Every finding on record at PruittHealth-Elkin

Based on observations, record review and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #4 failed to wear a gown while changing out Resident #1's catheter urine collection bag. In addition, the facility failed to implement their policy for Contact Precautions when Nurse Aide (NA) #10 and NA #11 provided incontinence care and a shower to Resident #76 without wearing a gown and Nurse #13 provided wound care without wearing a gown. The deficient practice occurred for 4 of 10 staff observed for infection control practices(Nurse #4, NA #10, NA #11, Nurse #13). The findings included:1. A review of the facility policy titled Enhanced Barrier Precautions with review date of 5/27/25, stated in part: EBPs refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. EBPs should be used when a resident has a wound or indwelling medical device. The policy noted examples of indwelling medical devices to include central lines, urinary catheters, feeding tubes, and tracheostomy (surgically created opening in the neck into the windpipe that allows a person to breathe when normal airways are blocked or impaired)/ventilator tubes). The policy defined high-contact resident care activities to include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care or use.A continuous observation was completed on 7/6/26 from 11:03AM to 11:10AM. An EBP sign was noted on Resident #1's room door and there was also a cart with Personal Protection Equipment (PPE) nearby. The EBP sign instructed staff to clean their hands (including before and when leaving the room) and to wear gloves and gown for high-contact resident care activities including urinary catheter care. At 11:03AM Nurse #4 was observed at Resident #1's bedside wearing gloves and was in the process of changing out the catheter urine collection bag. Nurse #4 discarded his gloves in the room and performed hand hygiene. Nurse #4 was interviewed 7/6/26 at 11:10AM after exiting Resident #1's room and stated the resident was on EBP, but that he didn't realize he needed to put on a gown, because he was just changing out the urinary catheter bag. He read the EBP sign posted on the resident's door at that time and then stated he should have had a gown on while changing out the urinary catheter bag. He further explained that he did have training on EBP when he was hired and that they continue to do trainings online at least yearly, but usually more often. An interview with the Director of Nursing (DON), who was also the Infection Preventionist for the facility, was completed on 7/6/26 at 1:00PM. She stated Nurse #4 should have had a gown on when he changed the resident's catheter urine collection bag. The DON stated all nurses were trained on EBP upon new hire orientation and at least annually after that. An interview with the Administrator was conducted on 7/9/2026 at 5:05PM. She stated Nurse #4 had spoken to her regarding changing out a resident's catheter urine collection bag without wearing and gown. The Administrator stated that Nurse #4 told her he knew he should have worn a gown while changing out Resident #1's urinary catheter bag but had just been in a hurry and forgot to put one on. 2. A review of the facility's Transmission-Based Precautions policy statement dated 11/4/25 revealed it was the policy of the facility to adhere to Transmission-Based Precautions (TBP) to prevent or to interrupt the spread of suspected or confirmed infections within the facility. The policy further stated Contact Precautions (a specific type of TBP) should be used for residents with multidrug resistant organisms (MDROs). Contact Precautions were indicated when performing resident-care activities that require touching the resident's skin, touching items in the resident' s environment, and providing high-contact resident care activities. Resident #76 was admitted to the facility on [DATE]. A careplan dated 6/28/26 included a focus of infection related to a multi-drug resistant organism (MDRO) VRE in the resident's urine. Approaches listed in the careplan included following Contact Precautions. On 7/6/26 at 10:02 AM a Transmission-Based Precautions (TBP) sign was noted on the outside of the door of the room of Resident #76 that indicated Contact Precautions were to be used. The signage instructed that all healthcare personnel must wear gloves when entering room and when touching resident's intact skin, surfaces, or articles in close proximity. Wear gown whenever anticipating that clothing will touch resident items and when dressing, bathing/showering, transferring, changing linens, provide hygiene, changing briefs or assisting with toileting, and device care or use; central lines, urinary catheter, feeding tubes, tracheostomy, wound care: any skin opening requiring a dressing. The signage instructed everyone to perform hand hygiene and apply gloves and a gown before entering the room and discard the gown and gloves before exiting the room and then perform hand hygiene. An observation on 7/6/26 at 10:32 AM revealed Nursing Aide (NA) #11 exiting Resident #76's room carrying the resident's personal clothes. The NA crossed the hallway and entered the unit shower room wearing no gloves or gown. A bin containing clean PPE was observed in the hallway. On 7/6/26 at 10:40 AM, NA #11 and NA #10 were observed providing incontinence care and a shower for Resident #76. Both NAs were wearing gloves but no gown. At 10:50 AM Nurse #13 entered the shower room and completed wound care on Resident #76's left arm wearing gloves but no gown. In an interview conducted on 7/6/26 at 11:14 AM Nurse Aide #10 stated she should have worn a gown when she showered and provided incontinence care for Resident #76 but was not aware Resident #76 was on Transmission-Based Precautions of any kind. She stated she was just helping NA #11and so did not see signage on the resident's door and would have expected NA #11 to tell her if precautions were in place. An interview was conducted on 7/6/26 11:22 AM with NA #11 who stated she simply did not pay attention to the signage when retrieving bath supplies and clothes from Resident #76's room. She further stated that she should have worn both gloves and a gown when providing incontinence care and a shower for Resident #76 and she knew better. An interview was conducted on 7/6/26 at 1:45 PM with Nurse #13 who had provided wound care in the shower room for Resident #76. She stated this was her first day back to work after a month off and was not aware the resident was on Contact Precautions. She stated she was not sure why Transmission-Based Precautions were in place. She stated she did not see the signage on Resident #76's door before entering the shower room and did not receive information during shift report that the resident was on Contact Precautions. Nurse #13 indicated she should have worn a gown. An interview was conducted on 7/7/26 at 8:00 AM with the Director of Nursing (DON) who also served as the facility Infection Preventionist. The DON confirmed Resident #76 was on Contact Precautions for an active multidrug resistant organism (MDRO) infection in his urine which required a gown and gloves to be worn by all staff when entering his room, touching surfaces in the room, and during care activities. The DON stated this included wound care and activities of daily living care. The DON explained that all staff were to follow the facility infection control policy for Transmission-Based Precautions and to identify the posting of the Contact Precautions sign on the residents' doors. She outlined that all staff received infection prevention and control education with training specific to Enhanced Barrier Precautions and Contact Precautions during orientation, annually, and when trends in infections were noted. The DON added that she conducted random audits to ensure staff adhered to PPE guidelines and reminded nursing staff about wearing PPE at least weekly and there was no reason for them to be unaware, as there were signs posted on the door outlining what PPE should be worn and when to remove it. The DON said NA #10, NA #11, and Nurse #13 should have worn both gloves and gowns when they provided care as the signage on the door indicated and did not know why they had not. In an interview on 7/7/26 at 8:30 AM, the Administrator stated all staff received extensive training on infection prevention and control. She said NA #10, NA #11, and Nurse #13 should have worn both a gown and gloves providing care for Resident #76 and did not know why they didn't. The Administrator stated she expected all care providers to follow infection control processes outlined on the Contact Precaution signs on the residents' doors. She further stated these infection controls measures were designed to prevent the spread of infections within the facility.

Based on observations, record review, and interviews with staff and residents, the failed to assess residents for self-administration of over-the-counter lubricating eye drops and topical pain-relieving gel for 2 of 2 residents observed with over-the-counter pharmacy products at bedside (Resident #9 and Resident #38).The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses that included dry eye syndrome. A review of Resident #9's physician's orders did not reveal any order for self-administration of medications or an order for lubricating eye drops. A review of Resident #9's medical chart did not reveal an assessment for self-administration of medications. Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. An observation and interview were conducted on 7/6/26 at 12:15PM with Resident #9 in her room. It was observed that she had a bottle of carboxymethylcellulose sodium 0.5% drops (lubricating eye drops) sitting on her bedside table. There was not a prescription label on the bottle. Observation of the hallway outside of resident's room revealed the nurse for that hallway (Nurse #1) was no longer passing medications in the hallway. Resident #9 stated she has had eye drops for several months since she had returned from a leave and used them daily for her dry eyes. On 7/6/26 at 12:20PM the Wound Care Nurse was informed Resident #9 had lubricating eye drops on her bedside table and she was accompanied to Resident #9's room. The Wound Nurse commented the lubricating eye drops should not have been in Resident #9's room and removed the eye drops. The Wound Care Nurse told Resident #9 she would check to see if they could get an order for her to keep the eye drops in her room. On 7/6/26 at 12:21PM the surveyor accompanied the Wound Care Nurse to the nurses' station and the Wound Care Nurse informed Nurse #1 about the lubricating eye drops removed from Resident #9's room. Nurse #1 stated that she had not noticed the drops in Resident #9's room. Nurse #1 accessed Resident #9's medical record and stated that Resident #9 did not have an order to self-administer her own medication and did not have an order for the lubricating eye drops that were removed from her room. B. Resident #38 was admitted to the facility on [DATE] with diagnoses that included pain disorder with related psychological factors, and osteoarthritis. A review of Resident #38's physician's orders revealed an order dated 4/14/26 for medicated topical pain-relieving gel to be administered to his left knee three times per day. The physician's orders did not reveal any order for self-administration of medications. A review of Resident #38's medical chart did not reveal an assessment for self-administration of medications. Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. An observation and interview were conducted on 7/6/26 at 12:25PM with Resident #38 in his room. It was observed that he had a bottle of menthol gel 4% medicated topical pain-relieving gel sitting on his bedside table. There was not a prescription label on the bottle. Observation of the hallway outside of resident's room revealed the nurse for this hallway (Nurse #1) was no longer passing medications on the hallway. Resident #38 stated a nurse had left the bottle in his room that morning after administering his medications. On 7/6/26 at 12:27PM the Wound Care Nurse was informed Resident #38 had medicated topical pain-relieving gel on his bedside table and she was accompanied to Resident #38's room. The Wound Care Nurse stated the medicated topical pain-relieving gel should not have been left in Resident #38's room and removed the medicated topical pain-relieving gel. On 7/6/26 at 12:29PM the surveyor accompanied the Wound Care Nurse to the nurses' station and the Wound Care Nurse informed Nurse #1 she had removed the medicated topical pain-relieving gel out of Resident #38's room. Nurse #1 accessed Resident #38's medical record and stated that Resident #38 did not have an order to self-administer his own medications but did have an order for the medicated topical pain-relieving gel. Nurse #1 stated that she must have left the medicated topical pain-relieving gel in Resident #38's room earlier that morning when she was providing his medication to him. During an interview with the Director of Nursing (DON), conducted on 7/6/2026 at 1:14PM she stated that Resident #9 and Resident #38 should not have had the lubricating eye drops and medicated topical pain-relieving gel in their rooms without an order to self-administer their own meds. She also stated that Resident #9 should not have had eye drops because she did not have an order for them. An interview with the Physician on 7/9/26 at 10:00AM revealed that he expected any resident who wanted to keep their own medications in their rooms, to have an order for the medication, a completed assessment for self-administration of medications and an order for self-administration of medications. An interview was conducted with the Administrator on 7/9/2026 at 5:05PM when she revealed she had been aware that lubricating eye drops were found in Resident #9's room but was not aware that the menthol gel 4% was found in Resident #38's room. The Administrator stated she would expect that no residents would have medications left in their room unless they had been assessed and found to be able to competently administer their own meds and had a physician's order for self-administration.

Based on observations, record review, and staff interviews the facility failed to refer residents with serious mental disorders to the state's mental health authority for Preadmission Screening and Resident Review (PASRR) assessments, upon admission for 2 of 2 residents reviewed with serious mental disorders (Residents #21 and #42). Findings included: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder. , The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21 was cognitively intact with the diagnosis of bipolar disorder and received antipsychotic medication. Review of the facility's records indicated Resident #21 was not referred to the state-designated authority for PASRR screening. On 6/4/25 at 11:14 a.m., the facility's Financial Counselor revealed she was responsible for requesting PASSR screenings of residents by the state-designated authority when notified by the MDS nurse of newly admitted residents who had diagnoses requiring a PASRR screening. An interview was conducted on 6/4/25 at 11:27 a.m. with MDS Nurse #1. She indicated a resident's diagnoses and/or medications determined if a resident required screening for a level II PASRR. MDS#1 revealed Resident #21 was screened and determined as a level II PASSR on 9/30/19. She stated the resident was upset with this determination and telephoned the state-designated authority demanding his PASSR number changed to Level 1; and it was changed to Level 1 on the next day. as indicated. During an interview on 6/4/25 at 10:59 a.m., the Administrator acknowledged a request for PASRR screening should have been submitted to the state-designated authority for Resident #21 at the time of his admission due to his diagnosis of bipolar disorder. During an interview on 6/4/25 at 11:53 a.m., the Administrator stated there was no paper trail at the facility indicating Resident #21 was referred for PASRR screening. 2. Resident #42 was admitted on [DATE] with diagnoses including: Bipolar Disorder and Anxiety. Resident #42's PASRR Level I Determination Notification document dated 8/16/24 revealed nursing facility placement was appropriate and that there were no diagnoses that would require a PASRR Level II to be done. This was sent with Resident #42 from the hospital when discharged to the facility. There was no expiration date. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was not cognitively impaired. Resident #42 was on an antidepressant and an antianxiety medication. Resident #42's current medication orders showed two active orders dated 4/18/25 for Clonazepam (an antianxiety medication) 0.25 milligrams twice daily and Duloxetine (an antidepressant medication) 30 milligrams once daily. During an interview with the facility's Financial Counselor on 6/4/25 at 11:16 am she stated she was in charge of submitting the information for PASRR screening for a resident with a severe mental health diagnosis if the initial screening recommended her to do so. The Finacial Counselor reported that MDS Nurse #1 will let her know when one needs to be done and she will take care of it. The Financial Counselor was unaware that Resident #42 had a mental disorder that would require additional screening. During an interview with the facility MDS Nurse #1 on 6/4/25 at 11:27 am, she stated she had not submitted a PASRR screen for Resident #42 based on her bipolar disorder diagnosis because she was waiting for Resident #42 to provide the facility with her previous medical records. MDS Nurse #1 reported that she should have had one completed upon entry to the facility. An interview was conducted with the facility's Administrator on 6/5/25 at 2:39 PM who stated she was aware of Resident #42's diagnosis but was unaware that she had not had an updated PASRR screening based on her mental health diagnosis. The facility's Administrator stated that the facility should have submitted the request for PASRR screening for Resident #42 to the state-designated authority at the time of her admission due to her diagnosis of bipolar disorder.

Based on observations, record review, facility policy, and interviews with Resident #1, staff, Local Health Department Representative, State Health Department Representative, State Health Department Medical Provider, Nurse Consultant to the North Carolina Hepatitis Program, facility Attending Physician, facility Medical Director, and Corporate Medical Director, the facility failed to immediately implement effective precautions to prevent further transmission of bloodborne pathogens to other residents who required blood glucose monitoring and failed to immediately begin training on acute hepatitis B following Resident #1's diagnosis of acute hepatitis B. Acute hepatitis B is a serious liver infection caused by the hepatitis B virus. The disease is commonly spread by unsafe injection practices and exposure to infected body fluids. This deficient practice affected 30 of 30 residents including Resident #1 who received glucose monitoring. Immediate jeopardy began on 05/10/24 when Resident #1 readmitted from the acute care hospital with a diagnosis of acute hepatitis B and the facility failed to implement effective precautions to prevent further transmission of bloodborne pathogens. Immediate jeopardy was removed on 06/25/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. The findings included: The facility policy titled, Infection Prevention and Control Plan dated 06/23/23 read in part, this infection prevention and control plan outlines the framework by which all facilities will assess, implement and evaluate an active, effective, comprehensive facility-wide infection prevention and control program. The Medical Director and Director of Health Services are responsible for the identification of appropriate resources and/or resource allocation that supports the infection prevention and control program. The goals of the program are to decrease morbidity/mortality, attributable to infections in residents; prevent and control outbreaks of infection in residents; prevent acquisition of infection by staff members, maintain resident functional status, maintain optimal social environment for residents; limit cost of care attributable to infections. Review of an additional facility policy titled, Infection Control: Glucometer Cleaning and Disinfecting dated 06/29/23 read in part, it is the policy of this facility to promote a safe environment for preventing the transmission of potentially infectious blood-borne pathogens between patients and healthcare professionals. Safe glucose monitoring is a part of standard precautions and is implemented to maintain basic levels of patient safety and partners protection. Review of the operator's manual for the facility's glucometers with no date noted read in part, you should perform a control solution test when: using the meter for the first time, at least once per week to verify that the meter and test strips are working properly together. The Centers for Disease Control defines: An outbreak or an epidemic is the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time. Resident #1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, spinal stenosis, weakness, calculus of kidney, diabetes, chronic kidney disease, neuromuscular dysfunction of the bladder, anemia, hypertension, and major depressive disorder. There were no documented diagnosis of hepatic issues. Review of a physician order dated 06/17/23 read, fingerstick glucose check with sliding scale insulin before meals and at bedtime. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was cognitively intact and received 7 days of insulin injections during the assessment reference period. A physician order for a routine lab draw dated 04/25/24 read, Hemoglobin A1C (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) and Comprehensive Metabolic Panel (a routine blood test). A laboratory report dated 04/25/24 read in part, TBIL (a test that measures the bilirubin in your blood was 7.0. AST (Aspartate Aminotransferase) was 1095. ALKP (a test that measures the alkaline phosphatase in your blood) was 462, ALT (used to diagnose liver disorder) 937. All of the lab values were reported as high which indicated that the resident may have liver disease. The report was finalized and reported to the facility on [DATE] at 3:42 PM. Nurse Aide (NA) #1 was interviewed on 06/20/24 at 11:07 AM who confirmed that she worked with Resident #1 six days in a row for 16 hours per day and was very familiar with her. About two days before Resident #1 fell (fall occurred on 04/26/24) and was transferred to the hospital she had noted a yellow tint on her entire face, but it was very light and contributed it to the lighting in the room. NA #1 stated she even asked another NA if she thought Resident #1 was yellow and that NA stated no, but thought it was just the lighting in the room. She added that Resident #1 had not been sick and had no complaints, so she just believed that the lighting in her room was making her face appear yellow. NA #1 stated a couple of days later she took Resident #1 to the shower room and when she got her into the shower room under different lights, she was definitely yellow, and she went and reported it to Nurse #1 who ended up sending Resident #1 to the hospital because she had a fall and was complaining of neck pain. A progress note written by Nurse #1 dated 04/26/24 at 12:05 AM read, resident complained of neck pain, resident yellow in color, neurological checks done as order, resident complained her neck was hurting, swelling edema 3+, complaining when turning head of popping sound or feeling to left side small hematoma to right side of head observed. O2 sats (oxygen saturations) 81 at room air, O2 started at 2 liters sat 91 on call notify of status new orders given to send to [hospital name]. Normal oxygen saturations range from 95% to 100%. Nurse #1 was interviewed on 06/20/24 at 6:32 PM. Nurse #1 stated that when she came to work on 04/26/24 she had gotten report that Resident #1 had fallen on the previous shift and was getting neurological checks. She stated that when she went down to see Resident #1, she was complaining of neck pain and was yellow in color in her face area and just looked different and Nurse #1 stated she was concerned. Nurse #1 stated she had not seen Resident #1 in a couple of days and when she last saw her, she was not yellow in color. She added that Resident #1's oxygen saturation level was 81% so she started oxygen at 2 liters, and her oxygen saturation level came up to 91%. She stated she called the on-call provider and told them what was going on. They stated to send Resident #1 to the emergency room (ER). Review of a discharge summary from the local hospital dated 05/10/24 read in part, discharge diagnoses: Acute hepatitis B with liver failure, concern for primary biliary cholangitis (serious infection of the liver's bile ducts), metabolic/hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease). The discharge summary read Resident #1 denied previously known history of liver disease but was noted to have jaundice over the last three days. Labs were notable for liver enzymes and bilirubin that were elevated. A computed tomography (CT) scan of the liver showed a normal sized liver with no intrahepatic bile duct dilation. Hepatology (doctor that specializes in the liver) was consulted and indicated that Resident #1 was not a liver transplant candidate due to age and co-morbidities. Recommended to continue with current treatment and if no improvement will need to consider palliative care. Infection Control notified and Center for Disease Control (CDC) notified. Resident #1 returned to the facility on [DATE]. Resident #1 was interviewed on 06/20/24 at 10:46 AM. She stated that she had been at the facility since June 2023 and recently slid out of bed and hit her head and ended up going to the hospital. She stated prior to her fall she had not been sick. She explained that she spent a couple of days in the ER and had numerous daily blood draws and they determined that she had hepatitis. Resident #1 stated that she was involved in a terrible car crash back in the 1970s and required multiple blood transfusions. Following the blood transfusions, she was told that she had contracted hepatitis although she could not recall which type and would never be able to donate blood. Resident #1 did recall the day before going to theER on [DATE] NA#1 had walked by her door and said something about being yellow in color and they drew blood that but the next day she had a fall and ended up going to the hospital for the fall. Resident #1 could not recall going out to any doctor appointment since she was admitted to the facility. She stated she went out with a family member one time shopping, but she stayed in the car. She added that the podiatrist had trimmed her toenails one time and she had not been sexually active since her husband passed away years prior. Resident #1 stated that she had diabetes, and the facility checked her glucose levels multiple times a day and gave her insulin from a vial. She explained that when she was at home, she had a pen that she gave herself insulin from but since coming to the facility they used a vial of insulin. The Local Health Department Representative and State Health Department Representative visited the facility on 05/14/24. A letter dated 05/15/24 from the State Health Department Representative to the facility read in part, thank you again for your partnership during our site visit on 05/14/24. The goal of this visit was to identify any possible areas of improvement and help guide blood borne pathogen/infection prevention recommendations going forward. Visit Summary and Recommendations: The recommendations included: individual glucometers for each resident are preferred. I understand that the quality control corporate policy is cumbersome but recommended considering the benefits of individual glucometers. This letter and recommendations were delivered via email to the facility Administrator on 05/16/24. The Local Health Department Representative was interviewed via phone on 06/20/24 at 9:12 AM. She stated that on 04/29/24 she received notification from the local hospital that Resident #1 had tested positive for acute hepatitis B. The representative stated she noticed from the report that Resident #1 resided in a nursing facility and so she made the State Health Department aware of the acute case of hepatitis B. The Local Health Department Representative stated that on 05/14/24 they did an onsite infection control visit with the State Health Department Representative and there were recommendations made to the facility to help prevent the spread and transmission of infections including hepatitis B. She stated that Resident #1 was scheduled to have additional lab work completed on 06/20/24 and that would be collected at the facility and taken to the local health department for transportation to the state lab and once the results were available, she would communicate those to the facility. A follow up interview was conducted with the Local Health Department Representative via phone on 06/25/24 at 11:27 AM. She stated that during their onsite visit to the facility on [DATE] they made the recommendation to the Administrator about getting glucometers for each resident that required glucose testing and the Administrator shared with them that they were not going to implement individual glucometers at that time because of the cumbersome quality control check's that the glucometers required each night. She stated that they encouraged the Administrator to reach out to the corporation because it was in the best interest of the facility to implement individual glucometers to stop or prevent any transmission of infectious agents. When the Local Health Department Representative was notified after the additional testing of other residents who were of concern for having hepatitis B it became a matter of a public health emergency and the Representative had direction from the State Health Department Medical Provider to put in a public health order if the facility gave any push back on implementing the individual glucometers. However, when the Local Health Department Representative called the facility on 06/14/24 they gave no push back and made it happen very quickly. On 6/14/24 at 7:50pm the facility Administrator was notified by the local health department that the facility was in outbreak status for Hepatitis B and the State health department was now requiring an individual glucometer for each resident on blood glucose monitoring. An interview was conducted with the State Health Department Representative on 06/20/24 at 8:39 AM via phone. She stated that on 04/29/24 she got a call from the Local Health Department Representative letting her know that Resident #1 who was recently admitted to the acute care hospital was diagnosed with acute hepatitis B. It had been reported that Resident #1 had been in a car wreck in the 1970s and received blood transfusions and was told she had hepatitis but could not say which type A, B, or C. The State Health Department Representative stated the records in the state where the accident occurred only went back to 2005 so they had no record of Resident #1 ever officially having hepatitis. She stated that state hepatitis program reviewed Resident #1's case and determined it to be acute infection based on her symptoms of being jaundiced and her hepatitis panel being extremely elevated and deoxyribonucleic acid (DNA) that showed a viral load (amount of infection in her body) was incredibly high and was only that high in acute infections. Resident #1 was very sick for a while and initially could not be interviewed. The State Health Department Representative stated the first step in their investigation was to conduct an onsite infection control assessment which was conducted on 05/14/24 which revealed some issues with hand hygiene and the realization that the facility was using shared glucometers. The State Health Department recommended switching to individual glucometers but we had push back from the facility because of the quality control testing that had to be conducted on each glucometer each night. She added that switching to individual glucometers was the biggest recommendation made as a result of the visit. She explained that they got involvement from the hepatitis program at the CDC and the decision was made to screen all residents still in the facility that received glucose monitoring from November 2023 to April 2024. There were 27 residents identified who required glucose monitoring. The State Health Department Representative stated that on or around 06/14/24 they received the initial results of the testing of the residents still in the facility that received glucose testing, there were three residents presumed positive for hepatitis, and at that point, they contacted the facility and insisted that they obtain individual glucometers. They were able to do that over the weekend of 06/15/24 because the facility was officially in outbreak status. The State Health Department Representative stated that they consider one positive resident an outbreak and we were not sure if the facility understood or if they were deflecting but it did appear that the corporation was on board with the insistence of obtaining individualized glucometers. She added that those entities involved were going to meet with the facility next week to do some additional education to the facility to help them have a better understanding of the situation. An interview was conducted with the Nurse Consultant to the North Carolina Hepatitis Program via phone on 06/20/24 at 9:31 AM. She stated she was notified in May 2024 of an acute hepatitis B case in the nursing home and because it was an acute case they started an investigation. Because they consider one case of acute hepatitis B in a nursing home an outbreak, the Nurse Consultant to the North Carolina Hepatitis program reported it to the CDC on 05/03/24 as well. She stated she attempted to get records from the hospital that treated Resident #1 after her accident in the 1970s and was unable to get any records. There is no known history of hepatitis B with this patient except for her verbal report that she was in an accident the 1970s and was told she had hepatitis and could not donate blood. When she was transferred to the hospital on 04/26/24 Resident #1's skin and sclera (eyes) were jaundiced, and the hospital did further testing which revealed she had hepatitis B. This was based on the hepatitis B surface agent which is a measure of the actual hepatitis B in the blood stream and that test was positive. That positive test along with her symptoms and other blood work told us that this was indeed an acute hepatitis B infection. The question became where had Resident #1 contracted hepatitis B from since she had been in the nursing home for over a year. Per Resident #1's reports she had not had any outside procedures, no extensive podiatry care, no barber services. When the testing of residents from November 2023 to April 2024 came back initially with 4 positive, the resident's medical history was reviewed and determined that they all received glucose checks so the CDC honed in on the glucometers that were being shared because beautician care, wound care, blood transfusion were ruled out. When Resident #1 returned to the facility the staff were convinced that this was a reactivation case (meaning she had hepatitis B in the past and then suddenly the resident has an increase of hepatitis B in their blood stream) so she (the Nurse Consultant) set up a meeting with the facility to provide education and explain how this was not a case of reactivation this is an acute case of hepatitis B. Symptoms of hepatitis B usually occur 9-21 weeks after exposure and her jaundice was reported on 04/23/24 so that timeframe encompasses November 2023 to January 2024 for exposure. The Nurse Consultant explained that the facility switched to individual glucometers on 06/15/24 to help mitigate any risk of transmission since it was not determined where Resident #1 contracted the virus. An interview was conducted with the State Health Department Medical Provider via phone on 06/20/24 at 11:37 AM. She explained that she and her team were notified of a possible acute hepatitis B infection who was admitted to the hospital but had resided in the nursing home. Initially the team was trying to discern if this was actually an acute case and if so, that would mean that exposure would have happened a month or so before her diagnoses or was this a reactivation case which is where someone had the virus and then cleared it but then some other infection caused the virus to reactive. If this would have been a reactivation case, we would not have been suspicious that transmission occurred in the health care setting but if this was an acute case, and we know that Resident #1 had been living in the nursing home since June of 2023 then our assumption was that she was exposed to Hepatitis B in the nursing home setting. One of the team members involved in the investigation coordinated additional testing and the Local Health Department Representative and State Health Department Representative conducted an onsite infection control visit to ensure the facility was doing things to prevent transmission of bloodborne pathogens. The only two things that stood out from that visit were that the alcohol-based hand sanitizer was not as accessible as we would like and that they were using shared glucometers after disinfecting them between residents. The State Health Department Representative shared with the facility that individual glucometers were definitely preferred even if disinfecting between residents. Ultimately there was discussion amongst all the agencies involved and the conclusion became that Resident #1 was an acute case of hepatitis B and was not a case of reactivation. After the testing of the other residents in the facility that received glucose checks revealed additional residents of concern we were obliged to take public health action on the presumption of 2 active cases of hepatitis B and we had to protect the population from further transmission. The two active cases were identified as Resident #1 and Resident #2. Last week the Local Health Department Representative was able to talk to the facility and get them to implement individual glucometers and the facility was able to procure them by Saturday 06/15/24. The State Health Department Medical Provider stated that the facility initially stated that they did not implement the individual glucometers because the quality checks that had to be conducted each night on each glucometer to ensure it was measuring correctly was logistically a burden for them, so they elected to continue to use the shared glucometers with disinfection. An observation of Resident #1 and Resident #2's room were made on 06/20/24 at 10:45 AM. Their rooms were noted to be located on the same hallway directly across from one another. Further observation revealed that Resident #1 and Resident #2's medications and glucometers were stored on the same medication cart. The Director of Nursing (DON) was interviewed on 06/20/24 at 1:01 PM. Shortly after Resident #1 was admitted to the hospital the Local Health Department called and stated that they had an acute case of hepatitis B. She stated that they immediately started doing education on hand washing, education about universal precautions and when the health department made recommendations we followed them. The DON explained that the facility currently did not have an Infection Preventionist and had not one since March 2024 and she was assisting with providing the education to the staff. The DON could not recall what the recommendations were, but she did recall that they had to draw blood from residents that had glucose checks that were still in the facility. When Resident #1 returned from the hospital she told us that she had been in a car wreck in the 1970s and had multiple blood transfusions and had contracted hepatitis B although she did not know which type and could never donate blood. The DON stated that about a week ago the facility switched to individual glucometers and stated that they had not done so earlier because we did not have a policy for that, so we had to obtain a policy before switching over to individual glucometers. The DON stated she felt like Resident #1's case of Hepatitis B was a historical case and could not see how she got it here. The Administrator was interviewed via phone on 06/20/24 at 5:44 PM who stated that on 04/27/24 Resident #1's attending Physician notified her that Resident #1 had hepatitis B. She stated Resident #1 was readmitted to the facility on [DATE] and she had talked about it with the Attending Physician, and we do not know where it came from or what made it became active because she had been in the facility for years. Representatives from the Local/State Health Departments came in on 05/14/24 and did not see any major issues, they talked to the nurses, looked at hand sanitizer etc. then we got a report from them, and we followed the recommendations. However, we thought it was ok to continue with our protocol of the shared glucometers with disinfection between use, mainly because the facility had so many residents that required glucose checks and that would have been a lot of glucometers. The Administrator stated that they communicated via email and answered any and all questions that the Health Department had until Friday 06/14/24 at 7:50 PM when she got a call from the Local Health Department Representative who stated that they had talked to the State Health Department Representative, and we needed to get individual glucometers tonight because we were in outbreak status. The Administrator stated she contacted and notified her MD and her corporate office, and they were able to procure enough glucometers and began using them on 06/15/24. She stated that the main reason for not implementing the individual glucometers sooner was due to the large number of residents with diabetes that we had and the quality control testing that each glucometer would require each night. The MD had been made aware of the recommendations made by the Local/State health department and was aware that we were going to continue to use shared glucometers with disinfection between uses and he was ok with that because he did not believe we had an issue. A follow-up interview was conducted with the Administrator on 06/25/24 at 11:10 AM who stated that initially stated when they were asked by the Local Health Department on 06/05/24 for a list of residents who required glucose testing that still resided in the facility which was provided to them. The list contained 30 names including Resident #1. The Local Health Department requested blood samples from those 30 residents on 06/06/24. The Administrator stated that they did not redraw Resident #1's blood, but obtained 23 samples, 4 residents refused the blood draw, and 2 residents had transferred to the hospital but were tested at a later date. The Attending Physician was interviewed on 06/21/24 at 9:06 AM. He stated Resident #1 had been back and forth to the hospital. The Attending Physician stated a few days into Resident #1's hospitalization on e of his colleagues at the hospital notified him of Resident #1's acute hepatitis B. The Physician stated Resident #1 had essentially returned to her baseline, and other than controlling her diabetes, she was fine. He stated he was aware of the recommendation made to the facility to switch to individual glucometers but did not have anything to do with the decision to continue using the shared glucometers. Looking at the case, I just don't think she got it from here, she had been here more than 6 months and had been in and out of hospital. Her risk of getting it from the glucometer is zero risk, she was exposed with way more things in the hospital. Finally, the Attending Physician stated, she had more opportunities to get it from anywhere but here. Review of Resident #1's medical record from 06/03/23 through 06/20/24 revealed that she had not been discharged from the facility to the acute care hospital since 06/12/23 and was readmitted on [DATE]. Resident #1 remained in the facility from 06/17/23 to 04/26/24. The facility Medical Director (MD) was interviewed via phone on 06/20/24 at 3:47 PM who stated, I don't think we have an outbreak. We have one case of reactivation of hepatitis B. He stated he was notified about Resident #1's case three weeks ago when she returned from the hospital. He stated he had not been kept up to date on the recommendations made by the Local/State Health department and was upset that no medical doctor had been involved in the decision-making process. The MD stated that initially when Resident #1 admitted to the facility the Attending Physician was concerned, she had MASH and did a workup for that, but when she got to the hospital, she had positive hepatitis B DNA in her blood and that was very indicative of reactivation of hepatitis B. We want to do what is right but we don't think this is an outbreak. I don't think this was spread from glucometers because that is rare. There are other possibilities of where she contracted hepatitis B from dentist, she has family members that are intravenous (IV) drug users, shared insulin pens etc. The Medical Director stated he would argue that this was not an acute case, as she had other liver problems. The MD was aware of the Local/State Health Department Representative onsite visit but was not aware of the recommendations and had not seen any report from the visit. He added that he had spoken to the Local Health Department Representative earlier in the day and she was very vague in her communication and very nonspecific, but they called a week ago and stated we had an outbreak and needed to get a glucometer for each person that required glucose testing by midnight. The Medical Director stated he would expect the facility to follow the recommendations made by the Local/State Health Department and to also let me know what the recommendations were. A follow up interview was conducted with the MD on 07/03/24 at 12:58 PM via telephone. The MD again confirmed that he was made aware of Resident #1's acute hepatitis B diagnoses when she returned to the facility on [DATE]. He also confirmed that he was aware of the recommendation made the Local Health Department on 05/14/24 and was also aware the facility elected to not implement the recommendation. He did state he was not involved in the decision, that decision was made between the facility Administration and the Corporation. The MD stated that at some point before 06/14/24 he was made aware that the facility had given Resident #1 her own individual glucometer but could not say when that occurred. He stated that he had reviewed all the lab work from the residents that were tested for hepatitis B and was aware of the results but thought they were unrelated and the first time the MD heard the facility was in an outbreak was on June 14, 2024. The MD stated he was surprised that the acute hepatitis B did not require different isolation and surprised that we did not investigate staff. A follow-up interview was conducted with the Administrator on 07/03/24 at 1:14 PM via telephone who stated the MD was aware of Resident #1's acute hepatitis B diagnoses on 04/27/24 but did not get involved until she readmitted on [DATE]. She stated that the facility gave Resident #1 her own glucometer about a week and half after the health department made their onsite visit on 05/14/24 but she could not recall he exact date that the induvial glucometer was issued to Resident #1. The Administrator stated that she had since been educated on the definition of outbreak status and that initially she thought it was more than one case but when she asked, she really never received a definitive answer and the first time she was aware that they were in an outbreak was on 06/14/24 when the local health department called and reported it to her. A follow up interview was conducted with the Administrator via telephone on 07/05/24 at 12:44 PM who stated that initially they set aside a glucometer for Resident #1, but they failed to follow through with the education to the staff and could not provide evidence that Resident #1 had her own individual glucometer prior to 06/15/24. The Corporate Medical Director was interviewed via phone on 06/20/24 at 4:21 PM who stated she had not heard about Resident #1 or understood the gravity of the case until 06/14/24 at 8:00 PM when she received a call from the Administrator who stated they had to get individual glucometers and the facility was in an outbreak of acute hepatitis B. They then began filling her in on Resident #1's history and her subsequent hospitalization . To her understanding the State Health Department came in on a non-regulatory visit to observe infection control practices and procedures and indicated that they recommended individual glucometers. The Corporate Medical Director stated that she needed time to research Resident #1's case and review all the lab work and see what was going on but in the meantime, she made the decision to stop all admissions and made the decision to test all current residents which was done. Resident #1 was definitely an acute case of hepatitis B, but her question was whether or not she has antimitochondrial DNA and this was a flair up of some chronic hepatitis B. The biggest issue she had seen with this case was the lack of communication. She stated when she read the recommendations made the Local/State Health Department made on 05/15/24 her first question was why did we not implement the individual glucometers at that time, it wou

Based on observation, record review and resident, staff and physician interviews, the facility failed to secure smoking materials, specifically, a lighter and failed to assess a resident's ability to smoke independently for 1 of 1 resident (Resident #2) reviewed for smoking. Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, idiopathic epilepsy, and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus (also called refractory, uncontrolled, or drug-resistant epilepsy), repeated falls, and vascular dementia, moderate, with other behavioral disturbance. A review of the observation for smoking assessment dated [DATE] revealed the facility had marked no on the smoking assessment form, indicating Resident #2 did not smoke. A review of the most recent quarterly minimum data set (MDS) dated [DATE] for Resident #2 revealed the resident had severe cognitive impairment. Resident #2 had impairment on both his upper and lower extremity and he was independent with setup/supervision for his activities of daily living. The MDS also revealed the resident was independent with ambulation. A review of Resident #2's care plan dated 01/15/24 revealed the problem area as the Resident used tobacco cigarettes. The goal was for the Resident to not have an injury related to smoking through the next review target date of 04/16/2024. The intervention for this goal was to offer a smoking apron to the Resident when he smoked. During the entrance conference on 03/11/24 at 10:10 AM the Administrator revealed the facility was a no smoking campus, but they did have one resident, Resident #2, who was permitted to smoke to deter aggressive behaviors. On 03/12/24 at 4:24 PM an interview with the Director of Nursing (DON) stated Resident #2 was a smoker and he smoked independently. The DON stated the observation for smoking assessment was incorrectly marked no on admission on 04/18/23. On 03/12/24 at 4:38 PM an interview was conducted with Nurse #1, and she stated Resident #2 kept his own smoking materials on himself. On 03/12/24 at 4:40 PM an interview was conducted with a Nurse Aide #1 (NA) on Resident #2's assigned hall. When asked where Resident #2 kept his smoking materials she stated, That is a [Administrator] question. The NA #1 stated she thought it could be possible the nurse kept them and gave them to him when he wanted to smoke. An in-room interview was conducted with Resident #2 on 03/12/24 at 5:00 PM and he stated he kept his cigarettes and lighters in his room. He turned on the light and indicated his cigarettes were on the floor by bed. On the floor by the bed was a clear plastic container with a lid and no lock. The container contained multiple loose cigarettes and a lighter inside, and 4-6 loose cigarettes were observed on the top of the container. On 03/12/24 at 5:35 PM an interview was conducted with the Administrator, and she stated a smoking assessment should have been done on admission and then quarterly. She further stated the resident was admitted in April, had behaviors that included attempts to exit the facility. The Administrator said the resident's sister advised the facility if Resident #2 could smoke his behaviors would decrease. The Administrator added they tried nicotine patches and vape pens but Resident #2 refused. She stated they started allowing Resident #2 to smoke in May 2023. The Administrator stated she kept Resident #2's smoking materials and apron in her office. She added she allowed Resident #2 to keep a couple of cigarettes on his person to placate him. The Administrator said when Resident #2 wanted to smoke, he would inform staff. Staff would then take Resident #2 to the courtyard and place a smoking apron on him and light his cigarette. When informed that Resident #2 had cigarettes and a lighter in his room, the Administrator and this Surveyor went to the Resident's room. Resident #2 showed this surveyor and the Administrator the cigarettes and lighter. Resident #2 gave the Administrator the lighter and she took him to the courtyard to smoke. A follow-up interview with the Administrator was conducted on 03/14/24 at 4:48 PM. She said the Resident should never have had a lighter in his possession. The Admistrator stated that Resident #2 had been accepted to a facility that allowed smoking.

Based on observations, resident and staff interviews, the facility failed to post the contact information for the State Survey Agency in an area accessible to residents and resident representatives and failed to post a statement that a resident may file a complaint with the State Survey Agency. This observation occurred for 2 of the 4 days of the recertification survey. Findings included: During tours of the facility on 3/12/24 at 4:07 PM and 3/13/24 at 10:20 AM, there was no information posted in the facility about how to contact the State Survey Agency or how to file a complaint with the State Survey Agency. A Resident Council group meeting was conducted on 3/13/24 at 2:30 PM. During the meeting, Resident #29 and Resident #58 stated they had seen some contact numbers on a board located on the wall on the 100 hall, but they were unsure if the contact information included the State Survey Agency. A tour of the facility was conducted with the Administrator on 3/13/24 at 2:45 PM. The Administrator verified the contact information for the State Survey Agency and process for filing a complaint was not posted on the board on the 100 hall and shared that typically information for contacting the State Survey Agency was posted on the board on the 100 hall. The Administrator explained the facility had recently taken some old information off the board and had replaced it with new information. The Administrator said the facility had just updated the board and stated all staff were responsible to maintain the board where pertinent information was posted for residents.

Based on observations and staff interviews, the facility failed to maintain the tile of the kitchen floor in good condition and failed to dispose of expired nutritional supplements in 1 of 3 residents' nourishment room refrigerators. Findings included: 1. During the initial tour of the kitchen on [DATE] at 10:00 a.m. and during the follow-up visit on [DATE] at 12:00 p.m., there were missing floor tiles observed beneath the meal tray serving steamtable, the dishwashing machine, and beneath the 3-compartment wash sink. An interview with the Dietary Manager revealed the kitchen floor had the missing tiles for approximately ,d+[DATE] years due to a problem with drainage pipes which were repaired, and the areas were covered with concrete, but the floor tiles were never replaced. During an interview on [DATE] at 9:32 a.m., the Administrator stated the kitchen's floor had been in that condition for approximately ,d+[DATE] years. She indicated she had been in discussion with corporate office's area vice president for about six months concerning the condition of the kitchen floor which will be a major undertaking. As of the date of this interview, no quotes had been obtained on the floor's replacement. 2. On [DATE] at 9:50 a.m., accompanied by the Administrator, the ,d+[DATE] hall nourishment room was observed. The refrigerator contained 6(8-ounce) cartons of therapeutic nutrition supplements for dialysis residents with the expired date of [DATE]. The Administrator discarded expired six cartons and indicated she would have the dietary manager double check her stock.

Based on observations and staff interviews, the facility failed to ensure the side doors and top lids of 2 of 2 trash dumpsters remained closed when not in use. Findings included: During the initial tour of the facility accompanied by the Dietary Manager on 1/08/23 at 10:50 a.m., two trash dumpsters were observed enclosed within a fenced in area with the side doors of the dumpsters open. Half of the top lid of 1 of 2 of the dumpsters was open with two filled trash bags lying on top of the closed half of the lid. Throughout the observation, it was raining and both dumpsters were filled with trash bags. A second observation with the Dietary Manager on 1/10/23 at 12:25 p.m. revealed the side door of 1 of the 2 trash dumpsters was open. There were plastic bags of trash in the dumpster.

Based on observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint surveys conducted [DATE] and [DATE], and a complaint survey conducted [DATE]. This was for three deficiencies that were cited in the areas of Activities meet the interest and need of each resident (F679), Increase or prevent a decrease in range of motion and mobility (F688), and food procurement, store/prepare/serve-sanitary (F812). The three areas were recited on the current recertification survey of [DATE]. The duplicate citations during two federal surveys of record demonstrates a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: 1. F679 - Based on observations, interview with the Resident Council, resident and staff interviews and record reviews, the facility failed to provide activities as scheduled when the Activities Director (AD) was placed in the Nurse Aide (NA) role. Additionally, the facility failed to provide any scheduled activities on the weekends. This was for 4 of 4 residents (Residents #52, #38, #20 and #26) reviewed for facility activities. During the complaint survey of [DATE], the facility failed to provide activities as scheduled when the AD was placed in the NA role for 3 of 5 residents interviewed for facility activities. An interview was conducted with the Administrator on [DATE] at 6:51 p.m. and she revealed the QAA committee meets monthly and consist of the Director of Nursing (DON), financial counselor, nurse navigator, Minimum Data Set (MDS) nurse, the wound care nurse, social worker, housekeeping/maintenance manager, dietary management, and the Medical Director. The team reviewed event monitoring, risk assessments, rounds on the unit, consultant reports, resident interviews, and town hall minutes. The Administrator indicated the facility had experienced administrative nursing turnover which she felt contributed to the repeat citation. She added the team would continue to work on staffing needs and a back up plan put into place to ensure the activities would be conducted as scheduled. 2. F688 - Based on observations, staff interviews, and record review, the facility failed to provide treatment and services to a resident (Resident #33) who demonstrated a reduction in range of motion of the bilateral lower extremities in the hips, ankles, and knee, and in the left upper extremity. This occurred in 1 of 2 residents reviewed for limited range of motion. During the recertification and complaint survey of [DATE], the facility failed to provide restorative services to one of three residents (Resident #62) reviewed for range of motion and Mobility services. An interview was conducted with the Administrator on [DATE] at 6:51 p.m. and she revealed the QAA committee meets monthly and consist of the Director of Nursing (DON), financial counselor, nurse navigator, Minimum Data Set (MDS) nurse, the wound care nurse, social worker, housekeeping/maintenance manager, dietary management, and the Medical Director. The team reviewed event monitoring, risk assessments, rounds on the unit, consultant reports, resident interviews, and town hall minutes. The Administrator indicated the facility had experienced administrative nursing turnover and this had prevented effective communication between the rehabilitation department and the administrative nursing team. She added the Rehabilitation and manager and herself would work to establish an effective plan. 3. F812 - Based on observations and staff interviews, the facility failed to maintain the tile of the kitchen floor in good condition and failed to dispose of expired nutritional supplements in 1 of 3 residents' nourishment room refrigerators. Based on observations, staff interviews and record reviews, the facility failed to label, and date opened refrigerated food items; failed to label and date refrigerated food that was brought in from outside the facility; and failed to discard expired food available for use in 3 of 3 of nourishment refrigerators. An interview was conducted with the Administrator on [DATE] at 6:51 p.m. and she revealed the QAA committee meets monthly and consist of the Director of Nursing (DON), financial counselor, nurse navigator, Minimum Data Set (MDS) nurse, the wound care nurse, social worker, housekeeping/maintenance manager, dietary management, and the Medical Director. The team reviewed event monitoring, risk assessments, rounds on the unit, consultant reports, resident interviews, and town hall minutes. She added the companies corporate team would need to be included in the resolution of the kitchen because the replacement of floor tiles was a major task.

Based on observations, interview with the Resident Council, resident and staff interviews and record reviews, the facility failed to provide activities as scheduled when the Activities Director (AD) was placed in the Nurse Aide (NA) role. Additionally, the facility failed to provide any scheduled activities on the weekends. This was for 4 of 4 residents (Residents #52, #38, #20 and #26) reviewed for facility activities. Findings included: 1. Resident #52 was admitted to the facility 12/19/2022 with a diagnosis that included, in part, diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact. The assessment indicated the resident stated it was very important to her to do things with groups of people, to have books, magazines and newspapers to read, to participate in religious services and to do her favorite activities. The care plan, updated 12/23/22, included a focus area of activities/recreation. A care plan intervention revealed Resident #52 was provided with a monthly calendar of facility activities. An activity/recreation note, dated 12/23/22 and authored by the Activities Director (AD) read, in part, .She is very pleasant to be around and stated she enjoys coming to every activity . During an interview with the Administrator on 1/9/23 at 9:40 AM, she shared the AD had been pulled to the floor today and worked as a NA since two of the scheduled NAs had called off work. The AD was interviewed on 1/9/23 at 9:48 AM and confirmed she was moved to work as a NA for the first shift (7:00 AM-3:00 PM). She stated when she worked as a NA, the facility group activities were canceled because she didn't have another staff member who helped her. An activities calendar for January 2023 was provided by the AD on 1/9/23 at 9:55 AM. A review of the scheduled activities for 1/9/23 included: -9:00 In room visits -10:30 Talk-n-toss ball -2:30 Corn hole -4:00 Mail Further review of the activities calendar specified every Saturday and Sunday's schedule included: Family Visitation and 4:00 Mail. Resident #52 was interviewed on 1/9/23 at 11:26 AM. She explained she had been at the facility for three weeks. She said the facility had activities during the week and she attended every activity that was held. She shared she was very active at home and wanted to participate in activities at the facility on the weekends, but no activities were scheduled. She stated she didn't think the AD worked on weekends. Resident #52 added the facility had some activities over the Christmas weekend, but none since then. On 1/9/23 at 11:45 AM an observation of the main dining room revealed a group activity was held (Talk-n-toss ball) and facilitated by the Administrator. Observations of the main dining room and other common areas of the facility on 1/9/23 at 2:30 PM, 3:04 PM and 3:15 PM revealed the corn hole activity was not being held as scheduled on the activity calendar. A Resident Council group interview was completed on 1/10/23 at 2:43 PM. During the group interview, residents stated there was a notation on the monthly activities calendar that said activities were subject to change. Residents reported the scheduled corn hole activity was not completed on 1/9/23 since the AD worked on the hall as a NA and no one was available to help conduct the activity. Resident #52 stated she would have come to the activity if it had been held as scheduled on the calendar. The Resident Council group further explained if the scheduled activity was canceled because the AD worked on the hall, either the AD or another NA notified residents of the cancellation of the activity. Follow up interviews were completed with the AD on 1/10/23 at 3:40 PM and 1/11/23 at 9:58 AM, during which she explained when a resident was admitted to the facility, she completed an activities assessment within 3-5 days. She shared when she completed the assessment for Resident #52, she learned the resident enjoyed mostly everything, including Bingo and going outside. She added Resident #52 tried to attend all the group activities unless she wasn't feeling well, and was willing to help during the activities. The AD recalled the resident had recently spoken with her and inquired about having activities available on the weekends. The AD said there were no group activities scheduled on Saturdays or Sundays since she didn't typically work on weekends. The AD explained if residents wanted to do an independent activity on the weekend, such as puzzles, radio, magazines, books, they made arrangements with her prior to the weekend and she then provided those materials for the resident. She added there was no common area in the facility that had independent leisure materials for residents to obtain when she was not in the building. The AD provided a copy of her timecard for November-December 2022 and January 2023. She reviewed the timecard during the interview and explained there were seven days where she worked as a NA, and therefore, group activities were not held on those days; or, if she worked during third shift (11:00 PM-7:00 AM), had not come to work the following day and worked as the AD. She added since she worked as a NA 1/9/23 on first shift, the corn hole activity was not completed as scheduled that day. The Administrator was interviewed on 1/11/23 at 5:07 PM. She stated when the AD was sent to the hall and worked as a NA, the facility attempted to find someone who assisted with the scheduled group activity, although it may not be the exact activity the AD had planned on the calendar. The Administrator said she had not kept records if another staff member did the activity while the AD worked as a NA. She shared there were some leisure activity items located at the end of the 600 hall that the nurses utilized, such as music and coloring sheets; nursing staff also visited with residents. Typically, there was not a staff member in the facility on weekends who conducted group activities. The Administrator added the facility was not as consistent with offering recreation on weekends to residents on the rehabilitation unit because families often visited at that time. 2. Resident #38 was admitted to the facility 11/15/18 with diagnoses that included, in part, diabetes and hypertension. The annual MDS assessment dated [DATE] revealed Resident #38 was cognitively intact. The assessment indicated the resident stated it was very important to him to do things with groups of people, to have books, magazines and newspapers to read, to participate in religious services and to do his favorite activities. The care plan, updated 1/9/23, included a focus area of activities/recreation. A care plan intervention revealed Resident #38 was provided with a monthly calendar of facility activities. During an interview with the Administrator on 1/9/23 at 9:40 AM, she shared the AD had been pulled to the floor today and worked as a NA since two of the scheduled NAs had called off work. The AD was interviewed on 1/9/23 at 9:48 AM and confirmed she was moved to work as a NA for the first shift (7:00 AM-3:00 PM). She stated when she worked as a NA, the facility group activities were canceled because she didn't have another staff member who helped her. An activities calendar for January 2023 was provided by the AD on 1/9/23 at 9:55 AM. A review of the scheduled activities for 1/9/23 included: -9:00 In room visits -10:30 Talk-n-toss ball -2:30 Corn hole -4:00 Mail Further review of the activities calendar specified every Saturday and Sunday's schedule included: Family Visitation and 4:00 Mail. On 1/9/23 at 11:45 AM an observation of the main dining room revealed a group activity was held (Talk-n-toss ball) and facilitated by the Administrator. Observations of the main dining room and other common areas of the facility on 1/9/23 at 2:30 PM, 3:04 PM and 3:15 PM revealed the corn hole activity was not being held as scheduled on the activity calendar. A Resident Council group interview was completed on 1/10/23 at 2:43 PM. During the group interview, residents stated there was a notation on the monthly activities calendar that said activities were subject to change. Residents reported the scheduled corn hole activity was not completed on 1/9/23 since the AD worked on the hall as a NA and no one was available to help conduct the activity. Resident #38 stated he would have come to the activity if it had been held as scheduled on the calendar. The Resident Council group further explained if the scheduled activity was canceled because the AD worked on the hall, either the AD or another NA notified residents of the cancellation of the activity. Resident #38 added he thought it would be good for residents to have activities on the weekend, in case they got bored, and said he would participate in weekend activities. Follow up interviews were completed with the AD on 1/10/23 at 3:40 PM and 1/11/23 at 9:58 AM, during which she explained when a resident was admitted to the facility, she completed an activities assessment within 3-5 days. The AD said there were no group activities scheduled on Saturdays or Sundays since she didn't typically work on weekends. The AD explained if residents wanted to do an independent activity on the weekend, such as puzzles, radio, magazines, books, they made arrangements with her prior to the weekend and she then provided those materials for the resident. She added there was no common area in the facility that had independent leisure materials for residents to obtain when she was not in the building. The AD provided a copy of her timecard for November-December 2022 and January 2023. She reviewed the timecard during the interview and explained there were seven days where she worked as a NA, and therefore, group activities were not held on those days; or, if she worked during third shift (11:00 PM-7:00 AM), had not come to work the following day and worked as the AD. She added since she worked as a NA 1/9/23 on first shift, the corn hole activity was not completed as scheduled that day. The Administrator was interviewed on 1/11/23 at 5:07 PM. She stated when the AD was sent to the hall and worked as a NA, the facility attempted to find someone who assisted with the scheduled group activity, although it may not be the exact activity the AD had planned on the calendar. The Administrator said she had not kept records if another staff member did the activity while the AD worked as a NA. She shared there were some leisure activity items located at the end of the 600 hall that the nurses utilized, such as music and coloring sheets; nursing staff also visited with residents. Typically, there was not a staff member in the facility on weekends who conducted group activities. The Administrator added the facility was not as consistent with offering recreation on weekends to residents on the rehabilitation unit because families often visited at that time. 3. Resident #20 was admitted to the facility 6/14/21 with a diagnosis that included, in part, hypertension. The annual MDS assessment dated [DATE] revealed Resident #20 was cognitively intact. The assessment indicated the resident stated it was very important to him to do things with groups of people and to do his favorite activities. The care plan, updated 11/29/22, included a focus area of activities/recreation. A care plan intervention revealed Resident #20 enjoyed certain group activities and needed to be reminded of the scheduled activities. During an interview with the Administrator on 1/9/23 at 9:40 AM, she shared the AD had been pulled to the floor today and worked as a NA since two of the scheduled NAs had called off work. The AD was interviewed on 1/9/23 at 9:48 AM and confirmed she was moved to work as a NA for the first shift (7:00 AM-3:00 PM). She stated when she worked as a NA, the facility group activities were canceled because she didn't have another staff member who helped her. An activities calendar for January 2023 was provided by the AD on 1/9/23 at 9:55 AM. A review of the scheduled activities for 1/9/23 included: -9:00 In room visits -10:30 Talk-n-toss ball -2:30 Corn hole -4:00 Mail Further review of the activities calendar specified every Saturday and Sunday's schedule included: Family Visitation and 4:00 Mail. On 1/9/23 at 11:45 AM an observation of the main dining room revealed a group activity was held (Talk-n-toss ball) and facilitated by the Administrator. Observations of the main dining room and other common areas of the facility on 1/9/23 at 2:30 PM, 3:04 PM and 3:15 PM revealed the corn hole activity was not being held as scheduled on the activity calendar. A Resident Council group interview was completed on 1/10/23 at 2:43 PM. During the group interview, residents stated there was a notation on the monthly activities calendar that said activities were subject to change. Residents reported the scheduled corn hole activity was not completed on 1/9/23 since the AD worked on the hall as a NA and no one was available to help conduct the activity. Resident #20 stated he would have come to the activity if it had been held as scheduled on the calendar. The Resident Council group further explained if the scheduled activity was canceled because the AD worked on the hall, either the AD or another NA notified residents of the cancellation of the activity. Resident #20 added it would be nice to have something to do on the weekends. Follow up interviews were completed with the AD on 1/10/23 at 3:40 PM and 1/11/23 at 9:58 AM, during which she explained when a resident was admitted to the facility, she completed an activities assessment within 3-5 days. The AD said there were no group activities scheduled on Saturdays or Sundays since she didn't typically work on weekends. The AD explained if residents wanted to do an independent activity on the weekend, such as puzzles, radio, magazines, books, they made arrangements with her prior to the weekend and she then provided those materials for the resident. She added there was no common area in the facility that had independent leisure materials for residents to obtain when she was not in the building. The AD provided a copy of her timecard for November-December 2022 and January 2023. She reviewed the timecard during the interview and explained there were seven days where she worked as a NA, and therefore, group activities were not held on those days; or, if she worked during third shift (11:00 PM-7:00 AM), had not come to work the following day and worked as the AD. She added since she worked as a NA 1/9/23 on first shift, the corn hole activity was not completed as scheduled that day. The Administrator was interviewed on 1/11/23 at 5:07 PM. She stated when the AD was sent to the hall and worked as a NA, the facility attempted to find someone who assisted with the scheduled group activity, although it may not be the exact activity the AD had planned on the calendar. The Administrator said she had not kept records if another staff member did the activity while the AD worked as a NA. She shared there were some leisure activity items located at the end of the 600 hall that the nurses utilized, such as music and coloring sheets; nursing staff also visited with residents. Typically, there was not a staff member in the facility on weekends who conducted group activities. The Administrator added the facility was not as consistent with offering recreation on weekends to residents on the rehabilitation unit because families often visited at that time. 4. Resident #26 was admitted to the facility 3/21/19 with diagnoses that included, in part, diabetes and hypertension. The annual MDS assessment dated [DATE] revealed Resident #26 was cognitively intact. The assessment indicated the resident stated it was very important to him to do things with groups of people and to do his favorite activities. The care plan, updated 12/24/22, included a focus area of activities/recreation. A care plan intervention revealed Resident #26 was provided with a monthly calendar of facility activities. During an interview with the Administrator on 1/9/23 at 9:40 AM, she shared the AD had been pulled to the floor today and worked as a NA since two of the scheduled NAs had called off work. The AD was interviewed on 1/9/23 at 9:48 AM and confirmed she was moved to work as a NA for the first shift (7:00 AM-3:00 PM). She stated when she worked as a NA, the facility group activities were canceled because she didn't have another staff member who helped her. An activities calendar for January 2023 was provided by the AD on 1/9/23 at 9:55 AM. A review of the scheduled activities for 1/9/23 included: -9:00 In room visits -10:30 Talk-n-toss ball -2:30 Corn hole -4:00 Mail Further review of the activities calendar specified every Saturday and Sunday's schedule included: Family Visitation and 4:00 Mail. On 1/9/23 at 11:45 AM an observation of the main dining room revealed a group activity was held (Talk-n-toss ball) and facilitated by the Administrator. Observations of the main dining room and other common areas of the facility on 1/9/23 at 2:30 PM, 3:04 PM and 3:15 PM revealed the corn hole activity was not being held as scheduled on the activity calendar. A Resident Council group interview was completed on 1/10/23 at 2:43 PM. During the group interview, residents stated there was a notation on the monthly activities calendar that said activities were subject to change. Residents reported the scheduled corn hole activity was not completed on 1/9/23 since the AD worked on the hall as a NA and no one was available to help conduct the activity. Resident #26 stated he would have come to the activity if it had been held as scheduled on the calendar. The Resident Council group further explained if the scheduled activity was canceled because the AD worked on the hall, either the AD or another NA notified residents of the cancellation of the activity. Resident #26 added he would like to have activities offered on the weekends. Follow up interviews were completed with the AD on 1/10/23 at 3:40 PM and 1/11/23 at 9:58 AM, during which she explained when a resident was admitted to the facility, she completed an activities assessment within 3-5 days. The AD said there were no group activities scheduled on Saturdays or Sundays since she didn't typically work on weekends. The AD explained if residents wanted to do an independent activity on the weekend, such as puzzles, radio, magazines, books, they made arrangements with her prior to the weekend and she then provided those materials for the resident. She added there was no common area in the facility that had independent leisure materials for residents to obtain when she was not in the building. The AD provided a copy of her timecard for November-December 2022 and January 2023. She reviewed the timecard during the interview and explained there were seven days where she worked as a NA, and therefore, group activities were not held on those days; or, if she worked during third shift (11:00 PM-7:00 AM), had not come to work the following day and worked as the AD. She added since she worked as a NA 1/9/23 on first shift, the corn hole activity was not completed as scheduled that day. The Administrator was interviewed on 1/11/23 at 5:07 PM. She stated when the AD was sent to the hall and worked as a NA, the facility attempted to find someone who assisted with the scheduled group activity, although it may not be the exact activity the AD had planned on the calendar. The Administrator said she had not kept records if another staff member did the activity while the AD worked as a NA. She shared there were some leisure activity items located at the end of the 600 hall that the nurses utilized, such as music and coloring sheets; nursing staff also visited with residents. Typically, there was not a staff member in the facility on weekends who conducted group activities. The Administrator added the facility was not as consistent with offering recreation on weekends to residents on the rehabilitation unit because families often visited at that time.

Based on observations, record review, and staff interviews, the facility failed to review and revise the care plan in the areas of range of motion for 1 of 2 residents (Resident #33) reviewed for range of motion. The findings included: Resident #33 was admitted to the facility on [DATE]. His cumulative diagnoses included nontraumatic intracerebral hemorrhage, Parkinson's disease, hemiplegia, and contractures of the bilateral hips, bilateral ankles, right knee, and left hand. A review of Resident #33 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated the Resident had severe cognitive impairment, was dependent on one staff member for all activities of daily living (ADL) care needs and had limited range of motion in bilateral upper and lower extremities. A review of Resident #33's care plan dated 9/5/2022 identified the following problem areas: 1) The Resident had impaired ADL functioning related to a history of a cerebral vascular accident (CVA) with left side hemiparesis, Parkinson's disease, and contractures to the bilateral hips, knees, and ankles. He cannot speak and requires total care with ADL's. 2) The Resident had the potential for alteration in comfort related to impaired mobility from a CVA with left side hemiparesis. He has contractures to the bilateral hips, knees, and ankles. He receives splinting to the hand for contracture prevention. Staff must anticipate and observe the resident for pain. There was not an intervention for the placement of the splint to the hand. A review of the physician notes dated 12/26/2022 documented there were no deformities to the extremities. A review of the physician orders did not include an order for splint placement to the upper or lower extremities. A review of Resident #33 's electronic medical record revealed a contracture risk assessment dated [DATE] at 12:38 p.m. and documented the Resident's general state of health was poor and declining, orientation was alert, with nonfunctional abilities in ADL care, immobile, severe limitation that was greater than 40% in present joint condition and had contributing factors that included Parkinson's disease. A score was calculated based on the assessment and each category was the most severe possible except for the orientation of the Resident. The orientation lowered the contracture risk to a moderate level instead of a severe level. The assessment question for referral needs, was checked, no referrals needed and continue current plan of care. An observation of Resident #33 was conducted on 1/9/2023 at 12:22 p.m. The Resident was observed lying in bed with a blanket covering his body. His left hand was bent at a 90-degree angle at the wrist and his fingers were curled and bent, from the back of his hand, at a 45-degree angle. There was not a splint in place to the left or right hand. An interview was conducted with a family member on 1/9/2023 at 12:30 p.m. of Resident #33 and revealed the Resident previously wore a splint to his left hand but they had not seen one placed in a long time. An observation of Resident #33 was conducted on 1/10/2023 at 10:48 a.m. and he was observed to be positioned on his left side with a pillow used to support his left arm. He did not have a splint in place to the left or right hand. An interview was conducted on 1/10/2023 at 3:21 p.m. with the Rehabilitation Manager and she revealed Resident #31 was last seen by Occupational Therapy (OT) on 4/15/2015. She stated the OT discharge summary identified the Resident demonstrated impaired range of motion of the left hand and all digits with neutral to hyperextension, without any flexion due to tightness in the joint. A recommendation was made for a left-hand orthotic device to be utilized to aid with achieving optimal skin and joint integrity without negative effect to the Resident in order to achieve neutral position for contracture management. She reviewed the electronic medical record for Resident #33 and did not see an order to discontinue the recommendation for the splinting device. The Rehabilitation Manager stated the Resident had not been evaluated for treatment by the OT since 2015. An interview was conducted with the Administrator on 1/10/2023 at 4:10 p.m. and she reviewed the chart for Resident #33. She stated she was not aware the Resident had not been referred to the Occupational therapy department in so long. She stated she was unsure of the reason the splint was no longer being placed on the left hand. She would review the chart and provide documentation if the splint had been discontinued. She revealed it was her expectation that communication occurs between the nursing department, that included the Director of Nursing (DON) and the MDS nurse, and the therapy department. Then orders should be implemented and/or referrals provided as a resident declines. The care plan interventions should match the current orders. She added a referral to the OT department would be made. An interview was conducted with Nurse #2 on 1/11/2023 at 11:34 a.m. and she revealed Resident #31 had a splint for his left hand a long time ago and she thinks this had been stopped. She was unsure of the reason the splint was stopped.

Based on observations, staff interviews, and record review, the facility failed to provide treatment and services to a resident (Resident #33) who demonstrated a reduction in range of motion of the bilateral lower extremities in the hips, ankles, and knee, and in the left upper extremity. This occurred in 1 of 2 residents reviewed for limited range of motion. The findings included: Resident #33 was admitted to the facility on [DATE]. His cumulative diagnoses included nontraumatic intracerebral hemorrhage, Parkinson's disease, hemiplegia, and contractures of the bilateral hips, bilateral ankles, right knee and left hand. A review of Resident #33 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated the Resident had severe cognitive impairment, was dependent on one staff member for all activities of daily living (ADL) care needs, and had limited range of motion in bilateral upper and lower extremities. A review of Resident #33 ' s care plan dated 9/5/2022 identified a problem area that read: The Resident has the potential for alteration in comfort related to impaired mobility from a cerebral vascular accident with left side hemiparesis. He has contractures to the bilateral hips, knees, and ankles. He receives splinting to the hand for contracture prevention. Staff must anticipate and observe the resident for pain. There was not an intervention for the placement of the splint to the hand. A review of the physician notes dated 12/26/2022 documented there were no deformities to the extremities. A review of the physician orders did not include an order for splint placement to the upper or lower extremities. A review of Resident #33 's electronic medical record revealed a contracture risk assessment dated [DATE] at 12:38 p.m. and documented the Resident's general state of health was poor and declining, orientation was alert, with nonfunctional abilities in ADL care, immobile, severe limitation that was greater than 40% in present joint condition and had contributing factors that included Parkinson's disease. A score was calculated based on the assessment and each category was the most severe possible except for the orientation of the Resident. The orientation lowered the contracture risk to a moderate level instead of a severe level. The assessment question for referral needs, was checked, no referrals needed and continue current plan of care. An observation of Resident #33 was conducted on 1/9/2023 at 12:22 p.m. The Resident was observed lying in bed with a blanket covering his body. His left hand was bent at a 90-degree angle at the wrist and his fingers were curled and bent, from the back of his hand, at a 45-degree angle. An interview was conducted with a family member on 1/9/2023 at 12:30 p.m. of Resident #33 and revealed the Resident previously wore a splint to his left hand but they had not seen one placed in a long time. An observation of Resident #33 was conducted on 1/10/2023 at 10:48 a.m. and he was observed to be positioned on his left side with a pillow used to support his left arm. He did not have a splint in place to the left hand. An interview was conducted on 1/10/2023 at 3:21 p.m. with the Rehabilitation Manager and she revealed Resident #31 was last seen by Occupational Therapy (OT) on 4/15/2015. She stated the OT discharge summary identified the Resident demonstrated impaired range of motion of the left hand and all digits with neutral to hyperextension, without an flexion due to tightness in the joint. A recommendation was made for a left-hand orthotic device to be utilized to aid with achieving optimal skin and joint integrity without negative effect to the Resident in order to achieve neutral position for contracture management. She reviewed the electronic medical record for Resident #33 and did not see an order to discontinue the recommendation for the splinting device. The Rehabilitation Manager stated the Resident had not been evaluated for treatment by the OT since 2015. She added, the process for any resident to receive therapy was to receive a referral from a member of the administrative nursing team or a physician, or to be identified by herself or another therapist when reviewing electronically generated reports. She indicated there were two reports that she reviewed on a weekly basis. These reports identified any resident that had triggered for contractures, pain, a decline in ADL's, weight loss, and falls. She added a long term resident like Resident #33 could be missed on these reports due to a slow decline in all areas, including contractures. She revealed communication between the direct care staff and the therapy department was important to ensure a resident receives therapy services. She provided a copy of an email she had sent to her corporate manager, dated 1/6/2023, for education topics to be provided during 2023. Referrals to the therapy department was the first area identified. She added she had not provided the education yet. An interview was conducted with the Administrator on 1/10/2023 at 4:10 p.m. and she reviewed the chart for Resident #33. She stated she was not aware the Resident had not been referred to the Occupational therapy department in so long. She stated she was unsure of the reason the splint was no longer being placed on the left hand. She would review the chart and provide documentation if the splint had been discontinued. She revealed it was her expectation that communication occur between the nursing and therapy departments and orders be implemented and/or referrals provided as a resident declines. She added a referral to the OT department would be made. An interview was conducted with Nurse #2 on 1/11/2023 at 11:34 a.m. and she revealed Resident #31 had a splint for his left hand a long time ago and she thinks this had been stopped. She was unsure of the reason the splint was stopped.

Based on observations, staff interviews, and record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 2 residents (Resident #33) reviewed with indwelling urinary catheters. The findings included: Resident #33 was admitted to the facility on [DATE]. His cumulative diagnoses included nontraumatic intracerebral hemorrhage, reflux uropathy, Parkinson's disease, and hemiplegia. A review of Resident #33 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated the Resident had severely impaired cognitive skills and had an indwelling urinary catheter. A review of Resident #33 ' s care plan dated 9/5/2022 identified a problem area that read: The Resident has a urinary catheter related to hydronephrosis and a ureteral stone with stent placement. The interventions included to keep the drainage bag below the level of the bladder with a privacy bag in place, prevent tension on the urinary meatus (the opening of the urethra, situated on male genitalia) from the catheter, and keep the tubing free of kinks. A review of the physician orders included an indwelling urinary catheter size 20 french with a 30 cubic centimeter (cc) bulb (the part of the catheter used to prevent the catheter from sliding out of the urinary bladder) for kidney stones and a stent placement. An observation was conducted of Resident #33 on 1/9/2023 at 12:18 p.m. The Resident was observed with a urinary catheter bag, containing dark amber urine. The catheter bag was on the door side of the room and lying directly on the floor. A privacy bag was in place and was opened at the bottom. The tubing used to empty the catheter bag was in direct contact with the floor surface. An observation was conducted of Resident #33 on 1/9/2023 at 3:55 p.m. The Resident was observed with a urinary catheter bag hanging on the window side of the bed. The bed was in the lowest position and the catheter bag was hanging on the bottom right side of the bed. The catheter bag was touching the floor, with a privacy bag in place that was open on the bottom. The tubing to empty the catheter bag was in direct contact with the floor surface. An observation was conducted of Resident #33 on 1/11/2023 at 9:47 a.m. The Resident was observed to have a urinary catheter bag on the window side of the room and the bag was lying directly on the floor. An interview was conducted on 1/11/2023 at 9:49 a.m. with Nursing Assistant (NA) #1 and she revealed she was one of two NA's that had provided care to Resident #33 on this shift. She stated they placed the urinary catheter at the foot of the bed on the right side and it was off of the floor. When asked why it was placed off of the floor, she replied because that would not be sanitary. She indicated she had received education to keep a catheter bag off of the floor several times in her years of working at the facility. She added when the two NA's left the room, Nurse #1 was still providing care. She stated she observed the urinary catheter to be lying on the floor at that time and stated she thought when Nurse #1 lowered the bed, the bag must have come loose and hit the floor. An interview was conducted on 1/11/2023 at 9:52 a.m. with Nurse #1 at the bedside of Resident #33. She revealed she observed the urine catheter bag lying directly on the floor with a privacy bag in place. The privacy bag was open on the bottom and the tubing for emptying the urine was lying directly on the floor. She stated she lowered the bed when she exited the room and this could be how the bag ended up lying on the floor. She added it was concerning to her that a urine catheter bag was on the floor because this placed the resident at risk for urinary tract infections. An interview was conducted with the Director of Nursing (DON) on 1/11/2023 at 10:33 a.m. and she revealed she had been employed at the facility for a month. She added it was her expectation that a urine catheter bag be kept off of the floor to prevent infection. She stated she was not sure when urine catheter education had last been conducted but she would investigate. A copy of the last urine catheter education was provided on 1/11/2023 at a later time. A review was conducted of the facility education log, dated 9/26/2022, titled, Catheter Care. The education was reviewed and did not include how to store a urine catheter bag after finishing with the cleansing a resident. An interview was conducted with the Administrator on 1/11/2023 at 4:00 p.m. and she revealed it was her expectation that a urine catheter bag be kept below the urine bladder area to help with drainage, be secured to prevent pulling of the tubing, and stored in an appropriate location on the bed. She added a catheter bag should never be stored directly on the floor. She stated education was conducted for Nurse #1 to ensure the placement of a catheter bag, after lowering a bed, and prior to exiting a room.

Based on record review and staff interviews the facility failed to follow care planned interventions for 1 of 3 residents (Resident #1) reviewed for Nutritional status. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility admission minimum data set (MDS), dated [DATE] revealed Resident #1 had severe cognitive impairment, required extensive assistance of one staff member with activities of daily living and minimal assistance with eating that included set up. A review of Resident #1's care plan, dated 12/13/2021 had a focused area that read; Resident #1 has a potential for weight loss related to, he leaves 25 % or more of uneaten food on his meal trays. He has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included: 1) To provide assistance for meals. 2) Offer available substitutes if resident has problems with the food being served. 3) Monitor and record weight. 4) Notify the physician and family of significant weight changes. 5) Monitor need for changing diet consistency to increase ease of eating. 6) Monitor and record food intake. 7) Encourage food and fluid intake. A review of the meal intake log for Resident #1 revealed for the month of December the Resident had 4 meal intake percentages recorded and for the month of January the Resident had one meal intake percentage documented. On 4/21/2022 at 10:59 a.m. an interview was conducted with the Director of Nursing, and she reviewed the meal intake log for Resident #1. She revealed the Resident had 4 meal intake percentages (the amount of food the Resident had eaten) for the entire month of December 2021 documented. She then reviewed the care plan for Resident #1 and stated the Resident was care planned to have all meal intake amounts documented. She added that it was her expectation that meal intake amounts be documented when the meal trays are picked up from a resident's room so the administrative team and the hall nurse can evaluate the care of a resident. On 4/21/2022 at 11:32 a.m. an interview was conducted with the facility Administrator, and she revealed for Resident #1 he was evaluated by Speech Therapy (ST) and the ST stated, staff to assist with meals. She revealed it was her expectation that meal intake be documented per the care plan.

Based on record review, physician and staff interviews the facility failed to document meal intake for 1 of 3 residents (Resident #1) reviewed for nutritional status. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the hospital discharge paperwork dated 11/30/2021 revealed Resident #1 weighed 174 pounds on 6/4/2021 and 171 pounds on 11/19/2021. A review of the facility admission minimum data set (MDS), dated [DATE] revealed Resident #1 had severe cognitive impairment, required extensive assistance of one staff member with activities of daily living and minimal assistance with eating that included set up. A review of Resident #1's care plan, dated 12/13/2021 had a focused area that read; Resident #1 has a potential for weight loss related to, he leaves 25 % or more of uneaten food on his meal trays. He has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included: 1) To provide assistance for meals. 2) Offer available substitutes if resident has problems with the food being served. 3) Monitor and record weight. 4) Notify the physician and family of significant weight changes. 5) Monitor need for changing diet consistency to increase ease of eating. 6) Monitor and record food intake. 7) Encourage food and fluid intake. A review of the meal intake log for Resident #1 revealed for the month of December the Resident had 4 meal intake percentages recorded and for the month of January the Resident had one meal intake percentage documented. A review of the facility weight logs documented: 12/3/2021 171 pounds 12/10/2021 168 pounds 12/17/2021 169 pounds 12/24/2021 168 pounds 1/10/2022 164.6 pounds Resident #1 was discharged from the facility on 1/20/2022 and admitted to the Hospital. A review of the hospital paperwork dated 2/11/2022, revealed Resident #1 was admitted to the hospital on 2/10/2022 and the emergency room physician note stated the Resident appeared very emaciated and was dehydrated on admission. The Weight documented at the Hospital was 49.9 kilograms (110.1 pounds) height 5 foot 8 inchs. On 4/21/2022 at 10:59 a.m. an interview was conducted with the Director of Nursing, and she reviewed the meal intake log for Resident #1. She revealed the Resident had 4 meal intake percentages (the amount of food the Resident had eaten) for the entire month of December 2021 documented. She then reviewed the care plan for Resident #1 and stated the Resident was care planned to have all meal intake amounts documented. She added that it was her expectation that meal intake amounts be documented when the meal trays are picked up from a resident's room so the administrative team and the hall nurse can evaluate the care of a resident. On 4/21/2022 at 11:32 a.m. an interview was conducted with the facility Administrator, and she revealed for Resident #1 he was evaluated by Speech Therapy (ST) and the ST stated, staff to assist with meals. She revealed it was her expectation that meal intake be documented per the care plan and she added that a nutritional consult was the facility policy within the first 30 days of admission and for this Resident it was conducted on 1/18/2022.

Based on observation, record review, and staff and resident interviews, the facility failed to provide scheduled showers and bathing for activities of daily living (ADL) dependent residents for 3 of 4 residents reviewed for showers and bathing (Residents #2, #4, and #6). Findings included: 1. Resident #2 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident ' s care plan dated 5/8/20 documented to assist with activities of daily living. A review of the resident ' s current Minimum Data Set (MDS) documented an intact cognition and assistance for bathing. Review of ADL care sheets for Resident #2 documentation from 4/27/2021 to 5/25/2021. Showers were documented as given for 4/30/2021, 5/2/2021, 5/7/21, 5/12/21, 5/19/21, 5/21/21, and 5/24/21. There were 7 showers in a 30-day period. Scheduled showers were Monday, Wednesday, and Friday. No refusals were documented. On 5/26/2021 at 3:30 pm an interview was conducted with Resident #2. The resident stated she was supposed to get a shower on Monday, Wednesday, and Friday. The resident commented she had not gotten a shower this week, and today (5/26/2021) NA #3 assigned informed the resident there was not enough staff for her to assist with a shower and provided a sink bath. The resident also commented that this was not the first time she had not received her shower. On 5/27/2021 at 9 pm an interview was conducted with NA #3. The NA was very familiar and assigned to Resident #2. The resident was scheduled to have a shower three times a week. The facility was under-staffed, and it was hard to get all the assignments done. As a result, the resident did not always receive her shower 3 times a week. The resident asked for her shower and was informed of the staffing shortage. Most of the residents have not been getting their showers three times a week due to staffing problems (shortage). 2. Resident #4 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident ' s annual MDS dated [DATE] documented an intact cognition and assistance for bathing. The resident ' s care plan dated 4/27/21 documented the resident required assistance with his activities of daily living (bathing). The review of ADL care sheets for Resident #4 documented from 4/27/2021 to 5/25/2021 was done. Bed baths were documented as given for dates 5/1/2021, 5/2/2021, 5/12/21, 5/14/21, 5/15/21, 5/21/2021, 5/24/2021, and 5/25/2021. There were 8 bed baths in a 30-day period. Scheduled bathes (3 times a week) were scheduled for Monday, Wednesday, and Friday. No refusals were documented. On 5/26/2021 at 2:10 pm an interview was conducted with Resident #4. The resident stated he felt that sometimes the shifts were understaffed by comments staff would make (there was not enough staff) and he had not always received his bed bath and many times I received my bath on evening shift. The resident commented I have not had my hair washed in a while. On 5/26/2021 at 2:10 pm an observation was done of Resident #4. The resident ' s hair was noted to appear greasy with strands segmented. His skin also appeared shiny/greasy. The resident ' s nails on the left hand were dirty. 3. Resident #6 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident ' s care plan was initiated on 1/1/20 and reviewed on 4/14/21. The resident can have behaviors of care refusal secondary to [CONDITION(S)]. The resident ' s quarterly MDS dated [DATE] revealed behaviors none and cognition was severely impaired with memory deficit. ADLS were extensive assistance of 1 staff. Nurses ' notes reviewed documentation for the past 30 days (4/27/21 through 5/25/2021) revealed the resident declined 1 meal and 1 shower. A shower was not repeated. A review of ADL care sheets for Resident #6 documented from 4/27/2021 to 5/25/2021 was done. Showers were documented as given for dates 4/27/2021, 5/1/2021, 5/6/2021, 5/11/2021, 5/13/2021, 5/21/2021. Scheduled showers were for Tuesday, Thursday, Saturday. Six showers in a 30-day period were documented. No refusals were documented on the sheets. On 5/26/2021 at 4:10 pm the Resident #6 was observed in her bed. Her hair appeared unkempt. On 5/27/2021 at 9 pm an interview was conducted with Nursing Assistant (NA) #3. The NA stated she was very familiar and frequently assigned to Resident #6. The resident was scheduled to have a shower three times a week. The NA commented that the facility was under-staffed, and it was hard to get all the assignments completed. As a result, the resident did not always receive her shower 3 times a week. Most of the residents had not been getting their showers three times a week due to staffing problems (shortage and call outs). The problem had been going on for a couple of months. On 5/28/2021 at 11:25 am an interview was conducted with Nurse #3. The Nurse stated that she was assigned to Resident #6. The resident can refuse care occasionally, but had not refused medications, meals, etc. for Nurse #3. Residents received shower three times a week. If a shower was not received on the scheduled day, it could be given the next day but that would possibly cause the schedule to decrease to 2 times a week. If the resident refused a shower, the NA was required to inform the assigned nurse. If a resident continued to have refusals the Administrator and/or social work and family or resident representative would be informed for intervention. If a resident refused showers, it would be documented in the nursing progress notes. On 5/28/2021 at 4:55 pm an interview was conducted with NA #4. The NA was usually assigned to halls 400 and 500 but was familiar with the care of Residents #2 and #4. The NA commented that the day shift NA to resident ratio was as high as 1 to 20 and the NA worked alone and did not have a partner except for 2-person assist. The NAs priority was incontinence care. There were 2 meals on day shift and showers had a low priority. There were days when Resident #2 was asked to have her shower before breakfast at 7:00 am and declined. This was not considered a refusal, but if there was not enough time that day, the shower was not done. 5/27/2021 at 12:10 pm interview with Director of Nursing (DON). The DON stated that alert and oriented residents that request a shower should receive a shower or bath. If there was a reason that the shower was not provided, this information was required to be documented and the assigned nurse notified to follow up.

Based on observation and staff and resident interviews, the facility failed to provide activities as scheduled when the Activities Director (AD) was placed in the Nursing Assistant (NA) role for 3 of 5 residents interviewed for facility activities (Resident #1, #2. and #4). Findings included: 1. Resident #1 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident ' s quarterly Minimum Data Set (MDS) dated [DATE] documented an intact cognition. The resident ' s care plan dated 4/6/2021 documented that the resident was independent with most of her activities of daily living and activities as desired. On 5/26/2021 at 3:30 pm an interview was conducted with Resident #1. Resident #1 stated she felt there was not enough staff and commented that the AD was pulled to the nursing assistant role frequently and residents were not getting activities as scheduled (they were cancelled). This had been going on for a long time. She commented that all last week there were no activities because the AD was working as an NA. 2. Resident #2 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident ' s care plan dated 5/8/20 documented to assist with activities of daily living and activities as desired. A review of the resident ' s last completed MDS documented an intact cognition. On 5/26/2021 at 3:30 pm an interview was conducted with Resident #2. Resident #2 stated that activities were frequently cancelled because the AD was pulled to the nursing assistant job when there was not enough staff. There was no one else (staff) to run the activities. She commented that all last week there were no activities, group or individual and this had been going on for months. 3. Resident #4 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident ' s annual MDS dated [DATE] documented an intact cognition. The resident ' s care plan dated 4/27/21 documented the resident required assistance with his activities of daily living and activities as desired. On 5/26/2021 at 2:10 pm an interview was conducted with Resident #4. The resident stated he felt that sometimes the shifts were understaffed by comments staff would make (short staffed today) and the activities were cancelled (bingo). On 5/26/2021 at 2:20 pm an observation on Hall 600 was done of the activities calendar. There were activities scheduled each weekday, including bingo twice a week. On 5/26/2021 at 4:05 pm an interview was conducted with the Administrator. The Administrator stated she was aware that activities were cancelled because the AD was pulled to the role of NA. The Administrator commented that the AD was placed in the role of NA (prior role) when there were call outs. When the AD was placed in the NA role, there were no replacement staff for the scheduled activities, and they were not held. On 5/26/2021 at 3:45 pm an interview was conducted with the AD. The AD stated that she was responsible for facility activities. The activities were posted on a calendar on each resident hall. Since COVID-19 there was an increased need to replace staffing shortage and call outs for NA coverage. The AD commented my prior role was an NA and I have been pulled periodically to NA duties for several months, more lately. The AD stated she was in the NA roll for 4 weekday shifts last week and the activities were cancelled because there were no replacement staff to hold the scheduled activity. On 5/27/2021 at 12:10 pm an interview was conducted with the Director of Nursing (DON). The DON stated she was aware that the AD was pulled from her duties to cover nursing assistant duties for staffing shortages and call outs and that there were full time employee (FTE) positions open. On 5/28/2021 at 11:25 am an interview was conducted with Nurse #1. The nurse stated the AD was also an NA and had been pulled from her activities duties to perform an NA role quite a few times, more lately. When the AD was placed in the NA role, the scheduled activities were cancelled because there was not a replacement (staff).

Based on observation, record review, and staff and resident interviews, the facility failed to have sufficient nursing staff to ensure residents received scheduled showers and bathing for 3 of 3 sampled dependent residents (Residents #2, #4, and #6). In addition, the insufficient staffing resulted in the frequent lack of activities for 3 of 3 sampled residents (Residents #1, #2 and #4). Findings included: Cross referenced to tags: F677: Based on observation, record review and staff and resident interviews, the facility failed to provide scheduled showers and bathing for activities of daily living (ADL) dependent residents for 3 of 4 residents reviewed for showers and bathing (Residents #2, #4, and #6). F679: Based on observation and staff and resident interviews, the facility failed to provide activities as scheduled when the Activities Director (AD) was placed in the Nursing Assistant (NA) role for 3 of 5 residents interviewed for facility activities (Resident #1, #2. and #4). A review of the May 2021 documented daily staffing revealed the average was 90. The average NA total for each shift was as follows: 7 NAs for days 6 NAs for eves 4 NAs for nights (low was 2 on 5/8/21) Total of six halls and cross-connect with resident rooms On 5/27/2021 at 12:10 pm an interview was conducted with the Director of Nursing (DON). The DON stated she was aware that the AD was pulled from her duties to cover nursing assistant duties for staffing shortages and call outs and that there were full time employee (FTE) positions open. On 5/26/2021 at 4:05 pm interview was conducted with the Administrator regarding staffing and concerns voiced by residents regarding staffing which had impacted resident ' s showers/bathing and lack of activities. The Administrator commented that the average census for the facility had been 90. The Administrator stated that the AD was pulled to the floor placed in the role of Nursing Assistant (NA) [prior role] when there were call outs. When the AD was placed in the NA role, there was no replacement staff for the scheduled activities, and they were not held. Licensed and administrative nurses were also placed in the role of nursing assistant when needed. Alternate weekends were short staffed and current staff were volunteering for overtime. The facility had not utilized outside staffing replacement. Two NAs were out on FMLA and cannot be replaced. There were currently nursing assistant FTE positions open for night shift 2, evening shift 4, and day shift 3. The Administrator commented that she took in new admissions based on staffing and had turned some potential admissions away.

Based on observation and staff and resident interviews, the facility failed to knock and/or announce entry before entering a resident ' s room for 2 of 2 resident room entry observations completed (Rooms 607 and 611). Findings included: On 5/26/2021 while observing on Hall 600 at 2:35 pm, there were 2 housekeepers working (cleaning). Housekeeper (HK) #1 was observed to step into resident Room #607, the lights were out, and both the residents appeared to be sleeping. HK #1 did not knock on the door and called while in the room for HK #2. HK #2 answered from the hall after exiting another resident room. Both HKs #1 and #2 entered resident Room #611 without knocking or announcing themselves to wash their hands in the resident ' s bathroom. While in the resident ' s bathroom, HK #1 and #2 were talking to each other and had not addressed the residents upon exit. The hand sanitizer dispensers were noted to be empty on Hall 600. An interview of HKs #1 and #2 was conducted on 5/26/2021 at 2:37 pm. HK #1 commented that she was required to knock before entering a resident ' s room and HK #2 did not respond. HK #1 acknowledged that she had forgotten to knock before entry. Both HK #1 and #2 both stated that they would knock and announce before entering a resident ' s room. On 5/26/2021 at 4:05 pm an interview was conducted with the Administrator. She stated that all staff were required to knock and/or announce before entry into a resident ' s room and would follow up with HK #1 and #2.

Based on observations, resident interview, resident representative interview, staff interviews and record review, the facility failed to provide a dignified dining experience by standing over a resident while providing assistance with feeding for 2 of 9 residents (Resident #25 and Resident #53) reviewed for dining. Findings included: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #25 had moderately impaired cognition. She required extensive assistance with eating. A nutrition care plan updated 2/5/21 revealed, assist with eating. On 3/29/21 at 12:37 PM Resident #25 was observed in her bed in an upright seated position. Nurse Aide (NA) #3 stood next to the resident's bed as she provided the resident with feeding assistance. NA #3 stood above eye level of the resident for the duration of the meal while she fed Resident #25. A straight back chair was observed in the room against the wall near the foot of Resident #25's bed. At 12:45 PM, NA #3 covered the plate of food and exited the resident's room. An interview was completed with NA #3 on 3/29/21 at 2:41 PM, during which she stated Resident #25 needed to be fed her meal. She said staff either sat in a chair or stood when they fed a resident and added, When we train they tell us to either sit or stand when feeding a resident. Resident #25 was interviewed on 3/31/21 at 3:06 PM. She said staff fed her during meal times and some staff sat when they fed her and some stood when they assisted her. Resident #25 shared when she lived at home she was accustomed to family being seated during a meal and preferred staff sat at bedside when they fed her. During an interview with the Clinical Competency Coordinator (CCC) on 4/1/21 at 9:49 AM, she said staff were educated to be seated when they fed a resident so they could be at eye level. The CCC explained staff were educated as needed on being seated when they assisted residents with meals and added, They should have had it back in their NA training before they came to work. The NA should have been seated when she fed the resident. An interview was completed with the Administrator on 4/1/21 at 12:52 PM during which she said staff were supposed to be seated when they fed residents. We tell staff they have to be eye level with the resident. We never tell them to either sit or stand. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #53 had severe cognitive impairment. She required extensive assistance with eating. A nutrition care plan updated 3/1/21 revealed, provide assistance for meals. On 3/29/21 at 12:37 PM Resident #53 was observed in her bed in an upright seated position. NA #4 stood next to the resident's bed as she provided the resident with feeding assistance. NA #4 stood above eye level of the resident for the duration of the meal while she fed Resident #53. A straight back chair was observed in the room against the wall near the foot of Resident #53's bed. At 12:55 PM, NA #4 covered the plate of food and exited the resident's room. An interview was completed with NA #4 on 3/29/21 at 12:48 PM, during which she stated Resident #53 needed to be fed her meal. NA #4 explained she typically either sat in a chair or stood when she fed the resident. NA #4 stated the facility had not specified whether to sit or stand when she fed a resident. Resident #53's representative was interviewed on 3/30/21 at 3:08 PM. He typically came to the facility daily and fed Resident #53 during the lunch and supper meals. He shared he was unable to visit on 3/29/21. The representative explained he sat in a chair by the bed when he fed Resident #53. He thought staff should also be seated and at eye level when they fed the resident. During an interview with the Clinical Competency Coordinator (CCC) on 4/1/21 at 9:49 AM, she said staff were educated to be seated when they fed a resident so they could be at eye level. The CCC explained staff were educated as needed on being seated when they assisted residents with meals and added, They should have had it back in their NA training before they came to work. The NA should have been seated when she fed the resident. An interview was completed with the Administrator on 4/1/21 at 12:52 PM during which she said staff were supposed to be seated when they fed residents. We tell staff they have to be eye level with the resident. We never tell them to either sit or stand.

Based on record review and staff interview the facility failed to follow safety measures during turning a resident in bed for 1 of 3 sampled residents who were totally dependent on staff for activities of daily living (Resident #1). As a result, the resident fell out of bed sustaining skin tears, hematomas and bilateral fractures of the lower extremities. The Findings included: Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 required total assistance of 2 persons for bed mobility. Resident #1 was totally dependent with 1 person assistance for bathing and had impairments of both upper and lower extremities. The MDS further indicated Resident #1 was severely cognitively impaired. Review of the resident ' s care plan updated 8/17/15 indicated a problem of Resident #1 was impaired with activities of daily living (ADL) related to severe dementia, history of lacunar infracts and cardiovascular accident. She had deformities of bilateral hands and contracture to her legs and feet making her dependent on staff for all ADLs. Review of Resident #1 ' s care plan dated updated 8/17/15 indicated a problem of Resident #1 potential for falls related to Resident #1 ' s impaired ability to transfer herself. Resident #1 was dependent on staff for transfers and was non-ambulatory. The goal stated Resident #1 would not have a fall through the next review. The approaches included transfer with total lift, bed in low position, and maintain safety with transfers. Review of Resident #1 ' s incident report dated 10/12/15 revealed Resident #1 had a fall from her electric bed (Bed B) which resulted in a skin tear, abrasion, and hematoma. The incident report stated, the resident was found semi-seated on the floor leaning with her back against bed A (the bed of Resident #1 ' s roommate) and head on the mattress of bed A. Resident #1 ' s legs were on the floor toward the window. Emergency medical services, medical doctor and responsible party were notified. The body check revealed Resident #1 had hematomas on the left and right knee and skin tear/abrasion on the left foot and right hand. The resident was transferred to the hospital. The incident report indicated that the facility was notified by the admitting hospital that Resident #1 had fractures of the lower extremities. The involved persons statement section of the incident report indicated NA#1 stated, I was giving resident bed bath and I had finished front and rolled resident over to wash backside. Rolled resident away from me when resident feet feel off bed and the resident of her body rolled out as I tried to hold onto her. Resident went off bed onto knees and onto backside. I immediately called for the nurse. ¼ (quarter) rails were up on both sides of the bed. Bed was approximately 3 to 4 feet high due to CNA giving bed bath . Review of the History and Physical (H&P) from the hospital indicated Resident #1 was admitted on [DATE]. The H&P stated Resident #1 presented to the hospital after a fall injury that occurred at the nursing home. In the emergency room the patient was evaluated and it was found that the patient had a fracture to the distal left femur and also right tibia. The assessment and plan provided pain control with oral and intravenous pain medications as needed. The assessment continued with Resident #1 would most likely not be a surgical candidate. Review of Resident #1 ' s Discharge summary from the hospital dated 10/19/15 stated, assessment/Plan fall with resultant distal left femur fracture and right tibia fracture. No surgery was recommended. The discharge summary stated, Conservative management per medical doctor. Interview with Nursing Assistant (NA#1) on 11/23/15 at 12:46pm revealed on the day of the fall she was giving Resident #1 a bed bath. When she turned Resident #1 over to do her backside Resident #1 kicked her legs off the bed and she went over onto the floor. Resident #1 fell off the bed feet first. NA#1 stated she had Resident #1 ' s bed elevated to provide care. NA#1 stated she was the only one in the room providing Resident #1 with care/bed bath. NA#1 further stated Resident #1 was a 2 person transfer. NA#1 revealed a 2 person transfer meant two people were needed to provide care including bed baths, positioning and turning. NA#1 stated she did not know why she didn ' t get another staff to assist. She further stated, I didn ' t want to pull anyone off their hallway. NA#1 indicated she rolled Resident #1 away from her. The facility trained staff to turn the resident toward staff but NA#1 indicated she rolled her away. Both bedrails were up at the time of the incident. Interview with the Assistant Director of Nursing (ADON) on 11/23/15 at 12:56pm revealed she got called down to Resident #1 ' s room following the fall that occurred on 10/12/15. Resident #1 was laying in the floor when the ADON arrived at the resident ' s room. Resident #1 was located In-between bed A and B. The ADON stated Resident #1 ' s head was lying near her roommate ' s bed and her feet were toward her bed. The ADON stated she was told by NA#1 that NA#1 was giving Resident #1 a bed bath. NA#1 told the ADON she had turned Resident #1 and her legs started off the bed and she couldn ' t hold Resident #1. The ADON revealed NA#1 rolled Resident #1 away from her instead of towards her. Resident #1 required the assistance of 2 persons at the time of the fall. The ADON stated she believed it was an honest mistake on NA#1 ' s part. The aides knew what type of assistance needed for each resident because it was communicated verbally and there was a book on the hall that contained resident care plans. Interview with Director of Nursing (DON) on 11/23/15 at 1:05pm revealed she got called down to Resident #1 ' s room following the fall on 10/12/15. When she got to the room, Resident#1 was on the floor between bed A and Bed B. The DON stated there was quite a bit of blood from skin tears Resident #1 sustained due to the fall. The DON revealed NA#1 turned Resident #1 while providing a bed bath when resident #1 kicked her leg off the bed. Resident #1 body followed her legs over the bed and onto the floor. The facility called the medical doctor and Resident #1 was ordered to the emergency room for evaluation. The DON indicated she did not know why NA#1 was trying to do Resident #1 ' s care by herself. NA#1 rolled Resident #1 away from her. NA training during orientation included safety measures to include rolling a patient toward the NA not away from them. Interview with the Administrator on 11/23/15 at 1:15pm revealed on the day of the incident she was called to Resident #1 ' s room. The Administrator stated she saw resident #1 on the floor with both legs out in front of her. Resident #1 ' s head was on her roommate ' s bed and legs were towards her bed. Resident #1 was observed to have skin tears following the incident and had no obvious signs of pain at the time. The Administrator revealed she immediately questioned NA#1 about what had occurred. NA#1 told the Administrator that while providing Resident #1 with a bed bath Resident #1 kicked out resulting in Resident #1 falling off the bed. The Administrator stated it was out of the ordinary for Resident #1 to kick out. The Administrator indicated NA#1 was suspended pending a facility investigation. The administrator revealed NAs had gotten comfortable with providing care with the assistance of 1 person because Resident #1 did not move. Resident #1 was coded on the MDS as requiring total care. It was found that NA#1 had rolled Resident #1 away from her and not towards her. Interview with the Administrator on 11/24/15 on 9:39am revealed her expectation that staff roll the patient toward them not away from them during ADL care.