Every finding on record at Signature Healthcare of Memphis

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when portable oxygen cylinders were unsecured in 2 of 107 (Residents #7 and #99) sampled residents' rooms. The findings include: 1. Review of the facility policy titled, Oxygen Storage, dated 1/31/2025, revealed .The facility acknowledges the special hazards associated with storage and use of compressed oxygen cylinders.has established procedures for the safe storage, use and transfer of oxygen in the facility.E-tanks [Emergency tanks] will be stored in an approved O2 [Oxygen] tank holding device or in an approved storage rack at all times. 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Seizures, Gastrostomy, Dysphagia, and Schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively impaired. Resident #7 received oxygen therapy. Review of Physician's Order dated 4/15/2026, revealed Oxygen Therapy.2 Liters BNC [Binasal Canula] Each Shift. Review of the Care Plan dated 4/16/2026, revealed .Resident requires use of oxygen . Observations in the Resident's room on 5/11/2026 at 9:52 AM, 11:58 AM, and at 3:11 PM, revealed a portable compressed oxygen cylinder free standing and unsecured between the resident's headboard and the bedside dresser. During an observation and interview in Resident #7's room on 5/11/2026 at 3:16 PM, Licensed Practical Nurse (LPN) A was asked if the portable oxygen cylinder should be stored unsecure in the resident's room. LPN A stated, No, it should not be stored unsecure in the resident's room. 3. Review of the medical record revealed Resident #99 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Pneumonia, Anxiety, and Schizophrenia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #99 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. Resident #99 received oxygen therapy. Review of the Care Plan dated 3/31/2026, revealed . Resident requires use of oxygen related chronic resp [respiratory] failure .Oxygen as ordered . Review of Physician's Order dated 4/6/2026, revealed Oxygen Therapy.via [by way of] NC [nasal canula] @ [at] 2 Liters per minutes. Observations in the Resident's room on 5/11/2026 at 9:56 AM and at 2:53 PM, revealed a portable oxygen cylinder free standing unsecured between the resident's headboard and the bedside dresser. During an observation and interview in Resident #99's room on 5/11/2026 at 3:17 PM, Licensed Practical Nurse (LPN) A was asked if the portable oxygen cylinder should be unsecured in the resident's room. LPN A stated, No, it should not be unsecure in the resident's room. During an interview on 5/13/2026 at 2:41 PM, the Director of Nursing (DON) was asked how portable oxygen cylinders should be stored. The DON stated, They should be stored in a rolling carrier or secured in a carrier on the back of a resident's wheelchair. The DON was asked if they should be free standing in a resident's room. The DON stated, No, they should not be free standing in resident rooms.

Based on facility policy review, medical record review, and interview, the facility failed to report an injury of unknown origin for 1 of 2 (Resident #2) sampled residents reviewed for abuse. The findings include: 1. Review of facility policy titled, Abuse, Neglect, and Misappropriation., dated 9/15/2023, revealed .It is the organization's intention to prevent the occurrence of.injuries of unknown origin.and to assure that all alleged violations of federal and State laws which involve.injuries of unknown origin.are investigated and reported immediately to agencies in accordance with Federal and State law.Injury of Unknown Source.This means an injury that meets both of the following conditions.the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and.the injury is suspicious because the extent of the injury; or the location of the injury (for instance, the injury in an area not generally vulnerable to trauma.Reporting.Every Stakeholder shall immediately report any injury of unknown origin.to the Facility Administrator. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Subdural Hematoma (bleeding on the brain), Dysphagia, Metabolic Encephalopathy, and Down's Syndrome. Review of quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment, which indicated severe cognitive impairment. Resident #1 required maximum assistance of staff to perform Activities of Daily Living. Review of Nurse's Note dated 1/3/2024, revealed, This nurse was called to the room via [by] the CNA [Certified Nursing Assistant] at approximately 7:45 AM. This nurse entered the room the resident was noted sitting in his wheelchair with the bedside table positioned in front of the resident. The resident's forehead noted lying on the bedside table with a pillow positioned under forehead. This nurse raised the resident's head off the bedside table the resident's forehead left and right side was noted with scratch marks and the resident's left eye lid and under eye was noted with some purplish discoloration along with a small scratch under left eye. The resident's inner eye also noted with some redness.The resident was unable to explain what happened. This nurse asked the CNA what happened the CNA states that when she entered the room the resident was sitting on the side of the bed with his head bent forward and when she assisted him back to bed to provide incontinent care she noticed the scratch marks and discoloration to the left eye. Review of the Event Report dated 1/3/2024, revealed .Description: Discoloration to left eye, scratch marks to forehead.Location of Bruise: left eye.Color of bruise: Purplish-black.Assessment of resident unable to verbalize pain.Facial expression: Sad, frightened, frown.Body Language: Tense, distressed, fidgeting.Resident unable to verbalize pain score.2 mild pain. Review of the Nure Practitioner Note dated 1/3/2024, revealed .Evaluation of patient for redness to left eye .Nurse reported that patient had redness to left eye. Patient is non-verbal and is currently leaning forward in the bed .Patient has discoloration and swelling noted beneath left eye. Discoloration and scratches noted to left side of forehead .We will obtain labs and imaging to rule out any active disease process . During a telephone interview on 10/7/2025 at 12:04 PM, the former Director of Nursing (DON) was asked if she recalled Resident #2's injury from 1/2/2024. The former DON stated she recalled completing an investigation related to the resident's injury stated that the injury was initially an injury of unknown origin until the conclusion of the investigation. During a telephone interview on 10/7/2025 at 3:10 PM, CNA B stated, I took care of [Resident #2] the previous day [1/2/2024] from 7:00 AM until 11:00 PM and the resident did not have any bruising or scratches on that shift. CNA B stated she initially noticed the resident's injury when she rolled him over to perform personal care on 1/3/2024. CNA B stated, [Resident #2] had scratches, a black eye with swelling to side of face and eye. During an interview on 10/7/2025 at 4:54 PM, the Administrator stated, Injuries of unknown origin should be reported to state and local agencies. The facility failed to report an injury of unknown origin for Resident #2.

Based on policy review, medical record review, and interview, the facility failed to ensure the resident's physician was notified of a significant change in a resident who complained of left leg pain and swelling from her leg getting tangled in a Hoyer lift pad for 1 of 4 (Resident #15) sampled residents. The facility's failure to notify the resident's physician resulted actual harm when the resident waited for approximately 20 hours and 15 minutes before being transferred to the hospital for treatment of a fractured hip. The facility had a census of 125. The findings include: 1. Review of facility's policy titled, Notification of Change of Condition Policy, dated 7/7/2022, revealed, .The facility must .consult with the resident's physician .when there is an accident involving the resident which results in an injury and has the potential for requiring physician intervention. A significant change in the resident's physical .status .Documentation of notification or notification attempts should be recorded in the resident electronic medical record .If unable to contact the physician .may contact the Medical Director . 2. Medical record review for Resident #15 revealed the resident was admitted to the facility on [DATE], with diagnoses incomplete Quadriplegia (unable to move arms and legs), Guillain-Barre Syndrome (disease of the nervous system resulting in loss of feeling to extremities), Lack of Coordination, Muscle Weakness, Anxiety Disorder, Chronic Pain Syndrome, Muscle Spasms, and Convulsions (abnormal uncontrollable body movements). Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #15 was assessed with a Brief Interview for Mental Status (BIMs) of 15, indicating the resident was cognitively intact, required total assistance from staff for activities of daily living (ADLs), and had range of motion (ROM) limitations on both sides for the upper and lower extremities. Review of the Care Plan dated 1/12/2023, revealed, .quadriplegia .transfers per mech [mechanical] lift with 2 staff . Review of a facility's Investigation report dated 3/28/2023, revealed on 3/28/2023 at 2:00 AM, Certified Nursing Assistant (CNA) #4 entered Resident #15's room to provide care and observed the resident's leg to be swollen. CNA #4 asked Resident #15 what had happened, and the resident told CNA #4 that her leg got caught in the mechanical lift pad when she was taking a shower. CNA #4 reported this to the charge nurse, Licensed Practical (LPN) #4. On 3/28/2023 at 7:00 AM, LPN #4 notified the oncoming nurse, LPN #7, of the status of Resident #15's leg. On 3/28/2023 at 7:40 AM, LPN #7 documented Resident #15's left leg was swollen and painful. Review of a Nursing Progress Note dated 3/28/2023 at 7:40 AM, electronically signed (e-signed) by LPN #4, revealed .Resident c/o [complain] of LLE [left lower extremity] pain. L. hip to foot noted to be edematous, pitting in the ankle and top of foot .Noted in NP [Nurse Practitioner] book . Review of a Nursing Progress Note dated 3/28/2023 at 8:00 AM, e-signed by the Director of Nursing (DON), revealed, At approximately 8am [8:00 AM] received report from nurse that resident was complaining of left leg pain and swelling and informed resident that an NP would see her today during rounding . Review of a Nursing Progress Note dated 3/28/2023 at 1:45 PM, revealed, NP at bedside, examined resident with new orders received. Review of a Radiology Order dated 3/28/2023, confirmed stat (immediate) x-rays were ordered for the Left Femur, Left Tiba/Fibula, and Left Ankle Stat. Review of the radiology report dated 3/28/2023 at 6:33 PM revealed, Comminuted (a type of broken bone) intertrochanteric left femur (area of the broken bone) fracture. Exam complicated by demineralized bones (bones can break easy). The facility's investigation documented that on 3/28/2023 at 6:55 PM, LPN #6 was notified of resident x-ray results from Radiology. Review of a Nursing Progress Note dated 3/28/2023 at 8:26 PM, revealed, Resident X-ray result show that resident has a sub-capital neck (area on the hip), and left hip fracture .NP gave order to send resident to hospital . The facility's investigation documented that on 3/28/2023 at 9:24 PM, the DON notified the Administrator of the events surrounding Resident #15's leg. Review of a Nursing Progress Note dated 3/28/2023 at 10:11 PM, revealed Resident #15 was transferred to the hospital by ambulance for evaluation of her left leg. Review of the Medication Administration Record (MAR) dated 3/28/2023 revealed no evidence Resident #15 had received pain medications as needed (PRN) for pain or orders for PRN pain medications. Review of the History and Physical with an admitted [DATE] revealed, .Pt [Resident #15] admit she got tangled in her Hoyer lift [mechanical lift] Saturday .resulting in current fxs [fractures] .History of Present Illness .Patient states that on Saturday [3/25/2023] an aide at the NH [nursing home] was trying to transfer her from her bed to the shower using a hoyer lift .she states that the attendant was being rough with her and moving her too fast, which caused her legs to dangle off the lift and hit various surfaces. She was then handled roughly in the shower and has had significant pain in her left leg (hip worst) since then as well as new LLE swelling (endorses a degree of swelling at baseline) .Patient underwent numerous XRs (X-Rays) of lower extremities which showed intertrochanteric [area on the hip] L hip fracture and Chronic R hip changes .Assessment / Plan .Orthopedics have evaluated and planning for operative repair when able . During an interview on 4/11/2023 at 9:40 AM, the DON was asked when were she had been notified about the Left Hip Fracture for Resident #15. The DON stated, The night we got the x-ray it was the 28th that night when the results came back . The DON confirmed that the only medication the resident received for pain was her scheduled medication for neuropathy. During an interview on 4/11/2023 at 11:21 AM, the Administrator was asked what occurred with Resident #15's left hip. The Administrator confirmed that Resident #15 was alert and oriented and she told the emergency room staff her leg got twisted and tangled in the mechanical lift and she told me that when she talked to me. The Administrator confirmed Resident #15 had stated she remembered hearing a pop. The Administrator confirmed she was unaware of any injury or swelling to Resident #15's leg until she was notified of the fracture the night of 3/28/2023. During an interview on 4/11/2023 at 5:25 PM, the DON confirmed she was unaware of the incident with Resident #15's leg getting tangled in the mechanical lift pad and verified it had not been reported to her until the x-ray results on the evening of 3/28/2023. The DON confirmed that LPN #4 should have called the NP or the physician the night of 3/28/2023 at 2:00 AM and should not have waited to pass it on to the next shift. The DON confirmed that LPN #4 should have also called her and the Administrator to report what Resident #15 had reported about the occurrence with her leg getting tangled up in the lift pad and that her documentation on 3/28/2023 at 7:41 AM in the progress notes should have contained that information along with her attempts to use the notification app and her attempts to call the NP. During an interview on 4/11/2023 at 6:48 PM, CNA #4 confirmed she worked from 11:00 PM on 3/27/2023, to 7:00 AM on 3/28/2023, and was assigned to give care to Resident #15. CNA #4 stated she was assisting with ADL care for Resident #15 and noticed the resident's left leg was swollen and asked her what occurred. CNA #4 stated Resident #15 told her that her leg got tangled in the mechanical lift. CNA #4 stated she immediately reported it to the charge nurse. CNA #4 verified this occurred around 2:30-2:35 AM. CNA #4 confirmed that Resident #15's leg was swollen more than normal that is what prompted her to ask what had happened to her leg. During an interview on 4/11/2023 at 7:37 PM, LPN #4 stated on 3/28/2023 at approximately 2:00 AM Resident #15 reported to CNA #4 that her leg was injured on Saturday (3/25/2023) while being transferred with the mechanical lift to go to the shower room. LPN #4 stated Resident #15 had said that CNA #1 and an unfamiliar CNA (CNA #2) were getting her up with the lift. LPN #4 stated she assessed Resident #15 and she attempted to notify the NP on call but was unable to access the on-call system to work. LPN confirmed she should have called the DON and the Administrator, and would have called the Medical Director instead of putting it in the NP book, and obtained an order for pain medication. During an interview on 4/12/2023 at 9:21 AM, NP #1 was asked how often she was onsite at the facility. The NP stated she was present Monday through Friday. NP #1 was asked how she communicated with staff. NP #1 stated there is an on-call system with availability around the clock for urgent issues and when there is a change in a resident's condition, and there is a communication book for non-emergent issues. NP #1 confirmed that a Registered Nurse will triage the call and determine if it is urgent or non-urgent. NP#1 confirmed that if it is during her working hours they can come find her or page her overhead. The NP was asked what if the nurse at the facility is unable to access the on-call system is there another alternative that can be utilized to contact a provider. NP #1 confirmed the Medical Director can be called at any time and he has been called in the past when there were issues with the system. NP #1 confirmed she was the NP on-call the day of 3/28/2023 and was covering the entire building because NP #2 called in sick. NP #1 was asked what time was she was informed of Resident #15's change in condition to her left leg the day of 3/28/2023. NP #1 confirmed she was not made aware of the swelling to Resident #15's left leg until she picked up the communication sheets from NP #2's communication book at approximately 7:45 AM or 8:00 AM. NP #1 confirmed that book is utilized for non-urgent issues. The NP stated staff did not describe the swelling to Resident #15's leg. NP #1 stated Resident #15 has always had some swelling from time to time around her ankles but staff failed to present the concern in an urgent manner and failed to mention about the leg being caught in a mechanical lift. NP #1 stated the communication sheet that she later reviewed was not written in an urgent manner and did not document any pain after transfer. NP #1 confirmed that the nurse never mentioned an injury occurred with the use of a mechanical lift. NP #1 confirmed she did not assess the resident until after lunch and when she assessed her she did have swelling around her left hip and she was complaining of pain. NP #1 confirmed that is when she learned that the injury occurred during the use of a Hoyer lift. NP #1 stated she ordered stat x-rays of the whole leg and that the swelling from around the ankle was normal for her. NP #1 was asked if pain medications were ordered for Resident #15's complaints of leg pain. The NP stated she thought Resident #15 had pain medication ordered already but was not certain. NP #1 confirmed that she should have been notified immediately of the situation upon arriving at the facility the morning of 3/28/2023. During an interview on 4/12/2023 at 5:23 PM, the DON verified the electronic entry made on 3/28/2023 at 8:00 AM was not made by her but was made by LPN #7. The DON verified she was unaware of Resident #15's leg until the evening of 3/28/2023. The DON confirmed this entry should not have been made by LPN #7. During an interview on 4/13/2023 at 10:38 AM, the DON confirmed that the pages of the NP communication book is addressed by the NP had been shredded. The facility was unable to provide the NP communication notification from 3/28/2023. During an interview on 4/12/2023 at 12:28, the Medical Director confirmed that he communicates with the facility Administration on a daily basis and is on site at least 4 times per week. The Medical Director was asked if the facility is unable to get in contact with the NP on call are you available. The Medical Director confirmed he is available around the clock for any facility issues. The Medical Director confirmed he was not made aware that Resident #15 had sated that she had sustained an injury from the use of a mechanical lift. During an interview on 4/12/2023 at 2:40 PM, the Medical Director was asked if Resident #15 complained of pain and they noticed swelling to the left leg should the NP or you have been notified. The Medical Director stated, Yes. The Medical Director confirmed that anything that urgent should not have waited to morning to contact the NP and should have been taken care of when it was reported and the resident's pain should have been addressed at that moment. The Medical Director confirmed the communication from nurse to provider should have been communicated urgently. During an interview on 4/13/2023 at 3:51 PM, LPN #6 confirmed she worked from 3:00 PM to 11:00 PM on 3/28/2023 and was the charge nurse assigned to give care to Resident #15. LPN #6 stated she was informed of Resident #15's x-ray results between 6:00 PM to 6:55 PM and she then notified NP #1 and was give an order to transfer Resident #15 out to the hospital. LPN #6 stated she also contacted Resident #15's RP and notified them of the xray results and that the Resident #15 would be transferred out to the hospital. LPN #6 confirmed that during nursing report at the beginning of her shift, she was informed Resident #15's left leg was swollen and that an x-ray was ordered. LPN #6 confirmed she went to tell Resident #15 about her results and that she was to be transferred to the hospital and that is when Resident #15 informed her that her leg got twisted in the lift a few days prior. LPN #6 confirmed she called the DON trying to get transportation to send Resident #15 out to the hospital. LPN #6 confirmed that LPN #7 only told her in a verbal report that Resident #15's leg was swollen and LPN #6 confirmed that Resident #15 was alert and can tell things that may have occurred to her. During an interview on 4/17/2023 at 12:02 PM, LPN #7 confirmed she worked from 7:00 AM to 3:00 PM on 3/28/2023 and was assigned the care for Resident #15. LPN #7 stated whenever there was a fall or any other occurrence with a resident that resulted in a possible injury the physician or the NP should be notified, and an event form should be completed in the electronic medical record. LPN #7 was asked did LPN #4 report to her that Resident #15 got her leg tangled in a mechanical lift and her left leg was now swollen and painful. LPN #7 confirmed that LPN #4 had asked her to go to Resident #15's room to observe the resident's leg, and that's when she observed the left leg was swollen. LPN #7 was asked if she had documented her observations in the medical record and LPN #7 stated she did not. LPN #7 stated she did not assess Resident #15. LPN #7 stated she did notify the oncoming nurse that radiology was coming to do an x-ray of Resident #15's left leg that it was swollen. The facility staff failed to notify in a timely manner the Administrator, DON, NP and /or the Physician of the injury to Resident #15 left leg that occurred during the use of a mechanical lift that resulted in a fracture to the left leg.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain privacy and confidentiality of resident medical records for 1 of 17 (Resident #4) sampled residents. The finding include: Review of the facility policy titled, Resident Rights, revised 8/16/2018, revealed, .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .Privacy and confidentiality .The unauthorized release, access, or disclosure of resident information is prohibited .All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses of Diabetes, Ileus (inability of the bowel to move waste out of the body normally), Anxiety Disorder, Retention of Urine, Major Depressive Disorder, Central Cord Syndrome at C5 level ( inability to move arms and/or legs normally), and Spinal Stenosis (a form of lower back pain). Observation in the 100 Hall outside of Resident #4's room on 3/28/2023 at 3:34 PM, and 3:38 PM, revealed an opened lap top sitting on top of a treatment cart with Resident #4's electronic medical record visible. During an interview on 4/17/2023 at 1:41 PM, the Director of Nursing (DON) confirmed that staff should close their computer when leaving the area to ensure the residents' medical records are kept private and secure.

Based on policy review, medical record review, and interview, the facility failed to ensure the completion of a Discharge Summary with a recapitulation of the resident's stay for 1 of 3 sampled residents (Resident #10) reviewed for discharge. The findings include: Review of the facility's policy titled Discharge Summary, dated 11/1/2022, revealed, .A discharge summary will prepared which will include .A recapitulation of the resident's stay that includes .diagnoses, course of illness/treatment or therapy and pertinent lab, radiology, and consultation results . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses of Peripheral Vascular Disease (a disease that decreases blood flow in the legs causing pain), Diabetic Foot Ulcer (an open sore/wound located on the foot), Non-Pressure Ulcer (wound) Right Foot, Diabetes (a disease which causes to much sugar in the blood), and Hypertension (high blood pressure). Review of the admission Minimum Data Set, dated dated dated [DATE], revealed Resident #10 with a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact, and expected to return back to the community with active discharge planning already occurring. Review of a Physician's Telephone Order dated 6/28/2021 revealed, .Discharge home with home health . Review of the facility's Discharge Summary dated 7/5/2021, revealed the facility failed to recapitulate Resident #10's stay while a resident in the facility. During an interview on 4/11/2023 at 4:42 PM, the Director of Nursing (DON) was shown the residents Discharge Summary dated 6/28/2021 and was asked if the Discharge Summary contained a recapitulation of the resident's stay while at the facility. The DON stated, No. The DON confirmed the Discharge Summary should be a summary of the resident's care and services she received while a resident in the facility.

Based on policy review, medical record review, and interview, the facility failed to conduct neurochecks and Fall Risk Assessments following falls for 1 of 4 (Resident #12) sampled residents reviewed for falls and accident hazards. The facility failed to ensure the environment was safe and free of accident hazards when hazardous chemicals were left unattended in a resident's room. The findings include: 1. Review of the facility policy titled, Accidents and Incident Investigating Reporting, revised 11/6/2019, revealed, .Accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the Administrator .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall initiate and document investigation of the accident or incident .The following data .shall be included in the Electronic Medical Record .The date and time the accident or incident took place .The nature of the injury/illness .bruise, fall, nausea, etc. [et cetera] .The circumstances surrounding the accident or incident .Where the accident or incident took place .The name(s) of the witnesses .The injured person's account of the accident or incident .This facility is in compliance with the current rules and regulations governing accidents and/or incidents involving a medical device .The incident will be reported to the Administrator and/or Director of Nursing . Review of the undated Fall Quick Reference Guide revealed neuro checks (a test to determine how an individual responds and reacts) should be initiated if a resident sustained an unwitnessed fall or a fall with head involvement and the oncoming nurse will continue neurochecks in the Fall Event if they were incomplete. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses Cerebral Infarction (lack of blood flow to the brain causing parts of the brain to die off), Hemiplegia (unable to move a part of your body), Repeated Falls, Dysphagia (trouble swallowing), Hypertension (high blood pressure), Abnormalities of Gait and Mobility, and Protein-Calorie Malnutrition (lack of proper food intake). Review of the quarterly MDS dated [DATE], revealed Resident #12 with a BIMS score of 00, which indicated severe cognitive impairment, and required extensive staff assistance for most activities of daily living (ADLs). Review of Event Reports dated 1/7/2023, and 1/16/2023, revealed Resident #12 sustained unwitnessed falls on these days. There was no documentation a Fall Risk Assessment and neurochecks performed following the unwitnessed each fall. Review of the Event Report dated 1/27/2022, revealed Resident #12 sustained a witnessed fall, and hit her head. There was no documentation neurochecks were not performed following the fall with the resident hitting her head. Review of the Event Report dated 2/20/2023, revealed Resident #12 sustained a fall. There was no documentation a Fall Risk Assessment was not completed following the fall. During an interview on 4/13/2023 at 10:38 AM, the DON was asked when Fall Risk Assessments should be completed. The DON stated, Quarterly, annually, [on] admission, [on] readmission, [with a] significant change, and at the time of a fall. The DON stated neurochecks should be completed when a resident sustained an unwitnessed fall if a resident did not have the cognitive ability to tell staff if they had hit their head or not and when a resident sustained a witnessed fall and hits their head. The DON provided the Fall Quick Reference Guide for review and stated it was an internal document, and a copy would not be provided. During an interview on 4/13/2023 at 3:42 PM, when requested for the neurochecks for Resident #12 following the falls the DON stated, I couldn't find neurochecks for those days [1/7/2023, 1/16/2023, & 1/27/2023] . 3. Observations in room [ROOM NUMBER], during tour on 4/13/2023 at 10:00 AM, revealed a plastic bottle of yellow liquid on top of a plastic container sitting on the bedside table, unsecured and unattended by staff. A resident was observed in the bed bedside the bedside table. At 10:03 AM, Housekeeper #1 was observed walking in the halls, entered room [ROOM NUMBER], retrieved the plastic bottle of yellow liquid from the room and walked back into the hall. Housekeeper #1 was asked what the liquid was in the bottle. Housekeeper #1 stated, Oh, it is peroxide cleaner .we use to clean the rooms. Housekeeper #1 was asked should it be left in the resident's room unsecured and unattended on the bedside table. Housekeeper #1 confirmed it should be stored in the housekeeping cart under lock and key and not in a resident's room. During an interview on 4/13/2023 at 10:38 AM, the Administrator confirmed that housekeeping chemicals should be stored on the housekeeping cart under lock and key and should not be left in residents' rooms unsecured and unattended.

Based on policy review, medical record review, observation, and interview, the facility failed to assess and monitor weights for 1 of 6 sampled residents (Resident #81) reviewed for nutrition. The findings include: Review of the facility's policy titled, Weight Monitoring, revised 7/11/2018, revealed .Interventions for Weight Management .If significant weight change is identified .The Registered Dietician will be notified .Residents will be weighed weekly X [times] 4 .and reviewed until the resident's weight has stabilized . Review of the medical record, revealed Resident #81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Weight Variance Report dated 7/4/2021, revealed Resident #81 weighed 188.4 pounds. Review of a Weight Variance Report dated 1/5/2022, revealed Resident #81 weighed 172.80 pounds. This represented an 8.28% weight loss in 6 months, a significant weight loss. Review of the Weight Variance Reports revealed weekly weights were not obtained for Resident #81 after his significant weight loss on 1/5/2022. Review of a Registered Dietician's (RD) note dated 1/24/2022, revealed .CBW [Current Body Weight] 166.6 lb [pounds] .triggers for sig [significant] wt [weight] loss of -22 lb / 11.9% [percent] in 176d [days] .No triggers in 30/90d .Continues current diet with good intake per documentation. Also receives a magic cup bid [twice a day] and pudding snack qd [every day] for wt maintenance .RD recommends continuing the current nutritional POC [Plan of Care] . Observation in the resident's room on 1/25/2022 at 6:10 PM, revealed Certified Nursing Assistant (CNA #1) was assisting Resident #81 with his supper meal. CNA #1 stated, .I always feed him .he always eats 100% .I'm here 12 hours and feed him every meal and he eats it all . During an interview on 1/26/2022 at 2:58 PM, the RD confirmed Resident #81 had a significant weight loss on 1/5/2022. The RD stated, I determined he has good intake .with assistance at meals .His current intake was meeting his nutritional needs .continue his current nutritional plan of care . The RD was asked if he recommended weekly weights for Resident #81 when he had the significant weight loss on 1/5/2022. The RD stated, .As far as weekly weights I try to prioritize, look at staff .wouldn't want to overload the staff and especially for me coming in only 2 days a week, have to prioritize who really needs the weekly weights . During an interview on 1/26/2022 at 6:02 PM, CNA #1 confirmed she weighed Resident #81 today and his weight was 172.8 pounds. She confirmed he was eating well and has gained weight. During an interview on 1/27/2022 at 8:27 AM, the Director of Nursing confirmed the RD should have identified Resident #81's significant weight loss on 1/5/2022 and should have put weekly weights in place for Resident #81.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 4 of 12 medication storage areas (South Hall Medication Room, 400 Hall Medication Cart, 200 Hall Low Medication Cart, and the Central Supply Room) when medications were found opened and undated, medications were expired, and internal and external medications stored together. The findings include: Review of the facility's policy titled, Medication Storage, dated 9/2018, revealed .Medication and biologicals are stored properly .to maintain their integrity and to support safe effective drug administration .Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments .Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock . Observation in the South Hall Medication Room on 1/25/2022 at 4:00 PM, revealed the following medical supplies and medications were stored together on a shelf: a. 1 bucket of germicidal wipes b. 1 bucket of bleach wipes c. 1 1/2 boxes of [MEDICATION(S)] patches 21 mg d. 1 box of Aspercreme [MEDICATION(S)] patches e. 1 tube of [MEDICATION(S)] Vaginal Cream f. 1 box of Anti-diarrhea tablets g. 1 bottle of Enema Mineral oil h. 1 bottle of B 12 vitamins i. 1 tube of Ammonium [MEDICATION(S)] cream with an expiration date of 1/27/2021 Observation in the 400 Hall Medication Cart on 1/25/2022 at 4:17 PM, revealed 1 bottle of Anti Dandruff shampoo with an expiration date of 5/2021. Observation in the 200 Hall Low Medication Cart on 1/25/2022 at 4:35 PM, revealed the following: a. 1 open and undated [MEDICATION(S)] Diskus inhaler b. 1 open and undated Incuse Ellipta inhaler c. 1 open and undated [MEDICATION(S)] and [MEDICATION(S)] inhaler During an interview on 1/25/2022 at 4:35 PM, Licensed Practical Nurse (LPN) #1 confirmed the inhaler should be dated when opened and was good for 30 days after opening. Observation in the Central Supply Room on 1/27/2022 at 7:50 PM, revealed the following: a. 1 box of [MEDICATION(S)] tablets with an expiration date of 10/2021 b. 1 bottle of Altalube eye ointment with an expiration of 11/2021 c. 1 box of [MEDICATION(S)] 12 hour tablets with an expiration date of 6/2021 d. 2 bottle of Geri [MEDICATION(S)] ([MEDICATION(S)]) with an expiration date of 11/2021 e. 8 boxes of Allergy Relief tablets with an expiration date of 7/2021 During an interview on 1/27/2022 at 10:32 AM, the Director of Nursing (DON) confirmed that the medication storage areas should not have opened and undated medications, expired medications, and internal and external medications stored together.

Based on policy review, observation and interview, the facility failed to ensure 3 of 4 shower chairs in 2 of 2 (North and South Shower Rooms) shower rooms were clean and sanitary. The findings include: 1. The facility's Cleaning and Disinfection of Resident-Care Items and Equipment documented, .Durable medical equipment must be cleaned and disinfected before use by another resident . 2. Observations in the North Shower room on 7/22/19 at 11:08 AM and at 11:40 AM revealed a dried brown substance on the seat of 1 shower chair. Interview with Certified Nursing Assistant (CNA) #1 on 7/22/19 at 11:05 AM in the North Shower room, CNA #1 was asked if the shower chair had been cleaned after resident use. CNA #1 stated, .I'll wipe it down. Looks like something is on it. CNA #1 confirmed the shower chair had been used earlier this day. Interview with the Director of Nursing (DON) on 7/22/19 at 11:40 AM in the North Shower room, the DON was asked if the shower chairs should be cleaned between each resident use. The DON stated, Yes . When the DON was asked what was the brown substance on the seat of the shower chair, she stated, Looks like BM (bowel movement). When asked if the shower chair had been cleaned, the DON stated, No ma'am, doesn't appear to have been. 3.Observations in the South Shower room on 7/22/19 at 11:10 AM and 11:48 AM revealed a brown substance on the seat and frame of 2 shower chairs. Interview with the DON on 7/22/19 at 11:48 AM in the South Shower room, the DON was asked what was the brown substance on the seat and frame of the shower chairs. The DON stated, Dirt, soiled. Needs cleaning .

Based on policy review, medical record review, observation, and interview, the facility failed to properly label and follow physician's orders for an enteral tube feeding for 1 of 3 (Resident #373) sampled residents reviewed with an enteral tube feeding. The findings include: The facility's .Gastrostomy Feeding policy dated 6/5/18 documented, .3. Verify correct formula .10 .Label bag with tube-feeding type, strength, and amount. Include date, time and initials . Medical record review revealed Resident #373 was admitted to the facility 4/29/19 with [DIAGNOSES REDACTED]. The Physician's Orders dated 5/5/19 documented, .[MEDICATION NAME] 1.5 @ (at) 50 hr (hour) x (times) 22 hrs (hours) . Observations in Resident #373's room on 5/6/19 at 9:49 AM, 11:32 AM, and 3:35 PM revealed an unlabeled enteral feeding and an unlabeled bag of water. There was no resident identification, date or time the bag was hung, rate of infusion, or initials of the nurse hanging the tube feeding. Observation In Resident #373's room on 5/8/19 at 8:39 AM revealed an enteral tube feeding infusing Glucerna 1.5 at 50 milliliters per hour by an enteral infusion pump. Interview with the Assistant Director of Nurses (ADON) on 5/7/19 at 9:10 AM at the South hall nursing station, the ADON was asked if she expected an enteral tube feeding and water bag to be labeled. The ADON stated, Yes, they both should be labeled. Interview with the ADON on 5/8/19 at 8:45 AM in Resident #373's room, the ADON was asked to confirm that the enteral tube feeding that was infusing was labeled Glucerna 1.5. The ADON confirmed Glucerna 1.5 was the incorrect formula.

Based on policy review, observation, and interview the facility failed to ensure medications were properly stored in 2 of 8 (medication cart #1 and South nurses station medication room) and expired medications in 1 of 8 (South hall nursing station medication room) medication storage areas. The findings include: 1. The facility's Medication Administration policy dated 9/18 documented, .17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .8. Check expiration date on package/container. No expired medication will be administered to a resident . 2. Observations on the 100 North hall on 5/7/19 at 4:38 PM revealed RN #1 left the medication cart unlocked and unattended and went to room [ROOM NUMBER] to assist another resident. Observations on the 100 North hall on 5/7/19 at 4:40 PM revealed RN #1 left the medication cart unlocked and unattended and went to room [ROOM NUMBER] to perform glucose monitoring. 3. Observations in the South hall medication room refrigerator on 5/8/19 at 12:30 PM revealed the following: a. One bag of [MEDICATION NAME] 650 miligrams (mg) per 100 milliliter (ml) normal saline (NS) with an expiration date of 4/27/19. b. One bag of [MEDICATION NAME] 625 mg per 100 ml NS with an expiration date of 4/4/19. c. One bag of [MEDICATION NAME] 650 mg per 100 ml NS with an expiration date of 4/29/19. 4. Interview with Licensed Practical Nurse (LPN) #1 on 5/8/19 at 12:40 PM at the South hall nurses station, LPN #1 was asked if the intravenous (IV) medications were expired. LPN #1 stated, Yes. Interview with the Assistant Director of Nursing (ADON) on 5/8/19 at 2:15 PM at the South nurses station, the ADON was asked if expired medications should be in the medication storage area. The ADON stated, No. Interview with ADON on 5/8/19 at 5:45 PM at the North nurses station, the ADON was asked if the medication cart should be left unlocked. The ADON stated, No.

Based on policy review, observation and interview, the facility failed to ensure practices to prevent the spread of infection were followed when 1 of 3 (Registered Nurse (RN) #1) nurses failed to perform hand hygiene after removal of soiled gloves during medication administration. The findings include: 1. The facility's Handwashing/Hand Hygiene policy dated (MONTH) (YEAR) documented, .7. Use an alcohol-based rub containing at least 62% (percentage) alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations .m. After removing gloves . 2. Observations on the North 100 hall on 5/7/19 at 4:45 PM revealed RN #1 cleaned the glucometer with a bleach wipe, removed her gloves, donned new gloves, performed an accucheck, removed her gloves, donned new gloves, administered oral medications, and removed her gloves. RN #1 failed to perform hand hygiene after removal of her gloves between tasks and before donning clean gloves. Observations in room [ROOM NUMBER] on 5/7/19 at 5:19 PM revealed RN #1 administered insulin, removed her gloves, and failed to perform hand hygiene. 3. Interview with the Assistant Director of Nursing (ADON) on 5/8/19 at 5:45 PM at the North hall nurses station, the ADON was asked if staff members should wash their hands after removing their gloves. The ADON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served in a sanitary manner when the walk in freezer had ice buildup on the floor and ceiling, the kitchen floor was dirty and covered with debris, and the reach-in freezer had thick ice buildup around the sides of the freezer. The facility had a census of 127 with 123 residents receiving a meal tray from the kitchen. The findings include: 1. The facility's Freezer policy documented, .Freezer should be frost free . 2. Observations in the kitchen on 7/9/18 at 9:10 AM and 2:45 PM, revealed the following: a. walk-in freezer with thick ice buildup on the floor and ceiling b. kitchen floor dirty, covered with debris and a small container lying underneath the table c. reach-in freezer with thick ice buildup around the sides of the freezer Observations in the kitchen on 7/10/18 at 10:20 AM and 2:30 PM revealed the kitchen floor was dirty, had small pieces of paper lying on the floor and a plastic cup lying underneath the table. Observations in the kitchen on 7/11/18 at 11:30 AM and 4:50 PM revealed the kitchen floor was dirty, had pieces of paper and plastic lying on the floor, a small container of jelly, Styrofoam cups and a linear fluorescent light bulb lying underneath a cart in the storage area. Interview with the Assistant Dietary Director on 7/11/18 at 5:00 PM, in the kitchen, the Assistant Dietary Director was shown all the debris on the kitchen floor and was asked if it was clean. The Assistant Dietary Director stated, No . The Assistant Dietary Director was shown the walk-in freezer and the reach-in freezer and was asked if there should be ice buildup in the freezers. The Assistant Dietary Director stated, No . Interview with the Director of Nursing (DON) on 7/11/18 at 6:16 PM in the DON office, the DON was asked if the walk-in freezer should have ice buildup on the floor and ceiling and if the reach-in freezer should have ice buildup around the sides of the freezer. The DON stated, No .not acceptable. The DON was asked if the kitchen floor should be dirty and covered with debris. The DON stated, No .

Based on medical record review and interview, the facility failed to ensure the provision of timely follow-up optometry consults for 1 of 1 (Resident #133) sampled residents reviewed for vision. The findings include: Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, and his ability to see was adequate with no corrective lenses. Review of the DIAGNOSTIC EYECARE consult dated 4/3/17 revealed [DIAGNOSES REDACTED]. Interview with Resident #133 on 7/9/18 at 10:51 AM in his room, Resident #133 was asked if he had any problems with his vision. Resident #133 confirmed he had vision problems that were not corrected by his current eye glasses. Resident #133 was asked if he had seen the eye doctor recently. Resident #133 stated, Not in about 2 years. Interview with the Social Services Director (SSD) on 7/11/18 at 11:15 AM, in the SSD office, the SSD confirmed the optometry follow-up consult was not provided in 8 months as recommended for Resident #133.

Based on medical record review, observation, and interview, the facility failed to ensure nutritional interventions were followed for 1 of 3 (Resident #108) sampled residents reviewed for nutrition. The findings include: Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #108 was extensive assist for activities of daily living and one person assist for meals. The Care Plan dated 6/13/18 documented, .Problem .at nutrition risk .REST (Restorative) DINING 3 MEALS D (day) X (times) 7 Dys (days) .CNA (Certified Nursing Assistant) X 8 Weeks .7-5-18 Pudding (and) Soda all meals . The physician's orders [REDACTED].Restorative dining 3 meals day x 7 days wk (week) x 8 wks . The RESTORATIVE SERVICE DELIVERY RECORD form documented, .Restorative Dining all meals 7 days/wk x 8 wks . This was not documented as completed on the following dates: 6/14/18 for all meals, 6/15/18 for all meals, 6/16/18-6/20/18 for the dinner meal, 6/21/18-6/22/18 for all meals, 6/23/18-6/27/18 for the dinner meal, 6/28/18-7/1/18 for all meals, 7/2/18-7/6/18 for the dinner meal, 7/7/18-7/9/18 for all meals, and 7/10/18 for the dinner meal. The (MONTH) (YEAR) Medication Administration Record (MAR) documented, .SNP (fortified foods)/JUICE MILK BY MOUTH THREE TIMES DAILY POOR APPETITE . This was not documented as completed for the following dates: 7/2/18 at 8:00 AM and 12:00 PM, 7/3/18 at 8:00 AM, 12:00 PM, and 6:00 PM, 7/5/18 at 8:00 AM and 12:00 PM, and 7/6/18 at 6:00 PM. The (MONTH) (YEAR) MAR documented, .RESTORATIVE DINING THREE MEALS A DAY SEVEN DAYS A WEEK FOR EIGHT WEEKS . This was not documented as completed for the following dates: 7/2/18 at 8:00 AM and 12:00 PM, 7/3/18 at 8:00 AM, 12:00 PM, and 5:00 PM, 7/5/18 at 8:00 AM and 12:00 PM, and 7/6/18 at 5:00 PM. The (MONTH) (YEAR) MAR documented, .ENSURE CH[NAME]OLATE AT 10A (AM) AND 2PM . This was not documented as completed for the following dates: 7/2/18 at 10:00 AM and 2:00 PM, 7/3/18 at 10:00 AM and 2:00 PM, and 7/5/18 at 10:00 AM and 2:00 PM. Observations in Resident #108's room on 7/10/18 at 7:50 AM, revealed Resident #108 in bed with her breakfast tray open. A staff member came in the room and said she would help her, left the room, and did not return to assist the resident. Resident #108 was not in the restorative dining room. Observations in the dining room on 7/11/18 at 8:48 AM revealed Resident #108 seated in a wheelchair and CNA #1 was assisting the resident to eat. There was no pudding or soda on the resident's meal tray. Interview with CNA #1 on 7/11/18 at 9:09 AM in the restorative dining room, CNA #1 was asked if there was pudding or soda on the meal tray for Resident #108. CNA #1 stated, No. Observations in the dining room on 7/11/18 at 12:30 PM revealed Resident #108 seated in the restorative dining room. There was no pudding on her meal tray. Observations in Resident #108's room on 7/11/18 at 5:43 PM revealed Registered Nurse (RN) #1 seated in a chair assisting Resident #108 with her meal. Resident #108 was not in the restorative dining room. There was no pudding or soda on her meal tray. Interview with RN #1 on 7/11/18 at 5:50 PM in Resident #108's room, RN #1 was asked if there was soda or pudding on her meal tray. RN #1 stated, No ma'am . Interview with the Registered Dietician (RD) on 7/10/18 at 2:52 PM in the conference room, the RD was asked if Resident #108 should be eating in the restorative dining room each meal. The RD stated, Yes . Interview with the Assistant Dietary Director on 7/11/18 at 5:15 PM in the Dietary Manager's office, the Assistant Dietary Director was asked who was responsible to ensure residents received the supplements ordered on their meal trays. The Assistant Dietary Director stated, If they are eating in the dining room .I believe it's the restorative CNAs and nursing . The Assistant Dietary Director was asked if the residents should receive what was ordered. The Assistant Dietary Director stated, Yes, we want them to get it. Interview with the Director of Nursing (DON) on 7/11/18 at 6:01 PM in the DON office, the DON was asked about Resident #108's weight loss. The DON stated, Yes, we discussed her at risk and clinic meeting .7/6 extra food ordered .on 7/5 restorative dining continue 3 meals a day .continue to monitor . The DON was shown Resident #108's MAR and was asked what did the empty spaces mean. The DON stated, .should not be empty .either it wasn't done .I assume it wasn't done . The DON was asked if there was an order for [REDACTED]. The DON stated, Yes .unless they refuse .we are working on those things .want to make sure they are taken care of . Interview with CNA #1 on 7/12/18 at 9:34 AM in the conference room, CNA #1 was asked if Resident #108 should be dining in the restorative dining room. CNA #1 confirmed Resident #108 should be in restorative dining and it should documented on the restorative dining form.

Based on medical record review, observation, and interview, the facility failed to maintain oxygen (O2) equipment in a sanitary manner for 1 of 7 (Resident #33) sampled residents reviewed for respiratory care. The findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment, required extensive to total staff assistance with all activities of daily living, and received oxygen therapy. The care plan dated 5/4/18 documented, .Pulmonary condition .potential for difficulty breathing .Approach .Administer O2 as Ordered . The physician's orders [REDACTED].O2 BNC (by nasal cannula) . Observations in Resident #33's room on 7/9/18 at 10:16 AM, 2:49 PM, and 4:59 PM, and on 7/10/18 at 9:16 AM, 2:09 PM, and 4:53 PM, revealed Resident #33 in bed with O2 on at 2 liters per minute BNC delivered by an O2 concentrator at the bedside. The O2 concentrator was covered with random dirty brown substance, and the concentrator filter was covered with thick gray dust. Interview with the Director of Nursing (DON) on 7/11/18 at 9:40 AM in the conference room, the DON was asked if she had seen Resident #33's O2 concentrator. The DON stated, Yes. The DON confirmed the O2 concentrator was dirty. The DON was asked who was responsible to clean the concentrators. The DON stated, Nurses .you have to hold people accountable .

Based on policy review, medical record review, and interview, the facility failed to ensure pain assessments were completed according to the facility policy for 1 of 1 (Resident #33) sampled residents reviewed for pain. The findings include: The facility's Pain Management policy dated 2/15/18 documented, .Each resident .identified with pain will have ongoing assessments, a monitoring system .ASSESSMENT .Assess when there is a potential for pain, noting the onset, presence, duration and characteristics of the pain .Use a pain scale for the resident to describe the severity of the pain and also for the evaluation of pain relief achieved after treatment has been administered .MANAGEMENT .The interdisciplinary team (IDT) will develop a pain management plan for the resident who has pain or the potential for pain .The Pain Flow Sheet shall be initiated upon admission and completed to include the descriptors, indicators, intensity, frequency, intervention and effectiveness of the treatment .A pain evaluation is completed on each shift on all residents and documented in (named electronic Medication Administration Record [REDACTED] Medical record review revealed Resident #33 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. There was no documentation on the electronic Medication Administration Record [REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment, required extensive to total staff assistance for activities of daily living, and received or was offered as-needed (PRN) pain medications. The Care Plan dated 5/4/18 documented, .At risk for Pain r/t (related to) resident with [DIAGNOSES REDACTED].Approach .Observe & (and) report to nurse any S/S (signs and symptoms) of Pain . The physician's orders [REDACTED].SCHEDULE PELVIC ULTRASOUND-LOWER ABDOMINAL PAIN .TYLENOL EX-STR (extra strength) 500 MG (milligrams) TABS (tablets) PER PT (Percutaneous Endoscopic Gastrostomy tube) Q (every) 12 HOURS PRN (as needed) DX (diagnosis): PAIN . Interview with Licensed Practical Nurse (LPN) #3 on 7/11/18 at 5:23 PM in the lobby at the 100-200 Nurses' Station, LPN #3 was asked if the pain assessments were documented. LPN #3 stated, .I couldn't find those pain assessments. LPN #3 was asked if the Pain Flow Sheets were completed. LPN #3 stated, We don't have them. Interview with Assistant Director of Nursing (ADON) #1 on 7/11/18 at 6:15 PM in the conference room, ADON #1 was asked how Resident #33's pain management plan was monitored for effectiveness since there was no documentation of pain assessments according to the pain policy. ADON #1 stated, Usually it's a pain monitoring template that we can initiate on admission so we can monitor it every shift. She did not have one .

Based on policy review, observation, and interview, 2 of 5 (Licensed Practical Nurse (LPN) #1 and 2) nurses failed to ensure infection control practices were maintained to prevent the potential spread of infection during medication administration observations. The findings include: 1. The facility's Standard Precautions policy documented, Policy Statement .Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents Standard Precautions include the following practices: 1. Hand hygiene .d. Wash hands after removing gloves (see below) .2. Gloves .g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments . 2. Observations at the medication cart on the 200 hall on 7/10/18 at 8:47 AM revealed LPN #1 was preparing medications. LPN #1 touched the [MEDICATION NAME] tablet, duloxetine tablet, and the [MEDICATION NAME] tablet with her bare hands. LPN #1 entered Resident #106's room and administered these medications by mouth to this resident. LPN #1 applied gloves, without performing hand hygiene, and administered 2 puffs of an inhaler to this resident. LPN #1 removed the gloves, applied new gloves, without performing hand hygiene, and administered a nasal spray to this resident. 3. The facility's Medication Administration Enteral Tubes policy documented, .GUIDELINES .16. Clean feeding syringe and return to bedside stand. Syringes are replaced after 24 hours or as required by state regulation . 4. Observations in Resident #33's room on 7/10/18 at 10:00 AM, revealed LPN #2 administered medications to this resident through a gastrostomy tube using a syringe. After LPN #2 had completed administering the medications, he placed the syringe back in the bag, and did not rinse the syringe. 5. Interview with the Director of Nursing (DON) on 7/12/18 at 8:42 AM in the conference room, the DON was asked if pills should be touched with bare hands. The DON stated, No. The DON was asked what should be done before applying gloves. She stated, Wash hands. The DON was asked what should be done with a syringe after administering medications through a gastrostomy tube. The DON stated, Should clean it and put it back in the bag.

Based on a medical record review, observation, and interview, the facility failed to preserve the dignity for 1 of 3 (Resident #3) sampled residents observed for incontinence care. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #3 was always incontinent of bowel and bladder and required extensive assistance with personal hygiene. A care plan dated 9/28/17 and reviewed 12/20/17 revealed, .Problem .Resident has a potential for complications associated with incontinence of bowel and/or bladder .Goal .Resident's dignity will be maintained without embarrassment or fear through next review date . Interview with Resident #3 on 2/21/18 beginning at 1:40 PM, in Resident #3's room, She was asked if she was checked and changed timely. Resident #3 stated, . I like to be out (in the facility) and they won't come and find me and they don't change me .I have not been changed at all today . Resident #3 was asked if she has told the Certified Nursing Assistant (CNA) she needs changing. She stated, I see them but they say they ain't got me .I can get in and out (bed to wheelchair) myself, but I need a little assistance sometimes and when I ask for a little, they don't give me no assistance .They say I have an attitude .I tell them in meetings that they leave me soaking . Observations in Resident #3's room on 2/21/18 from 1:40 PM until 2:30 PM, revealed Resident #3 had an odor of urine. At 2:30 PM, the Activity Assistant came in and wheeled her to activities. Observations continued in the dining room from 2:30 PM until 3:30 PM. Resident #3 was not checked by staff during the time she was in the dining room. Interview with the Activity Director on 2/21/18 at 4:30 PM, in the Activity Office, she was asked about what she saw and did concerning Resident #3. She stated, She had urinated all over the floor (in the dining room), she had wheeled herself up to the table with urine still dripping from her chair .I took her to her room and turned on the call light, then I told the nurse and told the CNA (CNA #1). Interview with CNA #1 on 2/21/18 at 4:41 PM, in the Dining Room, she was asked if she just changed and cleaned Resident #3. She confirmed she did. CNA #1 was asked if it looked like she had been changed at all today. CNA #1 stated, No, she was very soiled .her outside pants were wet too .it was still dripping on the floor in her room . Interview with Resident #3 on 2/22/18 at 8:45 AM in Resident #3's room, Resident #3 was sitting on the side of the bed. She was asked about the day before when she was in the dining room after the activity program and how did she feel after she wet on the floor. Resident #3 stated, .It upset me and embarrassed me, I don't like to do that . Interview with CNA #2 on 2/22/18 at 1:39 PM, in the Conference Room, she was asked if she was assigned to (Named Resident #3) yesterday (2/21/18). CNA #2 stated, Yes, I was assigned to her. CNA #2 was asked how often Resident #3 should be checked and changed if needed. CNA #2 stated, Every 2 hours. CNA #2 was asked if she checked her every 2 hours yesterday. CNA #2 stated, No . CNA #2 was asked why she did not check on her every 2 hours. CNA #2 stated, Well, sometimes she gets in her moods, sometimes we ask her and she says she is not wet .She was in a mood yesterday . Interview with the Administrator on 2/22/18 at 5:05 PM in the conference room, she was asked about Resident #3 and what are some things that should be done so her incontinence all over the floor won't continue and she won't be upset and embarrassed about it. The Administrator stated, .She should be gently encouraged to let them take her to her room and just check her. They don't need to just say ok and walk away because she might not realize she is wet and she is a heavy wetter so it could happen if they don't encourage her to let them check her. We will do additional education on this .

Based on a Certified Nursing Assistant (CNA) job description, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Resident #3) sampled residents who were incontinent of bladder received appropriate treatment and services to achieve or maintain as much normal bladder function as possible. The findings included: 1. A CNA JOB DESCRIPTION dated and signed by CNA #2 on 3/14/16 documented, .Essential Duties & Responsibilities .Provide personal care (I.e., grooming, bathing, dressing, oral care, etc.) of residents daily and as needed . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #3 was always incontinent of bowel and bladder and required extensive assistance with personal hygiene. A care plan dated 9/28/17 and reviewed 12/20/17 revealed, .Problem .Resident has ADL (Activities of Daily Living) Self Care Deficit .Approaches .Staff to provide only the amount of assistance/supervision to meet the Resident's needs for all ADLs .Refer to Therapy as needed to evaluate and treat as indicated . The personnel file for CNA #2 hired on 3/14/16 was reviewed and revealed 1 of 14 COACHING & COUNSELING SESSION forms dated 11/23/17 which documented, . (X) WRITTEN .(Named Random Resident's) call light was on. I answered it and she motioned that she needed to be changed. (Named CNA #2) was making her rounds and (Named Random Resident's) room was next. I left the light on and continued to pass my meds (medications). The light had being (been) sounding for a while. When I looked up or noted (Named CNA #2) had gone home leaving (Named Random Resident) in bed on urine saturated sheet and diaper and pad .Earlier .asked (Named CNA #2) to (Delta symbol meaning check) her. However, after noting (Named Random Resident) in bed with urine saturated diaper, sheet and pad it did not look as though she had been changed at all .Stakeholder (CNA #2) failed to provide proper care to a [MEDICAL CONDITION] Resident, failed to provide proper ADL's. She completely ignored the pt's (patient's) needs . There was no documented follow-up for CNA #2's counseling session dated 11/23/17. A grievance form dated 2/12/18 revealed Resident #3's sister (Power of Attorney) had a concern. The grievance form documented, .Describe concern in detail: Visited after lunch while she was still in d.r. (dining room). Says there was a puddle under her chair. (Named Sister) took her to room & helped change the resident. She says the urine poured out Concerned w (with)/timeliness of incontinence care .Plan to resolve complaint/grievance: Staff to rendered (render) incontinence care q (every) 2 (hours) per assist resident to BR (bath room) as needed. Ensure resident receives assistance c (with) toileting needs. Results of actions taken: Staff assisting resident to BR as needed. Supervisor & staff assisting w/ ensuring incontinence care under Q (every) 2 (hours) & (and) as needed . Interview with Resident #3 on 2/21/18 beginning at 1:40 PM, in Resident #3's room, She was asked if she is checked and changed timely. Resident #3 stated, .The person that gets me up in the morning time, they change me, clean me up and I get dressed, I like to be out (in the facility) and they won't come and find me and they don't change me .I have not been changed at all today . Resident #3 was asked if she has told the CNA she needs changing. She stated, I see them but they say they ain't got me .I can get in and out (bed to wheelchair) myself, but I need a little assistance sometimes and when I ask for a little, they don't give me no assistance .They say I have an attitude . Observations in Resident #3's room on 2/21/18 from 1:40 PM until 2:30 PM, revealed Resident #3 had an odor of urine. Resident was not checked by staff during this time. At 2:30 PM, the Activity Assistant came in and wheeled her to activities. Observations continued in the dining room from 2:30 PM until 3:30 PM. Resident #3 was not checked by staff during the time she was in the dining room. Observations on 2/21/18 at 4:20 PM, Resident #3 was observed in the hallway self ambulating toward the dining room. She was asked if she had been changed. She stated, Yes, they just changed me. (Named Activity Director) took me to my room because my urine was on the floor in the dining room and it was coming out of my wheelchair. She had the same color pants on and was asked if those were the same pair of pants she had on earlier. Resident #3 stated, She put a clean dry pair of pants on me. Resident #3 had no odor of urine at this time and was wearing a clean dry pair of pants. Interview with the Activity Director on 2/21/18 at 4:30 PM, in the Activity Office, she was asked about what she saw and did concerning Resident #3. She stated, She (Resident #3) had urinated all over the floor, she had wheeled herself up to the table (in the dining room) with urine still dripping from her chair .I took her to her room and turned on the call light, then I told the nurse and told the CNA (CNA #1). Interview with CNA #1 on 2/21/18 at 4:41 PM, in the Dining Room, she was asked if she had just changed and cleaned Resident #3. She confirmed that she did. CNA #1 was asked if it looked like she had been changed at all today. CNA #1 stated, No, she was very soiled .her outside pants were wet too . CNA #1 was asked if she came in to work and found (Named Resident #3) wet very often. CNA #1 stated, Yeah. She was asked if she had told anyone about how she found her. CNA #1 stated, I did a month or so ago, that nurse is no longer here though. She was asked if she had told anyone else. CNA #1 stated, No . Interview with CNA #2 on 2/22/18 at 1:39 PM, in the Conference Room, she was asked if she was assigned to (Named Resident #3) yesterday (2/21/18). CNA #2 stated, Yes, I was assigned to her. She was asked when she changed her. CNA #2 stated, I believe I changed her around 10 o'clock (AM). CNA #2 was asked how often Resident #3 should be checked and changed if needed. CNA #2 stated, Every 2 hours. CNA #2 was asked if she checked her every 2 hours yesterday. CNA #2 stated, No, that was the only time . CNA #2 was asked why she did not check on her every 2 hours. CNA #2 stated, Well, sometimes she gets in her moods, sometimes we ask her and she says she is not wet .She was in a mood yesterday. There are certain people she lets change her, but if you go back and ask her later, she will let you change her. Interview with the Assistant Director of Nursing (ADON) on 2/22/18 at 4:26 PM in the Conference Room, she was asked about Resident #3's incontinence care needs. The ADON stated, .I followed up with the sister (POA) again yesterday (2/21/18), I was still thinking what else can I do, so I thought about a referral to therapy for a toileting plan .and I put a monitoring log with the CNAs. I will do this monitoring log for about a week for each shift. It started today on the day shift, it is an incontinence check . The facility was unable to provide any documentation of interventions for Resident #3 after the grievance was addressed on 2/12/18.