Every finding on record at Pu'Uwai 'O Makaha

Based on observations, staff interview and record review of resident rights, the facility did not secure the biohazard room on the lower nursing unit. As a result of this deficiency, there was increased risk for accident hazards.Findings include:On 07/14/26 at 09:30 AM, observation of the biohazard room on the lower nursing unit revealed the locking mechanism was not functioning and the door was not secured. This surveyor was able to enter the room and there were no staff in the immediate vicinity. The room contained cleaning solutions and two full biohazard bins.During staff interview on 07/14/26 at 09:45 AM, Resident Care Manager (RCM)1 acknowledged the room was not secured and said that they would immediately follow up and secure the room.Review of resident rights read the following: Right to Safety and Quality Care; maintain safe environments, monitor resident's conditions and adjust care plans based on ongoing assessments.

Based on interview and record review, the facility failed to ensure an admission assessment accurately reflects the resident status for two (Resident (R) 65 and R49) of 18 residents sampled. Review of the resident's Minimum Data Set (MDS) documented R65 was coded as being on an anticoagulant, but R65 was on an antiplatelet. Also, R49 was coded and having received insulin, but did not actually receive insulin. Findings include: 1) On 07/14/26 at 12:59 PM, conducted a review R65's Electronic Health Record (EHR). Review of R65's admission MDS with an Assessment Reference Date (ARD) of 06/22/26, Section N, N0415. High-Risk Drug Classes: Use and Indication, E. Anticoagulant was marked yes, indicating the resident was receiving anticoagulant medication. Review of R65's current and discontinued medications did not include an anticoagulant. On 07/15/2026 at 1:08 PM, conducted a concurrent record review and interview with the MDS Coordinator (MDSC) responsible for completing R65's MDS. MDSC reviewed R65's current and admission records, then confirmed the MDS was coded incorrectly and R65 is receiving an antiplatelet, (Brilinta, tricagrelor), not an anticoagulant. 2) R49 was an [AGE] year-old resident admitted to the facility on [DATE] for long-term placement. Diagnoses included but not limited to pneumonia, bacteremia (bacteria in the bloodstream), atrial fibrillation (irregular rapid heart rate) and insomnia. On 07/16/26 at 10:32 AM, a review of R49's EHR was conducted. Review of the admission MDS with an ARD of 06/26/26 under Section N – Medications, indicated that R49 received insulin injections. Review of current and discontinued medications since admission to the facility did not include insulin. Review of hospital discharge summary that included a list of medications administered also did not include insulin. On 07/17/26 at 09:28 AM, a concurrent interview and record review was conducted with Resident Care Manager (RCM)1 at the nurses' station. Queried RCM1 if R49 was ever given insulin before admission or while at the facility. RCM1 reviewed current and discontinued orders, and the Medication Administration Records from the hospital prior to admission and did not find insulin in the list of medications given. On 07/17/26 at 09:38 AM, an interview was conducted with MDS Coordinator (MDSC) in her office. MDSC confirmed that Section N - Medications of the admission MDS was coded incorrectly and that R49 was never received insulin.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plans were revised or updated for two of 18 residents (Resident (R)6 and R10) in the sample. As a result of this deficient practice, staff did not have all the information necessary to effectively provide care for the two residents and placing them at risk of not meeting their highest potential of physical and psychosocial well-being. Findings included: 1) R6 was a [AGE] year-old resident admitted to the facility on [DATE] for long-term placement. Diagnoses included but not limited to diabetes, hemiplegia and hemiparesis (paralysis and weakness on one side of the body), atrial fibrillation (irregular and fast heartbeat) and end stage renal disease (kidney failure). On 07/14/26 at 10:24 AM, observed R6 lying in her bed. R6 had bump on her left forehead and bruises to the left side of her face, forehead and under her chin. Queried R6 how she got the injuries. R6 said she fell off her chair after dialysis (treatment that removes excess fluid and waste from the blood in patients with kidney failure). R6 said she was brought to the hospital after the fall for evaluation and treatment before returning to the facility. When asked what the nurses are doing for the bruises, R6 said they give her pain medication when she needs it. Review of current comprehensive care plan revealed goals and interventions for the monitoring of bruising and signs and symptoms of bleeding but did not include specific interventions for the care of the injuries sustained from the fall. On 07/16/26 at 10:36 AM, a concurrent interview and record review was conducted with Resident Care Manager (RCM)1 at the nurses' station. Asked RCM1 what care was being provided for the bump and bruises R6 sustained from the fall. RCM1 replied they apply cold compress to the bump on her forehead and administer pain medication as needed. Review of current comprehensive care plan conducted and RCM1 confirmed that it did not include specific care to be provided for the bump on her forehead and the bruises to her forehead, face and under her chin. 2) During an observation on 07/16/26 at 10:00 AM, R10 was lying in bed crying and appeared sad and depressed. Review of electronic health record (EHR) showed R10 was admitted [DATE] with diagnosis including stroke, hypertension, anemia, depression, dementia. The most recent comprehensive care plan had interventions for dementia, stroke but did not have anything for depression. Staff interview on 07/16/26 at 10:55 AM, Resident Care Manager (RCM)1 said that the care plan intervention for depression had been previously resolved and not restarted. RCM1 said they would make the necessary correction.

Based on observation, interview, and record review, the facility failed to prevent and manage pain adequately for 1 of 2 residents (Resident (R)8) sampled for pain. Specifically, the facility failed to ensure that R8's narcotic pain medication remained available and in stock for her as needed use and failed to offer her any non-pharmacological interventions in its absence. As a result of this deficient practice, R8 was prevented from attaining or maintaining her highest practicable level of well-being. Findings include:Resident (R)8 is a [AGE] year-old female admitted to the facility on [DATE] for long term care. Her diagnoses include, but are not limited to, polyarthritis (a condition characterized by inflammation, pain, and stiffness in five or more joints simultaneously), acquired (surgical) absence of left leg below knee, chronic post-traumatic stress disorder, and generalized muscle weakness. Review of her most recent Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/09/25, noted a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she had been determined to be cognitively intact. On 07/23/25 at 09:41 AM, an interview was done with R8 at her bedside. R8 reported that she normally has breakfast in her room, then likes to go out to the activity room until after lunch, but that she did not feel up to it today. When asked why, R8 stated that she was experiencing pain in her back, her left shoulder, the back of neck, her right knee, and all of her fingers, and rated her pain level as a 9 out of 10. When asked what she usually takes for her pain, R8 responded that she usually takes Norco (a narcotic containing hydrocodone and acetaminophen), which manages her pain well, but it's been out for a couple days. R8 went on to explain that she also has an acetaminophen order, but it does not help her pain, so she does not ask for it. When asked about non-pharmacological interventions, R8 stated that since her Norco has been out, staff have not offered her anything besides acetaminophen (such as a hot pack or a cold pack, massage, or exercises). R8 also stated that she was not receiving physical therapy but was interested in that to help decrease her pain and increase her mobility. R8 explained that the pain is distracting and causes her to move even slower than she normally does. On 07/24/25 at 09:49 AM, an interview was done with Registered Nurse (RN)2, who confirmed that R8's Norco had been out of stock at least all week. Review of R8's provider orders noted the following physician order: Hydrocodone-acetaminophen (Norco) 5-325 mg (milligram) 1 tablet by mouth every 4 hours as needed for moderate to severe pain (6-10). The order started on 04/07/25 and had no end date. Review of R8's Medication Administration Record (MAR) noted that she was last documented as taking the Norco on 07/21/25 at 01:15 PM. Review of R8's care plan for pain revealed the following planned interventions: Administer medications as ordered. Use non-medicated pain relief measures. application of heat/cold, massage, physical therapy, stretching and strengthening exercises, etc.On 07/24/25 at 02:46 PM, an interview was done with the Director of Nursing (DON) in his office. When asked how far in advance a pain medication should be refilled, DON responded that the expectation is that when 2 days' worth remains, the nurse should initiate a refill to ensure that the medication does not run out. Concurrent review and reconciliation of R8's June/July MARs and her Norco Controlled Drug Records with DON confirmed that R8's Norco had been completely out of stock from 06/11/25 to 06/14/25 and then again from the afternoon of 07/21/25 until the afternoon of 07/24/25. DON expressed surprise that R8's Norco ran out and agreed that it shouldn't have. DON stated that he does expect nurses to offer non-pharmacological interventions especially when the primary intervention is unavailable, and agreed that part of pain management is ensuring medications do not run out. On 07/25/25 at 09:20 AM, an interview was done with R8 in the dining room, where she was smiling and reported that she felt really good and much better now that the Norco was back in stock. R8 went on to share that she had been feeling unwell and extra tired the previous two days, not wanting to move around and participate in activities, and attributed that to being in pain and not having her Norco. Review of the facility's policy and procedure, Pain Management, effective date 02/27/25, revealed the following: In order to help a resident attain or maintain his/her highest practicable level of. well-being. the facility will. Manage or prevent pain, consistent with the. plan of care. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include. decreased participation in usual physical and/or social activities. Decline in activity level.

Based on observation, interview, and record review, the facility failed to ensure 1 of 6 residents (Resident (R)52) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and/or services to increase or prevent further decrease in his mobility. As a result of this deficient practice, R52 was placed at risk of worsening contractures and hindered from reaching his highest practicable well-being. Findings include:Resident (R)52 is a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses include, but are not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting his left side following a stroke, past fracture of the neck of his right femur (top of thigh bone/hip), and contractures (a shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of his left knee and left ankle. Review of his most recent Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/11/25, noted a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating he had been determined to be cognitively intact. On 07/22/25 at 10:48 AM, observations were made of R52 at the bedside as his adult incontinence brief (brief) was being changed. R52 appeared to have a severely contracted left wrist and fingers, a contracted left knee, a contracted left ankle that was mildly twisted, and as Certified Nurse Aide (CNA)3 lifted his left arm to change his gown, his left elbow and left shoulder appeared stiff and contracted as well. None of these joints could be straightened without, or even with, assistance. There were no splints, braces, or orthotic devices of any kind visible on or near R52, or at his bedside. On 07/22/25 at 12:34 PM, an interview was done with CNA3 as she delivered R52's lunch tray. CNA3 confirmed that she was familiar with R52's care, and when asked if he had any splints or braces for his left hand, arm, or leg, she answered that she believed he did but did not know where any of them were. Observed CNA3 check his bedside table, and she confirmed there were no orthotic devices there. CNA3 also confirmed that she had not applied, removed, or seen R52 with any splints or braces on for a while. When asked if he had any splints, R52 stated that he used to have one for his left lower leg but not anymore. On 07/22/25 at 02:41 PM, during a bedside interview with R52, he stated that it had been a long while since he had received any therapy or rehabilitation services for his limited range of motion.On 07/25/25 at 09:30 AM, an interview was done with Physical Therapist (PT)1 who confirmed that she was familiar with R52. When asked if he should be wearing any orthotic devices, PT1 confirmed that R52 should be wearing splints daily on his left arm and left leg. PT1 also stated that the CNAs should be offering to apply R52's splints daily and documenting the application (or his refusal) in his electronic health record (EHR). Review of R52's Comprehensive Care Plan (CP) revealed the following planned interventions: Apply left knee and ankle splints for up to 4 hours in am [morning] and pm [evening] shift. Apply left wrist/hand splint for up to 4 hours in am and pm shifts. neck stretching towards the right, 6 second hold x [for] 5-10 reps [repetitions] per shift. perform BUE [both arms] and BLE [both legs] AAROM [active assisted range of motion]/PROM [passive range of motion] exercises every shift. Perform left elbow, wrist, knee and ankle stretching exercises every shift.On 07/25/25 at 09:53 AM, interviews were done with CNA4 and R52 at his bedside. When asked about R52's splints, CNA4 stated they were kept in a large box on the floor above his bed and that they should be applied daily. When asked to retrieve the splints from the box, observed CNA4 dig into the bottom of the box, full of various items, to get them. CNA4 agreed that if the splints were being applied as they should, they should not be at the bottom of the filled box. When asked if he wears the splints every day, R52 answered, not every day. After being asked when the last time was that he wore them, R52 responded it's been a long time. On 07/25/25 at 10:20 AM, another interview was done with R52. When asked about ROM exercises, R52 stated that no one had done ROM of his arms, legs, or done his neck stretching exercises in a very long while. When they first started doing that [assisted range of motion exercises], it went on for about a week, and it felt really good, but that all stopped long ago, I would love it if they would do that [again]. On 07/25/25 at 10:38 AM, concurrent interview and review of documentation of R52's splint application and ROM exercises was done with the Director of Nursing (DON). DON agreed that with a BIMS of 13, R52 would be able to remember if his ROM exercises were done or if his splints were applied. After reviewing the documentation for the last 30 days, DON could not explain why AAROM and neck stretching was consistently documented as done when the resident stated it was not, or why his splints were documented as applied 4 times in the last 5 days when R52 reported they had not been applied in a long time. DON agreed that ROM/stretching exercises and a consistently applied splinting program would be beneficial for R52 and increase his quality of life.Review of the facility's policy and procedure, Range of Motion Exercises, effective date 06/19/23, revealed the following Purpose[s] for performing ROM: To improve or maintain joint mobility and muscle strength. prevent contractures. reduce pain. prevent complications of immobility.

Based on observations, interviews, and record review, the facility failed to ensure that medications in two of two medication carts were stored and locked in accordance with professional standards. Proper storage of medications and locking of the medication cabinet is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications.Findings include: 1) On 07/25/25 at 07:40 AM, Team 1 medication cart was inspected with Licensed Practical Nurse (LPN)10 present. Two expired medications for Resident (R)1 were found: · Genteal Tears Severe 3-94% ointment was observed with an open date of 05/04/25 and discard date of 07/04/25 written on a facility label attached to the ointment tube. Upon review of the Electronic Health Record (EHR), a readmission date of 06/05/25 for R1 was found with no readmission order for this medication. · Novolog U-100 Insulin vial was observed with an open date of 06/06/25 and discard date of 07/04/25 written on a facility label attached to the vial. Upon review of the EHR, this was an active order being administered per sliding scale subcutaneously (under the skin) five times a day. On 07/25/25 at 08:00 AM, LPN10 stated all expired or discontinued medications should be removed from the medication cart. On 07/25/25 at 11:25 AM, interviewed Resident Care Manager (RCM)1 in her office. RCM1 stated the expectation is that medications should be removed from the medication cart once discontinuation orders are obtained or if they are expired. RCM1 also stated that insulin medication has a 28-day expiration once opened and thinks that eye medication has a 60-day expiration once opened. RCM1 confirmed that all nurses should be looking at expiration dates when administering medications. A facility policy titled, “Medication Storage -Storage of Medication” dated 01/25 noted “PROCEDURES…14. Outdated, contaminated, discontinued, or deteriorated medications…are immediately removed from stock…” 2) On 07/24/25 at 07:42 AM, observed Registered Nurse (RN)9 as she was administering medications. After RN9 prepared the medications and placed the blister packs back in the medication cart, RN9 walked to the resident's room. Observed the medication cart was not locked and unattended. After giving the medications to the resident, RN9 went back to the medication cart and noticed the cart not locked, RN9 then proceeded to lock the cart. On 07/24/25 at 08:30 AM, an interview was conducted with Resident Care Manager (RCM)2 at the nurse's station. Shared observation of the unlocked and unattended medication cart with RCM2. RCM2 confirmed that medication carts should always be locked and secured when not in use. On 07/25/25, review of the facility policy titled, Medication Storage – Storage of Medication dated 01/25 stated, . Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Based on observation and interview, the facility failed to ensure appropriate protective and preventative measures were performed to prevent infections and communicable diseases as evidenced by two staff members not removing gloves and not performing hand hygiene after completing incontinence care and before touching clean items for Resident (R) 1. This deficient practice has the potential to affect other residents who require assistance with care of bowel and bladder incontinence.Findings include:On 07/24/25 at 01:58 PM, observed Resident Care Manager (RCM) 1 and Licensed Practical Nurse (LPN) 10 providing incontinence care, specifically, cleaning of bowel movement incontinence for R1. Once incontinence care for R1was completed, observed RCM1 and LPN10 not removing gloves, not performing hand hygiene, and not donning a new pair of gloves before application of a clean adult incontinence brief, straightening out R1's linens, repositioning his body position, applying bilateral heel protectors, and placing the top sheet over his body.On 07/24/25 at 02:21 PM, interviewed RCM1 who stated that the gloves used while providing incontinence care for R1 should have been removed along with performing hand hygiene before touching R1's clean items and areas. A facility policy titled, Incontinence Care dated 06/19/23, stated, PROCEDURE .5. Wash all soiled skin areas.8. Remove gloves. Perform hand hygiene. 9. Replace incontinence pad or apply disposable brief as necessary.11. Replace top linen and position guest/resident.

Based on observations, interviews and record review, the facility failed to provide the residents a safe and clean environment. The sink in one of the shower rooms had water leaking into a plastic bucket and spilling onto the floor. This deficient practice could affect all residents and staff in the facility if the environment is not kept in good repair, putting them at risk for falls and injury.Findings include: On 07/23/25 at 08:32 AM, while standing in the hallway outside of the resident's shower room, observed a bucket almost full of water that was dripping from the faucet and underneath the sink. Water was dripping on the bathroom floor from the pipes under the sink. No cautionary signs such as Wet Floor signs were observed to warn staff and residents. On 07/23/25 at 08:32 AM, an interview was done with Resident Care Manager (RCM2) and she confirmed the floor was wet from the leaking sink and stated that she will notify the maintenance department. On 07/23/25 at 09:17 AM, concurrent observation and interview done with Director of Maintenance (DOM) and Maintenance Staff (MS). Observed both staff fixing the leaking sink. When asked what day they were notified of the water leak, both staff confirmed they were notified one week ago. When asked about cautionary signs, DOM confirmed wet floor signage should have been used to warn residents and staff of the unsafe condition in the shower room. On 07/23/25, reviewed facility policy titled Routine Cleaning and Disinfection directs the facility, . to provide a safe, sanitary environment. 6. Cautionary signs such as wet floor signs will be utilized and posted .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the activities of daily living (ADLs), specifically personal and oral hygiene, for 1 of 1 resident sampled for ADLs. As a result of this deficient practice, Resident (R)41 was hindered from attaining his highest practicable well-being and placed at risk for a decreased quality of life. Findings include:Resident (R)41 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. R41's diagnoses include, but are not limited to, Guillain-Barre syndrome (neurological disorder where the immune system mistakenly attacks the body's peripheral nerves which can lead to muscle weakness, tingling, and in severe cases, paralysis) and quadriplegia (a condition characterized by the partial or complete paralysis of all four limbs and the torso), with a colostomy (surgery that creates an opening for the colon through the belly, allowing stool to collect in a bag or pouch attached to the opening) and a gastrostomy (surgery that creates an external opening into the stomach for nutritional support). Review of R41's electronic health record (EHR) noted that on his most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 05/26/25, R41 was documented as completely dependent on staff for oral hygiene, bathing, toileting, dressing, personal hygiene, and mobility. On 07/22/25 at 09:58 AM, observations were done of R41 at his bedside. Certified Nurse Aide (CNA)2 and CNA3 were preparing to change his adult incontinence brief (brief). R41 was observed to have extremely dry and cracked lips, dry and flaky skin to his forehead, and thick, dried, yellowish crust to the inner corners of both eyes. At 10:04 AM, observed CNA2 wipe R41's right cheek and right eye, but his forehead, left eye, and left side of his face (where CNA3 was) remained unwiped. Asked CNA2 and CNA3 if they were conducting perineal (area of the body between the groin and the tailbone) care or a bed bath, to which they both answered that they were doing a bed bath. Observed them (CNA2 and CNA3) perform perineal care, wipe down R41's back and chest, and change his brief, gown, and bed linen. When they were about to place R41's bed wedge pillows (used to position, support, and/or elevate the upper and lower body) under him, asked CNA2 and CNA3 if they were done with his bed bath, hygiene, and grooming, to which they both answered yes. Reminded them that they had neglected to wipe down R41's legs and feet, his forehead, or the left side of his face, and did not perform oral care, or brush his hair (which remained disheveled). Asked if a bed bath would normally include these things, to which CNA2 responded yes, it should. At 10:26 AM, CNA2 prepared to perform oral care but found there were not enough supplies in the room to do so. Asked CNA2 and CNA3 how often oral care is performed on residents who are completely dependent on staff for hygiene. CNA2 answered that she was helping out in R41's area today, but in the area she normally works, oral care is done on every shift. While CNA3 answered that to her knowledge, oral care is only done every morning. Looking at the status of R41's lips, CNA2 agreed that it appeared as if oral care was not being done for R41 every shift, or even every day. CNA2 also acknowledged that since R41 received his nutrition and fluids through a gastric tube and nothing by mouth, regular oral care was even more important. CNA3 left the room to obtain supplies for oral care. While she was gone, CNA2 wiped the left side of R41's face and his left eye. CNA2 agreed that from the amount of dried crust on his left eye, it appeared that R41's eyes had not been wiped in more than one day. When CNA3 returned with supplies, CNA2 performed oral care. As she repeatedly and carefully wiped R41's lips with an oral swab, his dry and cracked lip skin peeled off in large chunks. Review of R41's comprehensive care plan revealed that despite identifying him as dependent on staff for all activities of daily living, including hygiene, grooming, and oral care, no specifics were planned regarding how often oral care should be performed. On 07/24/25 at 03:25 PM, an interview was done with Resident Care Manager (RCM)1 in her office. When asked how often oral care should be done for residents completely dependent on staff for ADLs, RCM1 answered that her expectation is that CNAs should be performing oral care twice a day at a minimum, on day shift and evening shift. RCM1 agreed that a bed bath should include cleansing of the face, legs, and feet, oral care, and grooming.Review of the facility's Activities of Daily Living policy, effective date 05/01/21, noted the following: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, interview and record review, the facility failed to ensure call system equipment was within reach for one of one resident (Resident (R)2) sampled. The deficient practice placed R2 at risk of not having emergent needs met in a timely manner and has the potential to affect all residents that rely on staff for assistance with activities of daily living.Findings include: R2 was a [AGE] year-old resident admitted to the facility on [DATE] for long term care placement. Diagnoses included but not limited to quadriplegia (partial or complete paralysis of all four limbs), panic disorder and depression. BIMS (Basic Interview for Mental Status) score on 06/02/25 was 15, indicating that R2 is cognitively intact. On 07/22/25 at 12:04 PM, observed R2 lying in bed with head elevated. R2 had just finished eating lunch and was assisted by staff. The touch pad call light was on the floor and out of R2's reach. Returned to R2's room two separate occasions on 07/22/25 at 01:43 PM and 03:22 PM. Touch pad call light was observed on the floor and out of R2's reach for both times. On 07/23/25 at 03:32 PM, observed R2 lying in bed watching television. Touch pad call light was on the floor and out of R2's reach. Certified Nurse Aide (CNA)6 was in the hallway at that time and was asked if R2 was capable of using the touch pad call light. CNA6 said R2 was capable of using the call light since he was still able to move his upper extremities. Showed CNA6 the touch pad call light was currently on the floor. CNA6 acknowledged that it was out of reach and should always be placed on the bed close to R2's arms. Review of R2's care plan was conducted. Under Problem Category: Falls, intervention included I will recognize need for assistance and ask for help as needed, call (pad)bell in reach. Start dates for both problem and intervention was 11/13/24.

Based on observation and interview, the facility failed to ensure that one refrigerator was kept in a clean and sanitary condition in accordance with professional standards for food safety and resident food items were expired and not discarded. Both storing food items in an unsanitary refrigerator and not discarding expired food items has the potential to result in development of foodborne pathogens which may cause discomfort to the residents upon consumption and development of foodborne illnesses for the residents. Findings include:On 07/22/25 at 12:39 PM, an inspection of a refrigerator located in a room near the Team 1 and Team 2 nurses' station used to store resident food and liquids was done. The following was noted: [NAME] sediments in the compartments on the inside of the refrigerator door. Scattered red stains under the left side of a storage compartment in the refrigerator. Scattered red stains along the inside top edge of the freezer door. Scattered red stains and yellow sediments in a storage compartment of the freezer. Build up of yellow and brown debris at the bottom of the freezer.On 07/23/25 at 03:30 PM, an inspection of the same refrigerator was done with Resident Care Manager (RCM) 1 who confirmed seeing the same sediments, stains, and build up as listed above (07/22/25 at 12:39 PM). Two, unopened yogurt containers with a best by date of 06/25/25 noted on the containers were found in the freezer. RCM1 stated that the refrigerator was not clean, and the two yogurt containers were expired and proceeded to remove them from the freezer.

Based on observation, interview, and document review, the facility failed to provide a comfortable temperature of hot water to residents that received showers in two shower rooms in Unit Two. In addition, there was no hot water available in the bathroom sink between room [ROOM NUMBER] and 29. Findings include: On 07/22/24, at approximately 08:30 AM, during the initial tour of Unit Two, identified the hot water in the bathroom sink between Room (Rm) 27 and 29 did not get warm. On 07/25/24 at approximatley 01:30 PM, during an interview with the Maintenance Director, he said the facility had been having problems with the hot water on Unit Two, and had recent work completed to provide warm/hot water, but the issue continued. At that time, accompanied the Maintenance Director to the Unit Two. He ran the water in the sink of Rm 27/29 and confirmed there was no hot water. The two shower rooms were then checked by the Director, which were also confirmed not to have warm water of a comfortable temperature for showers. Reviewed the invoices dated 02/14/2024, 02/29/2024, 03/21/2024, 03/27/2024 and 06/12/2024, 06/12/2024, provided by the Maintenance Director, which confirmed previous issues with the hot water on this unit.

Based on observations, temperature log review and interview, the facility failed to: 1. Store clean dishes, pots, and pans on a rack free of rust colored debris: 2. Failed to document temperatures of all refrigerators and freezer on their logs for one day (07/14/24) and: 3. Failed to take off and dispose of dirty gloves before going from one kitchen to another. The deficient practice could affect all residents and visitors who eat meals provided by the kitchen. Findings Include: On 07/22/24 at 8:30 AM during initial tour observed clean dishes and clean pots and pans stored on a dirty rack which had rust colored debris. Inquired with Kitchen Manager who acknowledged rust colored debris on the rack. During this initial tour of the kitchen requested to review the temperature logs for the refrigerators and freezers and Kitchen Manager brought out five paper sheets of logs. Inquired which log belonged to each refrigerator or freezer and Kitchen Manager was unable to say. [NAME] was able to state which log belonged to each refrigerator and freezer, but surveyor noted two logs have the same heading which do not differentiate them from one another. Kitchen Manager stated the cook comes in the morning about 30 minutes before everyone else and at that time logs the temperatures which are kept in a binder. During revisit to the kitchen on 07/22/24 at 12:00 PM observed Kitchen Manager wash her hands, put on clean gloves, walk outside of the main kitchen building to go to the second kitchen area, open the outside door while wearing the gloves and proceed to take off saran wrap from cold beverage cups and take the temperatures. Kitchen Manager passed a lunch tray to Resident (R) 3 which included juice that she put on his tray. Kitchen Manager than got a paper plate, opened the refrigerator, took out two half papayas to put on the paper plate to give to the resident. Afterwards Kitchen Manager left the kitchen area, walked outside, and took off her gloves. At this time surveyor discussed observations with Kitchen Manager, pointing out she had worn dirty gloves into the second kitchen area, did not dispose of the dirty gloves, did not perform hand hygiene, and did not put on new clean gloves before she assisted R3 with his lunch tray and she stated, I'm sorry and acknowledged deficient practice. Observation in the kitchen on 07/24/24 at 1:30 PM the surveyor pointed out the dirty rack, where clean dishes, pots and pans are stored to Dietician 1, who stated they are in the process of replacing the rack. Interviewed the Kitchen Manager on 07/25/24 at 9:47 AM and inquired about the refrigerator and freezer logs that had a blank row for 07/24/24. Kitchen Manager stated, that's my mess. Inquired if a cook was working that day and she stated the cook was off and she was covering. Kitchen Manager acknowledged she had forgotten to log the temperatures on the log that day.

Based on Record Review (RR) and interview the facility failed to completely and accurately document on four residents reviewed out of the 16 sampled residents, Resident (R) 13, R32, R53 and R60. The deficient practice could affect all residents if their medical record is not complete and accurate. Findings Include: 1) On [DATE] during RR found R13 has a Care Plan (CP) in place for at risk for mouth or facial pain related to decaying (cavity) and/ or broken natural teeth [DATE] oral thrush. Dental appointment made for [DATE] for cleaning. Reviewed progress notes to see if R13 went to his dental appointment on [DATE]. Review of the progress notes written by facility nurses did not include where R13 went when he left the faciity on [DATE] and did not include where he returned from on [DATE] when facility nurses documented in R13's record progress note that R13 returned to the facility at 4 PM. On [DATE] at 12:20 PM interview and concurrent RR with Resident Care Manager (RCM) 1. At this time reviewed progress notes that were written by facility nurses on [DATE]. RCM1 was unable to determine what appointment R13 returned from on [DATE]. Inquired if R13 returned from the dentist that day and RCM1 was unable to verify this as there was no dental consult from [DATE] in R13's record. RCM1 confirmed he was not able to state what appointment R13 had gone to on [DATE] and where he returned from on [DATE] based on progress notes written by facility nurses and consultations in R13's record. 2) On [DATE] during RR of R53's record found resident's hospice certification expired on [DATE]. During this RR did not find an updated hospice certification form, no Hospice Care Plan, and no progress notes in R53's record were found. On [DATE] at 10:49 AM inquired of Director of Nursing (DON) where the progress notes from the hospice nurses would be kept for R53. DON stated she will look and find out and let me know. Also inquired where the hospice re-certification for R53's is kept and DON stated she would look for that too and provide a current copy. On [DATE] at 02:47 PM DON provided a copy of Hospice Progress Notes written on one piece of paper. Reviewed Progress Notes from Hospice which included the first admission note dated [DATE]. Next note was dated ,d+[DATE] (no year included with date), [DATE] [sic], [DATE] [sic], and ,d+[DATE] (no year included with date). There were no February notes written after the hospice admission note on [DATE] and no Hospice progress notes from March, April, May, and [DATE]. On [DATE] at 04:11 PM reviewed R53's Hospice binder and did not find any other progress notes from Hospice. At this time interviewed Resident Care Manager (RCM) 1 who confirmed the Hospice progress notes would be kept in this binder for R53. On [DATE] at 04:30 PM DON was able to provide copies of Hospice re-certification, progress notes and care plan for R53 which was provided to the DON from the hospice company that day ([DATE]). Review of the documents found R53's Hospice was renewed from [DATE] -[DATE] and 12 Hospice progress notes and Hospice care plan were sent to the facility which had not been previously in R53's Hospice binder or Electronic Health Record (EHR) prior to this survey and surveyor's request. On [DATE] at 09:55 AM interviewed DON regarding documents supplied from Hospice on [DATE]. Don confirmed this is the first time the facility received the progress notes and re-certification for R53 besides the one page of progress notes that was in R53's Hospice binder. DON stated she spoke with the nurse manager at the Hospice facility regarding documentation from the Hospice nurses and DON stated the Hospice nurse manager stated she will be talking to her nurses, and they will either give a copy right then and there after the visit (with R53) or email or fax the note to the facility. 39853 4) R60 was a [AGE] year old female with a medical history that included acute respiratory failure due to acute on chronic heart failure. RR revealed the following: Physician written order start date [DATE]: Code Status: Do Not Attempt Resuscitation/No artificial nutrition by tube. Provider Orders for Life-Sustaining Treatment (POLST) Document dated [DATE]: Do Not Attempt Resuscitation/DNAR (allow natural death) signed by R60. Social Service (SS) Progress note dated [DATE] at 10:44 AM.She does not wish to fill out an advance directive nor did she want educational pamphlet explaining it. Full code status . The SS progress note was inaccurate. 38870 3) R32 is a [AGE] year-old male resident with a diagnosis that included Dementia with other behavioral disturbances. R32's cognitive status is severely impaired (per RR of his Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE]. During an observation on the unit on [DATE] at 1:15 PM observed R32 had a fall alarm clipped to his gown. RR of CP for Falls [DATE]. Resident at risk for falling related to .restlessness & trying to get out of bed XXX[DATE] found on floor mat by bed. [DATE] unwitnessed fall at bedside, bump to left side of head .Resident has right eye bruise [DATE]; Resident has right calf bruise [DATE]; Resident has self-inflicted laceration to forehead [DATE]. RR of the care conference summary [DATE], protective devices assessed. Restraints: Alarm due to behavior of sliding off mattress to alert staff he is moving . Physician order report reviewed: No orders found for a bed alarm. Interview and concurrent RR with the DON and Social Services Director (SSD) on [DATE] at 2:51 PM. The surveyor asked if there is a Physician order for the bed alarm. The DON looked in the record and did not find an order for a bed alarm.

Based on observation, interviews, and record review (RR), the facility failed to make arrangements for one Resident (R35) to be transported to an appointment with a consultant. As a result of this deficiency, there was a delay taking her cast off. This deficient practice could affect any resident with outside appointments and may prevent them from meeting their highest potential of psychosocial and medical well-being. Findings included: R35 is a [AGE] year-old who had lived at the facility since 03/02/21. Diagnoses included cognitive communication deficit, major depressive disorder, severe psychotic symptoms, and dementia with behavioral disturbance. R35 has muscle weakness, difficulty walking and uses a wheelchair for mobility. She is moderately impaired with a Brief interview for Mental Status (BIMS) score of 8. On 05/24/24 R34 fell and injured her left lower leg (LLE). She was transferred to the emergency room for care, where she was diagnosed with fracture of the tibia/fibula. She returned to the facility on [DATE] with an orthopedic boot splint on her leg, with directions to follow up with the orthopedic (ortho). RR revealed the following progress note dated 06/17/24 entered at 5:07 PM: .Res (R35) left for appt. ortho this morning .Res with noted cast to LLE. On referral form: keep cast dry, non-weight bearing to Legy [sic] f/u (follow up) in 4 weeks for cast removal (July 15, 2024) at 10 am. On 07/24/24, at approximately 2:00 PM, observed R35 in the dining room in a wheelchair with her left leg elevated. She had a pink cast on her left lower leg (LLE). On 07/25/24 at 2:45 PM had an interview with the Resident Care Manager (RCM)1, in the nurse's station of Unit two. At that time reviewed the progress note that documented R35 was to have her cast removed on July 15, 2024. The RCM said the process to make appointments/arrangements for transport to outside appointments is when a resident returns from a visit, the RN reviews the consult notes and if there is another appointment made by the office, they notify the Unit Coordinator (UC) by phone, and she makes the arrangement. The RCM called the UC and asked about R35's appointment to remove the cast. After he got off the phone, he said another appointment had been made, but could not explain why R35 did not go on July 15th. On 07/25/24 at 3:00 PM interviewed the UC in her office. She said she arranges for transportation of Residents for upcoming apts. She went on to say the nursing staff will either give her the apt card that is returned with the Resident with a new apt detail on it, or they will call and notify her of the new apt date and time documented in the consult note. When inquired about R35's apt for the cast removal, she said it is arranged for August 5th, at 09:45 AM. The UC said she was not informed of the original appointment for July 15th. This caused a missed appointment and delay in removal of R35's cast.

Based on observation, interviews, and record review RR), the facility failed to provide supervision of one Resident (R) 3 to ensure the safety of female residents. Specifically, the facility investigated an allegation that R3 inappropriately touched a female resident (R6). As a result of that investigation R3 was to be supervised when in the presence of vulnerable females to ensure their safety. R3 was observed to be alone in the dining area with a female resident (R39) on 07/24/24, which put her safety at risk. If R3 is not supervised, it puts all female residents at risk of a similar occurrence, which could result in psychological or physical harm. Findings include: The Office of Healthcare Assurance (OHCA) received a facility incident report, (FRI) intake 11041 regarding an alleged resident to resident abuse. The report documented on 06/29/24 a Certified Nurse Assistant (CNA) observed R3 seeming to touch resident's (R6) private area over her clothing. Nursing attempted to find out more about the situation from R6, but R6 has very limited short-term memory and was not able to provide further details . Final report included: Based on interview with certified nursing assistant (CNA), she was entering the Station 2 dining area, . when she saw R3 touching/grabbing the private area of R6 over her clothing. No other residents or staff were present in the dining area. CNA asked R3 what he was doing and told him to stop, and he laughed and backed his wheelchair away saying he was doing nothing.R6 said R3 had grabbed her boobs and his touching had not been consensual. Based on interview with CN (Charge Nurse), .CN stated CNA had told her she had seen R3 touching Resident 6 in the lower private area. Based on interview with Social Services Director (SSD) . SSD spoke with resident 6, who stated that resident 3 had touched her and she did not like it. Per SSD, resident 6 stated resident 3 had touched her pubic area under her brief when asked. Resident 6 denied being afraid of resident 3. Resident 6 wanted police involved . Based on interview with SSD, she also spoke with resident 3 and asked him to explain what had occurred with resident 3 the day prior. Resident 3 said he had his hand on resident 6's thigh but denied touching her up there . Facility documented interventions implemented included Close monitoring of alleged perpetrator (P3) whereabouts when not in his room. Reviewed the facility Incident investigation and summary signed by the Administrator on 07/11/24. The additional information read Resident (R6) seen being touched inappropriately on private area over clothes by another resident (R3) in dining area. Resident had not called for help, .when asked if it was consensual stated she did not want to be touched. P3 is a [AGE] year-old male who had lived at the facility since 2017. His diagnoses included Type 2 Diabetes with left below the knee amputation. He has a history of impulsivity and provoking other residents. P3 uses a wheelchair (w/c) for mobility and is able to move himself around easily. He is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. Review of R3's care plan (CP) included: Problem start date 06/30/24, Category: Behavioral symptoms. R3 had physical behavior, alleged sexual, toward another female resident (R6). Short Term Goal: R3 will not touch or intimidate another resident. He will not be in the same area as the alleged victim or any vulnerable females unless he is supervised. Approach: Explain the details of this care plan to R3 who agreed and stated he understood. Approach: Keep R3 separated from other vulnerable females when out in the common area unless supervision is available. If vulnerable females come out into the common area, ask R3 to go to another area or his room .unless he is supervised. Problem start date 10/31/23, Category: Behavioral symptoms. R3 may use inappropriate language and expletives during dressing changes and medication passes. He also may make rude gestures and can be difficult to redirect. Approach start date 06/29/24: Monitor resident's whereabouts when not in his room. Provide supervision in the dining area when resident is present with other residents. Enforce rules about inappropriate/unacceptable behavior. Problem start date 10/30/24. Category: Behavioral symptoms. R3 has history of (hx)aggressive behavior: 10/30/23: Slapping staff hard and spewing profanities. 10/31/23. Pushing a nurse and swearing while she was giving wound care.11/05/23: Threatened to punch a CNA .01/29/24: Grabbed another residents hand to stop him from turning the dining room lights on and off. Long Term Goal: R3 will not harm staff or others. Reviewed R3's Psychiatry consult dated 07/05/24. The consult noted included: Chief Complaint/Reason for visit: Intrusive, argumentative in depression/cognitive decline. Orientation: aox3 . Psychiatric Diagnosis evaluated: Cognitive decline (likely MCI [mild cognitive impairment] at least) with impulsivity/verbally or physically intrusive, hx of situation-related depression but declined treatment. Plan/Recommendations: - Continue supervision in common area to deter pt from another inappropriate physical touch, he seems to have sufficient insight regarding appropriateness/legal implications and had complied thus far with expected boundary setting. On 07/22/24 at approximately 11:00 AM, observed R3 in dining area with several other residents. Staff was present playing cards. On 07/23/24 at 1:20 PM, observed R3's room door open with the curtains pulled all the way around the bed with no viability of the bed or R3. Surveyor knocked on the door and called his name, but no response. It was assumed at that time R3 was asleep in the room. A few minutes later observed R3 in his w/c, outside in the lanai area alone. Asked how long he had been outside, and he said awhile. Observed a door at the end of the building and asked R3 to confirm his room was at the end of the hall, close to that door, and he confirmed it was. R3 said he uses that door to go to the lanai. This area has very limited visibility from staff, unless walking outside from building to building. On 07/24/24 at approximately 3:50 PM, the surveyor walked into the dining room and observed R3 unsupervised sitting in his w/c at in front of the television, watching Family Feud. Noted one other Resident (R)39 in back of dining area sitting at a table. Surveyor sat at the back of the room for approximately 10 minutes and confirmed no staff came to monitor R3. Surveyor proceeded to Unit 2 Nursing Station to inform staff the whereabouts of R3 and that he was unsupervised. Notified the Administrator, who was on the unit. On 07/24/24 at approximately 4:05 PM, interviewed the Charge Nurse (RN6) in the nurse's station. Asked how they assign someone to supervise R3. She said they take turns, and sometimes the dietary and activity staff also assist with monitoring. RN6 said she was unaware that R3 was in the dining area unsupervised and said, I don't know how that happened. At that time, together reviewed R3's CP, and she confirmed R3 was to be supervised when in the dining area. Asked RN6 if she would consider R39 to be vulnerable. She hesitated and said. She would yell if someone approached her, and she didn't want them to. On 07/24/24 at approximately 4:30 PM, interviewed the Administrator in her office. Asked her if she could explain what had happened, and what surveyor had observed, and the Administrator. replied He's (R3) supposed to be supervised and he was not.

Based on record review and interview the facility failed to assist Resident (R) 13 in scheduling a dental appointment that he missed on 11/28/23 (per Dental clinic) and 12/05/23 (per resident's Care Plan) for a cleaning. The deficient practice could affect all residents in the facility who require assistance in scheduling dental appointments. Findings Include: On 07/23/24 at 10:48 AM during Record Review (RR) of R13's Electronic Health Record (EHR) found resident has a Care Plan (CP) in place for at risk for mouth or facial pain related to decaying (cavity) and/ or broken natural teeth 10/19/23 oral thrush. Dental appointment made for 12/05/23 for cleaning. During this record review of R13's progress notes found a nurse had documented on 12/5/23 R13 left the facility to go to an appointment but the facility nurse did not state what the appointment was for. Another progress note dated later in the day on 12/5/23 was written by another facility nurse who documented R13 returned to the facility at 4 PM but did not state where he returned from. On 07/25/24 at 12:20 PM interview and concurrent RR with Resident Care Manager (RCM) 1. At this time reviewed progress notes dated 12/05/23 with RCM1. Inquired of RCM1 if he could tell me if R13 went to the dentist on 12/05/23. RCM1 was unable to determine if the appointment resident returned on 12/05/23 was from the dentist. RCM1 also reviewed consult forms for 12/5/23 for R13 and did not find any dental consult for that day in R13's record. On 07/25/24 at 12:27 PM requested documentation from the Administrator regarding dental appointment for R13 that was scheduled for 12/05/23. Administrator interviewed on 07/25/24 at 02:08 PM regarding R13's dental consultation form, she stated she was not able to get any documentation from the dentist office because it was closed. Administrator stated she would call the dentist office the next day (07/26/24) and request the latest consultation form for R13 and provide surveyor with a copy. On 07/26/24 at 11:56 AM Administrator emailed surveyor a copy of R13's last dental consult report dated for 08/15/23. Administrator emailed last dental appointment for R13 was in August 2023. Administrator explained in her email that when she spoke with the dentist office, she was told R13 was not seen in November 2023 or December 2023. Through email inquired of the Administrator and Director of Nursing (DON) what appointment R13 attended on 12/5/23 and DON shared R13 went to see his vascular surgeon. On 07/29/24 at 10:38 AM surveyor called and spoke to dental clinic staff, where R13 went for his 08/15/23 dental appointment. Dental clinic staff explained R13 had missed his scheduled 11/28/23 appointment and facility staff had called the office to let them know R13 was not feeling well. Inquired if facility staff had rescheduled R13's dental appointment at that time and dental clinic staff stated the dentist appointment had been rescheduled today (07/29/24) and R13 would be seen on 07/31/24.

Based on observation, interview, and record review (RR) the facility failed to revise one Resident's (R35) care plan (CP) timely to reflect the status/treatment of her fractured leg after a fall. As a result of this deficiency, staff may not have been aware of the treatment plan required monitoring and interventions needed. This deficient practice could affect any resident. Findings include: R35 is a [AGE] year-old who had lived at the facility since 03/02/21. She had cognitive communication deficit, major depressive disorder, severe psychotic symptoms, and dementia with behavioral disturbance. R35 has muscle weakness, difficulty walking and uses a wheelchair for mobility. She is moderately impaired with a Brief interview for Mental Status (BIMS) score of 8. On 05/24/24 R34 fell and injured her left lower leg. She was transferred to the emergency room for care, where she was diagnosed with fracture of the tibia/fibula. She returned to the facility on [DATE] with an orthopedic boot splint on her leg. On 07/24/24, at approximately 02:00 PM, observed R35 in the dining room in a wheelchair with her left leg elevated. She had a pink cast on her left lower leg (LLE). RR revealed on 06/17/24, the nursing progress note documented .Res (R35) left for appt. (ortho (Orthopedic)) this morning res turned [sic] at around 1303 (1:05 PM). Res with noted cast to LLE. On referral form: keep cast dry, non-weight bearing to Legy [sic] f/u (follow up) in 4 weeks for cast removal (July 15, 2024) at 10 am. Reviewed R35's active CP, which included: Problem: Resident has a left ankle fracture and has a splint cast applied. Resident is non-compliant and keeps on removing the splint. Start date 5/31/24. Goal: Resident will maintain and keep the splint on until further instruction and treatment. Approach: Notify ortho and PCP (primary care physician) of resident's refusal to keep splint in place-ortho moved up appointment with note to keep splint on. Encourage resident to keep splint on. Provide distractions. Educate on reason for splint. Start date 06/08/24. Approach: Emphasize the importance of keeping the splint on at all times. Offer pain medications as needed. Check for circulation, motion, sensation (CMS) every (Q) shift. RR of nursing progress note revealed on 05/25/24, when R35 returned from the Emergency Department after the fall, she had a newly diagnosed fracture with a splint/wrap for treatment. The CP was not revised timely to reflect this change and the interventions needed until 05/31/24. On 06/17/24, the splint was replaced with a cast at the orthopedics office. The CP was not revised at the time of survey to reflect that change. On 07/25/24 at 2:45 PM, during an interview and concurrent RR with the Resident Care Manager (RCM)1, The RCM1 confirmed the CP had not been revised to reflect the current status of her fracture.

Based on record review (RR) and interview, the facility failed to: 1. Include an accurate assessment of resident's psychological state in the quarterly Minimum Data Set (MDS) for one Resident (R32) and; 2. Failed to identify that a bed alarm was in place. The deficient practice failed to accurately assess the resident's psychosocial wellbeing. The residents in the facility with psychological needs are affected. Findings include: Cross reference to F741 Behavioral health services. Electronic Medical Record (EMR) reviewed 06/17/24. Mood and behavior were not coded on the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 06/17/24 with any indicators of psychosis and the bed alarm was not coded as being used. The bed alarm is documented throughout the nursing notes as being in place for R32. Interview on 07/25/24 at 2:51 PM with the Director of Nursing (DON) and Social Services Director (SSD). The surveyor asked why the mood and behavior assessments didn't include an accurate description of the resident's documented behaviors. The SSD replied that the behaviors may not have been present at the time of the assessment. The surveyor discussed that R32's agitated behaviors are documented in the record prior to the annual review date, per the nursing care plan 12/14/23.

Based on observation, interview, and record review (RR) the facility failed to: 1. Ensure it provided an environment to promote the mental and psychosocial wellbeing for one resident in the sample Resident (R) 32 was agitated and distressed evidenced by loud yelling and acting out while isolated in his room. 2. The nursing staff did not monitor R32's behaviors or; 3. Report changes to the physician for four days and; 4. Implement non-pharmacological interventions in his plan of care. The deficient practice resulted in the resident having poor psychological and emotional health and self-inflicted injuries that occurred as a result of his behavioral outbursts. Residents in the facility with psychological and emotional health needs are at risk. Findings include: R32 is a [AGE] year-old male resident admitted to the facility on [DATE]. His Diagnoses included cerebral infarction (stroke) with left sided weakness; vascular dementia with behavioral disturbances; aphasia (unable to speak) and severe anxiety. His cognitive status is severely impaired (per RR of his Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/17/24. Per his RR, R32 was diagnosed with COVID-19 and placed in isolation on droplet precautions on 07/17/2024. On 07/23/24 at 1:15 PM during an observation and interview on the unit, loud yelling and banging was heard outside R32's room. A large red sign on the door stated, red room, indicating the resident is on droplet precautions for positive COVID 19. The yelling inside the room continued for 30 minutes between 1:15 PM to 1:45 PM. At 1:45 PM the surveyor went into the room with Registered Nurse (RN)12. R32's bed was placed in the middle of the room away from the walls. The bed was in lowest position from the floor with two fall mats on the right side of the bed and one fall mat on the left side of his bed. He had a fall alarm clipped to his gown and faced to the left with one hand holding onto the left candy cane side rail. The other hand was holding onto the headboard and shaking it back and forth. He appeared in distress; his hair was messy, and the sheets and blanket tangled around him. His gown was wet. R32 was nonverbal, and his upper body was very stiff. RN12 spoke to him and firmly pulled his hands from the left bed rail and headboard to reposition him. Surveyor observed DVDs and a television in his room, although the television was not turned on. Two call lights were hanging on the wall and out of R32's reach. RN12 stated that R32 is very agitated today and explained that the Trazodone (medication used to treat depression) was put on hold about five days ago which has caused R32 to become more agitated. RN12 stated that since he started working at the facility six weeks ago, R32 has always been nonverbal and occasionally agitated. The surveyor asked why his bed was in the middle of the room. R12 said he used to be next to the window, but it was moved because the team felt that he might kick the window out. The surveyor asked if R32 is a danger to his self and how can he call for help. RN12 stated that R32 can't use the call light, so we check on him frequently and he has a fall alarm in place. On 07/23/24 at 1:55 PM in the unit one nurse's station, the surveyor asked the Director of Nursing (DON) why R32 was so agitated. The DON said the trazodone was stopped due to an interaction with the Covid medicine (Paxlovid). The surveyor asked if R32 was given an alternative medication to help with the agitation. The DON stated that she just got off of the phone with the doctor and received an order to give half of the regular dose of his trazodone and the complete dose tomorrow. EMR review dated 07/19/24 revealed that R32's Trazodone and the Belsomra, (medication to treat a sleep disorder) were placed on hold from 07/19/24 to 07/23/24. Review of the Care Plan (CP) was developed for Falls 06/26/20. Resident at risk for falling related to .restlessness & trying to get out of bed .09/07/23 found on floor mat by bed. 06/18/24 unwitnessed fall at bedside, bump to left side of head .Resident has right eye bruise 01/10/24; Resident has right calf bruise 01/18/24; Resident has self-inflicted laceration to forehead 05/22/24. Review of the resident's incident reports verified the injuries. 06/18/2024 unwitnessed fall at bedside with bump to left side of head. Nursing approaches include the purposeful rounding .Keep call light in reach . Occupy resident with meaningful distractions: music, movies, open window to look outside. CP for behaviors 12/14/23, banging and pulling headboard, throwing linens, pillows on floor .Seen by psychiatrist, as needed medication added .01/04/24. Medication changes . Medication changes made by psychiatrist on 06/26/24. Nursing approaches include the following: Contacted psychiatrist on 06/27/24 .Administer PRN medication .Behavior Monitoring N/A - Not applicable. Non-Pharmacological interventions to address yelling, banging headboard and self-injurious behavior not documented. Orders reviewed. Medication: Abilify (anti-psychotic for agitation. [NAME] frequency how often behavior occurred & intensity how resident responded to redirection, every shift. Behavior flowsheet reviewed 01/01/24 to 07/25/24, no documentation of behavioral observations by the staff was found. Progress notes reviewed 06/27/24 Social Services .bed placement is being reconfigured 06/26/24, kicking at the windowpane and previously pulling at the window blind cords. He is also becoming more restless and helicoptering in his bed . 06/29/24. Resident can be heard shaking bed rails throughout the night. Difficult to redirect. Bed locked in lowest position, clip alarm on. 7/17/24. 16:08 alert to self. very restless, yelling, swearing, trying to damage mattress, ripping at it and bed, grabbing, and shaking parts violently, unable to redirect resident all shift .remains on isolation for Covid+ . 07/20/24. 14:52 alert to self. remains restless, yelling and shaking his bed violently on and off this shift. unable to redirect. remains on isolation for Covid+ . 22:36 .At times, patient observed yelling loudly and shaking bed. Receiving . 07/21/24. 7:20 AM, heard resident making loud/yelling noises throughout the entire night and shaking bed rails . Difficult to redirect. 07/23/24. 14:06 Spoke with psychiatrist regarding residents increased agitation today .Provider ordered for today Trazodone 12.5mg, to be given this evening . Resident to resume regular Trazodone orders. Activity Director (AD) interviewed on 07/25/24 at 1:54 PM. The surveyor asked how the activity staff are providing the activities to R32. The AD replied, no one is seeing him while he is in isolation although the nursing staff should turn the TV on for him when they go into his room. Interview and concurrent record review with the Director of Nursing (DON) and Social Services Director (SSD) on 07/25/24 at 2:51 PM. The surveyor asked how the nursing staff is monitoring his behavior? The DON said the behavior is being documented in the progress notes. His agitation comes and goes. The surveyor asked if the nursing staff contacted the physician to report R32's agitated behaviors of yelling and shaking the bed? The DON said she thought the physician was aware. Upon review of the record the DON was unable to find documentation to verify the physician was called. The surveyor asked what type of non-pharm interventions are being done for R32? The DON stated they place him out of bed on the floor mat. R32 likes it on the floor.

Based on interviews and record/document review, the facility failed to take immediate interventions and provide adequate supervision to one resident (R)1 after she attempted suicide. On 08/22/2023, R1 wrapped the call light cord around her neck in a suicide attempt. After R1 was found, the staff did not immediately remove all items that could be used to harm self, or provide adequate supervision. As a result of this deficiency, R1 was able to access cords and attempted to hurt herself again two times. At the time of survey, the staff was found to have addressed the deficiencies and were in compliance. The citation meets the criteria for past noncompliance. Findings include: 1) On 08/22/2023, the Office of Healthcare Assurance received the initial facility report (FRI) regarding an attempted suicide. The initial report included: - R1, admitted : 06/24/2023. Dx Hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting dominant side, dysarthria (speech difficulty) following nontraumatic intracerebral hemorrhage (stroke), aphasia (speech difficulty) non traumatic intracerebral hemorrhage, . and other psychoactive substance abuse (harmful use of psychoactive substances, including alcohol and illicit drugs), conversion disorder (mental health condition that disrupts how your brain works) with seizures or convulsions, ., major depressive disorder, anxiety disorder, . - BIMS Score: 14 out of 15, indicating cognitively intact. - Call light went off due to resident pulling cord out of the wall. Staff immediately went to room and found with call light cord out of the wall. Staff immediately went to room and found the resident with call light cord around their neck. After nursing staff observed the cord they immediately removed the cord from the resident's possession. Assessment done immediately by nurse, no injuries present. MD (physician/MD1) was present in building, immediately notified. MD1 assessed resident and ordered resident to be sent to ED (Emergency Department) for evaluation. Nursing staff remained with resident the entire time until EMS (Emergency Medical Services) arrived. Interventions implemented included: 1. MD, in house, notified immediately. 2. Resident's immediate vicinity cleared of items considered unsafe. 3. Nursing staff remained 1:1 with resident until EMS arrived. Completed Resort received 8/27/2023 - Based on CNA1 (certified nurse assistant) statement on 08/22/23 and COS statement on 08/24/23, CNA1 heard an alarm sounding from the resident's (R)1 room and she ran to check on the resident. Upon entering the room CNA notices R1 had pulled the call light cord from the wall and it was looped around her neck. CNA1 reported that it looked like the resident was trying to get up .CNA said Oh my god, .Can I take it off? Resident stared at CNA eyes wide open and earnestly said :Yes, take it off, take it off! CNA1 immediately removed the cord from the resident's neck. Nurse 1 (RN1) arrived directly after and asked CNA what happened. CNA1 relayed that the resident had the cord looped around her neck and she had just removed it. CNA stated she was in shock and her heart was pounding. She stepped into the hallway, right outside the resident's room, to calm down, while nurse 1 assessed the resident. - Based on nurse 1 statement on 08/22/23, nurse 1 heard the call light alarm going off and ran down the hall to the resident's room. CNA told nurse 1 what had just happened. Nurse1 did a quick assessment, no injury observed, and asked the resident if they were okay and the resident said yes. Nurse 1 wrapped the call light (cord) around enabler bar (bar attached to bed to assist with movement) and tied it off. CNA remained in the hallway outside the resident's room, resident within sight, as nurse 1 ran to get the doctor, who was .near by. Nurse1 and doctor returned to resident's room. Resident had the call light cord up against her neck but not wrapped around, taking it down when the doctor and nurse1 entered the room. Doctor talked to the resident, who then voiced I want to kill myself. Doctor ordered for the resident to be sent to the ED further evaluation and treatment. Nurse1 notified RCM (Resident Care Manager) while the doctor assessed resident. - Based on RCM statement, nurse1 came and informed RCM of resident's attempt of self-harm. Nurse1 and RCM went immediately to resident's room. RCM asked the resident if she was okay, resident responded saying, Yes, I am okay. I don't like it here. They don't like me. Resident than attempted to grab the call light cord, which was wrapped and tied around the enabler bar. RCM removed the call light cord and the resident's fan and put them on a bedside table, out of residents reach. The resident then reached for her cell phone charging cord, which was on the bedside table to the left. Resident put the cell phone charging cord up to her neck. Nurse1 and RCM both grabbed the cell phone charging cord. Resident was noncompliant when nurse1 and RCM asked her multiple times to release the cell phone charging cord, saying no and laughing. After much redirection the resident released the cell phone charging cord and nurse 1 removed it. The RCM then asked the resident .why she did that, and how she was feeling. The resident responded, I don't know. They don't like me here. I don't want to be here. All items in the room considered to be unsafe were removed from the residents immediate vicinity.CNA was present outside of room [ROOM NUMBER], charting as she kept the resident in sight. - Resident is transgender and prefers to use the pronouns she/her. In addition to the interventions listed in initial report, the following were added: 9. Inservice conducted regarding suicide precautions policy. 10. Resident continues at ED awaiting admission for psychiatric evaluation and treatment as necessary. 2) Reviewed the nursing progress note by RN1 dated 8/22/2023 at 04:42 PM. The note read Resident sent out to ED for suicidal ideation. This writer heard a call light going off and ran to the resident's room. CNA1 was already in there and told me that the resident had the call cord around her neck.Ran to MD1 to notify him .and we both went to the resident room. When arriving to back to the resident room, .the resident had the call light cord wrapped around her neck again.This writer notified RCM. RCM and I went back to the resident's room and the resident had the phone charging cord in her hand. 3) Reviewed investigation documents provided by facility. These included the following: Written statement of RN1: This writer heard a call light going off and ran to the resident's room. When I got to the room, CNA1 was already there and told me that the resident had the call light laying on top of the resident's neck. I asked the resident what was going on and if she was okay and she stated, yes and put the call light cord back around the siderail/enabler bar. I told the resident that ill [sic] be right back. Ran to MD1 to notify him of the situation and we both went to the residents room. When arriving back to the room w/MD1, the resident had the call light cord on top of her neck again and took it off when she saw the Dr. (MD1) and I in the room. MD1 proceeded to talk to the resident and the resident voiced, I want to kill myself.This writer notified RCM. RCM and I went back to the resident's room to remove anything that could potentially hard {sic} the resident. While we took the call light and fan out of the wall, the resident grabbed her long phone charging cord.This writer and RCM both had a part of the phone cord in our hands, so that it could not be tightened by resident . In total, resident attempted to put something in front of her neck 3 times. Written statement of RCM: .RN1 and I went to residents room . At this time, resident reached for her cellphone charger cord on her bedside cabinet to the left side of her. Resident put the cell phone cord that was already in a loop over her head and attempted to tighten it.Call light fan and phone charger and other harmful devices (other cords-inside resident bedside cabinet) removed from room. RN1 and I exited the room. CNA1 was outside of room at this time charting at wall computer with resident in sight. Interview by COS: Based on interview with CNA1 on 8/24/23 at 08:40 AM, .CNA described that she saw the call light cord looped around the resident's neck two times, .CNA states that the resident looked at her with both eyes wide open when the CNA approached him.While CNA was in the room, RN1 came rushing in to respond . RN asked the CNA what's going on. CNA explained to the RN that the call light cord was looped around the resident's neck. The RN was in the room, and the CNA began not feeling alright, so CNA left the room to calm herself down due to what she just witnessed. CNA states that she was in shock during that day and now she cannot remember where she was after she left the room. CNA remembered that she was in the hallway between rooms [ROOM NUMBERS], then near room [ROOM NUMBER] where Social Worker had passed her when she was heading towards room [ROOM NUMBER] because she had promised to return to change the resident in room [ROOM NUMBER]. Interview by COS: Based on interview with with RN1 on 8/23/23 at 930, .RN states that CNA told her that she removed the call light cord from the resident's neck. MD1 was in the building seeing other residents . RN states that she ran to where the MD was .and had asked MD if he could assess the resident. RN states that she left the resident to inform MD but could see CNA standing in front of the resident's room. When the RN returned to the resident's room, she observed the resident grabbing the call light cord that was wrapped around the enabler bar. RN states that she saw CNA1 standing outside of resident's room, so she left the room to inform RCM about the resident and both returned . Asked RN how long it took her to get the MD and RCM when she left the room. RN states that it's less than a minute on both occasion that resident was by themselves. While both nurses were in the room, they observed the resident trying to grab the call light cord that was wrapped around the enabler bar. RCM removed the call light cord . RN states that the resident then reached out to grab the cell phone charger cord that as nearby and placed it over their head and attempted to pull outwards from their neck.RN stated that they removed everything that was in the room that the resident could use to harm themselves.Both nurses left the room to prepare transfer paperwork. RN stated that CNA2, went into the room to check on resident and provide direct care. 4) On 08/31/2023, during an interview with CNA1, she said after RN1 came to the room, she stepped out in the hall to calm herself because she was so upset. She went on to say she did not remember a lot after that, but that she went on to take care for other residents, and did not interact with R again. 5) Reviewed the facility policy titled Suicide Precautions last updated 10/15/2017. The policy included, but not limited to the following: Purpose: .Entity will respond and immediately address the actual act, or intent to commit suicide by a guest/resident. Procedure: 1. Immediately provide one-on-one care to maintain visual surveillance and supervision at all times. 2. Inform guest/resident and/or responsible party of concerns for safety and the reason for search of all personal belongings. 3. Assign another staff member to search belongs for, and to remove specific item(s) mentioned to carry out suicide plan. If not a plan in place, then remove all medications and all other items considered unsafe including glass or sharp objects, .bed control cord, and call bell cords. 5. Notify physician, responsible party, 9. Document every 15 minutes by attending staff member assigned to provide one-on-one care and visual monitoring . Procedures: 6. Keep the guest/resident in sight and within reach at all times, providing 1:1 care until EMS arrives to transport out of the facility. 6) On 08/22/2023, when R1 was found with the the call light cord wrapped around her neck, the staff did not immediately implement interventions according to standard of care, and their own policy, which included: - The call light cord was left in the immediate vicinity of R1 when it was tied on the enabler. - During interviews, staff stated CNA1 was outside the room monitoring R1, and was 1:1. The FRI reported CNA was present outside of room [ROOM NUMBER], charting as she kept the resident in sight. It is the standard that if someone is assigned to supervise or monitor a resident and circumstances were appropriate to be outside of the room, the staff assigned should not be doing any task other than monitoring the resident. RN1 said she saw CNA1 outside the room in the hall, and felt she was monitoring R1, but CNA1 did not see or intervene when R1 attempted to use the call cord left on the enabler again to harm herself. This was identified when RN1 returned with the MD and entered the room. - The staff did not immediately remove all items R1 could use to harm self, which included but not limited to the fan cord, and cell phone cord. - There was no documentation every 15 minutes from a staff member assigned to be one-to-one supervision of R1. 7) At the time of the incident, the facility staff did not respond appropriately and did not have the knowledge of intervention steps. At the time of this survey, the deficiency had been corrected. The facility provided education to staff, which was validated by review of the staff attendance sheet and as well as interviews with three staff. The interviews included RN1 and CNA1. Their attendance at the inservice was also validated. During an interview with the SW who gave the inservice, she said the focus was on immediate response, which included not leaving the resident alone at any time, and ensuring a safe environment by removal of any objects that could be used for self harm.

Based on observations, interviews, and record review, the facility failed to ensure one resident sampled (Resident (R)2) sampled received professional standard quality of care. R2 was readmitted to the facility on [DATE] from an acute hospital with an ostomy bag. The facility did not develop care plans, which drives the care of residents for malnutrition, pain, and prevention of pressure injury/pressure ulcer. On admission, the physician identified R2 to be at risk for malnutrition, R2 was not assessed by the Dietician until 9 days after admission when contacted by the facility due to R2's poor oral intake, refusing meals, and having a significant weight loss of 12.09%. R2 was not ordered pain medication for severe pain (7-10 on the Numeric Pain Rating Scale) despite R2 reporting a pain score of 8 on two separate documented occasions, and a care plan was not developed for pain. R2 was not administered pain medication prior to or after treatment of a PU during which the resident verbally and non-verbally expressed pain and during another incident when nursing staff was informed of the resident's request for pain medication. R2 had a decline in mobility which resulted in a decrease of mobility functioning and R2 remained in bed, increasing the risk of developing a new pressure injury/ulcer (PI/PU). A care plan was not developed in response to R2's change in mobility functioning to prevent a new PI/PU and was not developed after staff first identified the sacral PI to prevent it from worsening. As a result of this deficient practice, R2 experienced physical harm and a high potential for psychosocial harm. Findings include: Observations were made of R2 on 07/25/23 at 10:20 AM, 12:10 PM, 01:15 PM, 02:31 PM; 07/26/23 at 09:10 AM, 11:17 AM, 01:35 PM, 03:23 PM; and on 07/27/23 at 08:55 PM, 09:30 AM, 10:15 AM, and 12:45 PM. During these observations, R2 was lying flat on his back, both heels were in direct contact with the air mattress, there was an observable indentation in the air mattress directly under R2's heels, and there were no indication interventions to turn, reposition, or use a wedge/pillow to off-load high contact points were implemented. Observations of R2 with staff present, noted staff did not attempt to reposition the resident or explain to the resident why off-loading the PU was necessary and/or beneficial to prevent worsening of current PU and prevent any new PU. During the observation on 07/25/23 at 12:10 PM, Nursing Staff (NS)38 and a hospice nurse, who was evaluating the resident for hospice services, were providing treatment to R2's PU and changing the dressing. Observed R2 wincing, grimacing, and squeezing his eyes tightly in pain while turning onto his side, also observed that the resident required the assistance of NS38 to turn and could not have turned on his own. While NS38 provided treatment to the wound bed, R2 stated Sore and Ouch in response to any contact with the wound bed. While R2 laid on his side, redness was observed on the outside portion of the resident's right foot. NS38 inquired with R2 if he had any pain, and the resident responded with Sore. At the time, it was unknown if R2 had been premedicated prior to the dressing change to mitigate amount of pain the resident would experience. After the dressing change, this surveyor did not observe NS38 administer pain medication to alleviate the resident's pain. Inquired with NS38 regarding R2's course of treatment at the facility. NS38 stated R2 was a long-term resident at the facility and had recently been readmitted to the facility on [DATE] with an ostomy bag (an external pouch used to catch urine or stool) due to a portion of the intestine twisting around it's blood supply, sigmoid volvulus). NS38 reported that prior R2's discharge, the resident was independent in most areas of care, could ambulate on his own, had a good appetite, and would spend most of the day in the unit dining room with other residents. However, on readmission, R2 hardly ate, continued to lose a significant amount of weight, could no longer walk independently, and just wanted to stay in bed. As a result of these changes, the contracted hospice nurse was there to assess R2 was an appropriate candidate for hospice services. Later in the day, this surveyor was informed that R2 was accepted and admitted to hospice services. On 07/26/23 at 09:55 AM, conducted a review of R2's Electronic Health Record (EHR). R2 was readmitted to the facility on [DATE] with a diagnosis which included a Sigmoid Volvulus, NSTEMI, hypokalemia, epilepsy, diabetes mellitus type 2, and a recent ileostomy resulting in the placement of an ostomy bag. Review of R2's care plan documented a care plan was not developed for the prevention of PU, decline in Activities of Daily Living (ADLs), pain, and risk for malnutrition. ---Record review related to R2's pressure include review of but not limited to multidisciplinary notes, physician orders, and assessments. No care plan was developed for prevention of PU. Review of nursing Admission Assessment on 07/12/23 at 08:00 AM documented under Skin, R2 did not have any skin alterations. A skin assessment on 07/21/23 at 04:14 PM, documented in a comment, Comments: Pressure wound to sacrum, Tx (treatment) in place, Triad and silver alginate., on 07/25/23 at 05:32 PM, Comments: Pressure wounds to sacrum persist and worsening. Tx (treatment) in place, Triad around wound border, silver alginate on wound bed and cover w/abd (abdominal) dressing.; and 07/26/23 at 10:35 AM, documented the sacrum wound as unstageable Pressure Injury, obscured full-thickness skin and tissue loss, measuring 4 cm in length 8.5 com in width, and 0.3 cm in depth. 100% eschar with attached edges and moderate serosanguinous drainage, the surrounding peri area is described as non-blanchable erythema: red. it documents that R2 does not have pain associated with the wound. Review of the physician orders documented the air mattress was ordered and applied on 07/20/23. Review of the Braden Scale for Predicting Pressure Sore Risk documented three assessments were completed. On 07/12/23 at 02:26 AM, Braden score was 21 indicating the resident was NOT AT RISK; on 07/19/23 at 01:25 AM Braden score was 14 indicating the resident was Moderate Risk, despite staff documenting a quarter sized dark non-blanchable discoloration to the resident's sacrum, a previous PU in the same spot in 2019 due to moisture; and on 07/26/23 at 01:12 AM, R2 remained as a Moderate Risk despite having an open sacrum unstageable PU. Review of the Aloha Wound Care Nursing Facility Service consultation, on 07/20/23, documented R2's wound was located on the sacrum. Wound previously occurred by pressure mechanism in March 2019 (healed). R2 was recently hospitalized on [DATE] to 07/11/23 for sigmoid volvulus and readmitted to the facility. The wound occurred after admission per staff. ---Record review related to R2's pain include review of but not limited to multidisciplinary notes, physician orders, and Medication Administration Record (MAR). No care plan was developed for pain. Review of physician orders related to PUs documented only Acetaminophen 650 mg (oral and suppository) were ordered to treat R2's mild to moderate pain. No medication was ordered to treat severe pain. On 07/12/23, a physician's order documented, Nutrition risk, Special Instructions: At risk for malnutrition. Review of the July 2023 Medication Administration Record (MAR) documented R2 was administered Acetaminophen 650 mg four times (since readmission on 07/11/23). - 07/23/23 at 04:18 AM, pain 8 of 10 a whole lot of pain, located in the buttock - 07/23/23 at 01:38 PM, pain 5 of 10, located in the bilateral lower extremities - 07/23/23 at 08:10 PM, pain 5 of 10, located in the buttock - 07/25/23 at 06:22 AM, pain 5 of 10, for general body pain A progress note on 07/24/23 documented R2 refused therapy due to his/her pain level being an 8 out of 10, however, R2 did not have a medication order to treat the resident's severe pain. Review of NS38's progress note on 07/25/23 at 03:55 PM, NS38 documented R2 denies pain, which contradicts this surveyor's observations and R2 verbalizing pain sore and expressing pain indicators (wincing, squeezing eyes closed tightly) while providing treatment to the PU. Also, on 07/27/23, after the Director of Nursing (DON)1 observed and assessed R2 and the resident reported pain, DON1 informed NS4 of R2's pain and request for pain medication, however, review of the MAR documented NS4 did not administer Acetaminophen 650 mg for pain as instructed by DON1. ---Record review of the EHR related to R2's nutrition include review of but not limited to multidisciplinary notes, physician orders, weights, and assessments documented there was a delay in addressing R2's risk for malnutrition, addressing R2's refusal of meals and potentially adding an appetite stimulant or other intervention, and the effects of untreated pain on R2's appetite, and the delay in identifying the resident significant weight loss. No care plan was developed for R2 related to the resident's risk of malnutrition related to the resident returning to the facility with a newly placed ostomy bag. A physician's order on 07/12/23 identified R2 was at risk for malnutrition. On 07/18/23 R2 was ordered and received 3 liters (L) of D5 1/2NS intravenous fluid (IV) on 07/18/23 for dehydration related to poor oral (PO) intake. On 07/11/23 (day of admission), R2 weighted 137 lbs. (pounds); 07/20/23 weight was 125.6 (11.4 lbs. loss in 9 days); and 07/24/23 weight was 121.4 lbs. (15.6 lbs. loss in 13 days). Although, there was a physician's order identifying R2 at risk for malnutrition on admission, the dietician did not assess the resident on admission to prevent R2 from experiencing malnutrition. The dietician was contacted via email on 07/20/23 to assess R2 after the resident had experienced a decline in ADLs, significant weight loss, received IV fluid for dehydration, and developed a new pressure injury. Progress notes documented a nutritional supplement was ordered on 07/20/23 to address the immediate issue, but the dietician did not come into the facility to conduct an in-person assessment of R2 until 5 days later (07/25/23). During that visit, the dietician documented R2 had experienced a significant weight loss of 12.09% since 07/11/23 (14 days after admission). Review of R2's intake of meals prior to the facility contacting the dietician from 07/11/23 to include 07/20/23, out of a total of 28 possible meals, R2 refused 10 meals, consumed 1-25% of 11 meals (staff documented resident had only eaten a couple of bites on more than one occasion), consumed 26-50% of 6 meals, and only one instance of R2 eating 51-75% of a meal. ---Record review of R2's EHR related to ADL decline included review of but not limited to the Minimum Data Set (MDS) and progress notes. The facility failed to identify R2's increased risk of PU due to a decline in the resident's mobility. Point of Care History documented R2 did not walk in room or out of unit starting on 07/13/23, prior to that the resident attempted but required 2+ person assist, extensive assist, or set-up. R2's discharge MDS with an Assessment Reference Date (ARD) of 06/14/23, prior to R2 discharge to an acute hospital, the resident required limited assistance from staff and was highly involved in the activity, staff provided guided maneuvering of limbs or other non-weight-bearing assistance for walking in the room, moving on the unit, bed mobility, transfer between surfaces (ex. bed to chair/wheelchair etc.), dressing, eating, toilet use, and personal hygiene. A nursing progress note written on 07/18/23 at 04:33 PM documented staff used a maxi lift to transfer R2 to and from the shower chair; 07/19/23 at 04:05 PM, R2 needed some help from staff with eating his meal; 07/24/23 at 04:42 PM, R2 requires 1 person assist for bed mobility, dressing, and personal hygiene care. On 07/27/23 at 12:30 PM, conducted a concurrent interview and record review of R2's EHR with the Director of Nursing (DON)1, then a subsequent observation of R2 with DON1 related to surveyor's concerns of the quality of care the resident received for risk malnutrition, prevention of PUs, pain, and ADL decline. DON1 reviewed R2's care plan and confirmed the current care plan did not include R2's risk for malnutrition, prevention of PUs, pain, or ADL decline on readmission from an acute hospital in accordance with professional standard of care. Inquired what would DON1 expect to see in a care plan to properly address prevention of a PU. DON1 stated R2 should be turned frequently, if the resident refuses staff can use pillows and wedges to off load the resident's weight on high-risk areas. The dietician should have been contacted shortly after R2 was readmitted addressing the resident's malnutrition, newly identified skin issues, and the resident's refusal to eat. Inquired if the team could have considered administering an appetite stimulate for a decline in the resident's appetite. DON1 confirmed it could have been considered but was not brought up as an option. DON1 reviewed the Braden Scale for Predicting Pressure Injury assessments completed by nursing staff. DON1 reviewed the assessments and stated that staff did not properly complete the for and if staff had identified R2 would be occasionally moist, the score would have prompted a care plan for PU to be developed and R2's assessment completed after the opening on the PI, R2 should be High Risk and not Moderate Risk. Informed DON1 of my observation of R2 while NS38 was providing treatment of the PU. DON1 reviewed the MAR and confirmed R2 had not received pain medication prior to or after treatment of the sacral PU, despite multiple pain indicators expressed by R2 and only had medication orders to treat mild to moderate pain and did not address severe pain. Informed DON1 of observations of R2's heels in direct contact with the bed and lying flat on the bed and requested for DON1 to assess the resident. At 12:55 PM, DON1 conducted a physical assessment of R2. DON1 observed R2's heels in direct contact with the mattress, the indentation of his heels on the air mattress, the outer part of R2's feet and heels were reddened, but blanchable and was at risk for developing a new PU. Also, on the bony prominence of R2's left ankle appeared to be the start of a sore and around the ankle, R2's skin was purple with extremely poor profusion, indicating the development of a PU. DON1 assisted R2 with turning so we could assess the resident's back. The bony prominence (spine, shoulder blade etc.) was in constant direct contact with the bed and were reddened indicating the resident had not been turned or repositioned to periodically off-load the areas. On the upper portion of the resident's back there were approximately four 1 inch (in.) by 1 in. patches of petechiae bruises. DON1 could not identify the source of or how the resident sustained those bruises. DON1 observed R2's non-verbal expressions of pain, assessed the resident's pain, asked R2 if he wanted medication for the pain, and R2 agreed. DON1 confirmed R2 appeared to be in constant pain, his pain was unmanaged, and pain most likely contributing to a decrease in ADL functioning and affecting the resident's appetite. DON1 and this surveyor went back to the unit nursing station where DON1 reported R2's pain to NS4 and requested that staff administer pain medication to R2. Later review of R2's MAR with another nursing staff on 07/28/23 confirmed NS4 had not administered pain medication to R2 as requested by DON1 and had not documented that R2 had refused NS4's attempt to administer the pain medication. After reviewing R2's EHR, inaccurate assessments of R2's risk for developing a PU on the Braden scale, and no care plan was developed and no interventions were implemented to prevent a new PI/PU DON1 confirmed R2's PI/PU was avoidable and R2's pain was not managed in accordance with professional standards of care.

Based on observations, interviews, record reviews, and review of policy, the facility: 1) failed to ensure Resident (R)26 remained free of accident hazards, 2) failed to keep R36's bed in the lowest position resulting in a fall and a laceration to R36's head that required stitches, 3) failed to collect/secure smoking material (lighter) from Resident (R)17, and as a result put R17 as well as all other residents at risk for accident hazards. Findings include: 1) On 08/03/22 at 11:36 AM, conducted a record review of R26's Electronic Health Record (EHR). R26 was admitted with diagnosis that include chronic [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], dysphagia, [CONDITION(S)], and contracture. The resident is unable to speak or move independently. On 04/26/22. R26 fell and sustained a laceration to his forehead that required stitches. A progress note documented R26 had an assisted fall onto the left side of his bed during a bed bath. Certified Nurse Aide (CNA)85 on the right side of the bed turned R26 and CNA63 (on the left side of the bed) held R26 and attempted to keep him on the bed but could not because of the resident's weight and uneven distribution of R26's body. R26 was sent out to the emergency room due to the amount of blood (coming from the injury to the resident's head). Review of the facility's Focused Clinical Event Review form documented the R26 was too heavy for CNA63 to hold and CNA85 (on the right side) was unable to help as R26 went to the floor. On 08/04/22 at 3:25 PM, conducted an interview with the Director of Nursing (DON) regarding R26's fall. The DON confirmed R26 is unable to move (quadriplegic), is totally dependent on staff to move, and staff was not able to manage the uneven distribution of weight resulting in the R26 falling. Inquired and requested to review documentation of staff training regarding safely turning R26. The DON stated the nurse manager had provided training but there was no documentation of the training or what the training consisted of. 2) On 08/02/22 at 01:43 PM, a concurrent observation and interview was done with R36. R36 was observed sitting in bed, with the head of the bed up at 45 degrees. R36's bed mattress was approximately elevated 2 feet off the ground. There were no fall mats on the floor. R36's bed also had handler bars approximately 6 inches in length located approximately 6 inches from the top of the mattress. R36 had amputations below both knees. He was alert and oriented to person, time, and place and answered questions appropriately. His eyes appeared gray and cloudy. He was able to move his body, grabbing items from his bedside table. He stated that he was legally blind. A review of R36's electronic health record was done on 08/03/22 at 10:00 AM. Resident Face Sheet documented that R36 was admitted on [DATE] for ischemic [CONDITION(S)]. He also has diagnoses of hypertensive heart and chronic kidney disease with heart failure, type 1 diabetes, [CONDITION(S)], major depressive disorder, [CONDITION(S)], presence of automatic implantable cardiac defibrillator (ICD), and acquired absence of both left leg and right leg below the knee. Minimum Data Set (MDS) Quarterly Review with assessment reference date (ARD) 06/20/22 documented a Brief Interview for Mental Status score of 15, meaning that R36 is cognitively intact. MDS with ARD 06/20/22, Section G documented that R36 requires one-person physical assist for bed mobility and transfers. Section H documented that R36 has no history of falls since admission. On 08/04/22 at 08:47 AM, R36 was observed laying in his bed with a rolled-up towel on top of his forehead. The bed was observed to be 16 inches off the ground. R36 stated that he was in bed when he blacked out and ended up on the floor. R36 stated that his roommate called staff for help and that he had a bump on his forehead. On 08/04/22 at 09:09 AM, R36 was observed being transferred to the hospital. On 08/04/22 at 09:30 AM, a review of R36's medical record was done. R36's Care Plan stated, Resident at Risk for falling related to impaired balance and use of antidepressant. The Care Plan stated, Approach Start Date: 03/26/2020 .Keep bed in lowest position with brakes locked. On 08/04/22 at 10:12 AM, a concurrent interview and observation was done with Certified Nursing Assistant (CNA) 1. CNA 1 stated that she was feeding another resident when she was called to R36's room because he had fallen. CNA1 stated that Nurse (N) 3 was there and R36 was on the ground. CNA1 stated that the height of R36's bed when she entered R36's room was approximately 2 feet high. CNA1 stated the bed was then lowered and staff transferred him from the ground to the bed. On 08/04/22 at 10:20 AM, a concurrent interview and observation was done with N3 in R36's room. N3 stated that this morning she was alerted by R36's roommate that something was happening in their room. N3 stated she went to check R36's room and found R36 on the ground. R36 was on the left side of the bed on the ground and was lying down on his right side. N3 stated he was able to talk and that he had a bump in the middle of his forehead. N3 stated that she called CNA1 for help. N3 stated that R36's bed was higher off the ground when she found R36 and that one of the staff lowered the bed afterwards. N3 observed the bed in R36's room and confirmed that R36's bed was now in the lowest position (16 inches off the floor) and that R36's bed was higher than 16 inches when she found R36 on the floor. When asked about R36's care plan that stated to keep bed in the lowest position, N3 stated that R36's bed is usually higher than 16 inches off the floor and that he prefers it higher than 16 inches. N3 stated that she was not sure whether R36 was educated on keeping his bed in the lowest position. On 08/04/22 at 12:06 PM, Resident Care Manager was interviewed. RCM reviewed R36's care plan and confirmed that the care plan documented to keep bed in the lowest position with breaks locked. RCM stated that there is no facility policy on what height is the standard for the lowest bed position. On 08/05/22 at 10:00 AM, Incident Report dated 08/04/22 was reviewed. Incident Report stated that R36 had a fall at 08:30 AM and that resident stated I don't know. I was on the bed and the next thing I know I heard you and I was on the floor .My head kind of hurts. Incident Report stated Resident reported hitting head on floor. Red lump to middle of forehead. Ice. Incident Report Witness Statement dated 08/04/22 by N3 stated that R36 was eating breakfast at the time of the fall and that prior to the fall resident did not attempt to get out of bed. N3 also stated No to the question Did the resident have safety devices intact (i.e. mats, alarms, low bed) at the time of the fall?. On 08/05/22 at 01:19 PM, a concurrent record review and observation was done with the Director of Nursing. DON reviewed [NAME] Hopkins Fall Risk Assessment Tool dated 06/14/22 and confirmed that R36 had a fall risk score of 9 points meaning that R36 had a Moderate Fall Risk. DON stated that interventions for Moderate Fall Risk would be to have the bed in the lowest position. DON then observed R36's bed in R36's room. DON pressed the height button to lower R36's bed and stated that the bed would be in the lowest position once it stops moving towards the ground. The bed did not move. DON confirmed that R36's bed should always be at this height (approximately 16 inches off the ground) as this would be the lowest position for R36's bed. DON stated that R36 prefers his bed to be higher than 16 inches. DON stated that he could not confirm whether R36 was educated on the purpose of keeping his bed being in the lowest position and that R36's preference of having the bed higher was not documented in his care plan. 3) During an observation and concurrent interview on 08/03/22 at 02:20 PM, R17 had a lighter stored in the bedside bottom drawer. R17 stated that the lighter was stored there after the last smoking session and that he was not aware that it should have been handed over to the nursing staff and stored in the medication cart. During staff interview on 08/03/22 at 02:30 PM, Nurse (N)4 acknowledged that the smoking material (lighter) should have been collected from R17 and stored in the medication cart. Review of facility policy on Smoking revealed the following pertinent statements: Purpose, . to provide a comprehensive and explicit policy governing the parameters of resident smoking to accommodate all residents and remain with Federal & State Law. To stay in compliance with F-Tag 323; 483.25(h) Accidents and Supervision and F-Tag 242; 483.15(B) Self-determination and Participation, and 42 CFR 483.15(g) (1)(F250) meeting the physical and emotional needs of each resident, and 42 CFR 483.15(d)(F245) to accommodate an individuals ' needs and choices for how she/he spends time, both inside and outside the facility, 483.90(h)(5) smoking safety and takes into account nonsmoking residents. All residents/guest that smoke .3. Will adhere to this policy & procedure . 6. Resident/guest will be required to return smoking material (lighter / matches / cigarettes) to Charge Nurse/or designee upon returning from smoking area. 10/19/22 - F689 S/S reduced to E from H due to IDR results per KRR.

Based on interview with facility staff, and record review (RR), the facility failed to ensure that licensed nurses and other nursing personnel had the knowledge and competencies to promptly identify and address a resident's change in health status so that interventions could be applied to prevent the condition from worsening. Specifically, the facility failed to recognize signs of a potential urinary tract infection in a resident (R)1 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of this deficient practice, R1 suffered harm and was transferred to the Emergency Department (ED) in acute respiratory distress and admitted to intensive care on a respirator with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice has the potential to affect all the residents in the facility. Findings include: 1) The Office of Healthcare Assurance received an event report from the facility on 08/18/21. The report included: On 8/17/21 R1 demonstrated yelling out and anxiousness behaviors. Went to HD [hemodialysis] treatment and had to finish 45 minutes early due to yelling out behaviors during treatment. On 8/18/21 at 05:10 am, change in condition observed with resident sweating, lethargic, O2 sat (saturation) 68% (normal 95-100 %), abdominal breathing, foaming at the mouth and nose. Staff notified MD and resident sent to ED [emergency room ] for further evaluation. ED found cocaine in resident's system. On 8/17/21 based on NOC (night 11:00 PM- 07:00 AM) nurse progress note, resident was yelling at staff while being prepared for [CONDITION(S)] treatment and refusing nursing care. At 0700 based on Day nurse progress notes, resident would intermittently call out and yell for staff. R1 wanted to get out of bed for breakfast, return to bed after breakfast, and then get him out of bed for [CONDITION(S)]. Day nurse spoke with resident and continued to yell out loud. At 0800 resident requested for an antianxiety medication. R1 became emotional and started crying prior to day nurse administering PRN (as needed) [MEDICATION(S)] (antidepressant) 50 mg (milligrams) at 0806. Resident ate breakfast in bed, transferred onto his wheelchair, and relocated into the dining room. While in the dining room resident was being disruptive by yelling out loud, staff tried to redirect but was noncompliant with redirection. Resident was brought to the front lobby for his handy van ride to [CONDITION(S)]. R1 complained of back pain and PRN Tylenol 650 mg administered at 0948. Day nurse and resident care manager (RCM) educated resident (R1) on the importance of attending his [CONDITION(S)] treatment. R1 left the facility at 1000 for his [CONDITION(S)] appointment. On 8/17/21 at 1636, day nurse received a call from the [CONDITION(S)] nurse reporting that R1 was yelling during his treatment. Resident's [CONDITION(S)] treatment was ended 45 minutes earlier due to his behaviors, MD was notified . On 8/17/21 based on evening nurse progress note, resident returned from [CONDITION(S)] at 1730 in stable condition and was transferred back to bed. Resident continuously calling out, needs and request provided but would repeatedly call out. Evening nurse educated resident on using his call light but refused to comply. R1 repeatedly yelled out that he is unable to sleep. Nurse notified APRN (Advanced Practice Registered Nurse) and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . At 2031 PRN [MEDICATION(S)] 50 mg administered for restlessness, anxiousness, and noncompliant with redirection. [MEDICATION(S)] 3 mg was also administered per residents request for inability to sleep. Right after medication was administered, R1 would continuously yell out I cannot sleep. Nurse educated resident that the medication would not take effect as soon as it was administered and to give it time. Resident did not adhere to nurse's education, continued to call out that he cannot sleep, and requested for another [MEDICATION(S)]. Resident was reminded that he has a roommate and if he could refrain from yelling out but continued to be noncompliant. At 2100, 2nd dose of [MEDICATION(S)] 3 mg administered, resident continues to yell out, and staff attended to his needs. Nurse observed resident sleeping at 2300. On 8/18/21 based on NOC nurse progress note, at 0510 resident demonstrated sweating, lethargic, abdominal breathing, foaming at the mouth and nose. Vital signs: BP 93/56, P 106, R 26, T 97.2, O2 sat [saturation-oxygen in blood] 68%. Nurse immediately positioned resident in high fowlers position, performed oral suction, and initiated oxygen 8L (liters)/min (minute) via mask. Vital signs rechecked with O2 sat at 92%. Nurse observed UOP 900 ml, creamy hematuria [blood in urine] in Foley bag. Resident was not responsive to verbal cues but responsive to tactile sternum rub with one eye open and focusing on nurse. Nurse notified 911 at 0513 and notified APRN at 0516. EMS arrived at the facility at 0530 and left the facility at 0538 to ED. On 8/18/21 at 1100, day nurse received a call from the ED . ED staff informed facility nurse that resident had been tested and was positive for cocaine. Nurse informed resident care manager of ED findings. . On 8/18/21 facility social worker notified [CONDITION(S)] social worker regarding resident's current condition. [CONDITION(S)] social worker . stated that on residents last [CONDITION(S)] day on 08/17/21, R1 was yelling to be done early from his [CONDITION(S)] session . On 8/18/21 at 1623, day nurse followed up with the hospital and R1 was admitted for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) On 09/18/21 reviewed the 08/18/21 ED notes which revealed R1 had a white blood cell (WBC) count of 25.40 (measurement in international units) A high level of WBC's is usually defined by laboratories if over 10.80. R1's urine results included red with cloudy appearance with >100 WBC and >100 RBC (red blood cells) which is consistent with urinary tract infection ([CONDITION(S)]). The ED physician's clinical impressions included acute respiratory failure with [CONDITION(S)] (low oxygen level), septic shock and [MEDICATION(S)] (inflammation of the bladder usually caused by a bacterial infection and called a [CONDITION(S)]. R1 was intubated and admitted to the intensive care unit. At the time of survey R1 remained hospitalized . 4) Review of the Vitals Report in the electronic medical record (EMR) has options for the certified nursing assistants (CNA's) to record the output (volume) of urine in milliliters (ml), the characteristic of the urine (i.e. color) as well as an area to free text any comments (i.e., notified RN). RR of the report was conducted on 09/16/21 which revealed the following entries by the CNA's: 08/14/21 at 17:54 PM shift (03:00 PM to 11:00 PM): 200 ml urine; Characteristics: Amber 08/14/21 at 21:20 PM shift: 50 ml; Characteristics: Straw/Yellow 08/15/21 at 05:49 Noc shift (11:00 PM to 07:00 AM): 100 ml. urine; Characteristics: Blood-tinged 08/15/21 at 13:15 day shift (07:00 AM to 03:00 PM): 500 ml urine; Characteristics: Straw/Yellow 08/15/21 at 21:47 PM shift: 500 ml. urine; Characteristics: Straw/Yellow 08/16/21 at 06:48 NOC shift 100 ml. urine; Characteristics: Orange 08/16/21 at 14:14 day shift 50 ml. urine Characteristics: Amber 08/16/21 22:39 PM shift 125 ml. urine Characteristics: Cloudy 08/17/21 06:32 NOC shift 50 ml. urine Characteristics: Orange 08/17/21 at 07:53 day shift none R1 left the facility for [CONDITION(S)] at 10:00 AM and returned at 05:30 PM. 08/17/21 PM shift; No documentation urine was checked by CNA this shift. 08/18/21 at 09:41 AM, LPN1 documented in progress notes 900 ml creamy hematuria after R1 was sent to the ED at 05:38 AM. 5) On 09/17/21 at 10:40 AM, during a phone interview with RN3 she said the CNA's check the Foley bags once or twice a night when they do rounds and empty the bag when they need or once a shift because they have to chart it. RN3 went on to say R1 was lately so grumpy. RN3 said she had only worked two nights recently and observed his misbehavior but was informed he was like that three or four or five nights in a row. When RN3 was asked if she routinely reviews the residents vitals report or monitors their urine, she said the urine is monitored by the CNA. They will report if unusual. RN3 was not aware R1's urine output or characteristics had changed and it was not passed on or endorsed at shift change. 6) On 09/17/21 at 02:00 PM interviewed the administration staff (AS) on duty in the front lobby where R1 was placed to wait for the handi van to go to [CONDITION(S)] on 08/17/21. AS said R1 is normally quiet and friendly and often calls his sister while waiting. AS went on to say he is usually very talkative, and recalled R1 had a headache and was loud saying his head hurt. AS said He [R1] was very loud. He was acting out so I went inside [to the resident unit] to see if someone [nursing staff] could look at him. Someone came out and took him back [to the unit] and returned him back to the lobby shortly after. The van came right after that. 7) On 09/17/21 at 09:00 AM during an interview with the facility Medical Director (FMD), he said due to the positive cocaine toxicology screen he was asked to help out to see if the result could be substantiated. FMD said he called the lab to try to get a confirmatory test, but they no longer had the specimen. He said the test is a pretty accurate test and he (R1) is not on any of the listed medications that could potentially produce a false positive. Inquired if FMD1 was aware of R1's behavior changes and he said he had reviewed the nursing progress notes and knew R1 had been acting up the day before. FMD was not aware R1 had documented changes in his urine output or characteristics beginning 08/15/21 as the nursing progress notes did not contain any notes of decreased urine or change in urine characteristics. The vitals report where the CNA's document their observations had not been reviewed. The FMD said if he had been aware of the cloudy urine along with the documented agitation R1 was displaying it could have explained R1's behavior. FMD said nine out of 10 [CONDITION(S)]'s manifest behavioral changes with this population. 8) Although R1's hospital admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing (DON), Patient Care Coordinator (PCC)1 and the Administrator were not aware of the changes in R1's urine. 9) As a result of R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor and report signs of sedation, [CONDITION(S)], or anticholinergic symptoms [dry mouth, constipation, urinary retention] and Monitor resident's mood and response to medication. R1's CP included interventions for his indwelling urinary catheter, such as Assess drainage. Record the amount, type, color, odor . and Provide catheter care as scheduled [ordered for every shift]. The CP directed staff to Report [CONDITION(S)] (acute confusion, .low back/flank pain .foul odor, concentrated urine, blood in urine). The CP lists different disciplines responsible for the approaches taken, with Nursing as one of the disciplines listed as responsible for 90% of the CP (including the interventions mentioned above). 10) A review of R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every shift Day, Evening, Night, ordered on 03/04/21, Target Behavior ([MEDICATION(S)]): Restlessness. At the end of each shift mark Frequency- how often behavior occurred & Intensity Code: 0=Did Not Occur; 1=Easily Altered; 2=Difficult to Redirect. Special Instructions: Staff Note: Add Frequency & Intensity med notes to order for tracking. Every Shift Day, Evening, Night, ordered on 03/04/21, and Irrigate Foley [indwelling urinary catheter] catheter with 60mL [milliliters] of NS [normal saline] Special Instructions: Irrigate if clogged or decreased urine output Every 8 Hours - PRN [as needed] ., also ordered on 03/04/21. 11) A review of the facility's undated Giving Daily Urinary Catheter Care procedure, received on 09/17/21 at 09:39 AM revealed The primary purpose for giving daily urinary catheter care is to prevent infection. The procedure instructs the caregiver to Check the urine for unusual appearance (i.e., color, blood, etc.) .Maintain an accurate record of the resident's daily intake and output .empty the collection bag every eight (8) hours or more often if necessary .Observe the resident for signs and symptoms of urinary tract infection and urinary retention .report the following .No evidence of drainage of urine through the tubing .Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), or odor. 12) On 09/16/21 at 04:13 PM, an interview was done with Registered Nurse (RN)2 in the conference room. RN2 stated she worked on the day shift the day prior to R1 being sent to the ED [08/17/21]. RN2 described R1's normal behavior as usually OK, calls out at times but easily redirected. On the morning of 08/17/21 though, RN2 stated that R1 was very agitated, yelling and calling out from the start of the shift until he left for hemodialysis. Although he did not seem to be listening to attempts to redirect or reason with him, RN2 stated R1 was cooperative with vital sign assessments. She remembers the CNA's that got him up out of bed told her R1 was different than usual. RN2 stated she gave R1 a prn (as needed) [MEDICATION(S)] for anxiety, per his request, at 08:06 AM. When asked, RN2 stated she could not remember having to give R1 a prn [MEDICATION(S)] before. R1 continued with the yelling, demanding behavior until he left for hemodialysis. Although she did notice a significant change in R1's behavior and mental status, RN2 stated she did not do a head-to-toe assessment of R1 because the change had been reported to her as beginning prior to her shift. RN2 did not receive report of any abnormalities in R1's urinary output for that shift and stated she does not usually check that unless she receives report of a change from the CNA. 13) An interview was done with the Director of Nursing (DON) in the conference room on 09/16/21 at 04:51 PM. During a concurrent review of R1's urinary output in the days leading up to his transfer to the ER, the DON acknowledged that there was no urinary output documented from 08/17/21 at 06:32 AM (50 ml, orange), until RN1 documented 900 ml creamy hematuria after R1 was sent to the ER. The DON stated the expectation is that the nurse should have been notified of decreased or no urinary output, and the doctor should have been called because the change in urinary output coupled with the change in mental status would have meant a significant change in condition. Given that information, the DON stated he would have checked for a urinary tract infection. 14) On 09/17/21 at 07:30 AM, an interview was done with CNA1 in the conference room. CNA1 stated she had worked the night shift the two nights prior [08/15/21-08/16/21] to R1 being sent back from hemodialysis early due to his behavior. CNA1 described R1's normal behavior as kind of gruff, but easily redirected, usually not any trouble. On the night of 08/15/21, CNA1 stated that R1 was yelling for his phone. Since it was the start of her shift, she grabbed the thermometer to take his temperature as she went in to help him find his phone. CNA1 stated she handed R1 his phone because she saw it resting on his belly and proceeded to begin taking his vitals. R1 was yelling, swearing and uncooperative, and when she went to put the thermometer in his mouth, R1 hit her hand away. R1 had never displayed behavior like this before, so she tried to address the behavior with him, but R1 only responded with, it's not like I hit you in the face. CNA1 stated R1 continued to be rude and refused to listen to anything she was saying, so she left the room and reported the incident to the charge nurse. CNA1 stated she told the charge nurse he's really out of it, and that she wanted the incident to be documented. CNA1 stated R1 continued to behave differently throughout that shift. At the end of the shift, when she went to empty R1's urinary drainage bag, she noted and documented that there was only 100 ml of dark urine. CNA1 stated R1's urinary output was usually small and dark, but that it was dark, dark that morning. When she reported it to the charge nurse, CNA1 stated she was told, just chart it. The next night, CNA1 stated that R1 continued to have erratic behavior, swearing, yelling, not redirectable, and uncooperative. At the end of that shift, CNA1 stated R1 had 50 ml of orange urine, which she again reported to the charge nurse. 15) On 09/17/21 at 07:48 AM, an interview was done with Licensed Practical Nurse (LPN)1 in the conference room. LPN1 confirmed that she was the licensed nurse on duty the night shift that R1 was transferred to the ED. LPN1 stated that R1's normal behavior was usually fine, happy-go-lucky, usually wakes up just for a snack, otherwise he sleeps through the night. LPN1 explained she had received report from the previous shift that R1 had been exhibiting behaviors such as yelling and swearing that day and had even had his hemodialysis cut short that afternoon due to his behavior. By the time LPN1 started her shift at 11:00 PM, R1 was asleep. LPN1 described how she went into R1's room at about 02:00 AM to take his vital signs, R1 was asleep but arousable, and cooperated without any trouble as she took his vital signs, then he went back to sleep. The CNA assigned to R1 that night was CNA2, and LPN1 stated that CNA2 did not approach her with report of anything unusual that shift until around 05:00 AM, when CNA2 reported that R1 was foaming at the mouth and nose. LPN1 went in to assess and found R1 with his eyes open but not focusing, unresponsive to commands, white foam out of his mouth and nose, he was breathing fast and gaspy with a gurgling sound in the back of his throat. LPN1 grabbed the crash cart and vital signs machine, [and] suctioned him but could not get all the fluid in the back of his throat, his oxygen saturation was in the 60s, LPN1 repositioned R1, and placed oxygen on him via an oxygen mask. She called 911, and called the doctor for orders, then she began preparing R1 for transfer to the ED. As she and CNA2 prepared him for transfer, LPN1 stated she noticed his urinary drainage bag had about 400 ml of creamy hematuria in it, describing the urine as brownish reddish, thick, and foamy, and had a really strong odor to it, describing the odor as pungent, fishy. LPN1 stated CNA2 emptied the urinary drainage bag at that time, as they continued to prepare R1 for the ER. After her shift was over, LPN1 stated she was charting and noted that there was no entry for R1's urinary output documented yet, so she asked CNA2, who reported to her 900 [ml] total [for the eight-hour shift]. LPN1 stated R1's normal urinary output was not more than 400 ml for an eight-hour shift, so she did think 900 ml was unusual, but she did not question it, she just asked about the character of the output. LPN1 stated that CNA2 reported the output had been a little bit darker than usual. LPN1 explained that if the unusual volume and character of the urine had been reported to her earlier in the shift, she would have assessed [R1], checked his vital signs, and notified the MD [doctor] because of a change in condition. 16) On 09/17/21 at 12:21 PM, a review of the Treatments Administration History for Catheter Care from 08/01/21 to 08/17/21 was done. The review noted the licensed nurses assigned to the resident on each shift had consistently signed off that catheter care was done. Not one shift was left blank to indicate that catheter care had not been provided. The review also noted that none of the licensed nurses documented that the urinary catheter had required irrigation for a blockage or clog, or more notably, for decreased urine output.

Based on interviews, record review, Policy and procedure, the facility failed to provide a safe environment for Resident (R) 174 which resulted in a fall with injury. R174 required hospitalization and surgery for her injury. Findings include: R 174 sustained a fall with injury while left unattended in the restroom during a shower. R174 has a history of cerebral infarction, [CONDITION(S)] affecting left nondominant side. dysarthria. She has generalized muscle weakness and is unsteady on her feet. Record review of a facility reported event report on 05/12/21 revealed that R174 requested to use a shower chair that was too small for her size, and insisted to the certified nursing assistant (CNA)1 to place 3 blankets on the chair to make her sit higher on the shower chair. CNA1 told R174 that this would be unsafe for her. CNA avoided more discussion because R174 would get upset with her. Although CNA1 did state that it was an unsafe shower chair, CNA1 did not get help from the assigned Registered Nurse (RN)17 who was the charge RN. Furthermore, the event report stated that CNA1 left the resident unattended during the shower three times, 1) while R39 was brushing her teeth, 2) CNA1 left to attend to R174's roommate and 3) to start to put away R174's shower belongings. At approximately 2015 on 04/24/21. CNA1 heard R174 yelling for help. Interview on 04/13/21 with RN17, stated that the night of the incident that R174 fell , CNA1 did not come and discuss the unsafe matter with her. She further stated that if the CNA1 had come to discuss this matter, she would not have allowed it. RN 17 showed me the shower chair that R174 sat on. R174 is reported to be approximately 205lbs and the shower chair was a small version, not the right size for someone of that weight. It was also noted by R 17 that there were three blankets placed on the shower chair at the time of the incident. This action propped the resident higher in the chair, making R174, at 205lbs, top heavy. This measure placed the resident at an unsafe risk for a fall. Record review of the job description for a certified nurse's aide, under safety and sanitation, (#14) Report all hazardous conditions and equipment to the charge nurse immediately. Record review of the job description of the Registered Nurse (RN) under essential functions, #12 states Communicates specifics of care for each resident to the C.N.A. Overseas care delivery by CNAs. Assists C.N.A.s as necessary. Record review of a competency checklist for CNA1 on giving a shower, (#14) states stay with the resident during the procedure for resident's safety. R174 sustained an unattended fall in the shower on 04/24/21 when she was left alone. In addition, R174 had insisted that she be placed in a shower chair that was too small for her and to add three blankets to be placed on the chair. This request placed R174 in an unsafe position in that the resident sat high above the armrests and had an unwitnessed fall. This deficient practice had the potential to affect the other residents identified in the facility

Based on observation, residents interview, staff interview, and review of policy, the facility failed to treat one out of eight residents (Resident (R) 63) selected in the initial pool for review with dignity and respect. The facility also failed to enhance the self-esteem and self-worth of R63 related to preferences and/or choices. As a result of this deficient practice, R63 showed signs of social withdrawal, anxiety toward staff, and resistance to care; such as not wanting to press the call light for assistance. This deficient practice had the potential to affect the remaining 76 residents at the facility if they were treated in a similar manner. Findings Include: During resident interview of R63 on 10/17/18 at 08:31 AM, R63 stated soon after being admitted , staff were mean and show no respect. R63 said after pressing the call light for assistance, staff would say loudly go to bed, go lay down, do you know how many residents are here - 100, I cannot help you right away, you have to wait. R63 said this had been happening since being admitted and stated it felt bad just to press the call light, I just lay down and no say anything, anymore. R63 could not identify any particular staff member or members and also wanted to remain anonymous at this point. During observation of R63 on 10/18/18 at 08:16 AM, R63 was in his/her room watching TV and preferred to stay in the room - away from the crowd and/or socializing. When asked the reason for staying in the room, the answer was I'd rather stay in the room, no reason, I can go outside later. At this point, it was observed that R63 did receive appropriate staff assistance with meals and the bed side commode. During record review on 10/18/18 at 10:10 AM, R63's Brief Interview for Mental Status (BIMS) score was fifteen which indicated that R63 was cognitively intact. This was consistent with previous interviews where R63 was answering questions appropriately and was oriented to person, place, and time. During an interview with R18 (the roommate of R63) on 10/18/18 at 12:09 PM, R18 witnessed hearing the above statements being said to R63 and further stating the staff are not nice, I could hear them grumbling. During an interview with R14 (the neighbor of R63) on 10/18/18 at 12:15 PM, R14 stated that staff have been treating me bad since day one. However, R14 also said it doesn't bother me because I treat them the same too. During a follow up interview with R63 on 10/19/18 at 04:15 PM, R63 agreed to no longer have anonymity and agreed to talk to facility staff about the concerns of not being treated with dignity and respect. It was at this time that R63 showed some signs of anxiety toward a staff member identifying him/her as the perpetrator. This information was immediately passed on to the facility Administrator and the Director of Nursing for further investigation.

Based on observation, record review, interviews, and a review of facility policies and procedures, the facility failed to provide the necessary care and services which include pain management to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 resident (Resident # 5) of the 31 residents in the Stage 2 survey. Findings include: On the afternoon of 9/03/2015, an Immediate Jeopardy (IJ) was found at the facility. There was harm for 1 resident (#5) due to the failure of nursing staff to anticipate, assess, identify, manage, or promote pain relief before/during/after wound care. Cross Reference to F314 and F441 Resident # 5 was admitted to the facility on [DATE]. She presented with a [MEDICAL CONDITION], pressure ulcers, [MEDICAL CONDITIONS] Reflux Disease (GERD), Multi-drug Resistant Organism (MDRO), [MEDICAL CONDITION], Diabetes Mellitus (DM), [MEDICAL CONDITIONS] [MEDICAL CONDITIONS] disorder, anxiety disorder, depression, asthma, [MEDICAL CONDITION], and later [MEDICAL CONDITION] and [MEDICAL CONDITION]. Special treatments included: oxygen therapy, suctioning, wound care, and [MEDICAL CONDITION] care. - On 09/03/2015 at 2:31 P.M., during an observation of wound care for resident #5, it was noted that LN #2 failed to anticipate or assess the resident for pain before beginning wound care. LN #2 changed dressings on two abdominal wounds using wet to dry dressings, then with assistance from a CNA, turned resident #5 to her left side where she proceeded to change the dressing on the hip wound using Triad Cream. LN #2, with assistance from the CNA rolled resident #5 to her right side to complete a dressing change near the buttocks using Triad Cream. When LN #2 noted that the wound vac was dislodged and the wound near her sacrum was filled with fecal matter, she stated it's not supposed to be changed today (wound vac) and that she needed to contact the wound nurse to get further instructions. LN #2 and the CNA rolled the resident onto her back leaving the unclean open wound area uncovered. - LN #2 did not assess the resident for pain at anytime during or after the 4 dressing changes. On 9/03/2015 at 3:14 P.M. LN #2 returned to resident # 5's room and stated that she was waiting to get orders for the last wound dressing. She proceeded to give resident #5 her routine medications via feeding tube. No pain medications were given at this time. On 9/03/2015 at 4:15 P.M. surveyors returned to resident # 5's room to continue monitoring the dressing change for wound #5. LN #2 was in the room with the evening shift LN who was there to assist/coach. LN #2 had a chux draped over the bedside table with all of her supplies laid out. It was at this time that LN #2 started cleansing the fifth wound by flushing with NS and wiping it with 4 X 4 gauze bandages. - LN #2 did not anticipate or assess for pain before starting the wound dressing change (5th wound) for resident #5, and it was noted that wound care had started 1 hour and 44 minutes ago. Resident #5 was noted to be tearful and had a grimace on her face when LN #2 started the 5th dressing change. The surveyor asked resident #5 if she was in pain and resident nodded yes. Resident had a trachea so was unable to vocalize or verbally express pain. Surveyor asked LN #2 if resident received any pain medication before the procedures and she stated no, she doesn't get pain meds. Surveyor shared observations that resident was displaying signs of pain. LN #2 then asked the resident if she was in pain and resident #5 again nodded affirmatively. LN #2 then returned to the task of wound care with coaching from the evening LN. LN #2 did not stop the procedure to address the resident's pain. - LN #2 failed to properly anticipate, assess, and identify pain for Resident #5 before or during the wound procedures. Of the five wound care/dressing changes, the fifth wound was the largest. According to the weekly skin assessment on 8/26/2015 this fifth wound was measured at 12 x 14 x 4 cm. LN #2 did not treat resident # 5's pain even after she received verification from the resident that she was experiencing pain. A review of the care plan was completed on 9/03/2015 at 5:14 P.M. The identified problems included a Stage 3 pressure ulcer with abdominal drains and surgical site care. One of the Interventions included: Assess and record pain status. Although noted in the care plan the pain was not assessed for resident #5 who had five open wounds. A record review on 9/03/2015 at 5:58 P.M. of the weekly skin assessment showed that from 05/01/2015 through 08/19/2015, 18 entries noted that resident #5 experienced no pain. However the observation by the surveyor on 09/03/2015 included a tearful grimace and a nodding of her head when resident was questioned about pain, and, the resident's wound was left unattended with no pain medication(s) administered to her.

Based on observation, record review, interviews, and a review of facility policies and procedures, the facility failed to provide pressure ulcer care in accordance with accepted professional standards and ensure that resident receives necessary treatment and services to promote healing, prevent infection, and prevent worsening of existing pressure ulcers for 1 resident (Resident #5), of the 31 residents in the Stage 2 resident census sample. Finding includes: On the afternoon of 9/03/2015, an Immediate Jeopardy (IJ) was found at the facility. There was harm due to the failure of nursing staff to: provide necessary treatment and services to promote healing of resident #5's Stage 3 pressure ulcer (PU), along with four other wounds, and to prevent infection. Cross Reference to F309 and F441. On 9/03/2015 at 2:31 P.M., during an observation of wound care for resident #5, it was noted that LN #2 failed to anticipate or assess the resident for pain before starting wound care. 1)LN #2 donned gloves without first sanitizing her hands, placed her supplies including a scissor, 4 X 4 gauze pads, abdominal pads, and tape on the resident's bed sheet, and failed to keep a sterile field per policy. The facility policy per NC #1 from Lippincott on wound dressing application states Dressing a wound calls for sterile technique and sterile supplies to prevent contamination. This was not done as LN # 2 removed the soiled gauze from the first 2 wounds on the upper abdomen, flushed the wounds with normal saline (NS), then proceeded to fold up a 4 X 4 gauze pads and saturate them with NS and place in the two abdominal wounds. She did not change gloves or sanitize her hands between the two abdominal wound dressings. The LN cut an abdominal dressing pad in half and placed one half over the first wound and taped it and repeated this step for the 2nd wound. The LN along with assistance from a CNA rolled the resident onto her left side. The LN removed her soiled gloves and put on a new pair she removed from the bedside table, once again, she did not sanitize her hands between glove changes. 2)LN #2 then flushed the third wound located on the right buttock with NS, reached into a plastic container located on the bedside table filled with supplies, and grabbed a cotton tipped applicator while still wearing her soiled gloves. LN #2 then applied Triad cream to the wound with the cotton applicator, cut an abdominal pad in half, and covered the wound. LN #2 failed to follow the treatment order which stated to apply Triad cream onto a gauze square and then onto the wound, then cover with an abdominal pad. LN #2 removed clean gloves from the glove box located on the room wall. She placed one set on the bed stand and put on the second pair. She did not sanitize her hands between glove changes. 3)The CNA and LN rolled resident #5 over to her right side. LN #2 removed the soiled dressing from the fourth wound and flushed it with NS, applied Triad cream to the wound with a cotton tipped applicator, and placed 1/2 of abdominal pad on the wound. LN #2 again failed to follow the treatment order which states to apply Triad cream onto a gauze square and then onto the wound. LN #2 removed the scissors from the bed, placed them in the supply container, removed her gloves, and removed the soiled dressings from the room. 4)The CNA removed the fifth dressing located in the sacral area. LN #2 stated that the wound was filled with fecal matter. LN #2 and the CNA rolled resident #5 onto her back without covering the unclean, open wound. LN #2 stated that she was going to call the wound nurse to see if it needs a wound vac because it's not ordered for today and the wound is so close to the buttocks it's difficult to keep clean. LN #2 left the room to find the wound nurse. On 9/03/2015 at 3:34 P.M. in an interview with LN #2 when asked about infection control and how she ensures clean supplies for dressing changes, she stated, it isn't supposed to be a sterile field. She then stated, I guess I should have put a clean pad down, and I guess I didn't wash my hands between wounds. 5)On 09/03/2015 at 4:15 P.M. surveyors returned to resident # 5's room to continue monitoring the dressing change for the fifth wound. LN #2 was in the room with the evening shift LN who was there to assist/coach. LN #2 had a chux draped over the bedside table with all of her supplies laid out. When entering the room it was noted that LN #2 was flushing the wound with NS and wiping it with 4 X 4 gauze bandages. Surveyor observed resident #5 had teary eyes and a grimace on her face and asked her if she was in pain. Resident #5 nodded her head yes. Resident #5 had a trachea and was unable to speak. Surveyor asked LN #2 if resident received any pain medication before the procedures and she stated no, she doesn't get pain meds. Surveyor shared observations that resident was displaying signs of pain. LN #2 asked the resident if she was in pain and resident #5 again nodded her head affirmatively. LN #2 then returned to the task of wound care. LN #2 did not stop the procedure to address the residents pain. 6)In a record review of the Weekly skin assessment dated [DATE], it was noted that the wound was measured as follows: Length 6 cm X Width 5 cm with a Depth of 4 cm, tunneling undermining: 11-2 O'clock 3 cm with 25% slough. Comments include 125 mg pressure, IAD to surrounding skin due to watery stool - very loose and frequent. By 8/26/2015 the resident #5's sacral pressure ulcer was documented by LN #8 as :Surrounding skin very macerated and breakdown occurring. Overall affected area surrounding and including wound 12 x 14 cm. Applied [MEDICATION NAME] to area and applied thick draping to help prevent stool seepage touching the skin. Surveyor observation during wound care on 9/03/2015 found the wound measured approximately 12 x 14 cm, which was a large increase in size from the previously documented size of 6 x 5 x 4 cm. On 9/03/2015 at 4:25 P.M. in a record review it was noted in the care plan that sterile technique is to be used for resident wound care. Sterile technique was not followed during any of the five dressing changes for resident #5 on 9/03/2015. LN #2 Verified that she did not use sterile technique when completing dressing changes for resident #5. On 9/03/2015 during a record review of treatments, it was noted that an order for [REDACTED]. LN # 2 did not follow treatment orders as written and instead placed Triad cream into the wounds with a cotton tipped applicator. On 9/03/2015 at 3:59 P.M. an interview was conducted with NC #1 and NC #2 regarding concerns with the competency of LN #2 completing wound care for resident #5, in addition to the lack of a pain assessment, and medication administration. - NC #2 verified that the policies and procedures for wound care had not been followed and that the resident should have been treated for [REDACTED]. After hearing concerns, NC #2 stated we are going to take care of this right now, I'm going to get orders for pain medication and we will get the ADON to check the dressings. On 9/03/2015 at 4:33 P.M. an Immediate Jeopardy was identified. The facility developed an abatement plan which included the removal of the LN #2 for further training and a facility wide in-service for all LN's.

Based on observation, staff interview, and a review of facility policies and procedures, LN #2 failed to demonstrate proper hand hygiene when caring for resident #5, and did not know the standard precautions to be taken prior to entering resident #5's room. Findings include: Cross Refererence to F309 and F314 On the afternoon of 9/03/2015, an Immediate Jeopardy (IJ) was found at the facility. There was harm due to the failure of LN #2 to follow proper infection control practices including hand washing, using sterile technique when performing wound care, and not identifying what standard precautions resident #5 was on before entering her room, thus not providing the necessary care and services to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of disease and infection. 1)On 09/03/2015 at 2:31 P.M. an observation was made of LN #2 performing a dressing change for resident #5. LN #2 put on gloves without first sanitizing her hands, placed her supplies including a scissor, 4 X 4 gauze pads, abdominal pads, and tape on the resident's bed sheet, and failed to keep a sterile field per policy. The facility policy per NC #1 from Lippincott on would dressing application stated, dressing a wound calls for sterile technique and sterile supplies to prevent contamination. That was not done as LN # 2 removed the soiled gauze from the first 2 surgical wounds on the upper abdomen, flushed the wounds with normal saline (NS), then proceeded to fold up 4 X 4 gauze pads, saturate them with NS, and placed the gauze in the first two wounds. LN #2 did not change gloves or sanitize her hands between wounds. The LN then cut an abdominal dressing pad in half and placed one half over the first wound, taped it, and repeated this step for the second wound. LN #2, along with assistance from a CNA rolled the resident onto her left side. She then removed her soiled gloves and put on a new pair without sanitizing her hands. 2)LN #2 then flushed the third wound on the right buttock with NS, reached into a plastic container located on the bedside table filled with supplies, and grabbed a cotton tipped applicator while wearing her soiled gloves. LN #2 then applied Triad cream to the wound with a cotton tipped applicator, cut an abdominal pad in half, and covered the wound. LN #2 failed to follow the treatment order which stated to apply Triad cream onto a gauze square and then onto the wound, then cover it with an abdominal pad. LN #2 then placed the scissors on resident's bed, then went to get clean gloves from the glove box located on the room wall, placing one set on the bed stand and putting on the second pair without sanitizing her hands. 3)On 09/03/2015 at 3:14 P.M. LN #2 returned to resident # 5's room and stated that she was waiting to get orders for the last wound dressing. She put on a gown and gloves without first sanitizing her hands, placed one supply tub into another to make room on the bed tray, set up tubing for resident # 5's tube feeding, and went into the bathroom to wash her hands. When asked what type of precautions resident #5 was on, LN # 2 stated I'm not sure if she's on contact or sputum precautions. LN #2 left the room, took off her gown and gloves, and went to the medication cart to check on which standard precautions resident # 5 was on, not finding he answer, she then asked another nurse about the resident's precautions. LN #2 returned to resident #5's room, and once again put on the gown and gloves without sanitizing her hands. LN #2 checked placement of the [DEVICE], removed air with a syringe, and gave a 10 cc bolus of water. LN #2 then started giving resident #5 her medications through the [DEVICE]. 4)When LN #2 was finished administering resident #5's mediations, she placed the cap of the feeding tube on a metal spike located at the top of the intravenous (IV pole). Surveyor asked LN #2 if the cap should be placed on an unclean metal surface, and she stated I guess I shouldn't. Per LN #2 the tubing sets are used for 24 hours and then changed at night. This tubing would be used one more time in the evening before being discarded. On 09/03/2015 at 3:34 P.M. in an interview with LN #2 when asked about infection control and how she ensures clean supplies for dressing changes, she stated it isn't supposed to be a sterile field, she then stated I guess I should have put a clean pad down and I guess I didn't wash my hands between wounds. - On 09/03/2015 at 4:25 P.M. in a record review it was noted that the care plan stated that sterile technique is to be used for resident wound care. - On 09/03/2015 in a record review the facility policy on wound dressing application was received from NC #1. The policy is from Lippincott and states Dressing a wound calls for sterile technique and sterile supplies to prevent contamination.