO (nothing by mouth) with no exceptions. - No order for [MEDICATION NAME] 1.2 or any other tube feed nutritional supplement. - The POS did not include any medication orders. Review of the facility's electronic medical records for 12/2/14, showed a stop order for [MEDICATION NAME] 1.2. Review of the nurses' progress notes, dated 12/2/14, at 10:35 P.M., showed staff documented the following: - admitted the resident from a hospital stay; - Received continuous [MEDICATION NAME] 1.2 tube feeding at 60 ml/hr. 400 ml every six hours. - Two large loose bowel movements. - Resident restless, moved lower extremities, no facial grimacing noted; - No eye contact made when asked if in pain; - Resident nodded head "no." - Resident allergic to [MEDICATION NAME], iodine, milk products, seafood. Review of the label for [MEDICATION NAME] 1.2 with fiber showed the mixture contained milk and soy ingredients. Review of the resident's bowel and bladder report showed on 12/3/14, at 3:56 A.M., staff documented the resident had an X (extra)-large, loose stool. Review of the nurses' progress notes, dated 12/4/14, at 12:00 A.M., showed staff documented they found the resident found face down on fall mat beside his/her low bed, incontinent of loose stool, resident nodded yes when asked if he/she hit his/her head, red area to forehead just above left eye noted, ice applied. Also red area to left elbow. Resident denies headache. Nods head "no" to pain. An initial care plan was not found in the computer files, the resident's first care plan was dated 12/9/14 and did not include information on pain. Review of the resident's bowel and bladder report showed on 12/4/14, at 12:51 A.M., staff documented the resident had an medium-sized, loose stool. Review of the resident's bowel and bladder report showed staff documented the following: - On 12/4/14, at 7:51 P.M., resident had a medium-sized, loose stool. - On 12/5/14, at 1:07 A.M., resident had two X-large and a large loose stool. Review of the nurses' progress notes showed staff documented the following: - 12/4/14, at 10:56 P.M., tube patent, feeding tubing changed per order. No signs of pain or discomfort. - 12/5/14, at 2:14 P.M. showed [DEVICE] patient, [MEDICATION NAME] 1.2 running at 60 cc an hour. Resident incontinent of loose brown bowel times three. Resident shook head no when asked if in pain. - 12/6/14, at 6:52 A.M., resident found beside bed in sitting position, helped back into bed. Resident restless. G tube patient [MEDICATION NAME] 1.2 continues. - 12/6/14, at 12:52 P.M., resident rolled out of bed at 9:45 A.M. Resident denies pain from incident. Resident very anxious and fidgety. Resident complained of abdominal pain stated "my stomach" and rubbed it. [MEDICATION NAME] 1.2 continuous via [DEVICE]. Review of the MAR for 12/6/14, showed: - Staff did not document they gave the resident any medication for pain or anxiety. - Did not have orders for pain medication including PRN Tylenol nor anxiety medication like PRN [MEDICATION NAME]. Review of the resident's computer physician orders [REDACTED]. - an order for [REDACTED]. - an order for [REDACTED]. Review of the resident's bowel and bladder report showed staff documented: - On 12/6/14, at 2:00 P.M., resident had an small loose stool. - On 12/6/14, at 9:28 PM., resident had an X-large and a medium loose stool. Review of the nurses' progress notes, dated 12/6/14, at 10:33 P.M., showed staff documented the following: - Resident found next to low bed on fall mat at 2:15 P.M.; - Resident stated "stomach hurts;" - Shook head "yes" when asked if trying to get up to have a bowel movement; - Staff reminded resident to use call light. Review of the resident's bowel and bladder report showed staff documented the following: - On 12/7/14, at 3:58 A.M., resident had an medium loose stool. - On 12/7/14, at 8:12 P.M., resident had an large loose stool. Review of the resident's MAR for 12/7/14, showed staff did not document they gave the resident any medication for pain or anxiety. Review of the nurses' progress notes, dated 12/8/14, at 12:07 A.M., showed at 11:35 P.M., staff documented: - Resident found on floor. - Resident said he/she did not hit his/her head. - Liquid fecal material on bed. - Brief saturated in fecal material. - Resident had been complaining about stomach hurting. - When asked if stomach hurt and cramped before he/she had bowel movement, resident said "yes." Review of the resident's bowel and bladder report showed staff documented: - On 12/8/14, at 1:09 A.M., resident had an X-large loose stool. - On 12/8/14, at 9:33 A.M., resident had an medium loose stool. Observation and interview during tour on 12/8/14, at 10:25 A.M., showed the resident lying in a low bed, [MEDICATION NAME] 1.2 with fiber running at 60 ml (tube feeding), lying in the fetal position on left side facing the doorway, eyes closed, hands on stomach. No sounds coming from the resident. Licensed Practical Nurse C said the resident was NPO (nothing by mouth) and received [MEDICATION NAME] 1.2 with fiber continuous. The resident had not complained of any pain and just starting talking over the week-end. The resident's bottom was red because he/she had multiple episodes of diarrhea. During an interview on 12/8/14, at 12:15 P.M., the resident's spouse said the resident was restless and had fallen out of bed four times since being admitted a week ago. He/she was allergic to milk and continued to have diarrhea. Staff fed the resident via a tube. He/she wanted full side rails on the resident's bed like the resident had in the hospital. He/she was concerned the resident would be badly injured if he/she continued to fall out of bed. Review of the MAR indicated [REDACTED] - At 5:04 P.M. [MEDICATION NAME] 650 mg because resident "writhing in bed, facial grimacing complained of back pain;" - At 5:19 P.M., [MEDICATION NAME] 0.5 mg for anxiety. Staff recorded at 5:58 P.M., [MEDICATION NAME] medication effective. - At 7:57 P.M., [MEDICATION NAME] 650 mg for pain. - At 10:14 P.M., [MEDICATION NAME] 0.5 mg but did not indicate why. Review of the nurses' progress notes, dated 12/8/14, at 10:53 P.M., showed staff documented the following: - Resident with increased restlessness, continuous tube feedings of [MEDICATION NAME] 1.2 at 60 ml per hour; - Constant observation given. - Four loose foul smelling bowel movements this evening. Review of the facility faxes concerning the resident between 12/2/14 through 12/8/14 to Physician A showed nursing staff did not notify the physician of the resident's continued loose stools or increased pain. Staff did not request a stronger pain medication. Review of the resident's care plan, dated 12/9/14, showed: - At risk for increased anxiety, notify physician at once if medication does not relieve restlessness. - Resident has periods of loose stools, clean immediately and provide moisture barrier after each incontinent episode. - Bed checks every two hours and as needed for incontinence. - The plan did not address the resident's pain. Review of the nurses' progress notes, dated 12/9/14, at 3:36 A.M., showed staff documented the resident continued to complain of stomach pain and had loose, liquid stools. Resident very restlessness. Observation and interview on 12/9/14, showed: - 5:42 A.M.: the resident lying in a low bed, naked, awake and moaning loud enough to be heard outside his/her room; - 5:45 A.M.: The resident's call light on. Unknown staff entered the room and asked if he/she was having pain, and the resident said, "yes," staff said they would report it to the charge nurse; - 6:30 A.M.: The resident remained in bed, awake, moving side to side in bed, moaning and said "my stomach hurts." - 6:47 A.M.: resident naked, thrashing legs back and forth. Resident holding his/her hands over his/her stomach saying "need something, oh! oh! oh!" The resident moved one hand to the rail and tried to move his/her body upward. "It hurts! It hurts! Oh! Oh! Help me! Do something!" distressful moans, legs continue to thrash back and forth. Restorative Aide (RA) A entered the room, covered the resident with a sheet and said, the resident was fidgety and uncomfortable. RA A left the room and told the nurse the resident was in pain. - 7:30 A.M.: The resident remained in bed awake, moaning and moving side to side in bed and said his/her stomach was hurting. During an interview on 12/9/14, at 8:10 A.M., RN A said the resident had Tylenol at 4:00 A.M., he/she had been complaining of stomach pain and had been restless the last few days. He/she would contact Physician A after he was done with rounds at the hospital. During an interview on 12/9/14, at 9:35 A.M., RA A said she told the nurse the resident was in pain earlier that morning, but the nurse said it was too soon for him/her to receive more Tylenol. Review of the MAR for 12/9/14 showed staff gave resident [MEDICATION NAME] 0.5 mg 9:03 A.M., for anxiety and [MEDICATION NAME] 650 mg at 9:03 A.M., for pain. Review of the nurses' progress notes, dated 12/9/14, at 9:34 A.M., showed staff documented the resident had gown and brief off at 9:00 A.M., restless and moving from side to side in bed. Stated his/her back hurts. Asked if he/she wanted anxiety medication and something for pain. The resident stated, "we gotta do something." Administered as needed (PRN) [MEDICATION NAME] and Tylenol at 9:00 A.M., the resident sleeping at this time. Observation on 12/9/14, showed: - At 9:25 A.M., showed the resident lying in the fetal position in bed, with both hands on his/her stomach making a light moaning sounds. His/her eyes closed. - At 9:35 A.M., the resident continued to lie in the fetal position in bed, holding his/her stomach and making moaning sounds. Review of the nurses' progress notes, dated 12/9/14, at 10:30 A.M., showed staff documented they faxed Physician A stating the resident was restless and complained of pain mainly in stomach. After [MEDICATION NAME] and Tylenol, restlessness decreased and resident lying with eyes closed. Observation and interview on 12/9/14, at 11:20 A.M., showed the resident complained of back pain. Certified Medication Technician (CMT) A said they gave the resident Tylenol at 9:00 A.M., and they did not have anything else to give him/her and it was not time for anymore Tylenol. Review of the nurses' progress notes, dated 12/9/14, at 1:00 P.M., showed Physician A ordered to hold [MEDICATION NAME] for six hours to see if this would help with stomach pain and to add [MEDICATION NAME] (medication used to treat symptoms [MEDICAL CONDITION] other conditions caused by excess stomach acid) to medications. Resident had one diarrhea today. Observation on 12/9/14, at 1:08 P.M., showed the resident in bed, staff and spouse in the room. From doorway, the resident was heard saying "it hurts, it hurts, do something!"and continue to making moaning sounds. Review of the nurses' progress notes, dated 12/9/14, at 3:31 P.M., showed staff documented: - Up in wheelchair for therapy; - Resident rocking back and forth with facial grimacing, states,"I can't stand it, my stomach hurts;" - Resident said pain was burning and sharp. - Received Tylenol at 1:00 P.M. and [MEDICATION NAME] at 9:00 A.M.; - Spouse at bedside, explained new order of [MEDICATION NAME]; - [MEDICATION NAME] on hold for six hours. During an interview on 12/10/14, at 5:15 A.M., Licensed Practical Nurse (LPN) A said staff sent the resident to the local hospital last evening (Medical Facility B) because of severe stomach pain. Staff from Medical Facility B reported they transferred the resident on to Medical Facility C. Review of the resident's emergency room (ER) records, dated 12/9/14, from Medical Facility B showed: - Resident arrived at 5:25 P.M., appeared to be in severe distress from acute abdominal pain. - The nursing facility reported the resident suffered from ongoing stomach pain for two days, but did not mention total of four days staff documented the resident's pain) - Resident moaning and saying "help, help". - Stated stomach hurts all over. - IV [MEDICATION NAME] given for pain times five without relief. - Pain exacerbated by movement relieved by nothing. - Resident continued to moan. - Questioned possible [MEDICAL CONDITION] versus spots caused from patient movement. - Resident transfer to Medical facility C ordered at 7:40 P.M.. Review of the laboratory test results from Medical Facility B, dated 12/9/14, showed: - A high Lipase level of 864 (normal 73 to 393, a test which measures the amount of this enzyme in blood. High amounts of lipase may be found in the blood when the pancreas is damaged or when the tube leading from the (pancreatic duct) to the beginning of the small intestine is blocked.) During an interview on 12/11/14, at 1:30 P.M., the director of nursing (DON) said the resident had diarrhea at the hospital before admittance. Nursing staff should have contacted the physician if resident was having multiple loose stools. She would consider four loose stools in 24 hours as multiple loose stools. The resident was restless and rolled out of bed four times. The resident had fall mats and a low bed. Staff should have updated the physician when resident was having pain. The resident moved his/her legs a lot, but nodded his/her head "no" when asked if in pain. The resident shook his/her head that he/she was not in pain even when his/her legs were restless. She believed the resident's stomach pain just started 12/8/14 about the time the survey began at 10:00 A.M. The resident complained of stomach pain, but was on [MEDICATION NAME] (used for stomach ulcers) and later put on [MEDICATION NAME] (used to treat excess stomach acid). The resident had Tylenol for pain. If staff gave the resident Tylenol for pain and it did not work, she expected the nurse to call the physician for another order. Tube feedings will normally give a resident diarrhea but nursing should have clarified the resident's milk allergy to make sure physician wanted him/her on a product like [MEDICATION NAME] that contained milk. The physician stopped the [MEDICATION NAME] 1.2 on 12/9/14, to see if it helped the resident's stomach pain. The resident's pain increased and the physician ordered the resident be sent out to the local hospital, Medical Facility B the evening of 12/9/14. Staff informed her the resident was transferred on to Medical Facility C. The nursing staff talked to the resident's husband this morning who told them the resident arrived at Medical Facility C unresponsive and Medical Facility C continued to run tests on the resident.

Based on observation, interview, and record review, the facility failed to assure staff instituted measures to prevent multiple falls from a wheelchair resulting in injuries for one of nine sampled residents (Resident #5) and failed to assure staff used proper techniques to reduce the possibility of accidents and injuries during gait belt transfers of two residents (Resident #4 and #6).The facility census was 39. 1. Review of the facility's undated Fall Policy and Fall Prevention Program showed: - Objective: To lower the incidence of falls and lessen the extent of injury from falls; - Procedure: Identify residents at risk for falls; identify risk factors; staff education; fault analysis; other assessments such as resident footwear, confinement to a chair, mental status, assistive devices, and low blood pressure; - Interventions: Corporate problem information in the resident's chart; implement therapy assessment with balance training; investigate falls within 24 hours; review/modification of medications; chair exercises, group exercises; and review programs/fall incidences monthly. 2. Review of Resident #5's nurse's notes dated 8/5/12, at 5:00 P.M. and 5:22 P.M., showed Licensed Practical Nurse (LPN) D recorded the following: - 5:00 P.M.: Staff wheeled the resident to the dining room; - The resident wore rubber soled shoes and staff reminded the resident to raise his/her feet off the floor; - The resident raised his/her feet from the floor, staff wheeled the resident a few feet down the hall, and the resident placed his/her feet on the floor, which caused an abrupt stop of the wheelchair; - The resident fell out of the wheelchair onto the floor and hit his/her face against the floor; - His/her glasses cut the left eye in four different places above the orbit (bone structure) of the eye, above and below the brow; - The resident complained of pain in the right and left shoulders and his/her left leg; - The resident had difficulty answering questions; - Applied Steri-strips (adhesive strips used to close a wound) to the eye to close the wound and control bleeding; - Orders received to transfer the resident to the hospital emergency room (ER) for evaluation and the director of nurse's and guardian were notified; - 5:22 P.M.: Transferred the resident to the ER. During an interview on 11/14/12, at 2:15 P.M., LPN D said the following: - He/she worked the evening of 8/5/12, when the resident fell out of the wheelchair and sustained a laceration to the left eye; - The resident sat in the TV room and wore rubber soled shoes; - He/she attempted to wheel the resident to the dining room, told the resident to raise his/her feet off the floor; - As he/she wheeled the resident, the resident put his/her feet onto the floor which caused the wheelchair to abruptly stop; - The resident fell forward out of the wheelchair and cut his/her eye; -The resident needed different shoes; - Staff tried foot pedals before, but because the resident wheeled him/herself around the facility, staff thought the pedals were unsafe; During an interview on 11/15/12, at 10:40 A.M., the DON said: - Foot pedals should not be used on the resident; - OT said the resident was not safe to use the foot pedals; - Staff should place their hand on the resident's shoulder as they wheeled to resident to prevent the resident from falling forward; - Staff should update care plans as needed when changes or problems occur with residents to keep the care plans updated. During an interview on 11/14/12, at 9:45 A.M., the OTR Manager said: - The resident self propelled (wheeled) randomly around the facility so they did not use pedals to allow the resident to move around the facility in the wheelchair and staff said the resident would lean forward and played with the pedals but staff should use the foot pedals when they wheel the resident around the facility; - The resident had several falls out of the wheelchair and one with an injury to his/her face; Review of facility nurse's notes dated 8/5/12, at 10:05 P.M., showed LPN recorded the resident returned to the facility. Review of a facility nurse's note dated 8/6/12, at 12:30 P.M., showed LPN F recorded: - Unidentified nurse recorded he/she spoke with therapy about recent resident falls from wheelchair, suggested adjustment of wheelchair wheels and if this did not help with falls, then send a referral for wheelchair positioning. Review of facility nurse's note dated 8/17/12, at 12:30 P.M., showed LPN F recorded the following: - The resident continued to lean forward in the wheelchair at times; - Encouraged to sit up straight. Review of nurse's notes dated 9/22/12, at 4:10 P.M., showed LPN D recorded the following: - The resident sat at edge of wheelchair seat; - Staff cued and adjusted the resident often to sit back in the seat; - The resident could not remember to sit back in the seat; - The resident was in his/her room and went through his/her drawers, leaned too far forward, fell out of the wheelchair onto floor mat, landed on his/her right cheek; - No apparent injury noted; Review of the annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/12, showed: - Long- and short-term memory problems; - Moderately impaired cognition, supervision needed in decision making; - Extensive assist of two or more staff for bed mobility, transfers, and toileting; - Not steady, only able to stabilize with staff assistance for moving from a seated position to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer; - Wheelchair; - Restorative nursing for range of motion exercises, no other therapy; - One non-injury fall; - Two or more falls with injury; - [DIAGNOSES REDACTED]. Review of the care plan, dated 9/27/12, showed: - Problem: Needed extensive assistance from staff for bed mobility, transfers, ambulation, wheelchair locomotion, and toileting; - Goals: No falls; - Approaches: Encourage resident to assist with positioning, assure position changes every two hours, transfer in and out of bed as needed, transfer into wheelchair for meals/activities, assist to move around the facility as needed, encourage as much independence as possible; - Problem: At risk for falls; - Goals: Will be safe and have minimal injury in the event of a fall; - Approaches: PT/OT to evaluate and treat as needed, assess for and treat injury, assess for signs and symptoms of infection, assess for medication side effects which contribute to safety risks, assess for environmental safety hazards, assess and provide for additional safety equipment, personal body alarm in place at all times, notify staff for increased risk for falls, Hi-Lo bed with fall mats; - Problem: At risk for increased confusion; - Goals: Will continue to be oriented to self and location; - Approaches: Explain all procedures, use simple commands, provide cuing and prompting; - The care plan did not address interventions to prevent falls out of the wheelchair or bed and prevent the possibility of injury. Review of facility nurse's notes dated 9/29/12, at 4:30 P.M., showed: - The resident continued to sit on the edge of the wheelchair seat, leaning over to touch imaginary objects on the floor; - Staff held the resident on the seat and constantly reminded him/her to sit back in the wheelchair seat; - The resident cannot remember to change positions in the wheelchair. Review of nurse's notes dated 10/9/12, at 10:10 A.M., showed LPN F recorded the following: - Staff called LPN F to the resident's room and found the resident on his/her abdomen in front of the wheelchair; - An unidentified housekeeping staff informed LPN F he/she saw the resident lean forward in the wheelchair and encouraged the resident to sit back in the seat; - Moved all extremities and denied pain. Review of the Therapy Screen Form dated 10/9/12, and completed by Physical Therapy Assistant (PTA) A showed: - Falls on 9/19/12, 9/26/12, 10/6/12, and 10/9/12; - Standard wheelchair; - Leg rests as needed; - No anti-tip bars; - Did not show any signs of poor posture in bed or wheelchair; - Could not benefit from therapy; - No cognitive decline; - discharged from OT on 9/20/12; set-up assist of one staff for wheelchair mobility and activities of daily living; minimal/moderate assist of one staff for all transfers; able to make needs known; no decline at this time; continue to monitor. Review of the physician's orders [REDACTED]. - Full weight bearing, ambulate with walker with the assist of one staff for short distances, use wheelchair for longer distances, fall risk precautions, Hi-Lo bed with fall mats; Observations on 11/12/12, showed the following: - 11/12/12 at 12:45 P.M: Staff wheeled the resident from the dining room in a wheelchair with no foot pedals and the resident's right foot dragged on the floor; - 11/12/12 at 5:00 P.M.: Staff wheeled the resident to the dining room in a wheelchair with no foot pedals and the resident's feet hung down and were approximately one inch from the floor. Observations on 11/13/12, and 11/15/12, showed the following: - 11/13/12 at 12:00 P.M. and 4:25 P.M.: Staff wheeled the resident to the dining room in a wheelchair with no foot pedals and the resident's feet hung down and were approximately one inch from the floor; - 11/15/12 at 7:30 A.M.: Staff wheeled the resident to the dining room in a wheelchair with no foot pedals and the resident's feet hung down and were approximately one inch from the floor. Observations on 11/14/12, showed the following: - At 6:15 A.M. the resident sat in his/her wheelchair in the hallway with his/her feet hanging down and his/her feet rested on the floor, no foot pedals were attached to the wheelchair; - At 7:00 A.M. staff wheeled the resident to the dining room in the wheelchair with no foot pedals and the resident's feet hung down and were approximately one inch from the floor. During an interview on 11/14/12, at 12:45 A.M., CNA D said: - The resident had foot pedals but he/she could not find the pedals and did not put the pedals on the wheelchair this morning; - The resident should have the pedals on the wheelchair when staff wheeled the resident in the facility; - Staff started using the pedals after the resident fell out of the wheelchair a few months ago; During an interview on 11/14/12, at 2:00 P.M., the MDS/Care Plan Coordinator said: - He/she was the MDS/Care Plan Coordinator and updated care plans quarterly and as needed; - Staff should care plan problems and interventions daily as problems occur; - Staff tried foot pedals before and they did not work for the resident; - He/she did not care plan for staff to use wheelchair foot pedals when they wheeled the resident throughout the facility; - Care planning the use of foot pedals when staff wheeled the resident was a good idea and he/she would do that today. - Interventions for falls are care planned for the resident. 3. Review of the facility's Gait Belt Policy revised 11/09, showed: - Gait belts must be used by nursing staff during ambulation and/or transferring of residents as stated in the resident's plan of care; - The purpose of the gait belt is to provide increased security for the resident and staff and prevent injury during gait training and transferring of the resident; - Note the need for use of a gait belt in the resident's care plan; - Considerations for not utilizing a gait belt, a severe heart or respiratory disease; - Apply the gait belt around the resident's waist snuggly to eliminate the possibility of gait belt movement; - Use the gait belt for during ambulation to stabilize the resident by grasping the belt firmly; - Walk along side and slightly behind the resident to quickly assist the resident as needed by use of the gait belt. 4. Review of Resident #4's quarterly MDS dated [DATE], showed: - A Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact; - Limited assistance of one staff for bed mobility, transfers, and to walk in the room and hallway; - Extensive assistance of one staff for toileting; - Not steady, only able to stabilize with staff assistance with moving from a seated to a standing position, walking, turning around, moving off and on the toilet, and surface to surface transfers; - [DIAGNOSES REDACTED]. Record review of facility nurse's notes, dated 11/12/12, showed: - 7:10 P.M: The resident up with the assist of two staff, transferred with a gait belt, balance and gait poor; During an observation and interview on 11/12/12, from 4:35 P.M. until 5:50 P.M., LPN C, CNA A and CNA B did and said the following: - Transferred the resident with a gait belt from the wheelchair to the toilet and the resident did not bear full weight on his/her feet/legs, knees were bent, difficult to turn the resident, dragged him/her to the toilet seat; - LPN C asked CNA A if the transfer was difficult and CNA A said yes, the resident did not stand up straight; - CNA A said staff sometimes used the sit-to-stand lift (allows the resident to stand on a foot rest, hold to the handle bar, and with a sling lifts, the resident to stand and be transferred) but not all the time, it depended upon how well the resident could stand on a given day; - CNA A and CNA B applied the gait belt, stood the resident and the resident did not bear weight; CNA A and CNA B turned and dragged the resident to the wheelchair with difficulty; - CNA A said the resident did not bear weight during the transfers and could not stand up straight; Review of the resident's care plan showed staff did not update the care plan after 11/2/12, with interventions related increased weakness and falls. During an interview on 11/14/12, at 9:45 A.M., the registered Occupational Therapy (OTR) Manager said: - She received reports the resident did not transfer well with a gait belt and staff did use the sit-to-stand at times for him/her; - The resident had a recent decline in status and might need a reassessment for type of transfer to use. During an interview on 11/15/12, at 10:40 A.M., the DON said: - If staff had problems with transfers they should notify the charge nurse; - A referral would be made to PT for evaluation; 5. Review of Resident # 6's quarterly MDS, dated [DATE], showed: - The resident was not steady with balance moving from seated to standing position; - The resident was not steady turning around while walking; - Mobility devises included a wheelchair; - [DIAGNOSES REDACTED]. - Transfers with extensive assistance of two staff members; Review of the Care Plan, updated 8/16/12, showed: - Risk for falls related to physical limitations; - Falls will be avoided and safety will be maintained; - Alert staff to increased risk for falls; - Transfer the resident with assist of one staff member as needed; - The care plan did not indicate the use of a mechanical lift (used to transfer residents with staff assistance) or a gait belt. Review of the Therapy Screen Form, dated 10/9/12, showed: - The resident uses a sit to stand ( mechanical lift) for transfers. Observation on 11/13/12, at 8:20 A.M., showed: - Certified Nurse Aides (CNA's) E and F transferred the resident using a gait belt; - The resident did not bear weight when the CNA's lifted the resident with the gait belt; - The CNAs held the resident in a standing position with the gait belt; - The resident's knees were buckled while he/she was in a standing position; - The resident was wearing heel protectors (padded Velcro heal covers) used to protect a residents heels that are at risk for skin breakdown when they are in bed or sitting; - CNA's pivoted the resident by turning him/her to the left as the residents feet slid into the position needed to sit him/her on the bed; - CNA's pulled the resident back using the gait belt with his/her feet sliding on the ground until his/her legs touched the side of the bed and sat the resident on the bed; During an interview on 11/13/12, at 8:30 A.M., CNA E said: - Staff always transfer the resident with the gait belt and heel protectors; - One staff member uses a mechanical lift because he/she has back problems. During an interview on 11/15/12, at 9:30 A.M., Registered Nurse (RN) A said: - The resident does not bear weight and staff should only transfer him/her with a mechanical lift; - Staff should not transfer any residents with heel protectors on. During an interview on 11/15/12, at 10:50 A.M., the DON said: - Staff should not transfer a resident using a gait belt if the resident is not able to bear weight and can't pivot during the transfer; - Residents should not have heel protectors on their feet during transfers; - CNA's should check the care plan to see how a resident is transferred before transferring the resident; - Staff should notify the charge nurse if there is a change in the residents transfer abilities.