Every finding on record at St Lukes Lutheran Care Center

Based on interview and document review, the facility failed to assess a significant weight gain, obtain a reweigh, and notify the physician 1 of 1 resident (F54) reviewed for weight gain. Findings include: R54's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, required partial/moderate assistance with personal hygiene and sit to stand, a weight of 213 pounds, no Gain of 5% or more in the last month or gain of 10% or more in last 6 months, received a diuretic (help remove extra fluid from the body), and diagnoses included hypertension (high blood pressure) and dyspnea (shortness of breath).R54's care plan dated 5/8/26, indicated potential for fluid imbalance R/T (related to) use of diuretic medications due to edema (swelling) and interventions included monitor for S/S (signs and symptoms) of fluid retention; increasing edema, puffy face, increased weight, dyspnea, increased coughing, wet sounding cough, bounding pulse, increased blood pressure and notify MD (medical doctor) as needed. R54's weights indicated:4/1/26 at 12:16 p.m., 213.0 lbs. (pounds)5/1/2026 at 2:55 p.m., 208 lbs. 6/2/26 10:19 a.m., 219.0 lbs. (5.29% weight gain from the previous month)On 6/23/26 at 8:44 a.m., licensed practical nurse (LPN)-A stated resident's weights were obtained by nursing assistants (NAs) on paper, provided to the nursing staff for entry into the electronic medical record (EMR). The nursing staff provided documented paper copy of the weights to the resident care coordinator (RCC) and weight concerns would be reported to the RCC. LPN-A confirmed R54 experienced a weight gain in June 2026 compared to the previous month and stated physician notification would be expected for the weight gain.On 6/23/26 at 9:50 a.m., registered nurse (RN)-A, known as the RCC, reviewed the R54's weight records and confirmed R54 on 5/1/26, weighed 208, and on 6/2/26 weighed 219. RN-A confirmed the 11 pound weight gain was a significant weight gain and stated a weight gain of more than five pound in one month required follow up. RN-A stated physician notification, dietitian notification, family notification, and evaluation of the resident's condition would be expected. RN-A confirmed there was no documented reweigh and no evidence the physician had been notified regarding the significant weight gain.On 6/23/26 at 10:34 a.m., director of nursing (DON) stated following identification of the R54's weight gain on 6/2/26, expectations would have included obtaining a reweigh, assessing for edema and lung sounds, evaluating for fluid retention, and notifying the physician regarding the change in condition.On 6/23/26 at 1:10 p.m., registered dietitian (RD)-B stated they had been employed at the facility for approximately two weeks and had not reviewed R54's weight gain because they were not employed at the facility when the weight was obtained. RD-B stated nursing staff were expected to communicate significant weight changes to the dietitian and physician for evaluation and follow-up.On 6/23/26 at 3:14 p.m., dietary manager stated nursing staff were expected to communicate significant weight gains greater than three percent in one month to the dietary department for evaluation and follow-up.Facility Weight Management Policy/Procedure dated 1/25, indicated; Residents weights are taken and entered into their electronic medical record.The RN Resident Care Coordinator is responsible for reviewing weights and determining the need for immediate reweights for verification and notification of physician, dietician and family for weight change that meets criteria as listed below. Trigger for weight gain concern include a 5% or greater weight gain in 30 days.

Based on observation, interview and document review, the facility failed to ensure physician orders and interventions were followed for pressure ulcer (PU) wound care and healing for 1 of 2 residents (R9) reviewed for pressure ulcers.Findings include:R9's face sheet printed 6/23/26, indicated diagnoses of presence of artificial knee joint, anxiety, arthritis, and rash or nonspecific skin eruption.R9's care plan dated 1/15/26, indicated resident at risk for impaired skin integrity and pressure ulcers as evidenced by diagnosis of diabetes, edema, impaired mobility, need for assistance with repositioning. Has unstageable pressure ulcer on right heel. Approach: assisted to reposition every two hours in chair and bed. Float heels with pillow in chair and bed.R9's physician's order dated 3/10/26, indicated suspend right heel at all times until wound heals, every shift. R9's physician's order dated 5/21/26, indicated apply skin prep to right heel and cover with Mepilex (foam bandage) two times per week on Wednesday and Saturday and as needed.R9's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors or rejection of care, at risk for developing pressure ulcers, and one unstageable pressure ulcer not present on admission.During observation on 6/23/26 at 9:01 a.m., R9 was seated in her recliner with her heels on the recliner footrest. R9's right heel was not suspended on a pillow as ordered.During interview on observation on 6/23/26 at 9:30 a.m., registered nurse (RN)-B stated R9's heel was not elevated off the recliner as ordered. RN-B removed R9's sock and no dressing was present on R9's heel wound. RN-B stated she had not been informed the dressing was not on as ordered and would complete wound care and apply a new dressing. RN-B further stated if no dressing was present, she would expect to be notified and she knew last time she worked there was a dressing on R9's heel wound.During interview and observation on 6/23/26 at 10:06 a.m., RN-C stated R9 should have her heel floated at all times, refused to wear heel boots, but would let staff put a pillow under her leg to elevate her right heel. R9 was seated in her recliner with her heel resting on the recliner footrest. RN-C stated that someone must have forgotten to elevate her heel and proceeded to put a pillow under R9's right leg, allowing the right heel to be suspended in the air. R9 stated it felt good to have her heel elevated and not pushing against the footrest. RN-C stated it was important to have a dressing on and the heel floating as ordered to encourage wound healing. RN-C stated she had been taking care of R9'S heel wound since January, it was improving and the wound care and interventions needed to be followed.During interview on 6/23/26 at 1:10 p.m., nursing assistant (NA)-A stated she had taken care of R9 that morning, was not aware her bandage was not on and did not know why her leg was not elevated on a pillow but knew she had a wound and her heel was supposed to be elevated off the recliner footrest.During interview on 6/23/26 at 1:30 p.m., NA-B stated she was not aware of the missing bandage or that R9's heel was not elevated. NA-B stated it was on R9's care sheet to elevate her right heel.During interview on 6/23/26 at 2:45 p.m., director of nursing (DON) stated she would expect orders for pressure ulcer treatment to be followed as ordered to allow for wound healing.A facility policy titled Skin Ulcer Assessment, Prevention, and Management dated 1/25, indicated pressure relief devices, including pillows, were available and residents who were dependent on staff would have measures implemented to reduce pressure. A physician's order will be obtained for all wound treatments.

Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority -SMHA) for 2 of 2 resident (R10 and R14) with new onset of mental illness since admission. Findings include: R10's 7/05/23, Initial Pre-Admission Screening (PAS), did not identify a diagnosis of mental illness and did not indicate the need for a Level II (PASARR) to be completed. R10's 12/26/24, quarterly Minimum Data Set (MDS) assessment identified R10 was admitted [DATE]. R10 had a diagnoses of non-traumatic brain dysfunction, dementia, anxiety, depression, and a psychotic disorder other than schizophrenia. R10 was severely cognitively impaired and took antipsychotic, antidepressant, and antianxiety medication on a routine basis. R10 was dependent on staff for cares and activities of daily living (ADLs). Section D-Mood, on the MDS, identified R10 had little interest or pleasure in doing things, felt down, depressed or hopeless, had trouble falling, staying asleep or slept too much, felt bad about herself, had let herself or family down, had trouble concentrating on things, moved or spoke slowly that other people would noticed, was fidgety, restless, stated that life isn't worth living, wished for death or attempt to harm self, was short tempered, and easily annoyed never to 1 day. R10 had felt tired, had little energy, had poor appetite or was overeating 12 to 14 days, during the 14-day assessment period. R10's undated, current diagnosis list identified R10 received a new diagnosis of unspecified psychosis not due to a substance or known physiological condition on 9/07/23. R10's undated, current care plan identified R10 was at risk for alteration in mood and behaviors related to late Alzheimer's dementia with psychotic disturbances, anxiety, unspecified psychosis not due to substance or known physiological condition and depression disorder. R10 had a history of verbal outburst, not wanting to be alone at times, physical aggression towards staff, and confusion. R10 was at risk for psychotropic medication side effects such as constipation, nausea, fatigue, poor appetite, dizziness and nervousness, and adverse drug reactions. R10 was at risk for psychosocial well-being related to traumatic life events of R10's past and present. Interventions was for staff to provide referrals to mental health professional, support groups and other appropriate resources as needed. R10's medical record lacked any indication that the county (SMHA) had been notified since the new onset of R10's mental illness. R14's 11/10/16, Initial Pre-Admission Screening (PAS), did not identify a diagnosis of mental illness and did not indicate the need for a Level II (PASARR) to be completed. R14's 5/24/18, Confidential Protected Health Information Enclosed faxed sheet identified a notice of voluntary transfer of R14 to the local hospital for changes in behavior. R14's 12/06/24, Risk and Benefit Assessment and Psych Summary identified R14 had a history of paranoia and delusions, was anxious, had thoughts of people talking about him and listening to his conversations, and had made bizarre verbal statements. R14's 1/10/25, quarterly Minimum Data Set (MDS) was admitted [DATE]. R14 had a diagnosis of depression and schizophrenia. R14 was cognitively intact and took antipsychotics and antidepressants on a routine basis. R14 required substantial/maximal assistance for cares and was dependent on staff for transfers. Section D-Mood, on the MDS, identified R14 had little interest or pleasure in doing things and had felt down, depressed, or hopeless never to 1 day, during the 14-day assessment period. R14's undated, current diagnosis list identified R14 received a new diagnosis of paranoid delusional disorder on 7/05/18, social phobia on 6/11/20 and schizoaffective disorder, depressive type on 6/11/20. R14's undated, current care plan identified R14 was at risk for alteration in mood related to depressive disorder, and delusional disorder. R14 had a history of suicidal thoughts or hurting oneself, auditory hallucinations and delusions. R14 was at risk for antidepressant antipsychotic medication use and had target behaviors of paranoia, anger and impatience. R14's medical record lacked any indication that the county (SMHA) had been notified since the new onset of R14's mental illness. Interview on 4/08/25 at 2:25 p.m., with licensed social worker identified the facility relied on the hospital to initiate the PASARR prior to admission. She identified she was not aware R10 and R14 new mental illness diagnoses. She identified the mental health authority was not contacted for referral. Interview on 4/09/25 at 11:06 a.m., with director of nursing had no knowledge of when to determine a Level II screening would be required. She stated her expectations would be for the facility to identify a process to review residents with a new mental illness for a Level II screening. Review of September 2024 Preadmission Screening Process For Entering A SNF policy identified Level I PASARR would be completed on residents before admission to the facility. In addition, the facility would notify the state mental health authority or state intellectual disability authority after a significant change in the mental or physical condition or a resident who had a mental illness or intellectual disability.

Based on observation, interview and document review the facility failed ensure a residents residing in the memory care unit were allowed clothing in a manner to promote dignity when residents were dressed in a hospital gown while participating in activities for 3 of 4 residents (R4, R9, R49) reviewed for dignity. Findings Include: R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R4 had moderately impaired cognition, required moderate assistance with dressing upper body and maximal assistance dressing her lower body and diagnoses of non-Alzheimer's dementia and depression. R4's care plan dated 3/7/25, indicated alterations and potential for further alterations in ADL (activities of daily living) abilities evidenced by history of falls, history TIA, diagnosis of unspecified dementia with behavioral disturbance, and visual impairment. Interventions included extensive assistance of 1-2 to dress, participates by lifting arms and helps to pull shirt on and dependent on staff to put pants on as well as socks and shoes. R9's quarterly MDS assessment dated [DATE], indicated R9 had severe cognitive impairment, required maximal assistance with dressing upper body and dependent on staff assistance dressing her lower body and diagnoses of weakness, non-Alzheimer's dementia, anxiety, and depression R9's care plan dated 2/7/25, indicated alterations in dressing, grooming, and bathing as evidenced by need for assistance and interventions included requires extensive to total assistance of one with daily dressing. R49's quarterly MDS assessment dated [DATE], indicated R9 had severe cognitive impairment, required maximal assistance with dressing upper body and dependent on staff assistance dressing her lower body and diagnoses of weakness, non-Alzheimer's dementia. R49's care dated 2/28/25, indicated alteration in ADL's evidenced by need for assistance with all aspects due to weakness and confusion extensive assist of 1-2 to dress, participates by lifting arms and legs with cues, one staff to keep calm or busy or on task while one staff to complete the task as resident is very busy with her hands and grabs at items, tries to sit or stand when not appropriate, etc, will sometimes also help to pull items part way on. On 4/7/25 at 6:00 p.m., R4, R9, R40, R49 were observed in the moonlight wing (locked memory care unit) activity area seated in wheelchairs wearing hospitals gowns, and nine other residents were present. The residents were positioned in a circle and participated in an activity while wearing a hospital style gown, where a ball was kicked around the circle from resident to resident. On 4/7/25 at 6:05 p.m., nursing assistant (NA)-A stated R4, R9, and R49 were assisted with evening cares after their evening meal. NA-A stated R4, R9, and R49 wore a hospital gown to bed and staff assisted with changing some of the residents into a hospital gown after the evening meal and then the residents were assisted back to the commons area. NA-A stated it was common facility practice that the residents participated in activities in their hospital gown. On 4/7/25 at 6:08 p.m., NA-E stated after the resident's evening meal staff routinely assisted some of the residents with evening cares and assisted resident's into a hospital gown they wore to bed. NA-E stated staff assisting some of the residents with evening cares after the evening meal was more convenient for staff to get the residents into their gown after the evening meal when toileting the residents. NA-E stated a reasonable person would not participate in activities wearing a hospital gown. On 4/7/25 at 6:14 p.m., NA-D and stated staff routinely assisted residents with evening cares after the the evening meal and into the hospital gown they wore to bed, and then the resident's would return to the commons area for activities. NA-D stated assisting some of the residents with bedtime cares after the evening meal helped staff get the residents to bed on time. NA-D stated she had never thought of residents wearing a gown during activities as a dignity concern as they wear the gown to bed. On 4/7/25 at 6:21 p.m., staff were observed and assisted the nine residents with an activity where a large ball was placed in the center of the circle of residents, and the residents kicked the ball around the circle. After that activity residents were assisted the dining room table area for a new activity. R4, R9, R49 were observed in hospital gowns and seated in their wheelchairs at the dining room table. On 4/7/25 at 6:22 p.m., R9 was seated in a wheelchair in a hospital gown with a blanket over her lap at the dining room table and staff were observed assisting other residents to the dining room for an activity. R9 stated she would rather wear normal clothes then wear the gown she was wearing while doing an activity. On 4/7/25 at 6:23 p.m., R4 and R49 were not able to verbalize if they had concerns wearing a hospital gown while they participated in activities. On 4/7/25 at 6:26 p.m., NA-B stated staff assisted residents to their rooms after the evening meal for toileting and stated some of the residents were provided evening cares at that time that included putting a hospital gown on that they wore to bed. NA-B stated residents who wore a gown to activities were expected to have a blanket on their lap and a sweater cover their top of the body . On 4/8/25 at 9:50 a.m., NA-C stated it was common for residents to wear hospital gowns to evening activities and stated a blanket was expected on the resident's lap and sweater if a hospital gown was worn while residents participated in activities. NA-C stated R4, R9, R49 were cognitively impaired and not able to verbalize if they would want to wear a gown during activities. NA-C stated a reasonable person would not wear a hospital gown during an activity. On 4/8/25 at 10:16 a.m., during telephone interview R49's family member (FM)-A stated R49 was a modest person and would not want wear a hospital gown while participating in activities. FM-A stated R49 was no longer able to make decisions or speak for herself. On 4/8/25 at 11:53 a.m., the director of nursing (DON) stated stated residents were not expected to wear a gown while participating in activities in a common area unless a blanket was placed over the resident's lap, or a sweater covering the upper body. The DON confirmed R4, R9, R49 were not able to verbalize if they had concerns with wearing a gown during activities and families had not been asked the resident preference. The DON stated resident's in other areas of the facility do not participate in activities wearing hospital gowns. Facility Resident Right to Receive Respect and Dignity policy dated 10/20/23, indicated It is the goal to provide dignity and respect to all residents in full recognition of their individuality. This includes but is not limited to the following: The right to retain personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on observation, interview and document review, the facility failed to identify, comprehensively assess and implement interventions for a 9.7 percent weight loss in one month for of 1 of 1 resident (R19) reviewed for nutrition. Findings include: R19's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R19 had moderately impaired cognition, no behaviors or rejection of care, a weight of 213 pounds, had a loss of 5% or more in the last month or loss of 10% or more in the last months and was not on physician prescribed weight loss regimen, required set up assistance with eating, dependent on staff for toileting, dressing, and required moderate assistance with personal hygiene, and diagnoses included hemiplegia or hemiparesis (weakness or partial paralysis on one side of the body), depression and weakness. R19's nutritional status Care Area Assessment (CAA) worksheet dated 5/16/24, indicated potential for alterations in nutritional status secondary to BMI (body mass index), at risk for weight gain or loss, dehydration, and/or skin breakdown, see nutritional documents, diagnosis list, physician orders, will proceed to nutritional care plan to address needs. R19's care plan dated 2/17/25, indicated potential for alteration in nutrition related to cerebral infarction (stroke) and interventions included diet: regular with average sized portions, regular liquid consistencies and regular texture foods, provide meals upon her request, independent with feeding herself, provide/set up as needed, encourage to eat, monitor food and fluid intake at meals, acceptance and tolerance to diet. Document titled MDS Listing Checklist dated 2/12/25, indicated current weight 213, weight one month ago 236, weight loss 9.75% in month, weight 6 months ago 234, significant weight change yes, regular diet, appetite varies, supplements in diet order. Progress note dated 11/7/24, dietary manager (DM)-A indicated R19 receiving a general diet with regular food textures and regular liquid consistencies, consuming approximately 75-100% of food served at 3 meals daily, this is good to excellent intake, able to feed self after tray is set up, most recent weight: 242 pounds,which is up 4 pounds from last month, no issues chewing or swallowing, skin is intact, continue to monitor weight, intake, and acceptance and tolerance to diet. R19's progress note dated 3/25/25 registered dietician (RD)-A indicated R19 had a significant weight change, as defined by regulatory standards, in the last 30-day reporting period, weight history is as follows: most recent weight: 245 pounds, BMI=46.3 (extreme obesity), based on 61 inches, 30-day weight: 213 pounds, up 32 pounds; 15% 165-day admission weight: 238 pounds, up 7 pounds, 3%; receives a general diet with regular food textures and regular liquid consistencies, consumes approximately 75% of food served at 3 meals daily, 90% of the time, this is good to excellent but is in excess of calorie needs, no issues chewing or swallowing, skin is intact, encourage healthful food selection, continue to monitor weight, intake, and acceptance and tolerance to diet. R19's vitals report printed 4/9/25, indicated the following weights: 10/1/24 242 pounds 11/8/24 236 pounds 12/1/24 243 pounds 1/1/25 236 pounds 2/1/25 213 pounds 3/1/25 245 pounds; 5.0 percent change in weight in 30 days 4/1/25 245 pounds On 4/9/25 at 7:34 a.m., during a telephone interview the registered dietician confirmed R19 had a significant weight loss form 1/1/25 to 2/1/25, that was not addressed. RD-A stated interventions were expected implemented with R19's significant weight loss of 9.7% in one month. RD-A stated she was responsible to address significant weight loss and confirmed R19's weight loss was not addressed as expected. On 4/9/25 at 8:25 a.m., RN-B stated the nursing assistants were responsible to weigh and document R19's weight monthly. RN-B stated on 2/1/25, and she reweighed R19's due to the significant weight loss from the previous month and ensure the documentation and weight was not an error. RN-B stated she has no documentation R19's weight on 2/1/25, was an error. RN-B stated a list of resident's weights were given to RN-C, known as the resident care coordinator, to address weights. RN-B stated she would have expected R19's signification weight loss addressed and investigated. On 4/8/25-4/9/25, RN-C was unavailable for an interview. On 4/9/25 at 8:33 a.m., R19 was seated in a wheelchair in the dining room and stated she ate her meal with no concerns. R19 was observed to have ate 100 percent of her breakfast meal. R19 stated she had no weight loss or no weight gain recently and further stated staff checked her weight weekly. On 4/9/25 at 8:35 a.m., dietary manager (DM)-A stated dietary assessed resident weights quarterly and DM-A was observed to find a document titled MDS Listing Checklist dated 2/12/25, and stated the document confirmed R19's significant weight loss. DM-A stated RD-A will address the significant weight loss and gains and was responsible for interventions. On 4/9/25 at 9:57 a.m., registered nurse (RN)-A, also known as the MDS nurse, confirmed R19 had a significant weight loss and confirmed R19's weight loss form 1/1/25 to 2/2/25, was not identified and was not aware of inventions put in place for the R19's weight loss. RN-A further explained R19's weight was maybe an error; however, the weight loss was not investigated to determine if R19 had actual weight loss or an error. On 4/9/25 at 9: 59 a.m., the director of nursing (DON) stated she would expect R19's weight loss on 2/1/25, identified and interventions put in place to follow the facilities policy and procedure. The DON further indicated there was not documentation R19's weight loss was identified or addressed. Facility Unplanned Weight Loss Management policy dated 1/18, indicated committed to providing a plan of care that supports each resident's optimal level of wellness. This includes acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible. Procedure: All residents are weighed upon admission, readmission and at least monthly on an ongoing basis. Residents at risk of weight loss are scheduled for more frequent weights as deemed appropriate by the health care team. Resident weights are taken and entered into their electronic health record. The RN Resident Care Coordinator is responsible for reviewing weights and determining the need for re-weights and notification of dietician and physician. Triggers for weight loss concern include 5% weight loss in one month and 10% weight loss in six months. The Registered Dietician reviews residents' nutritional status with the MDS schedule and upon notification of concerns by Dietary Manager and/or Nursing Department staff. After review, the Registered Dietician will make recommendations that will be communicated to the resident's physician.

Based on interview and document review, the facility failed to ensure all residents were consistently offered and provided a nutrient and/or calorie-substantive snack after the dinner meal and before bedtime for 4 of 8 residents (R40, R25, R21, R12) who voiced a concern. This had the potential to affect all 51 residents who resided in the facility. Findings include: During an interview on 3/18/24 at 12:33 p.m., R40, who's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, stated she had been a resident at the facility since 2/27/24, and had not been offered a snack after dinner and before bedtime. R40 stated she didn't know if she could get a snack if she asked and would like one sometimes. During an interview at resident council meeting on 3/19/24 at 9:46 a.m., the following residents indicated: -R25 who's admission MDS assessment dated [DATE], indicated intact cognition, stated she had never been offered a snack after supper and before bedtime, but would like one. -R21 who's quarterly MDS assessment dated [DATE], indicated intact cognition, stated he had not been offered a snack after dinner and before bedtime, but if asked, might want one. -R12 who's quarterly MDS dated [DATE], indicated intact cognition, stated she had never been offered a snack after dinner and before bedtime, but had asked for one in the past. During an interview on 3/19/24 at 4:05 p.m., nursing assistant (NA)-A stated diabetic residents and a few other residents received a snack from the kitchen after dinner and before bedtime. NA-A stated staff did not go around with snacks to offer other residents. During an interview on 3/19/24 at 4:06 p.m., NA-B stated diabetic residents received a snack after dinner and before bedtime, but other residents did not. During an interview on 3/19/24 at 4:08 p.m., NA-C stated diabetic residents received a snack after dinner and before bedtime. NA-C stated kitchen staff put the scheduled snacks on a cart and dropped the cart off in the hallway for nurses to pass. No snacks were provided to other residents. During an interview on 3/19/24 at 4:11 p.m., licensed practical nurse (LPN)-A stated certain residents received snacks after dinner and before bedtime, including diabetics, but the rest of the residents did not. During an interview on 3/20/24 at 7:47 a.m., the assistant culinary services director (ACSD)-C stated kitchen staff made snacks for certain residents for after dinner and before bedtime. ACSD-C listed the names of eight residents who received a scheduled evening snack from the kitchen. ACSD-C stated the memory care unit had their own snacks to offer residents, then it was up to nursing staff to provide snacks to residents on the other units. During an interview on 3/20/24 at 8:13 a.m., with registered nurse (RN)-A in the medication cart/charting room near the 200 wing, RN-A stated nursing had access to saltines and graham crackers, peanut butter, and pudding cups in the cupboards in the medication cart/charting room and opened a cupboard which revealed small tubs of crackers, peanut butter and pudding. RN-A stated if a resident was hungry, staff could offer these snacks. RN-A stated some residents had a scheduled snack listed on their diet card and it was brought to the nursing units from the kitchen. During an interview on 3/20/24 at 9:10 p.m., LPN-B who was working on the memory care unit stated some residents received a scheduled snack from the kitchen, such as a sandwich, after supper and before bedtime. LPN-B stated snacks were available to other residents who asked. LPN-B opened a cupboard in the kitchenette on the memory care unit displaying fresh fruit, cookies, crackers, granola bars, chips, and pudding. Ice cream was available in the freezer. During a telephone interview on 3/20/24 at 8:50 p.m., registered dietician (RD)-D was informed of findings and stated she was not aware snacks were not offered to all residents after dinner and before bedtime. RD-D stated if residents asked for something to eat, staff would find something for them. RD-D stated it could be a long time from the evening meal to breakfast, so residents should receive something to eat if they desired. During an interview on 3/20/24 at 8:16 a.m., the director of nursing (DON) thought residents were offered a bedtime snack and thought dietary staff passed out the snacks. However, the DON had not actually observed snacks being distributed at bedtime. During an interview on 3/20/24 at 10:30 a.m., the administrator was aware some residents received a scheduled snack after dinner and before bedtime, and thought staff went around with snacks in the evening to offer all residents. The administrator was not aware residents were not being offered a snack in the evening. Facility policy on resident snacks was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure dishwashing sanitization for 1 of 1 dishmachine was appropriately monitored. Findings include: During an interview and observation on 2/27/23, at 6:55 a.m., the initial kitchen tour was conducted with culinary services director (CSD). The dishmachine was observed and CSD stated dishes were sanitized by chemical disinfection with chlorine. During an interview and observation on 3/1/23, at 8:40 a.m., the dishmachine log, titled Dishwasher Temperature and Sanitizer Log, located in the dishmachine room, was observed to have sanitizer concentrations of chlorine documented below the required 50 to 200 ppm (parts per million). Some readings on the log were 0, some were 10, 50, 100 or 200 ppm. Dietary aide (DA)-A demonstrated the process of measuring the level of chlorine disinfectant in the dishmachine water by taking a long handled, metal scoop and obtained a sample of water from inside the dishmachine. As she was doing this, DA-A stated, We've been having issues with the sanitizer for awhile. DA-A then dipped a [NAME] brand chlorine test strip (expiration date 6/24), into the solution and held it against the colored squares on the container of strips. The paper strip did not change color indicating the proper ppm had not been reached. DA-A stated she had told assistant culinary services director (ACSD) about it today and he looked at it. DA-A did not know how long there had been readings below 50 ppm. The paper Dishwasher Temperature and Sanitizer Log had eight columns and three rows for each of the daily meals. One of the column headings was sanitizer concentration (ppm) and one column was corrective action taken. The date range on the log was from 2/22/23, through 3/1/21. Out of 21 readings, five entries on the following dates 2/24/23, 2/28/23, and 3/1/22, were documented at 0 or 10 ppm. The only date where corrective action was taken was on 3/1/23, when during the interview with DA-A, she noted the ppm to be zero and informed ACSD. During an interview on 3/1/23, at 8:55 a.m., ACSD stated they had problems with the dishmachine reaching appropriate disinfectant levels, adding it had been a problem for awhile and he had just called the vendor about it. ACSD was asked to provide logs from the past four months. Upon review, some logs had documented readings of 0 or 10 ppm, some dates were missing readings. ACSD stated he reviewed the sheets after they were filled, but had not noticed documented readings below 50 ppm. ACSD admitted he did not monitor the logs daily or on a regular basis in order to identify potential problems early on. ACSD provided additional Dishwasher Temperature and Sanitizer Logs from 10/25/22, through 2/21/23, which indicated: --11/1/22: following two of three meals, 0 ppm sanitizer concentration was documented on the log. No corrective action noted. --11/7/22: following two of three meals, 10 ppm sanitizer concentration was documented on the log. No corrective action noted. --12/25/22: following all three meals, 10 ppm sanitizer concentration was documented on the log. No corrective action noted. --12/26/22: following two of three meals, 0 ppm sanitizer concentration was documented on the log. ACSD was notified after the second. --12/28/23: following one of three meals, 10 ppm sanitizer concentration was documented on the log. No corrective action noted. --1/17/23: following all three meals, 10 ppm sanitizer concentration was documented on the log. ACSD was notified after the second. --1/18/23: following two of three meals, 10 ppm sanitizer concentration was documented on the log. No corrective action noted. The bottom of the form indicated: Report any inappropriate temperatures or sanitizing issues to the supervisor immediately for corrective action. During an interview on 3/1/23, at 9:48 a.m., culinary services director (CSD) stated she had not been aware the level of chlorine in the dishmachine had been below the required concentration. CSD stated they had done training on it in the past and staff were to let either CSD or ACSD know when out of compliance. During a telephone interview on 3/1/23, at 12:24 p.m., Ecolab representative (ER)-C stated they conducted preventative maintenance visits to the facility monthly. Staff were to test the dishmachine solution and if it dropped below 50 ppm, were to call the representative. When informed what was observed when DA-A obtained the water from the dishmachine with the scoop, ER-C stated by doing that, they might be getting mixed wash water, rather than just rinse water at the very end. ER-C suggested running an upside down plate through the dishmachine, then test the residual water. ER-C stated the risk of low concentration of chlorine meant dishes were not getting properly sanitized. During an observation on 3/1/23, at 12:40 p.m., CSD ran an upside down plastic plate cover through the dishmachine, then tested the water collected in the top of the dome. The chlorine strip did not change color indicating proper chlorine concentration had not been achieved. During an interview and observation on 3/1/23, at 12:47 p.m., with ER-C on speaker phone, and CSD and maintenance technician (MT)- B standing at the dishmachine, ER-C explained to MT-B what to do to verify correct placement of tubes/hoses in the bucket of liquid chlorine under the dishmachine. From MT-B's description provided to ER-C, the tubing/hose arrangement in chlorine bucket seemed to be positioned accurately. On 3/1/23, at 1:07 p.m., CSD stated she met with the administrator and the decision was made to switch to disposable dish products until the situation was resolved. During an interview on 3/1/23, at 3:26 p.m., the administrator stated after the last time this happened, they had trained staff and did audits. It was her expectation staff followed policies that were in place to monitor the solution and to report to CSD or ACSD if the solution was out of the required range. The Dishwasher Temperature and Sanitizer Logs were reviewed with the administrator and entries of 0 or 10 ppm and no action taken were pointed out. Facility policy titled Sanitation of Dishes/Dish Machine, dated 2010, indicated for low temperature dishwater, spray type dish machine using chemicals to sanitize: the wash water temperature was required to be at 120 degrees Fahrenheit, minimum. The final rinse sanitization should be 50 to 200 ppm hypochlorite range.

Based on interview, observation and document review the facility failed to assess and monitor for complications per standard of practice before and after dialysis for 1 of 1 resident (R43) reviewed for dialysis care. Findings include: R43's face sheet printed 3/1/23, included diagnosis of dependence on renal dialysis, heart failure, high blood pressure and atrial fibrillation (irregular heart rhythm that can lead to blood clots in heart). R43's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified intact cognition, required limited to extensive assistance with activities of daily living, and was on dialysis. Provider orders dated 1/11/23, indicated R43 receives warfarin (blood thinner) 2 mg tablet daily. R43's care plan dated 4/20/22, included at risk for complications and overall decline related to acute and chronic kidney disease stage 4 with need for dialysis. Interventions included dialysis treatments on Tuesday, Thursday and Saturdays. Monitor for signs of bleeding or infection at access site. Monitor vitals signs per protocol and consult with physician or dialysis center if abnormal blood pressure. During an interview on 2/27/23, at 2:44 p.m., R43 stated he had an access port on his upper chest for dialysis and staff did not assess it or provide any care for it. R43 included after dialysis he is tired and he generally gets in bed and sleeps the rest of the day. During interview on 2/28/23, at 2:43 p.m. licensed practical nurse (LPN)-A indicated there is no special monitoring or assessments that are completed on R43 prior to or after dialysis. The dialysis site is checked every morning to ensure no signs of infection are present. Dialysis monitors the dressing site, catheter and completes site care. LPN-A indicated R43 has not had any issues that she is aware of. Vital signs are done by dialysis and the facility does weekly vital signs per protocol. LPN-A added they (facility) send provider orders with R43 to dialysis and receive from dialysis his last set of vital signs, if midodrine (treatment for low blood pressure) was given, and pre and post weights. During continuous observation and interview on 2/28/23, at 1:50 p.m. R43 returned from dialysis and was assisted into bed by a staff member. No assessment was completed. R43 stated he was tired and just wanted to sleep. During observation over the next hour at 2:12 p.m., 2:37 p.m., and 3:00 p.m. no staff had entered R43's room and R43 remained sleeping. During interview and observation on 2/28/23, at 3:37 p.m., registered nurse (RN)-B indicated they check R43's catheter insertion site every day to ensure dressing is intact. The catheter that extends from the insertion site is left alone. RN-B added R43 has a central venous catheter (flexible, long plastic, Y-shaped tube threaded through skin into a central vein) for his dialysis site. R43's dialysis site was present on his right chest with an extending catheter with two ports present and covered with 4x4's. RN-B examined site and indicated no redness, swelling or bleeding was present. RN-B indicated R43 comes back tired and sleeps most of the day when he returns. During interview on 3/1/23, at 7:26 a.m. RN-E from dialysis facility indicated they receive physician orders from the facility but no pre-assessment. RN-E indicated they do vital signs before R43 leaves and has a history of low blood pressures. During interview on 3/1/23, at 8:56 a.m., RN-C indicated a physician order sheet is sent with R43 to dialysis and in return dialysis sends back pre and post weights, and vital signs if midodrine is given. RN-C indicated no assessment is completed prior to or after dialysis. The port is checked daily to be sure it is dry and intact. During interview on 3/1/23, at 9:50 a.m., RN-D indicated R43 has routine vital signs which are done weekly. Dialysis is responsible for vital signs before and after dialysis. The dialysis port site is monitored for infection daily but otherwise site care and monitoring is done by the dialysis center. During interview on 3/1/23, at 11:55 a.m., the director of nursing (DON) confirmed R43 should be assessed before and after dialysis including observing the port site for bleeding. The DON indicated this is the first dialysis patient they have had and she developed the policy and procedure today but prior to request for the policy did not have one. Facility policy titled Dialysis, undated, included the facility is responsible for the overall quality of care the resident receives, including ongoing assessments, care planning and provisions of care.

Based on interview and document review, the facility failed to provide sufficient organized, group activities on the weekend hours to meet resident need and desires for 1 of 1 resident (R10) who voiced there were not enough activities offered. Findings include: R10's annual Minimum Data Set (MDS) dated [DATE], identified R10 had intact cognition and was independent with activities of daily living (ADLs). Further, the MDS contained a section for activity preferences which identified R10 preferences included listening to music, doing things with groups of people, participating in activities, spending time outdoors and participating in religious activities or practices. R10's care plan dated 1/16/23, identified R10 has a potential risk for alteration of culturally competent care and his family and church are very important to him. R10 likes to listen to music to relax, enjoys being outside, gardening, fixing things and riding his 3 wheeled bike. R10 prefers things organized and scheduled. During interview on 2/27/23, at 10:24 a.m., R10 indicated since COVID-19 started, the facility offers very few activities to do. R10 indicated used to have bingo every week and now it is every other week. Weekends get very long. Saturday is generally nothing and Sunday they offer church and that is all. When interviewed on 2/28/23, at 12:47 p.m. R10 stated there was not enough activities offered by the facility especially on weekends. R10 indicated they do get a calendar but as a rule all that is listed is to do something yourself. A group of men play cards but they organize that themselves. R10 indicated part of the problem is a shortage of help. The untitled activity calendars provided for 1/15/23 through 2/28/23, identified each day of the week along with the days' corresponding activities being offered and provided by therapeutic recreation. Days with only worship service and coffee-social doorway/hallway are listed below along with days with only one activity which was play card with your friends not organized or attended by therapeutic recreation: 1/15/23 1/16/23, card games (please play with your friends, no activity person in the room). 1/21/23 1/22/23 1/28/23 1/29/23 2/2/23- Church services in morning and afternoon, resident council meeting. 2/4/23 2/5/23 2/11/23 2/12/23 2/18/23 2/19/23 2/20/23- Please play cards with your friends. 2/22/23- Ash Wednesday Service. 2/25/23 2/26/23 On 2/28/23, at 1:06 p.m., activities coordinator (AC)-A indicated coffee social-doorway/hallway is done by nursing staff. AC-A indicated right now there is no one to work Saturday and Sunday is church service day. AC-A indicated that residents are fairly independent and they will start their own activities. AC-A also added residents have a lot of family visits. AC-A included she is aware of gaps on the calendar due to staff being unavailable. Review of R10's activity attendance from 1/4/23 to 2/28/23 included two worship services and attended bingo four times, played cards or another game 4 times. During interview on 2/28/23, at 2:43 p.m., licensed practical nurse (LPN)-A confirmed the nursing staff deliver a snack cart and beverages to the residents every afternoon. LPN-A indicated the facility started that when COVID-19 outbreaks started and residents really liked it so they have continued to offer daily. During interview on 3/1/23, at 3:45 p.m. the administrator acknowledged they are currently short of activities staff. A policy and procedure for TR was requested and none received.

Based on observation and interview, the facility failed to ensure resident bathroom call light cords were within reach from the bathroom floor for 3 of 3 residents (R36, R153, R12), reviewed for call lights. Findings include: R36 R36's annual Minimum Data Set (MDS) assessment dated [DATE], included diagnoses of arthritis, weakness and glaucoma (eye disease that can cause blindness). R36 who was cognitively intact and required extensive assistance of one staff member for toileting, and did not walk. During an observation on 2/27/23, at 7:22 a.m., the call light cord in R36's bathroom was measured at 22 inches from the floor. R153 R153's admission Minimum Data Set (MDS) assessment dated [DATE], included diagnoses of weakness and arthritis. R153 who was cognitively intact and required limited assistance of one staff member for toileting, walked with limited assistance of one staff. During an observation on 2/27/23, at 7:24 a.m., the call light cord in R153's bathroom was measured at 18 inches from the floor. R12 R12's quarterly Minimum Data Set (MDS) assessment dated [DATE], included diagnoses of osteoarthritis and weakness. R12 who was cognitively intact and required extensive assistance of one staff member for toileting, did not walk. During an observation on 2/27/23, at 1:58 p.m., the call light cord in R12's bathroom was measured at 26 inches from the floor. During an interview and observation on 2/28/23, at 1:20 p.m., building services director (BSD) stated he was not aware of the regulation which required call light cords in resident bathrooms to extend to the floor and be accessible to a resident lying on the floor. Together looked in R153's bathroom and BSD verified the cord was not to the floor. During an interview on 2/28/23, at 3:02 p.m., the administrator was unaware of the regulation which required call light cords in resident bathrooms to extend to the floor and be accessible to a resident lying on the floor, and stated BSD would get going on that [replacing cords] right away. Facility policy on call lights was requested. According to the director of nursing on 3/1/23, at 3:30 p.m., the facility did not have a call light policy.

Based on observation, interview, and document review, the facility failed to ensure dishwashing sanitization for 1 of 1 dishmachine was appropriately monitored. In addition, the facility failed to date-mark opened containers of food in 1 of 1 kitchen refrigerator, and to ensure pans were completely dry before storing. Furthermore, the facility failed to ensure dietary staff received required training on an on-going basis for 3 of 3 staff: culinary services director (SD)-D, assistant director of culinary services (ADCS)-E, and cook (C)-A. This had the potential to affect all 64 residents who were served food from the kitchen. Findings include: During an observation and interview on [DATE], at 1:00 p.m., with SD-D and during the initial tour of the kitchen, observed a large metal bowl in a walk-up refrigerator. The bowl was covered with plastic wrap and aluminum foil. Handwritten on the foil was BRN (bran) cookies and date of ,d+[DATE]. Inside was dark colored, raw dough. CSD-D stated the dough was for bran cookies and was good for a couple of weeks. Observed multiple jelly roll plans stacked upside down. CSD-D was asked to look at the first few, and the surfaces were noted to be wet. CSD-D directed staff to run them through the dishmachine again. Observed multiple cutting boards stacked vertically, touching one another. CSD-D acknowledged inappropriate storage of pans and cutting boards could create an environment for bacteria to grow. Observed a three-compartment dish washing sink. The monitoring log hanging on a near by cupboard door was blank for the month of October. During an observation on [DATE], at 11:00 a.m., the bowl of bran cookie dough in large metal bowl was still in the refrigerator. At the three-compartment sink, an Ecolab Smart Power Sink and Surface Cleaner Sanitizer instructional poster was posted above the sink. Ecolab Sink and Surface Cleaner Sanitizer Test strips with expiration date of ,d+[DATE], were noted on the ledge above the sink. According to Ecolab website, measurements of the chemical sanitizing solution could be taken at any temperature above 65 degrees Fahrenheit. Measurement required a five second dip into the test solution, allowing 10 seconds for the color change to occur, and compare the strip against the color chart on the vial. The required ppm (parts per million) DDBSA (dodecylbenzenesulfonic acid) and ppm lactic acid was outlined by a black box on the color chart. During an interview and observation on [DATE], at 11:08 a.m. ADCS-E stated he had no format training for his role, adding he was going to start working on his CDM (certified dietary manager). ADCS-E stated he did not have ServSafe certification as it had expired. When asked what kind of training he had on the three-compartment sanitizer sink, ADCS-E replied, Not a whole lot. While standing at the three-compartment sink with ADCS-E and C-A, both stated they had not had training on monitoring and measuring the level of chemical. C-A used a test strip and inserted it in the first sink filled with water and chemical. When asked how long the strip was to be kept in the water, C-A replied 30 seconds. The container of strip container indicated 5 seconds. Then C-A held the strip against the color chart on the vial, but wasn't sure which number to read and record: ppm DDBSA or ppm lactic acid. During an interview and observation on [DATE], at 11:30 a.m., with ADCS-E and C-A at the walk-up refrigerator, C-A was asked to remove the bowl of bran dough. C-A stated they made and served bran cookies on Wednesday and Sunday nights. C-A stated the dough was good for two to three weeks, but but admitted there was nothing that indicated that. C-A obtained the recipe to see if it indicated how long the dough lasted in the refrigerator. It was a hand-written recipe on a card and did not include shelf-life for the raw dough. C-A stated they should probably make smaller batches of dough. At 11:34 a.m., with ADCS-E in walk-in refrigerator, observed a container of Mrs. Gerry's potato salad with approximately one-fourth left. The container did not have a date opened mark on it. ADCS-E stated, It's not dated; its supposed to be dated, adding if dated, it would be good for five days. A container of Monarch brand salad dressing was observed with approximately one-eight left in the container; the container did not have a date opened mark on it. ADCS-E stated it should have been dated, then discarded after being opened for five days. A large bunch of green onions wrapped in plastic were observed with received date of ,d+[DATE]. ADCS-E did not know if they were still okay to serve residents; he would need to inspect them. ADCS-E stated there wasn't a policy or reference tool that he was aware of for knowing how long produce and opened foods were good for, adding we say left-overs are good for seven days -- no matter what it is, and 5 days for vendor packaged food like potato salad. During an interview on [DATE], at 9:15 a.m., CSD-D could not recall when training was provided to staff on the three-compartment sink, including monitoring the sanitizing solution. CSD-D admitted she was to be the expert for this process, but did not recall the last time she had training. In addition, CSD-D admitted it was her responsibility to oversee staff to ensure they followed regulations and monitored the effectiveness of the sanitizing solution. CSD-D stated she reminded staff on Monday ([DATE]), to test it. CSD-D was informed that staff had not tested the solution the past two days because they stated did not know how. CSD-D stated the Ecolab representative was scheduled to come today for staff training. During the same interview, CSD-D stated unopened foods were good until the manufacturer best by or expiration date, and opened foods were good for five days. CSD-D stated staff were to date food when opened, but admitted she did not monitor this. CSD-D was informed of potato salad and salad dressing being opened, but not dated, and of green onions from September. CSD-D stated the potato salad, salad dressing and onions should be discarded. In addition, CSD-D stated she looked up how long the bran cookie dough was good for and learned it was good for a week. CSD-D admitted the dough in the refrigerator was 14 days old, would be discarded and smaller batches made going forward. Furthermore, CSD-D could not say, nor provide records that staff had specific training on dating foods when opened, how long foods were good for after opening, letting pans dry before stacking, and not stacking cutting boards. During an interview on [DATE], at 12:22 p.m., the Ecolab representative stated he trained CSD-D and staff how to measure the sanitizing solution in the three-compartment sink. CSD-D provided a list of six staff, plus herself, who received the training. During an interview on [DATE], 13:27 p.m. the administrator stating she was aware of the findings with the three-compartment sink, but not the wet pans, bran dough, and foods not labeled after opening. The administrator stated after findings from the last survey, she didn't expect this, adding she expected staff to be monitoring this and following regulations. During an observation and interview on [DATE], at 10:00 a.m., C-C stated she had training on ,d+[DATE], with the Ecolab representative on measuring the sanitizing solution. Observed the three compartment sinks filled with water and solution, but the monitoring log was empty for this date. C-C stated she had been too busy to test the solution. At that point, C-C tested the solution and wrote the information on the log hanging on the cupboard door. Facility policy titled Cleaning Dishes - Manual Dishwashing, dated 2010, indicated dishes and cookware would be washed after each meal to assure all dishes were clean and sanitary. Check sanitation sink often using a test strip to assure the level of sanitation solution is appropriate. Test the sanitizing solution in the sink using the manufacturers suggested test strips to assure appropriate level. Allow dished to air dry. Check all dishes to be sure they are clean and dry prior to storing. Facility policy titled Food Storage, dated 2010, indicated date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed or discharged , will be visible on all high risk foods. Left-over food is clearly labeled and dated before being refrigerated. Leftover food is used within 5 days or discarded. All food should be labeled and dated. All foods will be checked to assure that foods (including leftovers) are consumed by their safe use dates or discarded.

Based on observation, interview and document review, the facility failed to ensure infection control measures were maintained for indwelling urinary catheter care for 1 of 1 resident (R43) reviewed for catheter care. Furthermore, the facility failed to ensure hand hygiene was performed during resident care and meal-tray passes for 3 of 3 residents (R43, R54 and R41) observed for infection control practices. Findings include: R43's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R43 was cognitively intact, had adequate hearing and vision, clear speech, was able to make herself understood and could understand others. The MDS further indicated R43 had an indwelling urinary catheter, and required total dependence of one staff for moving about the facility in a wheelchair. R43's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's care plan problem dated 12/14/17, indicated R43 had urinary retention. In addition, a care plan problem dated 12/16/20, indicated there was the potential for overall decline and complications related to history of hospitalization for urinary tract infection with [CONDITION(S)]. During an observation on 10/25/21, at 4:58 p.m., observed R43's urinary drainage bag laying directly on the floor to the right of her recliner. During an observation on 10/25/21, at 5:04 p.m., R43 was observed being transported to the dining room via wheelchair. The bottom of R43's urinary drainage bag which was hooked to the underside of the wheelchair, and was dragged along the floor to the dining room. During an observation on 10/26/21, at 3:25 p.m., R43's urinary drainage bag was observed hooked to the side of her wastebasket which was to the right of her recliner, with the bottom of the bag touching the floor. Hand Hygiene During an observation and interview on 10/25/21, at 4:45 p.m., observed trained medication aide (TMA)-B enter R41's room and set her meal tray on an overbed table. TMA-B woke R41, helped her out of bed, opened the curtains, assisted her to ambulate to the recliner and set up her meal tray. TMA-B exited the room without performing hand hygiene. A hand sanitizer dispenser was observed on the wall near the door. At 4:48 p.m., TMA-B took a meal tray into R54's room and set it on an overbed table. TMA-B helped R54 up from bed, put her shoes on, placing her palm on the bottom of the shoes to get them in place, assisted her into a wheelchair, then to a recliner, then set up her tray. TMA-B exited the room without performing hand hygiene. A hand sanitizer dispenser was observed on the wall near the door. At 4:58 p.m., TMA-B entered R43's room without performing hand hygiene, donned gloves, emptied R43's urinary drainage bag into a urinal. TMA-B emptied the urinal into the toilet, flushed the toilet and removed her gloves. No hand hygiene was performed. TMA-B donned new gloves and helped a nurse with a mechanical lift to transfer R43 into a wheelchair. Once the transfer was complete, with gloved hands, TMA-B opened the curtains, and then removed her gloves. At 5:02 p.m., while standing near the door in R43's room, TMA-B made notations on paper documents, then folded them and tucked them behind R43's hand sanitizer dispenser, performed hand hygiene and exited the room. TMA-B was asked if she cleaned her hands in between resident rooms when delivering meal trays for R41 and R54, and providing care to R43, TMA-B stated she thought she did. When informed it was not observed, TMA-A stated she was sorry, and should have. TMA-B confirmed hand hygiene was important to prevent the spread of germs between residents. During an interview on 10/28/21 at 9:13 a.m., the DON was asked if it was acceptable practice to hang a urinary drainage bag from a wastebasket or lay it directly on the floor and she replied it was not acceptable, adding it was not appropriate due to possible contamination. The DON was informed of the observations of R43's urinary drainage bag secured to the wastebasket in her room, laying on the floor, and being dragged along the floor underneath her wheelchair. The DON stated that should never happen happen, that's not okay .it shouldn't be on the floor or hanging from the wastebasket. In addition, when informed of observations of lack of hand hygiene between resident cares, the DON stated staff were expected to clean their hands when entering and exiting a residents room to prevent cross contamination, adding they educated staff on that all the time. During an interview on 10/28/21, at 12:47 p.m., the administrator was informed of findings related to lack of hand hygiene between resident cares, and handling of a urinary drainage bag. The administrator stated she expected staff to perform hand hygiene between residents and acknowledged dispensers were readily available in each resident room, so there was no excuse not to do hand hygiene. Facility policy titled Policy and Procedure for Hand Hygiene with revised date of 11/2017, indicated the policy was based on CDC guidelines. The policy directed staff to wash hands with soap and water when visibly soiled, and at a minimum before and after each resident contact and after handling any contaminated items. When hands were not visibly soiled, alcohol-based hand rub for decontaminating hands in all other clinical situation. Examples included before and after any resident contact, and before donning gloves. Facility policy titled Urinary Catheter Use and Care Guide dated 11/2004, indicated the resident with an indwelling catheter shall be free from complications of infection. Hands would be washed before and after performing any procedure for residents with urinary catheters.

Based on observation, interview and document review the facility failed to ensure a range of motion program for lower extremities was completed for 1 of 2 residents (R12) reviewed with limited range of motion. Findings include: R12's face sheet, printed 10/27/21, indicated an admitted [DATE] and identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's admission Minimum Data Set (MDS) assessment dated [DATE], identified R12 had intact cognition, limited range of motion of both lower extremities and required extensive assist of 2 or more persons for transfers, bed mobility and bathing. R12's Range of Motion Observation and assessment dated [DATE], and 10/20/21, indicated R12 had very limited ability to perform ADL's, is non-ambulatory, and requires passive and active range of motion. R12 is able to complete upper range of motion but requires assistance with lower extremity as R12 is paraplegic, has sensation of pressure to lower body, is unable to ambulate and has no significant range of motion restrictions noted but joints are stiff. R12's care plan dated 8/3/21, indicated R12 has an alteration in activities of daily living (ADL's) is independent with upper body after setup, but requires staff assist with washing and drying back and lower body. The care plan did not include a restorative or range of motion program. A physician discharge order dated signed by the therapist on 7/28/21, and the physician on 8/7/21, indicated the resident will be discharged with nursing to complete the lower extremity range of motion program. Point of Care range of motion documentation sheet indicated range of motion once a day was completed five times in August, eight times in September, and seven times in October, 2021. During interview on 10/25/21, at 2:34 p.m., R12 indicated he has paralysis with loss of feeling in his lower half of his body. R12 indicated he can move his legs some, but not his feet. R12 demonstrated minimal movement of both lower extremities and was unable to lift his legs off the mattress. R12 further indicated he has not had therapy on his legs since he came to the facility and staff have not completed range of motion on his legs since therapy ended. During interview on 10/27/21, at 9:08 a.m., physical therapist (PT) indicated R12 received therapy upon admission in July 2021 and upon discharge a range of motion program was prescribed for his legs. PT indicated nursing was given a print out of exercises to complete with pictures and and listed how often to complete. PT stated R12 is not capable of doing the lower extremity range of motion without assistance. During interview on 10/27/21, at 9:26 a.m., registered nurse (RN)-A indicated the range of motion to lower legs program was listed on the daily task sheets for the nursing assistants to complete, but was not completed daily. During interview on 10/27/21, at 9:34 a.m., nursing assistant (NA)-A indicated she was unsure if R12 received range of motion exercises. During interview on 10/27/21, at 9:36 a.m., NA-B indicated she was unsure if R12 required range of motion exercises initially but after looking at the nursing assistant care sheet, NA-B stated it is listed to complete every a.m. while in bed. During interview on 10/27/21, at 9:44 a.m., R12 indicated he has not had any range of motion exercises since 10/25/21. During interview on 10/27/21, at 10:10 a.m., RN-B indicated generally range of motion instructions from therapy are posted in the bathroom, but R12 did not have any posted. RN-B did locate the instructions in a communication binder at the nurses station that included instructions for range of motion exercises to be completed for 5 exercises including diagrams with hand written note stating NA's to do with a.m. cares. During interview on 10/28/21, at 8:42 a.m., the director of nursing confirmed the range of motion wasn't completed daily and it should have been. The DON was able to locate the instructions in the communication book but indicated it should have been posted in the bathroom but was not. Facility policy and procedure titled Range of Motion undated, included: - The purpose is to move the resident's joints through as full a range of motion as possible, to improve or maintain joint mobility and muscle strength, prevent contractures, increase strength and activity tolerance, reduce pain and prevent complications of immobility. -General resident care plan documentation guidelines included identify the appropriate problem under which to list range of motion as an approach . Facility document titled Procedure: Range of Motion dated 10/18 included: - A range of motion assessment will be completed on each resident upon admission, quarterly, annually and significant change. - The therapy department will be contacted to screen residents if indicated for concerns related to joint mobility. - The resident or his/her responsible party will be contacted if therapy staff recommends an evaluation. If approved, the resident's physician will be contacted and a request for a therapy evaluation will be made. - Therapy recommendations for range of motion exercises and/or mobility maintenance program will be added to the resident care plan.

Based on observation, interview, and document review, the facility failed to implement a comprehensive infection control program to include the Centers for Medicaid and Medicare Services (CMS) COVID-19 recommendations to discontinue communal dining and/or maintain appropriate social distancing for 20 of 21 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21) observed in the Moonlight memory care unit during the lunch meal. This had the capacity to effect all 21 residents residing on the unit. Findings include: On 4/27/20, at 10:40 a.m. activities and nursing staff were observed gathering residents into the dining areas on the Moonlight memory care unit. Staff were assisting with placing residents together at tables (2-3 residents per table), in each dining area located on opposite sides of the kitchenette. The residents were approximately 3-4 feet from each other at each table. When interviewed at that time, the activity director (AD) confirmed all residents ate their meals in one of the 2 dining rooms with no more than 10 residents on each side. AD further confirmed many of the residents required assistance with eating. On 4/27/20, at 11:13 a.m. the food cart arrived for the lunch meal on the Moonlight memory care unit. Nine residents were observed seated together at tables in the dining room to the right of the kitchenette. R10 and R14 were seated together at a table and were able to eat independently after set-up. R7 and R11 were seated together at a table and received assistance from nursing assistant (NA)-A and activity assistant (AA)-A. R2, R12, and R17 were seated together at a table with the beautician providing assistance to R12 and R17, and AD providing assistance to R2. R1 and R21 were seated together at a table and ate independently after set-up. The residents seated together were not socially distanced at 6 feet or more. Two residents, R6 and R15, were observed seated on either side of the counter on the left side of the kitchenette. The residents were approximately 2-3 feet from each other. Nine residents were also observed seated together at tables in the dining room to the left of the kitchenette. R18 and R20 were seated together at a table and able to eat independently after set-up. R4 and R16 were seated at a table together and received assistance from NA-B. R3 and R19 were seated together at a table and received assistance by registered nurse (RN)-A and licensed practical nurse (LPN)-A. R5, R8, and R13 were seated together at a larger round table and received assistance from NA-C and AA-B. The residents seated together were not socially distanced at 6 feet or more. When interviewed on 4/27/20, at 12:09 p.m. LPN-A confirmed the current seating arrangement in the Moonlight dining areas had been implemented since the COVID-19 pandemic. LPN-A stated staff were directed that as long as they do some distancing and have no more than 10 residents on each side, that would be an acceptable arrangement. LPN-A confirmed the residents were not seated 6 feet apart or more at the tables. LPN-A further stated not having enough staff to provide assistance to all the residents who needed help and socially distance at the same time. During interview on 4/27/20, at 12:15 p.m. the director of nursing (DON) indicated dining and social distancing was challenging in the Moonlight wing. The DON indicated they had made dining tables available on both sides of the kitchenette and were doing the best we can. The DON confirmed all 21 residents residing on the unit are served the noon and evening meals together in the dining area. The DON verified residents should be kept as far apart as possible and staff should avoid placing residents next to each other within six feet. The DON agreed residents could be distanced more with a limited number of residents per table. A facility policy dated 3/14/20, included guidance to cancel communal dining. The policy directed: 1. Provide in-room meals service for those that are assessed to be capable of feeding themselves without supervision or assistance. 2. Identify high-risk choking residents and those at-risk for aspiration who may cough, creating droplets. Meals for these residents should ideally be provided in their rooms; or the residents should remain at least six feet or more from others if in a common area for meals, and with as few other resident in the common area as feasible during their mealtime. Staff should take appropriate precautions with eye protection and gowns given the risk for these residents to cough while eating. 3. If residents need to be brought to the common area for dining, do this in intervals to maintain social distancing. a. Attempt to separate tables as far apart as possible; at least six feet if practicable. b. Increase the number of meal services or offer meals in shifts to allow fewer residents in common areas at one time. c. Ideally, have residents sit at tables by themselves to ensure that social distancing between residents can be maintained, or depending on table and room size. d. If necessary, arrange for meal sitting with only two residents per table, focusing on maintaining existing social relationships and/or pairing roommates and others that associate with each other outside of mealtimes. 4. Residents who need assistance with feeding should be spaced apart as much as possible, ideally six feet or more or no more than one person per table (assuming a standard four person table). Staff members who are providing assistance for more than one resident simultaneously must perform hand hygiene with at least hand sanitizer each time when switching assistance between residents.

Based on observation, interview, and document review the facility failed to ensure the facility dishwasher was at proper sanitization parts per million which had the potential to affect all 69 of 69 residents in the facility. Findings include: An initial kitchen tour was conducted on [DATE], at 1:05 p.m. with the dietary manager (DM). In the dish room, staff were observed rinsing dishes and loading them on trays which were then pushed on a conveyor belt into the automatic dishwasher. The DM stated a low temperature chemical dishwasher was used in the facility and sanitization was monitored using test strips. On the wall by the dishwasher was a plastic sheath, containing a temperature log sheet and chlorine test strips. Review of the documentation results and strips with DM identified sanitizer levels of 10 parts per million (PPM) on all test results between [DATE] to [DATE] except for one on [DATE], at 8:15 a.m. which was documented as 50 PPM. DM indicated 10 PPM was an appropriate sanitizer result stating that number had been verbally told to her by the Ecolab representative. In addition, the chlorine test strips had an expiration date of ,[DATE], (1 year 3 months prior) which was verified by DM. During observation and interview on [DATE], at 10:57 a.m. dietary aide (DA)-A obtained a test strip from plastic sheath hanging on wall and dipped it in pooled water on dishwasher conveyor belt. DA-A then matched the strip to the color chart on bottle to determine the chlorine concentration which she read and documented at 10 PPM. DA-A further stated ,[DATE] PPM is the desired result, and she had been verbally instructed on this. DA-A further verified the strips had an expiration date of ,[DATE], and placed them back into the plastic sheath that hung on wall. During interview on [DATE], at 11:22 a.m. DM stated new test strips were ordered and did not have any others to use in between time. DM indicated she was unaware of why expired strips were being used stating it was her responsibility to ensure supplies were on hand. DM further stated manufacturers instructions should be followed for proper chemical sanitization three times daily following each meal time, and verified several missing sanitizer levels through out the month of October. DM added Ecolab routinely monitored the chemical concentration in between. During interview on [DATE], at 11:56 a.m. Ecolab representative stated the chlorine level needs to be 50 PPM for proper sanitation and anything less than 50 would not be appropriate. He further stated expired chlorine test strips would alter the chlorine reading. Review of the the facility's Ecolab service call results dated [DATE]-[DATE] all identified sanitizer results of 100 PPM. During a subsequent interview on [DATE], at 12:19 p.m. Ecolab representative was on site for chlorine level testing of dishwasher and verified the chlorine level read between ,[DATE] PPM and had given the DM unexpired strips to use. The facility's policy titled resource: Sanitation of Dishes/Dish Machine, dated (YEAR), identified low temperature dishwasher spray type dish machines using chemicals to sanitize at 50 PPM Hypochlorite for sanitization.

Based on interview and document review, the facility failed to follow up on concerns of missing personal items for 1 of 1 resident (R1) reviewed for missing personal property. Findings include: On 10/30/19, at 9:19 a.m. during interview R1 indicated she was missing a new white sleeveless blouse. R1 stated she thought she had reported the blouse missing to facility staff about 4 months ago. R1 further indicated she had not heard back from staff on what was being done to locate the missing item. Review of a Missing Item Report For Resident Property form dated 4/24/19, indicated R1 reported missing items that included a new white sleeveless knit top, a white pajama bottom, white socks and a bra. The form indicated that the clothing items were labeled with R1's name. The missing items were brought forward to the interdisciplinary team (IDT) during a care conference on 4/24/19. The form included a follow-up investigation that was left blank. The missing item form had been completed by social services (SS). Interview on 10/31/19, at 11:11 a.m., SS-A confirmed the above missing items for R1 had not been followed up on with R1. SS-A indicated she could not recall if the missing items had been investigated or not, but verified there was no further documentation indicating what had been done to locate the missing items. Review of the facility policy for Missing Items dated 4/13, directed staff to complete a missing item report when identified, interview resident/family to find out more details about the missing item, notify appropriate departments and document date notified, submit the missing item report to SS, SS will interview the resident/family for further information if needed, documentation of the interviews will be listed on the missing item report and SS will assure resident/family have been notified of the investigation.

Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 4 of 7 residents (R7, R26, R53, R49, R4, R46, R56) with cognitive impairment who were not served until staff were available to assist causing them to sit and watch others eat. In addition, an employee was standing and reaching over a resident during the meal and the facility failed to ensure shaving assistance was provided for 1 of 2 resident (R24) reviewed for activities of daily living, who was dependent upon staff for assistance with personal hygiene. Findings include: R7's annual Minimum Data Set ((MDS) dated [DATE], identified R7 had moderate cognitive impairment and required assist of one staff for eating. R56's quarterly MDS review dated 9/27/18, identified R56 had severe cognitive impairment and required extensive assistance of one staff for eating. R46's quarterly MDS dated [DATE], identified R46 had severe cognitive impairment and required assistance of one for eating. R26's quarterly MDS dated [DATE], identified R26 had moderately impaired cognition and required assistance of one for eating. R49's quarterly MDS dated [DATE], identified R49 had severe cognitive impairment and required assistance of one for eating. On 10/29/18, at 4:44 p.m. in the moonlight dining area meals were served to the residents. During observation on 10/29/18, at 4:55 p.m. R56, R49, R26 and R7 were sitting at the same table with their meals in front of them. Nursing assistant (NA)-A was standing and moving between the four residents to assist with feeding. During observation on 10/29/18, at 5:20 p.m. licensed practice nurse (LPN)-A arrived to assist R26 and R7 with eating. LPN-A was observed to reach across R26 to pick up R49's spoon and assist him with a spoonful of soup. LPN-A was further observed standing while assisting with feeding and holding spoon with palm upright while facing forward and moving arm back to feed R26 and R7. During observation on 10/31/18, at 7:44 a.m. R26 and R7 were at a table receiving assistance with eating from therapeutic activities (TA)-A. At 7:55 a.m. R56 was brought to the table. TA-A handed R56 her fork and instructed her to eat. R56 took 2 bites of food and was then observed to sit and watch other residents eat. At 8:35 a.m. (40 minutes later) NA-B arrived and assisted R56 with eating. During observation on 10/31/18, at 8:05 a.m. R46 was brought to the dining area in wheelchair and placed in the middle of the room facing residents at 2 other tables eating. At 8:28 a.m. R46 was brought to a table by TA-A. At 8:32 a.m. (27 minutes later) R46 was served a meal and TA-A assisted R46 with eating. During interview with TA-A, on 10/31/18, 1:02 p.m. TA-A stated it is always a struggle to get everyone to the table and fed. TA-A further stated he does his best to get to each person and to not feed more than two people at a time. He stated that when residents are brought to the moonlight dining room and there is not enough staff to assist, they generally put them in the middle of the room until staff are available. Once staff are available, they will bring the resident to the table. He further stated other NA's come and assist when they can but are usually busy getting residents up for the day. Upon observation 11/01/18. 8:07 a.m. R26 was at a table with no food in front of her. R26 stated I'm hungry. TA-B was observed to be assisting R56 and R7 with eating. At 08:32 a.m. TA-B stated she was done feeding other residents and asked the cook to prepare R26's breakfast. At 08:34 a.m. R26 pushed herself back from the table and removed her bib and placed it in her lap. At 08:35 a.m. R26's food was placed in front of her. At 8:38 a.m. R26 was chewing on her bib, attempting to get out of chair, and attempting to reach her food on the table. At 8:40 a.m. (33 minutes later) TA-B sat down by R26 and began assisting R26 with her meal. During interview 11/01/18, at 9:03 a.m. TA-B she stated it is challenging to get all residents fed in the mornings. The NA's will come in and assist if time allows. TA-B further stated generally she is the only one feeding in the mornings and she could give the residents more attention if she had more assistance. During interview with LPN-B 11/01/18, 9:07 a.m. LPN-B stated the NA's are generally getting people up and answering alarms but if available they will assist with feeding. During interview 11/01/18, 11:02 a.m. with director of nursing (DON) stated she would expect a resident to be fed right away once brought to the dining area without delays. She further stated she would expect staff when assisting with feeding to sit down, face towards and interact with the resident. The facilities undated procedure titled A.M. Care (Day Tour of Duty) stated: pass trays of residents that must be fed and begin to feed them. Do not feed only those residents assigned, but check to be sure all residents have been fed and trays collected. R24's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R24 had intact cognition and was dependant on staff for dressing and personal hygiene. R24's [DIAGNOSES REDACTED]. R24's care plan dated 6/30/18, indicated resident required extensive assistance of one person with combing hair, shaving chin and the application of deodorant. During an observation and interview on 10/30/18, at 9:30 a.m. R24 was noted to have hairs approximately 1/4 and 1/2 inches long on her chin. R24 reported it bothered her and wanted them to be shaved stating, I would like them taken care of whenever they need it. R24 reported that she would be getting her bath this morning. Review of the weekly bath schedule indicated R24 was to have a shower. During an interview and observation on 10/31/18, at 7:33 a.m. R24 indicated she still had chin hairs and wants them to be shaved. R24 further reported the bath aide said they would shave her in her room but R24 indicated the aides that get her dressed said shaving occurs at bath time. R24 stated, I would like them taken care of. During an observation and interview on 11/1/18, at 11:07 a.m. R24's chin is noted to be free of hairs. R24 reported that she has her own razor and when she saw this surveyor earlier this morning it reminded her to ask the aide to have her facial hairs shaved which the aide did. R24 states, I remembered I need to ask rather than to wait for them to not be busy and she took the time to help me. R24 further stated, Yesterday during lunch we had Halloween visitors and it embarrassed me to have the long hairs right here (touching her chin). During an interview on 11/1/18, at 11:19 a.m. licensed practical nurse (LPN)-C indicated facial care is to be done any time you see it or on their bath day, stating, It is expected. During an interview on 11/1/18, at 11:36 a.m. nursing assistant (NA)-C indicated shaving is supposed to occur on bath day and further reported she saw the long hairs and shaved them at R24's request. During an interview on 11/1/18, at 11:50 a.m. resident care coordinator, registered nurse (RN)-A, reported the expectation is that facial hair be removed as often as needed. Review of the Facial Hair Protocol, dated 2013, it directs that residents should be checked for facial hair and shaved as needed with am cares and also weekly bath time.

Based on observation, interview and document review, the facility failed to ensure shaving assistance was provided for 1 of 2 resident (R24) reviewed for activities of daily living, who was dependent upon staff for assistance with personal hygiene. Findings include: R24's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R24 had intact cognition, was dependant on staff for dressing and personal hygiene. R24's [DIAGNOSES REDACTED]. R24's care plan dated 6/30/18, indicated resident required extensive assistance of one person with combing hair, shaving chin and the application of deodorant. During an observation and interview on 10/30/18 at 9:30 a.m. R24 was noted to have hairs approximately 1/4 and 1/2 inches long on her chin. R24 reported it bothered her and wanted them to be shaved stating, I would like them taken care of whenever they need it. R24 reported that she would be getting her bath this morning. Review of the weekly bath schedule indicated R24 was to have a shower. During an interview and observation on 10/31/18, at 7:33 a.m. R24 indicated she still had chin hairs and wants them to be shaved. R24 further reported the bath aide said they would shave her in her room but R24 indicated the aides that get her dressed said shaving occurs at bath time. R24 stated, I would like them taken care of. During an observation and interview on 11/1/18, at 11:07 a.m. R24's chin is noted to be free of hairs. R24 reported that she has her own razor and when she saw this surveyor earlier this morning it reminded her to ask the aide to have her facial hairs shaved which the aide did. R24 states, I remembered I need to ask rather than to wait for them to not be busy and she took the time to help me. R24 further stated, Yesterday during lunch we had Halloween visitors and it embarrassed me to have the long hairs right here (touching her chin). During an interview on 11/1/18, at 11:19 a.m. licensed practical nurse (LPN)-C indicated facial care is to be done any time you see it or on their bath day, stating, It is expected. During an interview on 11/1/18, at 11:36 a.m. nursing assistant (NA)-C indicated shaving is supposed to occur on bath day and further reported she saw the long hairs and shaved them at R24's request. During an interview on 11/1/18, at 11:50 a.m. resident care coordinator, registered nurse (RN)-A, reported the expectation is that facial hair be removed as often as needed. Review of the Facial Hair Protocol, dated 2013, it directs that residents should be checked for facial hair and shaved as needed with am cares and also weekly bath time.

Based on interview and document review several facility staff failed to report abuse to facility management of 8 of 10 residents (R1, R2, R3, R4, R5,R6, R7 and R10) reviewed when nursing assistant (NA)-F used disparaging, derogatory, and humiliating language in front of the R1, R2, R4, R5, R6, R7, and R8. When NA-F assisted R3 to eat, NA-F teased R3 with her desert, and NA-F placed whipped cream on R3's face. Findings Include: Based on interview and document review the facility failed to prevent abuse for 8 of 10 residents (R1, R2, R3, R4, R5,R6, R7 and R10) reviewed when nursing assistant (NA)-F used disparaging, derogatory, and humiliating language in front of the R1, R2, R4, R5, R6, R7, and R8. When NA-F assisted R3 to eat, NA-F teased R3 with her desert, and NA-F placed whipped cream on R3's face. Findings Include: R1's medical record was reviewed. R1's [DIAGNOSES REDACTED]. R1's care plan dated 08/01/17, indicated R1 required extensive assistance from two staff persons for all activities of daily living, and a mechanical lift for transfers. R1 had an indwelling urinary catheter. R 1 required staff to push him/her wheelchair to destinations. R2's medical record was reviewed. R2's [DIAGNOSES REDACTED]. R2's care plan dated 10/23/17, indicated R2 required extensive assistance of one staff person for all activities of daily living, and to transfer. R2 used a wheelchair and was able to propel his/herself. R2 was able to make her needs known. R3's medical record was reviewed. R3's [DIAGNOSES REDACTED]. R3 required a mechanical lift to transfer, was unable to walk, and needed to be fed at most meals. R3 was able to hold silverware and feed herself approximately twenty-five percent of the time. R4's medical record was reviewed. R4's [DIAGNOSES REDACTED]. R4's care plan dated 08/02/17, indicated R4 required extensive assistance from two staff members to dress, groom, and bathe. R4 transfers with a mechanical lift and s/he was incontinent of bowel and bladder. R 4 was not able to make his/her needs known. R5's medical record was reviewed. R5's [DIAGNOSES REDACTED]. R5's care plan dated 10/17/17, indicated R5 assistance from one staff members for dressing, grooming, and from one staff person for bathing. R5 required the assistance from two staff members and a mechanical lift for transfers. R5 was incontinent of bladder, and at times incontinent of bowel. R6's medical record was reviewed. R6's [DIAGNOSES REDACTED]. R6's care plan dated 12/15/17, indicated R6 required assistance from one staff person to dress, groom, and bathe. R6 required the assistance of one staff person to transfer and ambulate. R6 was able to communicate his/her needs. R7's medical record was reviewed. R7's [DIAGNOSES REDACTED]. R7's care plan dated 12/19/17, indicated R7 required extensive assistance from one to two staff persons to dress, groom, and bathe. R7 required two staff persons, and a mechanical lift to transfer. R 7 was frequently incontinent of urine and stool. R8's medical record was reviewed. R8's [DIAGNOSES REDACTED]. R8's care plan dated 01/16/18 indicated R8 required extensive assistance from one to two staff persons to dress, groom, and bathe. R8 required two staff persons, and a mechanical lift to transfer. R8 was frequently incontinent of urine, and occasionally incontinent of stool. An Employee Hand Book Acknowledgement Form dated 09/06.17, signed by NA-F indicated NA-F read the employee handbook. An Employee Hand Book Quiz dated 09/06/17, indicated NA-F received Vulnerable Adult Abuse and Patient Rights information when hired at the facility. A facility internal investigation dated 03/16/18, indicated NA-A and NA-F worked together on 05/08/18. On 03/12/18, in front of R1 and R2, NA-F used the word[***]when speaking about R1's sling. On a separate occasion (no date specified), NA-F talked about R4 and used the words jerk off in front of R1 and R2. On a separate occasion (no date specified), NA-F, was in a room with NA-A and NA-G, in front of R4, used the word butt hole in reference to R4. With no dates specified NA-L reported while providing cares: NA-F said that R5's bowel movement was disgusting in front of R5, NA-F called R6 crazy in front of R6, NA-F asked why R7's butt hole was sticking out of R7 while in front of R7. NA-L reported R5's feelings were hurt when NA-F made the comment about the disgusting bowel movement. NA-H reported during dinner NA-F teased R3 with desert, and place whipped cream on R3's nose. NA-G reported she heard NA-F use the words[***]and butt hole in front of residents. Management staff reminded all the nursing assistants interviewed that they are mandated reported and should have reported these incidents at the time they occurred. On 03/12/18, the facility suspended NA-F, began the internal investigation, and reported the incidents of abuse to the state agency. On 03/20/18, the facility contacted NA-F and terminated her employment effective 03/12/18. On 03/13/18, the facility put out a memo to remind staff that staff are mandated reporters. A termination report dated 03/20/18, indicated the facility hired on 09/06/017. The facility dismissed NA-F on 03/13/18, for a violation of policies and procedures that included her behavior with residents. During an interview on 05/02/18, at 1:20 p.m., NA-A stated she cared for R1 and R2 along with NA-F on a weekend day. She was unable to recall the exact date. NA-A stated that when the nursing assistants checked R1 for incontinence and found R1 had a bowel movement in her wheelchair. NA-A stated NA-F said R1's back is full of[***] During the cares for R1 NA-F said the word[***]several times. On 05/02/18, at 4:35 p.m., during an interview R3 was eating a cookie, and did not make eye contact. R3 did not answer questions directly, and most of the time spoke incoherently. During an interview on 05/04/18, at 9:51 a.m., NA-G stated she worked with NA-A and NA-F one day she did not recall the date sometime during (MONTH) (YEAR). While in the room with R8, NA-F said that they did not need to put R8 into bed because R8 will just jack off (masturbate) while in bed. NA-F said to clean up all that[***]when R8 had a bowel movement. During an interview on 05/04/18, 10:30 a.m. NA-F stated that she never used the words[***] butt hole, or jack off in front of R1, R2, R4, R6, R7, or R8. NA-F stated she never called R5 crazy. NA-F stated she never teased R3 or placed whip cream on R3's nose. During an interview on 05/04/18, at 1:45 p.m. NA-H stated she worked with NA-F in the locked dementia unit several weeks ago. That day NA-F fed R5 dinner and R5 reached for desert a pie. NA-F moved the pie away from R5 and told R5 that she needed to eat dinner first. R5 continued to reach for the pie and NA-F continued to move the pie away from R5. When the NA-F began to feed R5 the pie, NA-F place a small amount of whipped cream on R5's nose. Approximately five minutes later R5 took her napkin and wiped off the whipped cream. NA-H stated she witnessed the event but did not report the event to facility staff. During an interview on 05/09/18, at 9:57 a.m. social worker (SW)-J stated that RN-E notified her on 03/12/18, of the note that NA-A wrote regarding the NA-F's derogatory comments. SW-J stated that the facility suspended NA-F 03/12/18, and a report was submitted a short time later. The facility conducted an investigation, interviewed four nursing assistants who reported that NA-F made derogatory and humiliating comments in front of several residents. None of the nursing assistants reported the behavior at the time of the occurrences. NA-H reported that NA-F teased R3 with desert and placed whipped cream on R3's nose. NA-H could not recall the date and did not report the incident when it occurred. During the investigation, the facility interviewed all the residents involved. All the residents had cognitive impairments and just one recalled that NA-F made derogatory and humiliating comments. R3 told SW-J that NA-F's comments made her feel embarrassed. The facility's management staff interviewed NA-F and the NA-F all the allegations. The facility terminated NA-F's employment. During an interview on 05/09/18, at 1:48 p.m. NA-L stated she worked with NA-F. Once while NA-L and NA-F toileted R7 NA-F laughed and said look at R7's butt hole. NA-L stated that NA-F repeatedly said butt hole and laughed during the cares. NA-L stated she cared for R8 with NA-F. When NA-L and NA-F assisted R8 to the bathroom NA-F commented on R8's bowel movement and said it is so gross. NA-L stated that NA-F told NA-L to look at the size of R8's bowel movement. An undated policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Prevention Plan, indicated each resident has the right to be free from mental abuse. Any facility staff that become aware of abuse are required to report it immediately to facility administrator.

Based on interview and document review the facility failed to prevent abuse for 8 of 10 residents (R1, R2, R3, R4, R5,R6, R7 and R10) reviewed when nursing assistant (NA)-F used disparaging, derogatory, and humiliating language in front of the R1, R2, R4, R5, R6, R7, and R8. When NA-F assisted R3 to eat, NA-F teased R3 with her desert, and NA-F placed whipped cream on R3's face. Findings Include: R1's medical record was reviewed. R1's [DIAGNOSES REDACTED]. R1's care plan dated 08/01/17, indicated R1 required extensive assistance from two staff persons for all activities of daily living, and a mechanical lift for transfers. R1 had an indwelling urinary catheter. R 1 required staff to push him/her wheelchair to destinations. R2's medical record was reviewed. R2's [DIAGNOSES REDACTED]. R2's care plan dated 10/23/17, indicated R2 required extensive assistance of one staff person for all activities of daily living, and to transfer. R2 used a wheelchair and was able to propel his/herself. R2 was able to make her needs known. R3's medical record was reviewed. R3's [DIAGNOSES REDACTED]. R3 required a mechanical lift to transfer, was unable to walk, and needed to be fed at most meals. R3 was able to hold silverware and feed herself approximately twenty-five percent of the time. R4's medical record was reviewed. R4's [DIAGNOSES REDACTED]. R4's care plan dated 08/02/17, indicated R4 required extensive assistance from two staff members to dress, groom, and bathe. R4 transfers with a mechanical lift and s/he was incontinent of bowel and bladder. R 4 was not able to make his/her needs known. R5's medical record was reviewed. R5's [DIAGNOSES REDACTED]. R5's care plan dated 10/17/17, indicated R5 assistance from one staff members for dressing, grooming, and from one staff person for bathing. R5 required the assistance from two staff members and a mechanical lift for transfers. R5 was incontinent of bladder, and at times incontinent of bowel. R6's medical record was reviewed. R6's [DIAGNOSES REDACTED]. R6's care plan dated 12/15/17, indicated R6 required assistance from one staff person to dress, groom, and bathe. R6 required the assistance of one staff person to transfer and ambulate. R6 was able to communicate his/her needs. R7's medical record was reviewed. R7's [DIAGNOSES REDACTED]. R7's care plan dated 12/19/17, indicated R7 required extensive assistance from one to two staff persons to dress, groom, and bathe. R7 required two staff persons, and a mechanical lift to transfer. R 7 was frequently incontinent of urine and stool. R8's medical record was reviewed. R8's [DIAGNOSES REDACTED]. R8's care plan dated 01/16/18 indicated R8 required extensive assistance from one to two staff persons to dress, groom, and bathe. R8 required two staff persons, and a mechanical lift to transfer. R8 was frequently incontinent of urine, and occasionally incontinent of stool. An Employee Hand Book Acknowledgement Form dated 09/06.17, signed by NA-F indicated NA-F read the employee handbook. An Employee Hand Book Quiz dated 09/06/17, indicated NA-F received Vulnerable Adult Abuse and Patient Rights information when hired at the facility. A facility internal investigation dated 03/16/18, indicated NA-A and NA-F worked together on 05/08/18. On 03/12/18, in front of R1 and R2, NA-F used the word[***]when speaking about R1's sling. On a separate occasion (no date specified), NA-F talked about R4 and used the words jerk off in front of R1 and R2. On a separate occasion (no date specified), NA-F, was in a room with NA-A and NA-G, in front of R4, used the word butt hole in reference to R4. With no dates specified NA-L reported while providing cares: NA-F said that R5's bowel movement was disgusting in front of R5, NA-F called R6 crazy in front of R6, NA-F asked why R7's butt hole was sticking out of R7 while in front of R7. NA-L reported R5's feelings were hurt when NA-F made the comment about the disgusting bowel movement. NA-H reported during dinner NA-F teased R3 with desert, and place whipped cream on R3's nose. NA-G reported she heard NA-F use the words[***]and butt hole in front of residents. Management staff reminded all the nursing assistants interviewed that they are mandated reported and should have reported these incidents at the time they occurred. On 03/12/18, the facility suspended NA-F, began the internal investigation, and reported the incidents of abuse to the state agency. On 03/20/18, the facility contacted NA-F and terminated her employment effective 03/12/18. On 03/13/18, the facility put out a memo to remind staff that staff are mandated reporters. A termination report dated 03/20/18, indicated the facility hired on 09/06/017. The facility dismissed NA-F on 03/13/18, for a violation of policies and procedures that included her behavior with residents. During an interview on 05/02/18, at 1:20 p.m., NA-A stated she cared for R1 and R2 along with NA-F on a weekend day. She was unable to recall the exact date. NA-A stated that when the nursing assistants checked R1 for incontinence and found R1 had a bowel movement in her wheelchair. NA-A stated NA-F said R1's back is full of[***] During the cares for R1 NA-F said the word[***]several times. On 05/02/18, at 4:35 p.m., during an interview R3 was eating a cookie, and did not make eye contact. R3 did not answer questions directly, and most of the time spoke incoherently. During an interview on 05/04/18, at 9:51 a.m., NA-G stated she worked with NA-A and NA-F one day she did not recall the date sometime during (MONTH) (YEAR). While in the room with R8, NA-F said that they did not need to put R8 into bed because R8 will just jack off (masturbate) while in bed. NA-F said to clean up all that[***]when R8 had a bowel movement. During an interview on 05/04/18, 10:30 a.m. NA-F stated that she never used the words[***] butt hole, or jack off in front of R1, R2, R4, R6, R7, or R8. NA-F stated she never called R5 crazy. NA-F stated she never teased R3 or placed whip cream on R3's nose. During an interview on 05/04/18, at 1:45 p.m. NA-H stated she worked with NA-F in the locked dementia unit several weeks ago. That day NA-F fed R5 dinner and R5 reached for desert a pie. NA-F moved the pie away from R5 and told R5 that she needed to eat dinner first. R5 continued to reach for the pie and NA-F continued to move the pie away from R5. When the NA-F began to feed R5 the pie, NA-F place a small amount of whipped cream on R5's nose. Approximately five minutes later R5 took her napkin and wiped off the whipped cream. NA-H stated she witnessed the event but did not report the event to facility staff. During an interview on 05/09/18, at 9:57 a.m. social worker (SW)-J stated that RN-E notified her on 03/12/18, of the note that NA-A wrote regarding the NA-F's derogatory comments. SW-J stated that the facility suspended NA-F 03/12/18, and a report was submitted a short time later. The facility conducted an investigation, interviewed four nursing assistants who reported that NA-F made derogatory and humiliating comments in front of several residents. None of the nursing assistants reported the behavior at the time of the occurrences. NA-H reported that NA-F teased R3 with desert and placed whipped cream on R3's nose. NA-H could not recall the date and did not report the incident when it occurred. During the investigation, the facility interviewed all the residents involved. All the residents had cognitive impairments and just one recalled that NA-F made derogatory and humiliating comments. R3 told SW-J that NA-F's comments made her feel embarrassed. The facility's management staff interviewed NA-F and the NA-F all the allegations. The facility terminated NA-F's employment. During an interview on 05/09/18, at 1:48 p.m. NA-L stated she worked with NA-F. Once while NA-L and NA-F toileted R7 NA-F laughed and said look at R7's butt hole. NA-L stated that NA-F repeatedly said butt hole and laughed during the cares. NA-L stated she cared for R8 with NA-F. When NA-L and NA-F assisted R8 to the bathroom NA-F commented on R8's bowel movement and said it is so gross. NA-L stated that NA-F told NA-L to look at the size of R8's bowel movement. An undated policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Prevention Plan, indicated each resident has the right to be free from mental abuse. Any facility staff that become aware of abuse are required to report it immediately to facility administrator.

Based on observation, interview and document review, the facility failed to properly assess and implement interventions to prevent reoccurring falls for 2 of 3 residents (R10, R23) reviewed for accidents. This resulted in actual harm for R10, who sustained nasal fractures and a wrist injury and was transferred to the emergency room for treatment. Findings include: R10 sustained nasal fractures and wrist injury after a fall in his room on on 11/1/17. R10 was noted lying face down on the floor next to his bed, with bleeding from the nasal area and pain in his left wrist. A chair alarm was sounding and the call light had been activated. R10 was transferred to the emergency room after the fall for evaluation. R10's current [DIAGNOSES REDACTED]. R10's physician progress notes [REDACTED]. R10's annual Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, extensive assistance of one person for transfers and ambulation, and two or more falls since the prior assessment. R10's Care Area Assessment (CAA) related to falls, dated 9/1/17, indicated R10 had several falls in the past few months, was impulsive, would not put the call light on, unsteady/unsafe with transfers and had abnormal gait due to [MEDICAL CONDITION]. R10's care plan, last reviewed 10/10/17, indicated R10 was at risk for falls related to weakness, unsteadiness, impulsiveness, [MEDICAL CONDITION], antidepressant use, and history of falling. The goal listed was: no falls and injuries. Approaches included: (1) providing assistance of one to two staff with all transfers and walking, (2) sets off alarms getting up to the bathroom, (3) try to anticipate needs as much as possible, (4) toilet after meals and put in recliner, (5) keep call light within reach and remind to ask for assistance, (6) black transfer belt with buckle that goes on and off quickly adjusted to size and kept in walker pocket, and (7) walk part way to destinations and give ride in wheelchair rest of way. R10's most recent fall risk assessment dated [DATE], indicated a score of 25 (high risk for falls). The fall summary section identified: continue current fall interventions. Review of the incident reports revealed R10 experienced repeat falls on 8/14/17, 8/28/17, 11/1/17 (which resulted in nasal fractures, a wrist injury and emergency room visit) and on 11/5/17. The incident reports indicated the following information: (1) dated 8/14/17, R10 fell at 1:35 a.m. remained in recliner after evening cares, and found sitting on the floor next to recliner with the walker near him; had several small abrasions on lower extremities. Cause: self -transfers. Interventions to prevent further falls: continue with current fall precautions, alarms on, refuses to wear gripper socks. (2) dated 8/28/17, at 6:40 p.m. R10 fell in room with alarm sounding and found seated on the bathroom floor with incontinent pad removed, a walker beside him and the floor wet with urine. R10 had abrasion on left shoulder and a scratch to the right hip. Probable cause: self-transfer. Interventions to prevent further falls: non-compliant with education to wait for help, transfers self frequently, continue with alarms, wheeled walker, and transfer belt; refuses to wear gripper socks. (3) dated 11/1/17, at 6:20 p.m. R10 lying on the floor next to his bed with bleeding from the nasal area and pain in his left wrist. R10 wearing shoes at the time, had an irregular breathing pattern and had been transferred into his recliner chair after evening cares at 6:00 p.m. A chair alarm was sounding. R10 stated he needed to use the restroom to have a bowel movement, and stated the floor is very hard. Probable cause: attempted self-ambulate. Interventions to prevent further falls: reminded to wait for staff assistance- non-compliant and setting off alarms frequently. R10 transferred to the emergency room for evaluation. (4) dated 11/5/17, at 7:00 p.m. R10 noted in the doorway to his room, bumped head against the door, walker tipped over near R10 who was lying on his side. R10 pointed to the back on his right head, neuro checks initiated and within normal range. Probable cause: self-transfer to the bathroom. Interventions: given frequent reminders to wait for assist, but is non-compliant and demonstrates this by setting off alarms frequently. The report indicated evening cares had been completed at 5:45 p.m. and R10 sat in his recliner to watch television with alarm on and call light within reach. An undated section on the bottom indicated: Immodium would be offered at 1:00 p.m. due to recent loose stools and another physical therapy (PT) evaluation would be requested. When interviewed on 11/28/17, at 3:44 p.m., family member (F)-A stated R10 had been transferred to the emergency room in early November 2017, after a fall which resulted in a wrist and nose injury. F-A commented, Ninety percent of the time he is going to the bathroom. F-A stated R10 was incontinent of urine (bladder) but continent of stool (bowel). F-A stated R10 had sustained a couple of falls recently. During observation on 11/29/17, at 4:02 p.m., R10 was asked by nursing assistant (NA)-C whether he needed toileting and he responded affirmatively. After toileting assistance was provided, NA-C helped R10 return to his recliner. Prior to the move, NA-C moved the wheelchair alarm to the recliner. Rubber grips were noted beneath the legs of the recliner chair. R10 was able to operate the control located on his recliner with his right hand. After the pivot transfer, R10 raised and lowered the recliner back to a sitting position. At this time, NA-C shared the NA care guide which indicated R10 was a two-person transfer. When asked the reason why she transferred R10 alone to the bathroom versus seeking additional help as indicated on her care guide, she responded, Oh, I think that (note to use two people for transfers) was on there because of his last fall. NA-C stated R10 had a bed alarm and a chair alarm for safety, to alert staff of self-transfers. NA-C indicated that R10 was often not cooperative with using the call light, and it was the responsibility of R10's assigned staff to keep an eye on him to prevent falls; however, no scheduled time was determined. During interview on 11/29/17, at 4:26 p.m. NA-B stated R10 needed toileting immediately after supper to prevent falls and staff checked on R10 every two hours or so, for toileting. NA-B explained an alarm sounded in the hallway via the call light system as well as on their pagers when R10 attempted self transfer. NA-B stated R10 was impulsive and Doesn't think about what he is doing and attempts self-transfer on a weekly basis or so. NA-B stated R10 was usually continent of urine. During further observation on 11/29/17, at 4:56 p.m. R10 activated the call light to request a blanket. NA-B responded to the request. During interview on 11/29/17, at 5:14 p.m. licensed practical nurse (LPN)-C stated R10 had a bed and chair alarm, self-transfers when staff don't respond quickly, uses a white board to communicate due to hearing loss and has bowel medications scheduled at 1:00 p.m. LPN-C stated that R10's loose stools were a contributing factor related to his most recent fall on 11/5/17. LPN-C confirmed that R10 generally utilized the control device on his recliner to elevate himself from the recliner and self-transfer. LPN-C verified it was observed to be elevated after the most recent fall on 11/5/17, which she noted when she responded to the alarm sounding. She stated R10 preferred to choose his own toileting schedule and stated R10 seldom self-transferred from bed after bedtime cares and typically the falls occurred when attempting to get up from the recliner. LPN-C stated nursing staff could provide better supervision after supper for R10 when NA's assist other resident's with evening cares. LPN-C stated staff checked on R10 frequently and described R10 as impulsive and stubborn; R10 did not reliably use his call light. LPN-C explained a physical therapy evaluation had been ordered after the 11/5/17 fall. During observation on 11/29/17, at 5:28 p.m. R10 was lying in bed as NA-B assisted him to pull up his blankets and remove his pants. R10 was fully dressed and indicated he did not want evening cares yet. NA-B stated the call light was responded to, and R10 had been assisted with toileting. During interview on 11/30/17, at 8:15 a.m. the director of nursing (DON) stated R10 desired evening cares completed soon after returning from the supper meal to his room. The DON explained R10 had been recently been started on Immodium (anti-diarrheal) (at 1:00 p.m.) post-fall episode dated 11/5/17. In addition, a referral for a PT evaluation had been initiated since the fall with injury. The DON explained that falls were reviewed daily at the morning meeting and an immediate intervention by nursing staff should be initiated after a fall. Upon review, the interdisciplinary team identifies approaches and subsequently, the care plan is updated to reflect the change. The DON stated staff had not considered R10's recliner to be a root cause of his falls. The DON stated she had not seen R10 misuse it. The DON stated staff allow R10 to determine his routine. An incident report related to the fall experienced on 11/5/17 was noted in R10's chart, however, the DON did not have a copy of it at the time of the interview. During observation on 11/30/17, at 8:42 a.m. R10 was seated in his recliner in his room, with the call light activated. LPN-A responded with providing R10 his TV remote. LPN-A described R10 as very impulsive and staff attempt to provide toileting immediately after meals but confirmed no staff were designated to supervise R10 while located in his room in the recliner. LPN-A stated R10 usually had the recliner elevated when he attempted self-transfer. During interview on 11/30/17, at 10:08 a.m. R10's nurse manager/registered nurse (RN)-C, stated R10 had several falls interventions, including the addition of grips underneath the recliner chair to stabilize and were initiated earlier in the year, after a fall during which he attempted to move a recliner. RN-C stated R10 was located in a room near the nurses' station and was administered scheduled Immodium to remedy loose stool and prevent falls; however, these updated interventions were not reflected on the care plan. RN-C verified the care plan did not include all the current fall precautions for R10. RN-C indicated that although R10 daily attempts to get up from his chair, it has not been as frequent lately. RN-C stated she did not feel the operation of the recliner contributed to the falls R10 experienced. RN-C described R10 as cognitive but could be strong-willed and did not utilize his call light consistently. RN-C agreed the recliner would certainly make it easier. RN-C stated Immodium to control bowel movements had been scheduled post fall on 11/5/17. A schedule to supervise R10 while alone in his room had not been determined, but RN-C stated staff were to keep a close eye. During a follow-up interview on 11/30/17, at 10:08 a.m., the DON stated an assessment related to R10's cognition and ability to make decisions had not been conducted as he was hard of hearing and had difficulty with communication, but F-A had been informed of the fall risks in March 2017, including the potential for fractures. The DON stated R10 was located in a room near the nurses station, staff anticipate his needs and attempted to keep items within reach. The physical therapy assistant (PTA) who was present during the interview stated R10 had a very unsteady gait and a shuffling, fast walk which caused him to fall once he was up with his walker. PTA stated R10 currently received PT three days/week. When interviewed on 11/30/17, at 1:30 p.m. R10's primary physician (MD)-A stated he provided medical care for R10 the past eight years and believed R10's cognitive abilities waxed/waned depending on the time of day. MD-A stated R10 maybe exhibiting some sundowning behaviors and described R10 as impulsive. MD-A indicated R10 definitely has some cognitive changes occurring. MD-A stated, It certainly wouldn't hurt to check on him more often. MD-A verified most of R10's falls were from the recliner chair, adding R10's cognitive component and inability to communicate are a 'bad marriage', it contributes to falls and his impulsiveness. (R10's) personality is such as that he doesn't want to be told what to do. During interview on 11/30/17, at 1:35 p.m. F-A stated she attended a meeting today with the administrator, DON, social worker and assistant DON to develop interventions to reduce R10's falls. F-A stated it could be beneficial to locate the wheelchair near him when in the recliner so R10 wouldn't attempt to walk as far to use the walker. F-A indicated she had been asked to discuss with R10 the issue of waiting for help in lieu of self-transfer. F-A stated R10 becomes easily frustrated with respect to communication and thought he was cognitive. However, F-A stated he's stuck in his mind, due to severe hearing loss. During observation on 12/01/17, at 8:57 a.m. R10 was seated in his recliner with his walker near him on one side and the overbed table located on his left side. During interview on 12/04/17, at 1:23 p.m. NA-E stated R10 used the electric recliner chair to assist with getting up and confirmed most falls were from the recliner. NA-E stated it was rare R10 self-transferred out of the wheelchair except into the bathroom, where he could use the grab bars on the wall to pull himself up, and tended to lean more with pivot transfers than previous. When interviewed on 12/4/17, at 1:23 p.m. NA-D stated R10 indicated if he had more activity during evening hours, it would reduce falls. NA-D stated an alarm was located on the back of his chair to alert staff of self-transfers; however, R10 was already out of the chair when staff arrive, indicating he's difficult to supervise. NA-D stated R10's leg often locked up on him during transfers. During observation on 12/04/17, at 1:35 p.m. R10 was seated in his recliner chair with it in a half raised position, with his walker alongside him as he watched television. The facility's policy entitled Fall Prevention Protocol, last revised 4/17 indicated a fall risk assessment done for each resident upon admission and with a significant change, reviewed by RN quarterly, annually and with a significant status change that does not impact mobility. At the time a fall is reported, the charge nurse and/or RN care coordinator will complete and document an investigation using the fall incident report form. RN care coordinator and interdisciplinary team will review incidents and interventions to assure accuracy and effectiveness. R23's current [DIAGNOSES REDACTED]. R23's annual Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment, extensive assistance of one person for transfers and ambulation in room, and two or more falls with injury. R23's care area assessment (CAA) for falls, dated 9/7/17, indicated R23 had a history of [REDACTED]. R23's fall risk assessments were completed on 3/16/17, 6/15/17 and 9/14/17. The fall risk assessment dated [DATE], indicated a score of 11, the 6/15/17, indicated a score of 16, and on 9/14/17, a score of 17. A score of greater than 15, indicated at high risk for falls. The summary section indicated: continue current fall interventions and was lacking any analysis of the circumstances surrounding the falls, and any contributing factors. The fall assessments identified: interventions in place- see care plan. R23's care plan, last reviewed 9/18/17, indicated R23 was at risk for falls related to [DIAGNOSES REDACTED]. Current interventions included, supervise mobility during the day, remind to use walker when ambulating. Bed alarm on when in bed to alert staff to self transfers. Needs limited assist with getting in and out of bed and walking to and from the bathroom during the night. Gait unsteady ambulates with one assist and transfer belt. R23's current resident assignment sheet dated 11/29/17 identified R23 to have bed alarm on whenever in bed. Review of the therapy discharge summary dated 9/26/17, identified a Tinetti balance score of 13/28 indicating a high fall risk, needed step by step instructions/cueing to performs task of ambulation and needed contact guard assistance with transfers, standing and ambulating. Review of R23's incident reports revealed 4 falls since May 2017: 5/30/17, 7/29/17, 9/28/17 and 11/26/17; (which resulted in skin tears to right and left elbows with bruising, a bump to the left side of head and a reddened area to R23's back). Review of these incident reports noted the following: (1) dated 5/30/17, at 3:25 p.m., indicated NA walking by R23's room discovered R23 lying on floor by bed. Wheel chair was by bed, not locked but anti-roll brakes in place. R23 unable to tell what happened. Current intervention: call light available. Interventions: no interventions. The 48 hour fall assessment dated [DATE], identified a small abrasion to the right elbow. Interventions are in place, added bed alarm to be on when in bed, and to see current plan of care. (2) dated 7/29/17, at 3:50 p.m., indicated staff walked by room noted R23 lying on floor on right side with walker tipped over. R23 was gotten up with 2 assist and a transfer belt. R23 noted to have skin tear right and left elbows with bruising, a bump to left side of head, 2 cm hematoma left elbow with scant .5 open area, and a slight red area on back. Current interventions: call light available, alarm in use not plugged in (vulnerable adult report was completed), and wheeled walker. Care plan: alarm on at all times when in bed; alarm was not plugged in. 48 hour fall assessment 7/30-7/31/17, neuro checks completed. Therapy started 8/1/17. (3) dated 9/28/17, at 5:30 a.m. staff entered room to find R23 self transferring. R23 knees went out and was lowered to floor by NA; call light available and alarm sounding. The Inter Disciplinary Team (IDT) noted the alarm was sounding and NA intervened appropriately. It also indicated R23 had been discharged from PT due to progress plateau, and staff were to provide close supervision to manage impulsiveness. (4) dated 11/26/17, at 7:50 p.m., alarm on low and call light on. R23 had gotten up from bed, had walker and found lying on floor on left side. No witness. When questioned what happened, R23 stated I don't know. Current interventions: call light not available, alarm in use on low volume, other device walker. No interventions were added nor revised post-fall and no follow-up completed. On 11/29/17, at 2:19 p.m. R23 was asleep in bed; alarm hanging on bed and call light within reach. Wheelchair with anti-tip brakes located at foot of bed. On 11/30/17, at 2:00 p.m. R23 asleep in bed, alarm on bed, call light in reach and wheelchair at foot of bed. On 12/1/17, at 3:00 p.m. R12 asleep in bed, alarm on bed, call light not within reach and wheel chair located at foot of bed. During interview on 12/4/17, at 11:30 a.m. clinical manager (CM)-A stated a low bed would be a greater hazard as R23 attempts to get up out of bed. R23 has a bed alarm and staff try to keep an eye on her. CM-A verified she was unaware of the fall dated 11/26/17, and explained it was not sent to her and therefore IDT did not review and no interventions implemented. During interview on 12/4/17, at 12:04 p.m. the DON confirmed no interventions were implemented after the fall on 11/26/17, and confirmed it had not been reviewed by the IDT for evaluation and therefore no new interventions identified and/or implemented, no revisions or analysis completed. The facility protocol for tracking incident reports undated, identified when an incident occurs, a Resident Incident Report Form is completed and routed to the Resident Care Coordinator to: determine if the appropriate action has been taken to prevent a further occurrence, determine if the resident's care plan is updated if appropriate, and check the clinical record for documentation of the incident.

Based on observation, interview, record and policy review, the facility failed to provide adequate supervision and interventions to prevent accidents for 1 of 4 resident's (R36) in the sample at risk for choking which created an immediate jeopardy for R36; and for 1 of 4 resident's (R132) at risk for falls which caused actual harm, a hip fracture, for R132. The findings include: R36 had a history of [REDACTED]. Although the facility was aware of the resident's choking risk, they failed to provide him with foods that were appropriately cut up on 10/8/10. Due to these findings the administrator and the director of nursing were informed of an Immediate Jeopardy situation on 10/11/10 at 12:40 p.m. The facility developed and implemented an action plan including education of nursing and dietary staff, dietary agreement to cut all of R36's foods into small pieces, and initiation of audits at meals related to the prevention of choking for R36 and any other residents potentially at risk. The Immediate Jeopardy was removed on 10/11/10 at 4:15 p.m. after the facility's development and implementation of interventions to alleviate the immediate jeopardy condition had been reviewed. This reduced the severity of the deficient practice to actual harm for R132. R36 had been admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's record was reviewed on 10/7 and 10/8/10. A quarterly MDS (minimum data set) assessment dated [DATE], identified that R36 required extensive assistance of 1 staff with eating and that the resident had moderately impaired cognition and decision making. This had been a decline from the previous quarterly MDS dated [DATE], which had identified R36 as independent with eating, requiring set-up assistance only, and as having demonstrated only modified independence with decision making. During record review, a review of the progress note dated 4/9/10, indicated that R36 had choked on a piece of food at the supper meal. An entry on 7/5/10, with the focus topic "Choked", indicated R36 had been observed coughing at the noon meal and that the food went down the "wrong pipe." A progress note entry dated 9/17/10 indicated R36 had a choking episode at supper and the Heimlich thrust had been conducted to dislodge a chunk of banana. Further review of the notes indicated that the speech therapist (SLP) had been in the dining room during the evening meal when R36 had been unable to independently expel a banana. The speech therapist had conducted the Heimlich thrust, R36 had proceeded to cough and had ultimately expelled a chunk of banana. The note stated "residents's food needs to be cut into small pieces (reminder to staff). SLP will review with the charge nurse." In addition to the above incidents, the medical record also showed that R36 had experienced large emesis on 5/22/10 and 7/30/10 at the noon meals without any other symptoms of illness. Review of the resident's current care plan revealed that R36 should receive a therapeutic diet of 1800 calories; required staff assist of 1 to set up; and a care plan revision had been added 9/18/10, to include: "potential for choking, eats fast, doesn't always chew adequately." The goal included: "will not choke." Approaches included: "cut food into small pieces when tray is delivered." In addition, the resident's care plan indicated he had dentures. During observation of the noon meal on 10/8/10, R36 had been served his noon meal without his food having been cut up into small pieces. The dietary card that was placed on the serving tray was noted to include the need for the resident's food to be cut up. The noon meal on 10/8/10 consisted of: seafood salad, 2 crackers, a half slice of peach, a half slice of pear, a small bunch of grapes, and 2 strudel rolls. During interview with the Dietary Manager (DM) at 12:50 p.m. on 10/8/10, she stated that she expected R36's food to be cut into small pieces before serving. She further indicated that the person responsible for cutting up the food would be the person that delivered the tray to the resident. The DM further stated that staff should be looking at the dietary card that is placed on the resident's tray which clearly indicated R36's food should be cut up into small pieces. During interview with the Assistant Director of Nursing (ADON) at 10:00 a.m. on 10/8/10, she stated that R36 did not have a history of choking prior to the choking incident on 9/17/10, which had required Heimlich Maneuver. The ADON further stated that the speech therapist had witnessed that choking spell, had recommended that R36's food be cut up into small pieces, however had not felt that a speech evaluation was not needed at that time. During interview with the Speech Therapist at 1:15 p.m. on 10/8/10, she verified that she had recommended R36's food be cut up into small pieces after the resident had choked on the banana. She further indicated that she had not recommended a speech evaluation because she understood that to have been the resident's first occurrence of choking on food. During interview with the Registered Nurse (RN)Manager-C at 11:00 a.m. on 10/11/10, she stated that after R36 had choked on 9/17/10, there had been a discussion about further interventions and recommendations for R36 to prevent choking. RN-C further stated that the speech therapist had indicated that a speech evaluation was not needed at that time and that cutting up R36's food into small pieces would be the intervention. RN-C confirmed that she was aware of the choking episodes which had occurred on 4/9/10 and 7/5/10 and verified that no interventions had been implemented to prevent further choking episodes. During interview with the DON (director of nursing) at 11:15 a.m. on 10/11/10, she confirmed that she had been informed of the above stated findings and that she expected the staff to cut R36's food up prior to serving his meal. She also verified that she had not been aware of the choking episodes on 4/9/10 and 7/5/10. The facility policy for Choking, undated, included the following procedure to identify ..."signs and symptoms of distress: a. Unable to speak or breathe. b. Turning blue and/or unconsciousness. c. If resident is coughing, allow him/her to cough to dislodge the object himself. d. Coughing is a defense mechanism of the body which serves the purpose of ejecting foreign objects from air passages." Prevention of obstructed airway: "1. Cut food into small pieces. 2. Chew food slowly and thoroughly, especially if resident is wearing dentures. .." The facility had provided an addendum to this policy dated 10/11/10. The Protocol for Change in Status in Swallowing Needs included: "The following are signs and symptoms putting a resident at risk for choking: Functional: -Inability to initiate a swallow -Impaired ability to transfer food from mouth to esophagus - Nasal regurgitation -Coughing (aspiration) -...Structural: -Pocketing of food in cheeks, on hard palate, or under tongue - Food gets stuck after swallowing -Speech abnormalities... If any of the above noted signs and symptoms are noted to cause problems with chewing and swallowing, notify MD (medical doctor) and family for need to refer to Speech Therapist." R132 had been admitted to the facility on [DATE] following a hospitalization for a fall with a skull fracture and subdural hematoma. The facility failed to provide adequate supervision for the resident following her admission and the resident experienced harm from a fall on 4/13/10. The resident had ambulated without assistance and had gone outside, had fallen and fractured her hip. R132's record was reviewed on 10/7 and 10/11/10. The resident's physician notes included documentation of hospitalization s for a skull fracture 4/1/10 prior to admission, and hospitalization for a hip fracture 4/13/10 after her admission to the facility. The admission history and physical dated 4/2/10 indicated the resident had fallen the day prior and had been diagnosed with [REDACTED]. The physical exam assessment had identified the resident as having a Parkinsonian gait and having inaccurate movements for coordination. The Assessment/Plan documentation by the physician included: "At this point, given the history and the bump, this fracture is most likely new. I do not feel it would be safe for her to return to (assisted living). The nursing staff of (assisted living) have contacted me with the same concern. I spoke with Dr (resident's primary physician) regarding this issue and he agreed that she needs to be in the SNF (skilled nursing facility). I explained that I did not feel it would be safe for her to return to her apartment and could not adequately treat her back pain because of this as well...She has a history of falls with 1 every month for the last 3 months, mainly revolving around going to smoke..." The incident report for the fall the resident had experienced 4/13/10 indicated, "resident found lying outside of S (south) breakroom door on sidewalk with her L (left) leg pivoted out and a skin tear on L cheek...staff states resident up and ambulating independently previous night." Additional notes on the incident report revealed that a visitor had reported that they had seen the resident fall and had contacted the nurse to assess her. The incident report included interventions to prevent further falls: "Resident education appropriate? Yes (circled)...Cannot go to (assisted living) unassisted." An initial fall assessment conducted on 4/2/10 indicated the resident had a history of [REDACTED]. A temporary care plan had been developed for the resident at the time of admission on 4/2/10. This temporary care plan indicated the resident required physical assistance of one and a transfer belt to transfer and required the use of a walker and personal help of one with a transfer belt to walk. An additional comment on the temporary care plan indicated the resident required the use of a wheelchair for transportation long distances. On 10/11/10 at 1:30 p.m., the Registered Nurse (RN)- A (the resident's case manager) was questioned about how the resident could have gotten down the hall and out the door without staff having seen her. She stated the resident had made improvements in her mobility after admission and had likely walked with her walker down "Leisure Lane" which had no residents living on it. She also stated the incident had occurred at 7:45 p.m., both factors that might have affected staff not having immediately noticed her. She stated the resident had been going outside to smoke. RN-A further stated no other interventions had been considered at that time to prevent falls. The facility's lack of supervision contributed to the resident's fall on 4/14/10 with subsequent hip fracture.