Every finding on record at Pruitthealth - Scenic View

Based on observations, staff interviews, record reviews, and review of facility's document titled Dressing a Wound, the facility failed to maintain infection control for two out of nine sampled residents (R) (R39 and R6). Specifically, the facility failed to maintain infection control practices during a wound care procedure for R39 and during medication administration for R6. The deficient practices had the potential to place R39 and R6 at risk of exposure to infection which had the potential to contribute to their decline in health. Findings include:Review of the facility's undated document titled, Dressing a Wound, revealed, Under the document's Description: This checklist identifies the steps needed to dress a wound. It also provide rationales to explain why these steps are performed. The checklist includes, but is not limited to, remove the old dressing while supporting the peri wound. Remove any packing, if applicable if the dressing is adhered to the wound bed moisten it with normal saline to prevent damage to any granulated tissue. Observe the dressing fr any type and amount of drainage and odor. Dispose of the dressing in the trash bag. Perform hand hygiene. Apply clean gloves. Rationale: Prevents transmission of microorganisms.1. Review of medical records revealed R39 was admitted to the facility with the following diagnoses that included but not limited to complete traumatic amputation at left between left hip and knee, pressure ulcer of sacral region, unstageable, local infection of the skin and subcutaneous tissue. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Pattern) revealed, R39 had a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had little to no cognitive impairment; Section M (Skin Conditions) revealed a stage three pressure ulcer.Review of care plan dated 3/16/2023 revealed, Problem: R39 has a pressure ulcer related to impaired mobility and loss of feeling due to paralysis. Coccyx pressure wound. Goal: R39's ulcer will have no signs and symptoms of infections and/or complications. Approach revealed treatments as ordered, assess the pressure ulcer for stage, size (length, width, depth), presence/absence of granulation tissue and epithelization and condition of surrounding skin. Conduct a systematic skin inspection. Report any signs of any further skin breakdown (sore, tender, red, or broken areas). Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry and wrinkle free as able.Review of R39's physician orders dated 7/30/202025 revealed wound care orders to cleanse ulcer to coccyx with wound cleanser, pat dry, apply lotrisone to peri wound, then calcium alginate and foam dressing once daily and as needed. Observation on 8/6/202025 at 9:15 am with the Licensed Practical Nurse (LPN)/Wound Nurse DD performing wound care for R39 in the resident's room. LPN/Wound Nurse DD donned disposable gown and gloves in hallway. LPN/Wound Nurse DD sanitized the bedside table in the doorway of R39 and covered it with trash bag lining. She removed her gown and gloves, used hand sanitizer and donned clean gown and gloves. LPN/Wound Nurse DD gathered wound care supplies and placed them on covered bedside table. Upon entry to R39 room, she introduced herself to R39 . Certified Nurse Assistant (CNA) AA was present in the room, donned with disposable gown and glove. CNA AA positioned and held R39 on his left side to support during wound care procedure. LPN/Wound Nurse DD removed the soiled dressing and discarded it in the trash can. LPN/Wound Nurse DD then removed the right glove with the soiled gloved left hand. She picked up the wound cleanser, sprayed into dry gauze held by soiled gloved left hand to cleanse wound area twice. LPN/Wound Nurse DD removed both gloves, washed hands with soap and water and donned clean gloves. LPN/Wound Nurse DD applied wound cream to back of left gloved hand and dated the dressing with a black marker using her right gloved hand. LPN/Wound Nurse DD removed the right glove and donned a clean glove with the assistance of the left soiled gloved hand. She removed the adhesive from the clean dressing. LPN/Wound Nurse DD used the left soiled gloved hand to pat the dry dressing on the adhesive dressing to prevent it from slipping off and applied the dressing to the wound. LPN/Wound Nurse DD removed gloves from both hands and the disposable gown. She washed her hands with soap and water. She donned clean gloves to clean bedside table with sanitizing wipes and placed them aside to air dry.Interview on 8/6/202025 at 9:45 am with LPN/Wound Nurse DD confirmed that she received infection prevention and control in-services on a quarterly basis. In review of infection control practices during wound care procedure, LPN/Wound Nurse DD acknowledged that she should not have used the technique of changing one glove during the wound care process. She confirmed using the soiled gloved hand in assisting with the donning of the clean gloved hand and when applying the clean dressing.2. Review of medical records revealed R's was admitted to the facility with the following diagnoses that included but not limited Chronic respiratory failure with hypoxia, Chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, Acute and chronic respiratory failure with hypercapnia, Pneumonia, unspecified organism, and Bronchitis.Review of R6's physician orders included but not limited to: fluticasone propion-salmeterol inhaler blister with device; 100-50 microgram (mcg)/dose; one puff inhalation twice a day, dated 9/26/2024 and ipratropium-albuterol 0.5 milligrams (mg)-3 mg-one vial inhalation every six hours, dated 11/14/2024.Observation of medication administration was completed on 8/7/2025 with LPN CC. Prior to preparing medications and upon entry to R6's room, LPN CC did not wash her hands or use hand sanitizer. After administering oral medications, LPN CC gave the fluticasone propion-salmeterol inhaler to R6 to self-administer, then assessed R6's breath sounds with stethoscope and proceeded to prepare a breathing treatment and dispensed a vial of ipratropium-albuterol 0.5 mg-3 mg to the nebulizer. LPN CC assisted R6 with placing the mask on and turned the nebulizer machine on. LPN CC exited the room and did not wash her hands or use hand sanitizer. LPN CC proceeded with returning the fluticasone propionate inhaler to the medication cart drawer and picked up a pen to document on a paper at the medication cart and then used the hand sanitizer. During an interview on 8/7/2025 at 5:00 pm with the Infection Preventionist (IP). The IP revealed that she was responsible for training on infection control and prevention. The IP confirmed that her expectations for infection control during wound care include maintaining hand hygiene, changing gloves throughout the process, keeping a sterile field maintained, and assuring proper disposal of bandages. With the changing of gloves, the IP confirmed that gloves need to be changed after soiled dressings are removed and moving from one wound to another. The IP confirmed that her expectations for medication administration procedures such as applying eye drops and administering inhalers, include handwashing with soap and water and changing gloves in between and before, hand washing with soap and water. The IP revealed, upon leaving the room, hand hygiene should be completed.Interview on 8/7/2025 at 5:10 pm with the Director of Nursing (DON) revealed that her expectations for wound care that staff follow wound care procedures as ordered by the physician. The DON revealed that the wound nurse should follow infection control practices throughout the wound care procedure to include the gloving procedure and hand hygiene. She confirmed that the Personal Protective Equipment (PPE) carts were set outside the room and was frequently stocked. The DON confirmed that her expectations during medication administration include the nurse assuring that the equipment being used was clean, such as the blood pressure cuff and glucometer, and was ready for use. She confirmed that nurses were to perform hand hygiene and wear gloves after any medication administration procedure such as application of eye drops, inhaler or nebulizer treatments. She confirmed that after the procedure, the nurse was to remove gloves, use hand sanitizer and apply clean gloves in between a medication administration with the same resident. The DON confirmed that after the entire medication administration procedure for one resident was complete, the nurse would need to wash their hands before leaving the room and proceeding to the next resident.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to implement interventions/approaches identified on the comprehensive care plan for one of four sampled Residents (R) (R2) reviewed for falls. Findings include: Review of the facility's policy titled, Care Plan reviewed and revised on 7/27/2023 revealed in the Policy Statement, It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Under the subtitle admission Comprehensive Plan of Care section number four, review of the third paragraph revealed, The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Review of the Electronic Medical Record (EMR) revealed R2 was admitted to the facility with diagnoses including but not limited to hypokalemia, fracture of fifth lumbar vertebra, gait abnormality. Review of R2's care plan revealed resident with problem start date of 12/31/2024 with category for falls, patient/resident at risk for falls related to recent hospitalization. Goals with short-term goal target date: 5/10/2025, patient/resident will not sustain injury related to falling through next review, Fall 2/23/2024 no injury. The care plan approaches included but not limited to: Anti-rollback bars to wheelchair (w/c) approach start date: 3/20/2025; encourage resident to wear shoes when wearing regular socks and as needed, approach start date 2/23/2025; encourage use of non-skid socks, approach start date 1/11/2025. Review of R2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed, a Brief Interview for Mental Status (BIMS) of 9 which indicated moderately impaired cognition. Section GG-Functional status revealed, R2 required supervision with eating, oral hygiene, and toileting hygiene, dependent for shower/bath, supervision for upper and lower body dressing and putting on/taking off footwear, supervision for bed mobility, partial/moderate assistance for transfers, resident uses a wheelchair. Section H- Bladder and Bowel status revealed R2 with occasional incontinence of bladder, frequently incontinence of bowel. Section J- Health Conditions revealed, a fall in the last month prior to admission/entry or reentry and a fracture related to a fall in the 6 months prior to admission/entry/reentry. Observation on 3/24/2025 at 1:40 pm revealed, R2 sitting in a wheelchair beside the bed looking down towards the floor. Further observation revealed, there was not an anti-rollback bar attached to the back of the wheelchair. In an interview with Physical Therapist Assistant (PTA) PTA AA on 3/26/2025 at 9:10 am revealed, that R2 was on therapy case load, and she was the one who primarily worked with R2. She confirmed that the resident did not have anti-rollback bars on the wheelchair and was not aware she was care planned for having anti-rollback bars. Observation and interview on 3/26/2025 at 9:25 am with CNA BB revealed, R2 was sitting in a wheelchair at the nurses' station wearing navy blue thick socks. R2's socks was noted not to be non-skid socks nor was there an anti-rollback bar attached to the back of the wheelchair. CNA BB confirmed R2 was not wearing non-skid socks or shoes and did not have an anti-rollback bar attached to the back of the wheelchair as care planned. Cross Reference F689

Based on observations, staff interviews, record review, and review of the facility's policies titled, Occurrences and Occurrence Reduction Program, the facility failed to ensure the environment was free of accident hazards and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four sampled Residents (R) (R2) reviewed for falls. This deficient practice had the potential to increase the risk for falls for R2. Findings include: Review of the facility policy titled Occurrences last reviewed and revised on 1/11/2024 revealed under the Policy Statement, The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Review of the facility policy titled Occurrence Reduction Program last reviewed and revised on 1/29/2021 revealed under the Policy Statement, In an effort to prevent occurrences, each patient/resident will be assessed for risk and appropriate and realistic interventions will be implemented upon identification of risk and after a fall. These interventions will be included in the care plan. Review of the facility document titled, All Falls for Facility with a start date of 2/1/2025 and an end date of 2/28/2025 revealed, R2 had two unwitnessed falls on 2/2/2025 and 2/3/2025, and one fall (not documented as witnessed or unwitnessed) on 2/23/2025. Review of the facility document titled, All Falls for Facility with a start date of 3/1/2025 and an end date of 3/24/2025 revealed R2 had one witnessed fall on 3/6/2024 and three unwitnessed falls on 3/1/2025, 3/12/2025, and 3/20/2025. Review of the Electronic Medical Record (EMR) under events revealed R2 also had falls on the following dates: 1/11/2025, 1/16/2025, and 1/21/2025. Further review of the EMR revealed R2 was admitted to the facility with diagnoses including but not limited to hypokalemia, fracture of fifth lumbar vertebra, gait abnormality. Review of the care plan for R2 revealed resident with problem start date of 12/31/2024 with category for falls, patient/resident at risk for falls related to recent hospitalization. Goals with short-term goal target date: 5/10/2025, patient/resident will not sustain injury related to falling through next review, Fall 2/23/2024 no injury. Approach: Anti-rollback bars to wheelchair (w/c) approach start date: 3/20/2025; Fall 3/12/2025: encourage to use w/c with going into the bathroom, approach start date: 3/15/2025; Fall 3/6/2025: added to Restorative program, approach start date: 3/6/2025; Fall 3/1/2025: bed in low position as appropriate, approach start date: 3/1/2025; encourage resident to wear shoes when wearing regular socks and as needed, approach start date 2/23/2025; Fall 2/3/2025: encourage use of bathroom call light for assistance transferring from toilet, approach start date: 2/3/2025; Fall 1/22/2025: provide reminders to call for assistance when getting out of bed, approach start date 1/22/2025; Fall 1/21/2025: assist patient with dressing as allowed, approach start date 1/21/2025; Fall 1/11/2025: encourage use of non-skid socks, approach start date 1/11/2025; Cue for safety awareness, place call light within reach, approach start date 12/31/2024 Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), R2 with a Brief Interview for Mental Status (BIMS) of 9 which indicated moderately impaired cognition. Section GG (Functional Status) revealed, R2 required supervision with eating, oral hygiene, and toileting hygiene, dependent for shower/bath, supervision for upper and lower body dressing and putting on/taking off footwear, supervision for bed mobility, partial/moderate assistance for transfers, resident uses a wheelchair. Section H (Bladder and Bowel Status) revealed, R2 with occasional incontinence of bladder, frequently incontinence of bowel. Section J (Health Conditions) revealed, the resident had a fall in the last month prior to admission/entry or reentry and a fracture related to a fall in the 6 months prior to admission/entry/reentry. Review of R2's progress notes included the following but not limited to: On 1/11/2025 at 1:45 pm - witnessed fall while ambulating in room - no injuries noted - physician (MD) and Responsible Party (RP) notified. On 1/16/2025 at 7:00 pm - resident reported to staff that she had fallen in the bathroom while trying to pull her pants up - no injuries noted - MD and RP notified - neuro checks initiated. On 2/2/2025 at 3:18 pm - resident with witnessed fall at approximately 9:00 am - observed resident in wheelchair at closet door - resident started to stand, did not lock w/c which rolled backwards, resident sat down on floor - no injuries noted. On 2/3/2025 at 8:30 am - unwitnessed fall in the bathroom - no injuries noted. On 2/23/2025 at 11:16 am- resident fell in bathroom - no injuries noted. On 3/1/2025 at 3:07 pm - resident observed sitting in hallway on the floor outside her room - stated she thought she was in the bathroom - no injuries noted. On 3/6/2025 at 5:54 pm- resident with witnessed fall in her room - nurse passing meds observed resident holding bathroom door frame and standing half-way up, before the nurse could reach her, she dropped to her knees - redness noted to bilateral knees - no other injuries noted On 3/12/2025 at 6:00 pm- resident with unwitnessed fall at 6 pm - found sitting on the floor in front of the bathroom door - no injuries noted. Observation on 3/24/2025 at 1:40 pm revealed, R2 sitting in a wheelchair beside the bed looking down towards the floor. Further observation revealed, there was not an anti-rollback bar attached to the back of the wheelchair. In an interview with Physical Therapist Assistant (PTA) PTA AA on 3/26/2025 at 9:10 am revealed, that R2 was on therapy case load, and she was the one who primarily worked with R2. She stated that they were working on cueing the resident to lock her wheelchair before she transfers from the wheelchair to the toilet and back to the wheelchair. She further stated that they were working on balance and strengthening exercises as well as making sure she had something to hold onto when she is brushing her teeth at the bathroom sink. She further stated that they would train the Certified Nursing Assistant (CNA)s who took care of the resident on how to safely transfer the resident and what type of cueing the resident needs. She confirmed that the resident did not have anti-rollback bars on the wheelchair and was not aware she was care planned for having anti-rollback bars. She also stated that R2 has a walker that she uses to ambulate with supervision. Observation and interview on 3/26/2025 at 9:25 am with CNA BB revealed, R2 was sitting in a wheelchair at the nurses' station wearing navy blue thick socks. R2's socks was noted not to be non-skid socks nor was there an anti-rollback bar attached to the back of the wheelchair. CNA BB confirmed R2 was not wearing non-skid socks or shoes and did not have an anti-rollback bar attached to the back of the wheelchair as care planned. Cross Reference F656

Based on observations, staff and resident interviews, record review and review of the facility's policy titled, MDS Assessment Accuracy, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment, for one of 36 sampled Residents (R) (R32) reviewed for resident assessment. Findings include: Review of the facility's policy titled, MDS Assessment Accuracy, last reviewed 1/11/2024, under the Policy Statement revealed, It is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices .Each Assessment Reference Date (ARD) will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident. Review of R32's undated Resident Face Sheet located in the Face Sheet tab of the electronic medical record (EMR), revealed R32's diagnoses included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Review of the quarterly MDS located in the EMR under the MDS tab with an ARD of 8/13/2023 for Section O (Special Treatments, Procedures, and Programs) indicated R32 received oxygen therapy while a resident and within the last 14 days prior to the ARD; Section C (Cognitive Patterns) indicated R32 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R32 was cognitively intact. Review of the quarterly MDS located in the EMR under the MDS tab, with an ARD of 10/13/2023 for Section O (Special Treatments, Procedures, and Programs) indicated R32 did not receive oxygen therapy while a resident and within the last 14 days prior to the ARD. Review of the annual MDS located in the EMR under the MDS tab with an ARD of 1/13/2024 for Section O (Special Treatments, Procedures, and Programs) indicated R32 did not receive oxygen therapy while a resident and within the last 14 days prior to the ARD; Section C (Cognitive Patterns) indicated R32 had a BIMS score of 14 out of 15 indicating R32 was cognitively intact. During observations on 3/25/2024 at 10:19 am, R32 was observed using oxygen via nasal cannula. During observations on 3/27/2024 at 2:53 pm, R32 was observed using oxygen via nasal cannula. During observations on 3/28/2024 at 1:21 pm, R32 was observed using oxygen via nasal cannula. Review of the most recent Comprehensive Care Plan located in the resident EMR under the Care Plan tab with a problem start date of 10/26/2020 and last reviewed 3/22/2024, revealed a focus area for oxygen use as needed related to congestive heart failure, with interventions which included oxygen two liters via nasal cannula as needed for shortness of breath and notify MD (Medical Doctor) of any changes in oxygen use .oxygen use as needed. Review of discontinued orders located in the EMR under the Orders tab revealed the following order with a start date of 12/19/2020 and a discontinuation date of 2/12/2023: Oxygen at two liters per minute via nasal cannula as needed for shortness of breath. Review of active orders located in the EMR under the Orders tab revealed the following order with a start date of 2/12/2023 and an end date of Open Ended: Oxygen at two liters per minute via nasal cannula as needed for shortness of breath. Review of documentation of oxygen saturations for 1/1/2024 to 3/28/2024, located in the EMR under the Vitals tab, revealed R32 used oxygen therapy nearly every day and, more specifically, the 14 days prior to the annual MDS dated [DATE]. Review of documentation of oxygen saturations for October 2023, located in the EMR under the Vitals tab, revealed R32 used oxygen therapy during the 14 days prior to the quarterly MDS dated [DATE]. During an interview on 3/27/2024 at 8:08 am, Licensed Practical Nurse (LPN) 4 stated R32 usually kept oxygen on all the time. During an interview on 3/27/2024 at 8:16 am, Certified Nurse Aide (CNA) 6 stated R32 almost always used oxygen. During an interview on 3/27/2024 at 8:34 am, CNA7 stated R32 used oxygen pretty much around the clock. During an interview on 3/27/2024 at 2:53 pm, R32 stated she used oxygen when she was in her room but did not usually take it with her to the dining room to eat. R32 clarified she usually always ate in her room. During an interview on 3/28/2024 at 1:21 pm, R32 stated she used oxygen all the time except when she ate her meals. She stated she had been on oxygen since she left the hospital and coming to this facility several years ago. During an interview on 3/28/2024 at 4:54 pm, the MDS Coordinator (MDSC) stated the MDS was probably not coded for oxygen therapy on the two MDSs because the Medication Administration Record (MAR) showed R32 did not receive oxygen therapy during the look back period. The MDSC reviewed the oxygen saturation documentation for the months of the two incorrect MDSs for October and January. She acknowledged that the oxygen saturation documentation indicated R32 used oxygen regularly during those time intervals and that oxygen therapy should have been coded on the MDSs for October and January. Cross Reference F842

Based on observations, staff and resident interviews, record review, and review of the facility's policy Activities Program, the facility failed to provide suitable activities for two Residents (R) (R109 and R101) out of 36 sampled residents. Findings include: Review of the facility's policy titled, Activities Program, with a revised date of 9/28/2023, revealed The Health Care Center provides an ongoing program of Activities was designed to meet the physical, mental, and psychosocial well-being of each resident while offering a rich array of activities to the residents of the center. Under the Procedure revealed, Number 7. After reviewing the Activities Assessment & Preferences for Customary Routine & Activities on the MDS the activity director would designate specific activities for individual residents in the resident's care plan based on their likes/dislikes, preferences, and impairments. 1. Review of R109's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR), revealed R109 was admitted to the facility after a hospitalization that included diagnoses of intestinal adhesions with partial obstruction, pleural effusion, glaucoma, hypertension, bacteremia, and hypoglycemia. Review of R109's Admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 3/4/2024 for Section C (Cognitive Patterns) revealed R109 had a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated she was cognitively intact; Section F (Preferences for Customary Routine and Activities) revealed her preference for activities was somewhat important to her. Review of the admission comprehensive Care Plan, dated 2/29/2024 with a target date of 3/29/2024, located in the EMR under the Care Plan tab, revealed a problem for Potential for social isolation and low activity participation related to short stay patient/resident. Review of the care plan further revealed the goal was to choose and participate in activities of her choice. Review of the care plan interventions included for activity staff to introduce themselves and welcome the resident. Review of the physician orders, dated 2/28/2024 and located under the Orders tab of the EMR, revealed R109 could have activities as tolerated. Review of the Activity Calendar, located on the wall in the hall of the rehab unit, revealed on 3/27/2024, bingo was scheduled at 2:00 pm. During an interview on 3/25/2024 at 2:22 pm, R109 revealed she did not go to any activities. R109 further revealed she had only gone to therapy. R109 revealed no one had invited her to any activities. R109 revealed she would go to activities if she was invited and that also depended on what the activity was and if she felt okay. During an observation on 3/27/2024 at 2:14 pm, R109 revealed she had wheeled herself into the rehab dining room and was looking out the window. During an interview on 3/27/2024 at 2:14 pm, R109 revealed she liked bingo but had not been invited to bingo at 2:00 pm. During an interview on 3/28/2024 at 11:28 am, the Director of Nursing (DON) revealed residents were supposed to be invited to the activities. The DON further revealed activity staff and nursing staff should have asked the residents if they would like to attend activities. The DON revealed it was important for the residents to have activities so they could socialize and interact with others. During an interview on 3/28/2024 at 12:22 pm, the Administrator revealed the Certified Nursing Assistants (CNA's), and the activity department staff should have asked the residents if they would like to go to activities and then assist them to get there. During an interview on 3/28/2024 at 12:30 pm, the Activity Director (AD) revealed staff would have asked and assisted residents to the activity room and that included residents on the rehab unit. The AD further revealed R109 did not like activities so she would go to her room, and they would have conversed. However, the AD clarified that she was thinking of another resident and R109 had not been to any activities until the brain booster yesterday on 3/27/2024 at 10:00 am. 36190 2. Review of R101's significant change MDS with an ARD date of 1/28/2024 located in the RAI (Resident Assessment Instrument) tab of the EMR for Section C (Cognitive Patterns) revealed R101 had a BIMS score of 12 out of 15 indicating R101's cognition was moderately impaired; Section GG (Functional Abilities and Goals) revealed upper and lower extremities were impaired on one side; Section F (Preferences for Customary Routine and Activities) revealed activity preferences included snacks between meals; Section K (Swallowing/Nutritional Status) indicated R101 had a feeding tube, and Section I (Active Diagnoses) revealed diagnoses which included hemiplegia or hemiparesis, metabolic encephalopathy, and disorientation, unspecified. Review of R101's Care Plan, dated 1/16/2023, located in the EMR under the RAI tab, revealed Problem: Potential for social isolation and low activity participation related to long Patient/ Resident with a Goal: Patient/ Resident will choose and participate in activities of choice ___ Independent Activities 1:1 Visitation/Small groups Group activities. Approaches included Interview patient/ resident about preferences, past roles, customary routines, and interests, Describe activities available and assist patient/ resident to choose activities to match interests and abilities, and Check with patient/ resident regularly to assess satisfaction with activities offered. Review of R101's Activity Participation for March 2024, provided by the facility, revealed four times an activity was provided. These included on 3/1/2024, R101 was in isolation due to COVID-19 exposure, on 3/7/2024, R101 received one on one, 3/12/2024, R101 received one on one, and on 3/19/2024, R101 received one on one. During an observation on 3/25/2024 at 10:40 am, R101 was in her bed lying on her back with the head of the bed elevated and her gastrostomy feeding in progress. R101 stated she did not get out of bed much, but she would like to at times. R101 stated she didn't get invited to activities. Review of the facility's Activities for March 2024 calendar, provided by the facility and on 3/25/2024, revealed Brain Boosters was scheduled at 10:00 am and Morning Motion was scheduled at 10:15 am. During an observation on 3/26/2024 at 10:02 am, 3:19 pm, and 3:30 pm, R101 was in bed asleep on her back with the head of her bed up and the television on. Review of the facility's Activities for March 2024 calendar, provided by the facility and on 3/26/2024, revealed Brain Boosters was scheduled at 10:00 am and Morning Motion was scheduled at 10:15 am. During an observation on 3/27/2024 at 1:12 pm and 2:10 pm, R101 was in bed on her back awake with the head of the bed up. Review of the facility's Activities for March 2024 calendar provided by the facility and on 3/27/2024, revealed Resident Council was scheduled at 12:45 pm and Bingo was scheduled at 2:00 pm. During an interview on 3/28/2024 at 12:31 pm, the AD was asked about facility activities and how residents knew about them. The AD stated she posted the activity calendar monthly in their rooms and in the hall and included a calendar in the resident's Welcome Packet. The AD stated residents also got a daily reminder as well as an overhead announcement. The AD stated she had a helper, but it was the CNA who helped get residents to the activities. The AD was asked if she kept a log of the residents who attended or were offered activities as well as their response to the activities. The AD stated she kept a census and highlighted the resident's name and what activity they attended. The AD was asked about R101's activities and her attendance. The AD stated R101 didn't go to activities that involved food as she had a gastrostomy tube. The AD stated she did one on one's such as going outside, watching television in her room, and family visits. The AD stated R101 had her television on in her room and got out of her bed and sat in the lobby on Monday, 3/25/2024. The AD was asked if television and family visits should count since, they didn't have anything to do with the facility's initiation. The AD stated she thought they did. The AD was asked what activities had R101 missed because they involved food. The AD stated Birthday parties, Delicious Delights with Dietary, and restaurant outings. The AD was asked why R101's care plan didn't have defined goals. The AD stated she was going through all the care plans and updating them. During a follow up interview on 3/28/2024 at 4:36 pm, the AD was asked if she went into R101's room and invited her to activities. The AD stated R101 didn't respond to her questions. The AD stated her goals for R101 were to get out of bed, participate in some group activities, and go outside. During an interview on 3/28/2024 at 4:56 pm, activities helper CNA5 was asked why R101 didn't get invited to activities. CNA5 stated she didn't know because R101 hardly went to activities. CNA5 went on to say R101 had a gastrostomy tube, and it took two CNAs to get her up. CNA5 stated she announced the activities over the intercom but CNA5 stated she didn't think R101 could hear it.

Based on observations, staff and resident interviews, record reviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure oxygen therapy was used properly for one of 36 sampled Residents (R) (R220) reviewed for oxygen use. Findings include: Review of the facility's policy titled, Oxygen Administration, with an effective date of 12/1/2018, reviewed on 8/2/2023 and revised on 8/2/2023, revealed It is the policy of [Name] centers to provide oxygen safely and accurately to appropriate patient/resident. The policy further revealed oxygen will be administered by licensed personnel only when ordered by the physician, physician assistant (PA), or nurse practitioner (NP). Review of R220's the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR), revealed R220 was admitted with diagnoses of displaced intertrochanter fracture of the left femur, chronic obstructive pulmonary disease (COPD), heart failure, diabetes mellitus, and dermato polymyositis. Review of the Face Sheet further revealed a picture of R220 utilizing an oxygen cannula. Review of R220's five-day Minimum Data Set (MDS) located in the MDS tab of the EMR dated 3/21/2024 for Section C (Cognitive Patterns) revealed the Brief Interview for Mental Status (BIMS) was not yet conducted. This MDS was still in progress. Review of the physician orders, dated 3/19/2024 and located in the Order tab of the EMR, revealed R220 had an order for oxygen (O2) at three liters (L) via nasal cannula continuously. Review of the physician orders, dated 3/28/2024 and located in the Order tab of the EMR, revealed an order was obtained for O2 at one-three L per nasal cannula to keep saturations greater than 90 percent (%). Review of the admission Care Plan under the Care Plan tab and located in the EMR with a date of 3/20/2024 and a target date of 5/29/2024, revealed R220 had a problem for oxygen use related to COPD and a goal to maximize oxygen levels. Review of the intervention for the problem revealed to use oxygen as ordered. Review of the Progress Notes located in the EMR under the Progress Notes tab, dated 3/28/2024, revealed R220 was alert and oriented times three and able to make his needs known. Review of R220's precautions daily therapy sheet, dated 3/28/2024, revealed oxygen use was not included on the guide to resident care, however it showed R220 had asthma. During an observation on 3/25/2024 at 12:31 pm, R220 was in his room, in bed and had O2 at 2.5L per nasal cannula. During an observation on 3/28/2024 at 9:22 am, R220 was in his wheelchair in the hallway by his room and did not have any oxygen on and was doing exercises. During an observation and interview on 3/28/2024 at 9:45 am, R220 was in the therapy room resting and still did not have any oxygen on. R220 revealed he had worked up a sweat in therapy. During an interview on 3/28/2024 at 9:45 am, Register Nurse (RN) 2, who was also the unit manager, revealed R220 should have his oxygen on at 3L via nasal cannula continuously as the physician had ordered. RN2 revealed R22 could have become hypoxic, was more at risk for falls, and could have become dizzy. RN2 further revealed R220 oxygen saturations were 92% on room air. RN2 revealed the oxygen saturation needed to be above 90%. During an interview on 3/28/2024 at 10:06 am, the Occupational Therapist (OT) revealed she had done the initial evaluation on R220 and did the precautions paperwork, which showed staff what type of precautions the resident was on. During the interview, the OT reviewed the precaution document and revealed the oxygen at 3L was not included in the document. The OT further revealed she would review the physician orders and talk to the resident. She revealed R220 told her he was not on oxygen at home and that was why she did not include it on the precaution document. The OT revealed she did not know R220 had been in the hospital prior to coming to the facility, even though she had checked the physician's orders which said he was on oxygen continuously. The OT further revealed the lack of oxygen use could have affected R220's therapy progress. During an interview on 3/28/2024 at 10:32 am, the Physical Therapy Assistant (PTA) revealed the precaution sheet for R220 did not include oxygen and therefore she did not think he needed it. During an interview on 3/28/2024 at 10:32 am, the Therapy Director revealed the evaluating therapist would have filled out the precautions document after reviewing physician orders and if the resident was on oxygen, it should have been outlined on the precaution document. The Therapy Director further revealed the precaution document alerted staff to what the care needs were for R220. She further revealed if a resident told the evaluating therapist that they weren't on the oxygen at home then they should have reviewed the physician orders again and educated the resident on the need for oxygen according to the physician orders. During an interview on 3/28/2024 at 10:44 am, Certified Nursing Assistant (CNA) 1 revealed R220 refused his oxygen that morning after getting up and she did not report it to the nurse because she was new and did not know she was supposed to report it. During an interview on 3/28/2024 at 11:15 am, the Administrator revealed if a resident had oxygen ordered continuously at a prescribed rate, then they should have had oxygen on. The Administrator further revealed not using oxygen could possibly affect their therapy performance. During an interview on 3/28/2024 at 11:32 am, the Director of Nursing (DON) revealed R220 had an order for O2 at 3L via nasal cannula continuously and he should have had the oxygen on. The DON further revealed the lack of oxygen could have caused shortness of breath, air hunger, confusion, and possibly tiredness. During an observation and interview on 3/28/2024 at 3:04 pm, R220 was lying in bed in his room and had O2 at 3L via nasal cannula. R220 revealed he told the CNA he did not use oxygen at home after he was gotten up. Interview with R220 further revealed he stated he did not exactly refuse to use the oxygen since he had been wearing it every day and night since had he been admitted . R220 further revealed he was not able to adjust any of the settings on the oxygen concentrator or oxygen tanks.

Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Unnecessary Medications Use and Monitoring, the facility failed to ensure the appropriate use of antibiotic therapy for two of 36 sampled Residents (R) (R18 and R1) reviewed for unnecessary medications. Findings include: Review of the facility's policy titled, Unnecessary Medications Use and Monitoring, revised 12/6/2022, revealed It is the policy of [name] Pharmacy Service that the use of unnecessary medications will monitored based on the resident's need, duration, effectiveness of therapy, and adverse consequences. The consultant Pharmacist will recommend discontinuation, and/or GDR [gradual dose reduction] of the medications that do not meet all regulations and requirements to the attending physician or prescribing practitioner. Number 3. Evaluate current Antibiotic Stewardship Program to ensure through use of infection assessment tools, monitoring of antibiotic use, and feedback and education to prescribers that unnecessary antibiotic use ix [sic] not taking place. 1. Review of R18's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 2/4/2024 located in the RAI (Resident Assessment Instrument) tab of the electronic medical record (EMR), for Section C (Cognitive Patterns) revealed R18 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating cognition was intact; Section I (Active Diagnoses) indicated R18 had no infections and Section N (Medications) indicated R18 was taking an antibiotic. Review of R18's Urine Culture, dated 5/17/2023, located in the EMR under the Resident Document tab, revealed results Greater than 100,000 colony forming units per ml [milliliter]. Susceptibility profile is consistent with a probable ESBL [Extended-spectrum beta-lactamases] (an enzyme produced that is resistant to some antibiotics due to the overuse or long-term use of antibiotics). Review of R18's Urine Culture, dated 11/13/2023, located in the EMR under the Resident Document tab, revealed results Greater than 100,000 colony forming units per ml and a handwritten note Cipro 500 mg [milligram] BID [twice daily] x [times] 10 days. Review of R18's Progress Notes, dated 10/2/2023 to 11/13/2023, located in the EMR under the Progress Note tab, revealed no urinary tract infection (UTI) symptoms documented. Review of R18's Progress Note, dated 11/18/2023, located in the EMR under the Progress Note tab, revealed Resident continues on observation related to ABT [antibiotic] for UTI, no adverse reactions observed. No complaints of pain, itching, or burning with urination. Fluids encouraged and tolerated well. Review of R18's Progress Notes, dated 11/13/2023 to 12/4/2023, located in the EMR under the Progress Note tab, revealed no UTI symptoms documented. Review of R18's Order, dated 12/4/2023, located in the EMR under the Order tab revealed Macrobid (nitrofurantoinmonohyd/m-cryst) capsule; 100 mg; amt [amount]: 1 cap; oral Special Instructions: Prophylactic for UTI At Bedtime 9:00 pm. Review of R18's Consultant Pharmacist Communication to Physician, dated 12/5/2023, located in the EMR under the Resident Document tab, revealed Patient is currently receiving Macrobid routinely to prevent UTI. Prophylaxis of UTI in the elderly nursing home is not recommended due to increased exposure to side effects and the possible development of resistant strains of bacteria. Can we please consider D/C [discontinue] of the Macrobid at this time? If the current therapy is continued, please document the reasoning below, and that the risks vs. [versus] benefits have been considered. The only remark was a handwritten note No Change. Review of R18's Care Plan located in the EMR under the RAI tab revealed no care plan for urinary tract infection or antibiotic use. During an observation and interview on 3/26/2024 at 12:03 pm, R18 was observed in bed dressed and groomed eating lunch. R18 was asked about her medications. R18 stated she got her medications on time but did not recall what medications were. When R18 was asked about pain or discomfort, she stated she didn't have any. During an interview on 3/28/2024 at 12:15 pm, the Infection Preventionist (IP) was asked why R18 was on an antibiotic. The IP stated R18's family requested she be on a prophylactic antibiotic for recurring UTIs. The IP was asked what symptoms R18 exhibited. The IP stated mental change and dysuria. The IP was asked if a family request for prophylactic antibiotic was per their antibiotic stewardship program. The IP then stated, no. The IP stated they ran it by the doctor, and he prescribed it. The IP was asked for their UTI policy and at 2:37 pm the IP confirmed the facility didn't have a policy for UTI, just a general infection control policy that didn't address UTI. During a follow up interview on 3/28/2024 at 3:47 pm, the IP stated the last urinalysis (UA) that was performed on R18 was in November of 2023. The IP was asked if she discussed the antibiotic stewardship program with the medical director. The IP stated, yes in the past. The IP was asked if she educated the family about the overuse of antibiotics. The IP stated, yes, but they still want it prescribed. The IP confirmed R18 had ESBL. The IP stated she was aware there was no need necessarily to obtain a UA if R18 was asymptomatic. During a telephone interview on 3/28/2024 at 4:10 pm, Nurse Practitioner (NP) 2 stated R18 was his patient and it had been about 30 days since he saw her last. NP2 confirmed R18 had an antibiotic ordered for back-to-back UTIs. NP2 stated, the patient must have four or more UTI to be prescribed a prophylactic antibiotic, even if the culture came back without anything. NP2 went on to say if the resident was still complaining of symptoms, he would still prescribe an antibiotic. NP2 was asked what symptoms R18 was complaining about. NP2 stated he couldn't answer that because he didn't have R18's record in front of him. NP2 was asked if he was aware R18's family had requested the antibiotic. NP2 stated, sometimes the family may know better and so we prescribe an antibiotic. NP2 was asked if the facility's IP shared with him their antibiotic stewardship program. The IP stated, yes, we know about it. NP2 was asked if he was aware R18 had ESBL. NP2 stated, No, he didn't recall that. NP2 was asked if this was an appropriate application of the antibiotic or was it against the antibiotic stewardship program. NP2 then stated, usually if we have a patient with three to four UTIs, we decide to do something and prescribe an antibiotic prophylactically, but not just for one [UTI]. 35693 2. Review of R1's undated Resident Face Sheet located in the Face Sheet tab of the EMR, revealed R1 was originally admitted with diagnoses that included chronic kidney disease, stage three (moderate), and metabolic encephalopathy. Review of the quarterly MDS located in the EMR under the MDS tab with an ARD of 1/25/2024, for Section GG (Functional Abilities and Goals) indicated R1 required maximal assistance to total dependence on staff for activities of daily living; Section C (Cognitive Patterns) indicated R1 was staff rated as having moderate cognitive impairment. Review of the most recent Comprehensive Care Plan, located in the resident EMR under the Care Plan tab with a problem start date of 7/24/2019, revealed a focus area for urinary incontinence, with interventions to keep resident clean and dry. R1 was also care planned for hospice services with a start date of 7/30/2020, and interventions that resident would experience death with dignity and physical comfort and advanced directive wishes would be honored. Review of discontinued orders located in the EMR under the Orders tab revealed the following order with a start date of 11/13/2023 and an end date of 11/20/2023: Macrobid 100 mg (antibiotic) every 12 hours for diagnoses of UTI. Review of progress notes from 11/8/2023 to 11/24/2023 indicated R1 received antibiotic therapy for a UTI but there were no progress notes related to R1's UTI symptoms or work up. Review of provider notes for the time frame surrounding the start of the antibiotic did not reveal any provider notes dated 11/13/2023. Review of hospice notes for the time frame surrounding the start of the antibiotic did not reveal any hospice notes dated 11/13/2023. Review of laboratories for R1 did not reveal any laboratory results for a urinary tract infection near the date of the antibiotic order. Review of an Event Report for R1 located in the EMR under the Events tab, dated 11/13/2023 revealed the IP had completed the Infection Tracker with McGeer's Criteria. The assessment indicated R1 had no fever, dysuria, or abnormal urinalysis to warrant antibiotic therapy. The assessment indicated R1 was not a candidate for antibiotic therapy. During an interview on 3/28/2024 at 7:09 pm, the IP stated she had completed the McGeer's Criteria for R1 and acknowledged that it indicated there was no dysuria, no fever, no leukocytes, no urinalysis, and that the score at the bottom of the assessment for R1 did not meet criteria for a UTI. The IP stated she looked everywhere in the R1's chart for any documentation of any symptoms that R1 may have had to indicate treatment for a UTI, and she could not find any documentation. She reviewed R1's hospice notes, laboratories, and provider notes, located in the EMR and acknowledged there were no notes in the EMR around the date and time of the antibiotic order. The IP stated she did not collaborate with the hospice staff on the antibiotic initiation, and was unaware of the antibiotic initiation, because the hospice nurse has access to the EMR and entered the order from the hospice doctor directly into the EMR without any secondary verification from facility nursing staff. The IP added that the hospice doctor would not order laboratories, imaging, or anything invasive because the residents were on hospice for comfort issues. The IP acknowledged there was no justification for the antibiotic.

Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Maintenance of Medical Records, the facility failed to ensure a complete and accurate Medication Administration Record (MAR) for one of 36 sampled Residents (R) (R32). Findings include: Review of the facility's policy titled, Maintenance of Medical Records, last reviewed 1/11/2024, revealed It is the policy of [Name] and its affiliated entities (collectively, the Organization) to maintain a medical record for each patient/resident in the healthcare center/agency that is to be accurate, complete, and systematically organized. Review of the Resident Face Sheet for R32 located in the Face Sheet tab of the electronic medical record (EMR), revealed R32 admitted with diagnoses that included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 8/13/2023 for Section C (Cognitive Patterns) indicated R32 had a Brief Interview of Mental Status (BIMS) score of 14 indicating R32 was cognitively intact; Section O (Special Treatments, Procedures, and Programs) indicated R32 received oxygen therapy while a resident and within the last 14 days prior to the ARD. Review of the Annual MDS located in the EMR under the MDS tab with an ARD of 1/13/2024 revealed R32 had a BIMS score of 14 indicating R32 was cognitively intact. Review of R32's most recent Comprehensive Care Plan located in the resident EMR under the Care Plan tab with a problem start date of 10/26/2020 and last reviewed 3/22/2024, revealed a focus area for oxygen use as needed related to congestive heart failure, with interventions which included oxygen two liters via nasal cannula as needed for shortness of breath and notify MD (Medical Doctor) of any changes in oxygen use .oxygen use as needed. Review of R32's discontinued orders located in the EMR under the Orders tab revealed the following order with a start date of 12/19/2020 and a discontinuation date of 2/12/2023: Oxygen at two liters per minute via nasal cannula as needed for shortness of breath. Review of R32's active orders located in the EMR under the Orders tab revealed the following order with a start date of 2/12/2023 and an end date of Open Ended: Oxygen at two liters per minute via nasal cannula as needed for shortness of breath. Review of documentation of R32's oxygen saturations, dated 1/1/2024 to 3/28/2024 and located in the EMR under the Vitals tab, revealed R32 used oxygen therapy nearly every day. Review of R32's MAR for the months of January 2024, February 2024, and March 2024 revealed R32 was not marked as having received oxygen therapy. During observations on 3/25/2024 at 10:19 am, R32 was observed using oxygen via nasal cannula. During an interview on 3/27/2024 at 8:08 am, Licensed Practical Nurse (LPN) 4 stated R32 usually kept oxygen on all the time. During an interview on 3/27/2024 at 8:16 am, Certified Nurse Aide (CNA) 6 stated R32 almost always used oxygen. During an interview on 3/27/2024 at 8:34 am, CNA7 stated R32 used oxygen pretty much around the clock. During an interview on 3/28/2024 at 1:21 pm, R32 stated she used oxygen all the time except when she ate her meals. She stated she had been on oxygen since she left the hospital. During an interview on 3/28/2024 at 4:54 pm, the MDS Coordinator (MDSC) reviewed the MARs for January, February and March 2024 and acknowledged the MARs did not indicate R32 received oxygen therapy. The MDSC reviewed the oxygen saturation documentation for the months of January, February, and March 2024. She acknowledged that the oxygen saturation documentation indicated R32 used oxygen regularly and that the MARs should have been marked for administering oxygen therapy for R32. Cross Reference F641

Based on observations and interviews, the facility failed to protect the residents right to privacy and dignity for two of four residents (R) (R#50 and R#78), by not ensuring one of three Licensed Nurse's observed during morning medication pass, knocked on residents door and asked permission before entering room to administer medications. Findings: 1. Review of the clinical record for R#50 revealed she was admitted to the facility on [DATE] with diagnoses consisting of chronic obstructive pulmonary disease (COPD), urinary tract infection (UTI), hypertension (HTN), and depression. Review of the residents most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental status (BIMS) score of 7, indicating severe cognitive impairment. Observation on 3/1/2023 at 8:21 a.m. Registered Nurse (RN) BB prepared 9:00 a.m. medications for R#50. She went to room [ROOM NUMBER] to administer R#50's medication. She entered the resident's room without knocking or asking permission to enter. 2. Review of clinical record for R #78 revealed she was admitted to the facility on [DATE] with diagnoses consisting of transient cerebral ischemic attack (TIA), end stage renal disease (ESRD), type 2 diabetes, systolic heart failure, and chronic atrial fibrillation. Review of the residents most recent quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment. Observation on 3/1/2023 at 8:27 a.m. RN BB prepared 9:00 a.m. medications for R#78. She went to room [ROOM NUMBER] to administer R#78's medication. She entered the resident's room without knocking or asking permission before entering. Interview on 3/1/2023 at 9:14 a.m. with RN # BB revealed she is supposed to knock on resident room doors before entering and stated that she was just nervous about surveyor watching her, and she forgot to knock. Interview on 3/1/2023 at 9:22 a.m. Director of Health Services (DHS) stated her expectation is that all staff are to knock and/or announce themselves before entering a resident's room.

Based on observations, interviews, and review of facility policies titled Infection Prevention and Control Plan, and Medication Administration: General Guidelines, the facility failed to demonstrate proper infection control practices as evidenced by one of three Licensed Nurse's observed during medication administration, handling medications with her bare hands and placing them in medication cups, for administration to resident. Findings: Review of the policy titled Infection Prevention and Control Plan, reviewed 10/11/2022, revealed the plan outlines the framework by which the facility will assess, implement, and evaluate an active, effective, comprehensive facility-wide 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; and limit costs of care attributable to infections. Program Objectives: 9. Continuous education for all partners relating to infection prevention and control, with emphasis on hand hygiene, respiratory etiquette, transmission of infectious diseases, OSHA bloodborne pathogen standards, tuberculosis and its mode of prevention/transmission, standard and transmission-based precautions, and susceptibility of residents to infectious diseases. Review of the policy titled Medication Administration: General Guidelines reviewed 5/20/2022, revealed the policy is medications are administered in accordance with good nursing principles and practices. Procedure 23. If breaking tablets is necessary to administer the proper dose, hands are washed with soap and water or alcohol gel prior to handling tablets (preferably gloves should be worn). Observation on 3/1/2023 at 8:57 a.m., Licensed Practical Nurse (LPN) II during morning medication pass, prepared the prepackaged medications and placed into a clear medicine cup. She then retrieved an over the counter floor stock medication bottle of enteric coated Asprin 81 milligrams (mg) from the top drawer of the cart. She removed one Aspirin tablet from the bottle with her bare fingers and then placed it in the medication cup, and replaced the bottle back in the drawer. She then retrieved a floor stock bottle of FeroSul 325 mg, from the top drawer of the cart, and removed one tablet from the bottle with her bare fingers and placed it into the same medication cup with all the residents' other morning medications. Interview on 3/1/2023 at 9:12 a.m. with LPN II, stated she was not supposed to be picking the medications out of the bottle with her bare fingers or hands. She stated that she should have poured medications in the bottle cap, and then poured the required number of pills into the medicine cup. She stated that she knew better, and that she was just nervous. Interview on 3/1/2023 at 9:14 a.m. with the Director of Health Services (DHS), revealed nurses are not to be passing medication and handling floor stock medications with hands. She stated that LPN II should have poured the prescribed number of pills into the cap of the bottle and then poured them into the medicine cup.

Based on observation, staff interviews and facility policy review, the facility failed to prepare, distribute, and serve food under sanitary conditions. Dietary staff were observed touching plates, utensils, cups and containers with contaminated gloves used to serve the food to 122 out of 123 residents. A dietary aid touched the tops of two resident's plastic ware. Also, during the observation, a dietary cook performed a test strip on the three-sink sanitizer inappropriately. The practice of improper utensil, food handling, glove use, and improper testing of the three-sink sanitizer had the potential to affect residents eating in the facility. The sample size was 27 residents. The resident census was 123. Findings include: On 8/2/17 at 425 p.m., during an observation of the kitchen evening meal service the following was observed: 1. When first entering the kitchen, Dietary Aide (BB) was observed to wear his beard net below his chin rather than covering his face where the beard area would be covered. 2. At 4:30 p.m., the Assistant Dietary Manager (ADM) and three Dietary Aides (AA, BB and CC) were all observed to put on gloves without washing their hands. 3. At 4:30 p.m., Dietary Aide BB was observed to put on gloves without washing his hands and carried a stack of plate warmers in which the rims of the plate leaned up against his stained shirt. 4. At 4:35 p.m., Dietary Aides AA and CC were bringing in dishes and desserts and set to serve them for the evening meal. They continued to gather items while wearing the same gloves. 5. At 4:40 P.M., the ADM was going to different areas of the kitchen gathering utensils to put into the containers that would be used for service. ADM continued to wear the same gloves throughout the prep process. 6. At 4:45 p.m., service of the evening meal began. Four of the Dietary staff continued to serve the meals in the same gloves they had on while performing the prep. 7. At 4:45 p.m., Dietary Aide CC was seen leaning on a clean service with the same gloves worn throughout the gathering of dishes and food items. 8. At 4:45 p.m., Dietary Aide CC performed a glove change but did not wash hands. 9. At 4:55 p.m., Dietary Aide CC was observed to be in the dirty area placing some dirty dishes on the rack for washing. Another staff member asked Dietary Aide CC to fetch some ice cream and bring a towel to the service line so spilt food could be wiped up. Dietary Aide CC left the dirty area with his gloves on and brought the towel to the ADM who proceeded to wipe the food up with the towel did not change gloves after doing so. Dietary Aide CC proceeded to the freezer and brought in the ice cream in a box and gave them to Dietary Aide AA. Neither dietary staff changed gloves. 10. At 5:00 p.m., Dietary Aide BB was observed to be adjusting his beard net as he was preparing trays for the residents in the dining room. 11. At 5:05 p.m., ADM was observed to have hair hanging outside the hair net and continued. 12. At 5:13 p.m., Dietary Aide AA was observed to touch utensils on the top of the utensils in which the residents would place in their mouths. 13. At 5:20 p.m., Dietary Aide CC was observed to take the 400 hall carts out while wearing gloves. He returned wearing gloves. He prepared to take out the rehabilitation cart while wearing the same gloves. 14. At 5:30 p.m., the ADM was observed to reach down and pull up her pants while wearing the gloves she had been plating the residents food. 15. At 5:35 p.m., Dietary Aide CC was observed to place cups into bags. As Dietary Aide CC pulled on the bag to place it in the bag, Dietary Aide CC braced the cup rim up against his stained shirt. 16. At 5:40 p.m., the Dietary Cook was asked to perform the sanitizer check with the test strip. The Dietary Cook tore off a piece of the test strip. The Dietary Cook than stuck the strip in the first sink with suds. The Dietary Cook then proceeded to test the middle sink with the same strip. After dipping it in then she moved over to the third sink with the sanitizer. She then dipped the strip in and pulled it back out. Then the Dietary Cook tried to match up the color of the strip to the color chart on the bottle. She stated, it was at 100 parts per million (ppm), but the color did not match. When asked if the test strip was done correctly and left in long enough. The Dietary Cook stated, it was done the way she was trained. On 8/2/17 at 5:45 p.m., the Dietary Manager (DM) was asked if it met her expectation staff did not wash hands prior to wearing gloves and serving the meal. The DM stated, the staff should have washed hands prior to putting on gloves. The DM also stated, staff should be changing gloves and washing hands as they move on to different tasks. The DM was asked if gloves should be worn out of the kitchen and upon returning to the kitchen. The DM stated, No, that was unacceptable. Gloves should not be worn from the kitchen when leaving and hands should be washed upon return to the kitchen. When asked if staff should carry the dishes against themselves the DM stated, no that should not be happening. The DM was told staff had touched the top of two sets of utensils. The DM stated that was, unacceptable. Then the DM was told how the cook performed the test strip for the sanitizer. The DM indicated it was not the appropriate way to check the sanitizer and then stated, The sanitizer has to be checked with the strip, not all three sinks. It should come out to 100ppm (part per million) and at 110 degrees Fahrenheit. Review of the facility's policy titled, Handwashing, reviewed date 04/14/2016, revealed, .Policy Statement: It is the policy of (name of facility) to prevent the spread of bacteria which may lead to foodborne illness by using proper hand washing techniques. Review of the facility's policy titled, Pot/Pan Washing and Sanitation, reviewed date 04/11/2016, .Policy Statement: It is the policy of (name of facility) that equipment and utensils are cleaned and sanitized appropriately after use to maintain a clean and sanitary environment for food preparation Pots, pans, and utensils must be sanitized in the sanitizer sink according to the following methods: Chemical Sanitizers: Chlorine concentration is 50-100 ppm and has a 75 degrees Fahrenheit-110 degrees Fahrenheit water temperature with a one minute immersion, .Quaternary concentration is to be 200-300 ppm's, .Test strips should be available to check the sanitizer level before each use. On 4/3/17 at 9:00 a.m., the DM was asked if there were any other pertinent policies and the DM stated, No.

Based on observations, staff interviews, and facility policy review the facility failed to arrange and store medications and biologicals properly in three of six facility medication storage carts. Three of six facility medication storage carts contained multiple medication and biological types and routes (eye medication, nose medication, oral medication/s, injectable, inhalation medication, topical ointment medications and alcohol soaked pads) stored unseparated in the same resident compartment drawer/s. The sample size was 27 residents. Findings include: Review of the facility's policy titled, Medication Storage in the Healthcare Centers, reviewed date 1/9/17, revealed, Policy Statement: .Medications and biologicals are stored safely, securely, and properly . Further review of the policy revealed, Procedure: .4. The Consultant Pharmacist will monitor storage of medications by performing a review of storage areas at least quarterly. 5. Types of medications and routes of administration are stored separately. 6. Potentially harmful substances (e.g., urine test, reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in a locked area and separated from medications . An audit of 400, 500 and 600 Hall medication carts conducted on 8/1/17 at 9:27 a.m. and 10:22 a.m., revealed multiple resident compartment drawers had a combination of different types and routes of medications and/or biologicals stored in the same drawer compartment/s. Interview with Licensed Practical Nurse (LPN) AA on 8/1/17 at 9:27 a.m., revealed she rearranged and organized the resident's medications by room number and container/s. She indicated it was acceptable to place multiple types and routes of medications and biologicals in the same drawer compartment/s of the medication cart and could not recall what the facility policy stated. Interview with Licensed Practical Nurse (LPN) BB on 8/1/17 at 10:22 a.m., revealed medications types and routes stored together in the same drawer compartment/s of the medication cart was acceptable and there was no specific area designated for different routes of medications and/or biologicals. LPN BB further stated, this is how we do it and she thought it was up to each nurse on how to store and arrange the resident compartment drawers. Interview with the Consultant Pharmacist (CP) on 8/1/17 at 10:45 a.m., indicated his expectation was if the different types and routes of medication/s and/or biological/s were in pharmacy supplied bottles or manufacturers packaging, it was ok to store them together in the same resident compartment drawer/s. He further indicated he knew he had a policy on medication storage, however was not sure if how to store the medication/s and biological/s in the medication cart/s was specified in the policy. Interview with the Director of Health Services (DHS) on 8/1/17 at 3:25 p.m., revealed her expectation for the storage of different types and routes of medication/s and biological/s in the medication cart/s for each resident was in correlation with the CP expectations as stated in his interview. She further indicated she had discussed this issue with the CP, however was not aware of the details of the facility's policy on medication and biological storage. She did however acknowledge best practice was, different types and routes of resident medication/s and/or biological/s should be stored and arranged separately for the safety of the residents. The DHS continued to indicate she would do an audit of all the medication carts, correct any resident drawers where multiple medications and biologicals were stored in combination by separating them, educate all the facility nurses and monitor the medication carts for correct storing of medications and biologicals going forward. (F431) . It is important that the facility implement procedures that address and monitor the safe storage and handling of medications in accordance with manufacturers' specifications, State requirements and standards of practice (e.g., United States Pharmacopeia (USP) standards). In accordance with the United States Pharmacopeia Standards (USP), who references the Institute for Safe Medication Practices (ISMP) states, .Use shelf dividers to separate all mediations. Cluttered shelf stock and drawers increase the possibility of picking errors. It is important to separate each medication in stock and never place multiple different mediations in the same shelf bins.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure the proper handling and transporting of soiled linens to minimize contamination as observed during one of two lunch services in the dining room. Observation was noted of one Dietary Aide dragging two plastic bags of soiled kitchen cleaning rags across the dining room floor while 25 residents were eating lunch. The sample size was 22. Findings include: Review of the facility's policy titled, Infection Control-Linen and Laundry Services dated reviewed 4/20/17, revealed the Scope of the policy was, .This policy applies to all healthcare centers in the organization. The Procedure section of the policy stated, .Routine Handling of Soiled Linen: .1. All soiled linen will be treated as potentially infectious. 2. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling the linen . There was no policy/s or guideline/s provided specifically for the dietary staff in relation to handling and transporting of clean or soiled linens. Observation on 7/31/17 at 1:25 p.m., revealed Dietary Aide DD drug across the floor two large plastic bags with soiled kitchen rags from the kitchen preparation area through the dining room to the laundry room while residents were eating lunch. Interview with the Laundry Services Aide (LSA) on 7/31/17 at 1:45 p.m., revealed dietary staff were to transport soiled kitchen linens through the dining room after all resident meals were completed. She further indicated the dietary staff normally brought the soiled kitchen linens at 10 p.m. for the third shift laundry staff to wash. Interview with the Assistant Dietary Manager (ADM) on 7/31/17 at 1:50 p.m., revealed each dietary staff member had a specific duty assigned to them daily depending on their shift worked. She further revealed there were no formal schedules made, only staff to staff verbal communication of each duty. When asked about Dietary Aide DD transporting the bags of kitchen soiled linens across the dining room floor during lunch meal, the ADM stated, she should have walked around the back of the kitchen to transport soiled linens, especially if residents were eating in the dining room, its unsanitary. When asked if Dietary Aide DD was aware of the proper process on how to transport soiled kitchen linens during dining service, ADM stated, Yes, everyone is aware of their assigned duties and how to perform them. Interview with the Director of Health Services on 8/3/17 at 9:40 a.m., revealed staff should not be dragging bags of soiled linens across the dining room floor during meal time. Interview with Dietary Aide DD on 8/3/17 at11:18 p.m., revealed It was normal practice to transport dirty linens to the laundry room regardless of meal service. She further stated she had not been told or trained until 8/2/17 about the improper practice of transporting dirty linens during meal times. She stated No one ever told them to transport dirty linen through the back door and not through the dining area.

Based on observations, record reviews, review of the facility policy and procedure entitled Restraint Use, Long Term Care, and staff interviews, the facility failed to ensure residents were free from restraints unless medically necessary. This affected five (5) residents, (#72, #15, #186, #199, and #108) from a sample of twenty-one (21) residents who were observed wearing a self-releasing Velcro waist band the duration of the survey. Findings include: On 09/23/15 at 10:15 a.m., an interview with HH , Licensed Practical Nurse, (LPN), Unit Manager, revealed morning rounds are made inclusive of the following employees; Director of Health Services (DHS), Minimal Data Set (MDS) Coordinator, Social Services Director, Education Coordinator, and all of the Unit Managers. During these rounds, recent falls and wandering episodes are discussed. Self -releasing Velcro waist bands are placed on certain residents as a safety intervention on an as needed basis. After placement of the physical device, there is not a systematic way each resident is re-assessed to determine if the waist band is still required; determination is made on a case by case basis. The determination is based on staff observations if the resident attempted to get up from the wheelchair or fidgeted with their waist belt. On 09/23/15 at 11:00 a.m., an interview with II , Assistant Director of Health Services (ADHS), stated she would provide the survey team with a list of all residents that use the self-releasing Velcro waist band and the rationale basis for each device. This surveyor asked the ADHS to please include on the list those that can release it themselves ; ADHS responded, I hope they all can. On 09/24/2015 4:03 p.m. an interview with the DHS stated her definition of a restraint was Anything that impairs body movements. When asked her to define limitation of movement, she responded, it's in the policy. 1. Resident #72 (R #72) was an eighty-six (86) year old Caucasian female admitted to this facility on April 13, 2007 with a [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] Disease. Review of the Quarterly Minimal Data Set (MDS), reference date 06/29/15, Section P. Restraints: revealed no documented use of restraints. R #72 had a Basic Intellectual Mental Status (BIMS) score of 99, which indicated she was not cognitive to person, place, time or location. R #72 was observed sitting in the hallway in her wheelchair with a self-releasing Velcro waist band secured in place on the following dates and times: 09/21/15 at 10:30 a.m. 09/21/15 at 02:30 a.m. 09/22/15 at 11:00 a.m. 09/22/15 at 02:00 p.m. 09/22/15 at 04:30 p.m. 09/23/15 at 07:30 a.m. On 09/23/15 at 04:37 Resident #72 was asked if she could undue her belt for this surveyor, the Center Medicaid/Medicare (CMS) Federal surveyor and the DHS; the resident is non-verbal and did not respond verbally or physically. The resident gave no indication she cognitively understood the request. Review of the Resident #72 ' s care plan revealed the potential for falls related to a history of falls, [MEDICAL CONDITION] medication use and decreased mobility. She was to be monitored for safety with assistive device use. Her care plan listed several interventions as assisted devices which were less restrictive than the use of a self-releasing Velcro waist band. The other interventions listed were a clip alarm and forward tip device to a reclining wheelchair. No Physician order for [REDACTED]. Review of the Initial/Annual Observation for a Physical Device form, reference date 09/01/2015, under the Classification of the Device heading documented that the resident was unable to release the device easily. On 09/24/2015 3:29 p.m., an interview with this resident ' s primary Certified Nursing Assistant (CNA), JJ ,revealed, Resident #28 rocks in her seat and the seat belt reminds her to stop rocking so she will not fall forward. This resident had forward tip devices on her reclining wheelchair listed as one of the interventions. In addition, JJ , further stated that R #72 transfers with a pivot and a two (2) person assist. 2. Resident #15 was a ninety (90) year old Caucasian female admitted to this facility on June 06, 2012 with a [DIAGNOSES REDACTED]. Review of the MDS, reference date 08/27/15, Section P. Restraints: revealed no documented use of restraints. Resident #15 had a BIMS score of 05, which indicated she was limited in her processing of cognition to person, place, time or location. On 09/24/2015 10:48 a.m. Resident #15 was observed seated in her wheelchair with a self-releasing Velcro waist band secured. Resident #15 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the resident's care plan revealed she was at risk for falls related to her debility, [MEDICAL CONDITION], sensory deficits, lumbar stenosis, osteopenia, and [MEDICAL CONDITION]. She was to be monitored for safety with assistive device use. Her care plan listed several interventions as assisted devices which were less restrictive than the use of a self-releasing Velcro waist band. The other interventions listed were patient educated not to stand for long periods of time, chair alarm, clip alarm to wheelchair, Dysem Cushion to wheelchair, and non-skid socks. No Physician order for [REDACTED]. Review of the Initial/Annual Observation for a Physical Device form, reference date 08/19/2015, under the Classification of the Device heading documented that the resident was unable to release the device easily. In addition, no medical symptoms or problems were listed regarding the rationale as to why physical devices were considered. The resident was able to stand for short periods of time. The documentation for a family signature, responsible party or the resident regarding notification of this device was blank. Interview on 09/24/2015 at 3:53 p.m., with LL , CNA, revealed R#15 required a bed alarm and clip alarm, both devices reminded her she cannot walk and is also used to alert the staff R #15 is attempting to get up. 3. Resident # 186 (R #186) was a seventy-eight (78) year old Caucasian female admitted to this facility on October 04, 2013 with a [DIAGNOSES REDACTED]., [MEDICAL CONDITION], and Gastrointestinal [MEDICAL CONDITION] Reflux (GERD). Review of the MDS, reference date 06/29/15, Section P. Restraints: revealed no documented use of restraints. R #186 had a BIMS score of 99, which indicated she was not cognitive to person, place, time or location. On 09/24/2015 11:48 a.m. R#186 was observed seated in her wheelchair with a self-releasing Velcro waist band secured. R #186 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the R #186 ' s care plan revealed she was an elopement risk. Her location was to be monitored. The only assisted physical device listed on the care plan was a Wander guard bracelet. The self-releasing Velcro waist band was not listed on the care plan. No Physician order for [REDACTED]. Review of the Initial/Annual Observation for a Physical Device form, reference date 09/15/2015, under the Classification of the Device heading documentation regarding the resident ability to release the device easily the response No was scratched out and was changed to a Yes. The documentation for a family signature, responsible party or the resident regarding notification of this device was blank. Interview on 09/24/2015 at 3:25 p.m. with NN, CNA, revealed Resident #186 was 2 person assist for transfers and she was not ambulatory and did not attempt to get up. NN stated, If Resident #186 attempted to get up, she would redirect her. 4. Resident # 199 (Resident #199) was an eighty (80) year old Caucasian female admitted to this facility on June 26, 2015 with a [DIAGNOSES REDACTED]. Review of the Admission MDS, reference date 07/03/2015, Section P. Restraints: revealed no documented use of restraints. R #199 had a BIMS score of 99, which indicated she was not cognitive to person, place, time or location. On 09/24/2015 11:48 a.m. Resident #199 was observed seated in her wheelchair with a self-releasing Velcro waist band secured. Resident #199 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the resident's care plan revealed she was an elopement risk. Her location was to be monitored. The only assisted physical device listed on the care plan was a Wander guard bracelet. Review of the Resident #199 ' s care plan revealed she is at risk for injury from falls related to a history of falls, Alzheimer's Dementia, and poor safety awareness. On the care plan is was documented the resident had a fall with injury on 09/17/2015 and the alarming seat belt was secured to the wheelchair for safety. No Physician order for [REDACTED]. Review of the Initial/Annual Observation for a Physical Device form, reference date 09/19/2015, under the Classification of the Device heading documented that the resident was unable to release the device easily. In addition, no medical symptoms or problems were listed regarding the rationale as to why physical devices were considered. The resident was able to stand and walk for short periods of time. The documentation for a family signature, responsible party or the resident regarding notification of this device was blank. Interview on 09/24/2015 at 3:35 p.m., with KK , the resident ' s primary CNA, revealed R #199 is now a 2 person assist for transfers, however, when R #199 arrived at the facility she was able to stand on her own only required assistance to walk to the bathroom. She further stated the Wander guard and the seat belt helps keep her from sliding out of wheel chair. R #199 does not attempt to get out of her chair, she plays or fidgets with belt and until it comes undone, she does not purposefully undue her seat belt. 5. Resident #108 (Resident #108) was a ninety-two (92) year old Caucasian female readmitted to this facility on June 18, 2007 with a [DIAGNOSES REDACTED]. Review of the MDS, reference date 07/29/15, Section P. Restraints: revealed no documented use of restraints. R #108 had a BIMS score of 03, which indicated she was limited in her processing of cognition to person, place, time or location. On 09/24/2015 11:05 a.m. Resident#108 was observed seated in her wheelchair with a self-releasing Velcro waist band secured. Resident #108 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the Resident #108's care plan revealed she was at risk for injury from falls related cognitive deficits and decreased mobility. She was to be monitored for safety with assistive device use. Her care plan listed several interventions as assisted devices which were less restrictive than the use of a self-releasing Velcro waist band. The other interventions listed were maintain proper shoe size, non-skid socks, anti-lock brakes to wheelchair, sensor alarm to bed. Wander guard or clip guard or Dysem were not listed on the care plan although all were observed to be utilized for this resident. No Physician order for [REDACTED]. Review of the Initial/Annual Observation for a Physical Device form, reference date 07/28/2015, under the Classification of the Device heading documented that the resident was unable to release the device easily. The documentation for a family signature, responsible party or the resident regarding notification of this device was blank. Interview on 09/24/2015 at 3:39 p.m. with MM, CNA, stated if Resident #108 is in a good mood, she will stand and assist with transfer, she is a 1 person assist. She has a seat belt with an alarm, if she takes the belt off and the alarm goes off. The alarm alerts the staff R #108 is attempting to walk. Review of the facility policy and procedure entitled, Restraint Use, Long-term Care, stated the following: Anything that restricts the freedom of movement is considered a restraint. Federal regulations for long-termcare facilities state that residents have the right to be free from any physical or chemical imposed for purposes of discipline or convenience and not required to treat medical signs and symptoms. Limit restraint use to the least restrictive method needed to address the resident's symptoms and assist him attaining or maintaining his highest practicable level of physical and mental well-being.' Under the heading of Implementation it states the following: Obtain a practioner's order for restraint use. make sure the order includes the type of restraint, duration of time that it can be used, and the signs and symptoms, or behaviors that required the use of a restraint. Don't use an 'as needed' or PRN order for restraint use.

Based on observations,review of individual Minimum Data Set Assessments and staff interviews, the facility failed to adequately assess residents for restraint use. This affected five (5) residents, (#72, #15, #186, #199, and #108) from a sample of twenty-one (21) residents who were observed wearing a self-releasing Velcro waist band the duration of the survey. Findings include: 1. Resident #72 (R #72) was observed sitting in the hallway in her wheelchair with a self-releasing Velcro waist band secured in place on the following dates and times: 09/21/15 at 10:30 a.m. 09/21/15 at 02:30 a.m. 09/22/15 at 11:00 a.m. 09/22/15 at 02:00 p.m. 09/22/15 at 04:30 p.m. 09/23/15 at 07:30 a.m. On 09/23/15 at 04:37 R#72 was asked if she could undue her belt for this surveyor, the Center Medicaid/Medicare (CMS) Federal surveyor and the DHS; the resident is non-verbal and did not respond verbally or physically. The resident gave no indication she cognitively understood the request. Review of the Quarterly Minimal Data Set (MDS), reference date 09/02/15, Section P. Restraints revealed no documented use of restraints. Section G 0400: A: Upper Extremities, one (1) impairment on one side B: Lower Extremities, two (2) impairment on both sides Review of the Census & Condition completed by the facility at the onset of the survey revealed that they have documented 0 restraints. 2. Resident #15 (R #15) was observed in the hallway seated in her wheelchair with a self-releasing Velcro waist band secured in place throughout the survey. On 09/24/2015 10:48 a.m. R#15 was observed seated in her wheelchair with a self-releasing Velcro waist band secured. R #15 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the Quarterly MDS, reference date 08/27/15, Section P. Restraints revealed no documented use of restraints. Section G 0400: No impairment upper and lower extremities Review of the Census & Condition completed by the facility at the onset of the survey revealed that they have documented 0 restraints. 3. Resident #186 (R#186) was observed seated in her wheelchair with a self-releasing Velcro waist band secured. R #186 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the Quarterly MDS, reference date 06/29/15, Section P. Restraints revealed no documented use of restraints. Section G 0400: No impairment upper and lower extremities Review of the Census & Condition completed by the facility at the onset of the survey revealed that they have documented 0 restraints 4. On 09/24/2015 11:48 a.m. R#199 was observed seated in her wheelchair with a self-releasing Velcro waist band secured. R #199 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the Admission MDS, reference date 07/03/15, Section P. Restraints revealed no documented use of restraints. Section G 0400: No impairment upper and lower extremities Review of the Census & Condition completed by the facility at the onset of the survey revealed that they have documented 0 restraints. 5. On 09/24/2015 11:05 a.m. R#108 was observed seated in her wheelchair with a self-releasing Velcro waist band secured. R #108 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the Quarterly MDS, reference date 07/29/15, Section P. Restraints revealed no documented use of restraints. Review of the Census & Condition completed by the facility at the onset of the survey revealed that they have documented 0 restraints. On 09/23/15 at 10:15 a.m., an interview with HH , Licensed Practical Nurse, (LPN), Unit Manager, revealed morning rounds are made inclusive of the following employees; Director of Health Services (DHS), Minimal Data Set (MDS) Coordinator, Social Services Director, Education Coordinator, and all of the Unit Managers. During these rounds, recent falls and wandering episodes are discussed. Self-releasing Velcro waist bands are placed on certain residents as a safety intervention or to hinder elopement on an as needed basis. After placement of the physical device, there is not a systematic way each resident is re-assessed to determine if the waist band is still required; determination is made on a case by case basis. The determination is based on staff observations if the resident attempted to get up from the wheelchair or fidgeted with their waist belt. On 09/24/2015 4:03 p.m. an interview with the DHS stated her definition of a restraint was Anything that impairs body movements. When asked her to define limitation of movement, she responded, it's in the policy.

Based on observation, staff interview, and facility policy review the facility failed to provide service with dignity evidence by provide privacy by ensuring that the privacy curtain was closed during care for one (1) # 28 resident from a total resident sample of forty-six (46). Findings include: Resident # 28 ( R #28), a ninety-nine year old resident was admitted to this facility on December 16, 2009 with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) reference date June 10, 2015, revealed the resident has a Basic Intellectual Mental Status (BIMS) of 99 and has a history of combative physical and verbal behaviors. Observation revealed that during peri-care on 09/13/15 at 11:30 a.m. Resident #28 was exposed from the waist down while staff provided pericare. During this observation resident privacy curtain was not fully closed exposing her to two (2) roommates who was present in the room during care. One of Certified Nursing Assistants (CNA) walked to the side of the bed between the bed and the privacy curtain. As she walked, she brushed against the curtain, opening it more than half way, exposing Resident #28 to her room mates. The CNA made no effort to cover the resident or pull the curtain around the bed. Review of facility policy and procedures Perineal Care of the female patient states provide privacy Interview with Director of Health Services (DHS) on 9/23/15 at 4:00 PM stated staff are educated annually and through compliancy demonstration. She provided the facility 2015 Skills Checklist Perineal Care of the female patient that includes provide privacy. Interview with Assistant DHS on 09/24/15 at 7:00 p.m. revealed that her expectation is for all employees when providing peri-care to provide privacy by closing the door, pulling the curtain and to have all supplies ready prior to beginning peri-care.

Based on record review and interviews, the facility failed to give notice to two (2) B & C of 3 sampled residents when there was a roommate change. The findings include: 1. During an interview on 9/23/15 at 10:00 AM, Resident C stated her most recent room mate came to her room several months ago. She stated she did not know if she got notice she would be getting a new roommate. Record review revealed Resident #66 was moved on 4/27/15 to room [ROOM NUMBER] C. Record confirmed Resident C did not have notice that she was getting a new roommate. 2. Interview with Resident B on 9/24/15 at she stated I have been here 10 weeks and have had numerous roommates and was never given notice. During discussion with Social Worker (SW) confirmed that Resident B was not given notice that she would be getting a new roommate. The SW stated she did not realize it was necessary because the new roommate was a new admit and not being transferred from within the facility. The SW stated it was her impression since rehab had such a turn over, it was not required.

Based on observation, record review and staff interview, the facility failed to develop a care plan for one (1) resident (#100) having been assessed as edentulous from a sample of forty six (46) residents. Findings include: A record review for resident #100 revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 3/15/15 which documented in Section L- Dental/Oral Status the resident has no natural teeth/edentulous. In Section V- Care Area Assessment (CAA) which triggered Dental with the decision to be care planned. A review conducted of the care plans revealed no evidence of a Dental Care Plan. A Review of the Nursing Monthly Observation Form dated 9/3/15 documents Dental Status: Dentures/Removable Bridge they are using daily. An observation conducted on 9/21/15 at 3:39 PM of the resident revealed she has no natural teeth with upper dentures in use. An Interview conducted on 9/23/15 at 11:05 AM with the MDS Coordinator AA confirmed the MDS assessment dated [DATE] identified the resident is edentulous with upper but no lower dentures. She confirmed the CAA triggered dental status with the decision to be care planned, however, no care plan had been developed for Dental Status. She said a modified care plan would be developed for Dental Status.

Based on observations, record review, and staff interviews, the facility failed to ensure residents received the help needed for Activities of Daily Living (ADLs) affecting two (2) residents ('A' and #28) from a sample of forty six (46) residents. Findings include: 1. Resident 'A' complained on 9/21/15 at 2:41pm that her roommate had to help her pull up her pants every morning, that staff were supposed to, but never did. Review of the most recent Quarterly assessment dated [DATE] indicated the resident needed ADL supervision and set up help only. Review of the Care plan updated 7/29/15 indicated resident required limited assist with daily care, including daily grooming and toilet assist. Further review of the Certified Nursing Assistant (CNA) Care Record indicated that resident needed assistance at all times for dressing and grooming. On 9/23/15 at 8:16 am resident observed sitting at bedside in wheel chair fully dressed. Stated roommate assisted with pulling up pants that morning as she did every morning. On 9/24/15 at 8:53 am interview with resident revealed that her roommate had helped pull up her pants that morning. Interview with CNA BB on 9/24/15 at 9:56 am revealed she checked the Care Record on the back of resident's closet door for interventions needed. Also had change of shift report with previous shift. Checked with charge nurse as well to ensure nothing was missed. Feels like resident would probably need help with pulling up pants because she had to hold on with both hands when standing up or transferring, it would be hard to pull up pants while using both hands for balance, but she had not dressed her in a very long time. Night staff usually got resident up. 2. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION],severe dementia. Resident is cognitively impaired. Interview with facility staff QQ nursing assistant on 9/22/15 at 8:42 confirmed the resident does not speak often. He stated she is very combative at times. Review of the Care Plan dated 9/09/15 for ADL's confirmed Resident #28 needed extensive assist with ADL's, can be resistive of care. cognition: dementia with impaired short term memory with disorientation to date, time and place. delusions, hallucinations, talks to self and others who are not there .disorganized thinking. mood: resists care, verbally/physically abusive with staff. LITTLE INTEREST IN DOING THINGS SLEEPING TOO MUCH FEELING TIRED AND TROUBLE CONCENTRATING inappropriate behaviors include: spitting, smearing waste, puts fingers down her throat. incontinence- incontinent of B&B. approaches include monitor for s/s of UTI;use incontinent briefs ; preventive moisture; provide good continent care as needed; call light within reach, change soiled or wet clothing, maintain privacy while providing incontinent care, monitor for reddened or excoriated skin on an ongoing basis. Observation at 09/22/2015 2:43:21 PM , resident room was closed. When surveyor knocked, staff reported they were doing resident care. Interview with QQ (NA) at 09/22/2015 3:11 PM in presence of cart nurse informed us he changed Resident #28 when he came in at 7 am , checked her at 9 am and changed her a little before 3. Interview with staff FF on 09/22/2015 3:36 PM reported to the nurse he did not check or change the resident throughout the day. Interview with nurse DD on 09/22/2015 3:35 PM reported that she was with QQ when he changed her. She reported that her buttocks were excoriated and appeared to be scratched. The treatment nurse stated that she did a treatment to her ankle and applied [MEDICATION NAME], a skin protectant paste with zinc oxide that is ordered to her buttocks. Review of the treatment record shows CHRONIC clean buttocks and pat dry, apply calazome to bilateral buttocks Q day and PRN. Interview with the unit manager on 9/22/2015 at 4:00 PM confirmed facility policy is to check residents every 2 hours for incontinence care and to change when needed.

Based on observation, record review and interviews, the facility failed to to provide appropriate peri-care for 1 ( #28) of 5 sampled residents to prevent urinary tract infections. The findings include: 1. Peri care was observed for Resident # 28, bed 616 A, at 09/13/15 at 11:30 a.m. Performed by staff FF and EE, both CNA's. The Resident was lifted from wheelchair by both CNA's; each CNA placed their arm under her armpit and lifted her. Staff FF grabbed the back of her pants at the waist band to assist with lifting the resident. During lift, red quarter size stain noted on the right buttock of the resident ' s pants. Resident moved to bed on top of clean draw sheet. Curtains & door closed. Staff EE moved to the side of bed, and in doing so, moved the divider curtain more than half the way open. She never re-closed the curtain. The resident was partially exposed to her other roommates throughout the entire peri care observation. Staff EE unfastened the resident ' s briefs, instructed resident to grab the side rail to her right, using a draw sheet she turned the resident onto her right side and lowered brief. While she did this,staff FF removed his gloves and searched for Peri wash throughout the room. After FF found Peri wash in resident ' s bin, he washed hands and pulled gloves on. Staff EE sprayed Peri wash on the wipes & pulled wipes from the container and began wiping the resident from under side of peri area up her buttock. She did not change her gloves. Staff FF assisted the resident to grab the opposite side rails and turned her and lowered her brief and removed her brief. Peri care was never performed on her frontal peri area, red excoriated area in the resident ' s inner thigh folds noted. Resident was very combative, cursing and clawing at her perineum. Her brief was completely removed, noted a 3 x 3 circular purplish area on her right ischium. A 5 x 5 purplish circular area with yellow halo observed on her right trochanter, on left hip area, 3 separate .5 x .5 circular purplish area with long yellow areas below the purplish area on the time of her outer thigh noted. On the left lower back side 4 x 4 circular purplish discolored area noted. Staff EE changed gloves, applied Calamize lotion to buttocks. Gloves removed, hands washed, fresh gloves donned. Resident #28 was moved side to side with draw sheet. Fresh brief applied. Review of the treatment record shows CHRONIC clean buttocks and pat dry, apply calazome to bilateral buttocks Q day and PRN. Interview with the unit manager on 9/22/2015 at 4:00 PM confirmed facility policy is to check residents every 2 hours for incontinence care and to change when needed. Review of the Care Plan dated 9/09/15 for ADL's confirmed Resident #28 needed extensive assist with ADL's, can be resistive of care. cognition: dementia with impaired short term memory with disorientation to date, time and place. delusions, hallucinations, talks to self and others who are not there .disorganized thinking. incontinence- incontinent of B&B. approaches include monitor for s/s of UTI;use incontinent briefs ; preventive moisture; provide good continent care as needed; call light within reach, change soiled or wet clothing, maintain privacy while providing incontinent care, monitor for reddened or excoriated skin on an ongoing basis.