Every finding on record at Stonehill Care Center

Based on observation, clinical record review, staff interview, and facility policy review the facility failed to properly clean glucometers for 4 out of 4 residents reviewed for blood glucose monitoring (Resident #90, Resident #144, Resident #174, Resident #175). The facility failed to utilize enhanced barrier precautions for 2 out of 3 residents with a gastrostomy tube (Resident #35, Resident #90). The facility identified a census of 158 residents. Findings include: 1.) Review of Resident #90's Care Plan revealed a problem initiated on 7/23/25 for enhanced barrier precautions. It directed staff to wear personal protective equipment while providing direct care including dressing, bathing, toileting, transferring, personal hygiene, assessment/manipulation of device, and linen changes. On 08/06/2025 at 9:32 AM Staff A, Registered Nurse (RN) administered medications via gastrostomy tube to Resident #90. Upon entering the room, Staff A donned a mask and gloves, and failed to put on a gown. The room had a magnet on the door frame with enhanced barrier precautions. The isolation cart in the room had a sign on it which instructed staff to use enhanced barrier precautions with gastrostomy tube. 2.) Review of Resident #35's Care Plan revealed a problem of enhanced barrier precautions dated 5/15/25. It directed staff to wear personal protective equipment while providing direct care including dressing, bathing, toileting, transferring, personal hygiene, assessment/manipulation of device, and linen changes.On 08/06/2025 at 11:19 AM Staff C, RN went in Resident #35's room to administer medications via gastrostomy tube. Staff C failed to put on a mask or don a gown for enhanced barrier precautions. There was a small magnet on the door frame for enhanced barrier precautions. The isolation supply cart inside the room had a sign on top of the cart which stated to use a gown for gastrostomy tube. On 08/06/2025 at 12:14 PM Staff D, Licensed Practical Nurse (LPN) stated she received education on enhanced barrier precautions. Staff D explained it should be used on residents with a catheter or an open wound. Per Staff D, would use them on a gastrostomy tube, and it would entail to gown up and utilize gloves. On 08/06/2025 at 4:00 PM Staff A, RN stated enhanced barrier precautions should be used when providing cares or close contact to a resident with a chronic wound or a catheter. Per Staff A, she should have done it with the gastrostomy tube, and she looked for the magnet on the door which indicated they needed enhance barrier precautions. Staff A explained she walked out of the room and saw the magnet and realized she forgot to wear it for Resident #90. On 08/07/2025 at 12:20 PM Staff G, RN, Director of Nursing (DON) stated facility provided education on enhanced barrier precautions, and did it initially when it came out with hands on training. The DON further explained also provided literature, annually after that, and with the hire of new staff. The DON explained their expectation with enhanced barrier precautions was per the regulation when they were direct care, and the residents who needed enhanced barrier precautions were catheters, chronic wounds, and feeding tubes. Per the DON, would expect them to wear a mask, gown and gloves. The facility provided a policy titled Enhanced Barrier Precautions revised 4/2025 directed staff that enhanced barrier precautions will be initiated for residents with any of the following: Wounds (for example: chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (for example: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multidrug-resistant organism). 3.) On 08/06/2025 8:05 AM Staff A, RN checked a blood sugar on Resident #174. She cleaned the glucometer with a hydrogen peroxide wipe, just wiped it, and immediately put it back in the drawer. On 08/06/2025 at 8:20 AM Staff B, RN completed a blood sugar on Resident #144, then cleaned the glucometer with an alcohol wipe, and set it on top of the medication cart. On 08/06/2025 at 9:16 AM Staff A, RN completed a blood sugar on Resident # 175. She wiped the glucometer with a hydrogen peroxide wipe and set it on the medication cart. On 08/06/2025 at 9:32 AM Staff A, RN completed a blood sugar on Resident #90, and wiped the glucometer with a hydrogen peroxide wipe for 4 seconds. On 08/07/2025 12:09 PM Staff E, RN stated glucometers should be cleaned after each using the green sani-wipes, and staff should clean it completely and let it dry. Staff E explained they were used for multiple residents on the unit, hydrogen peroxide wipes were what they used, she was unsure of the wet time, and maybe should be 5 minutes. The wet time was how long it took to completely disinfect and dry it. On 08/07/2025 at 12:11 PM Staff F, LPN stated the policy for cleaning the glucometer was to clean with the green wipes hydrogen peroxide wipes and thought they needed to stay wet for 2 minutes. Alcohol wipes should not be used on the glucometer. The wet time was the time needed to kill off the bacteria, and the glucometers were used on multiple people in the unit. On 8/7/25 at 12:20 PM Staff G, RN DON stated to clean a glucometer staff should use the disinfectant wipes with green lids, and always told them to look at the label for kill time and they can vary. Per the DON, the general rule was 2 minutes if were unsure. The facility provided a policy titled Blood Glucose Monitoring with revision date of 4/2025 it directed staff to clean and disinfect the glucometer. The technical information sheet for hydrogen peroxide cleaner disinfectant wipes directed to disinfect, let stand for the required contact time a listed on the product back label. Special Instructions for using this product to clean and decontaminate surfaces/objects soiled with blood/body Fluids: contact time: allow surfaces to remain wet for HBV (Hepatitis B), HCV (Hepatitis C) and HIV-1 (Human Immunodeficiency Virus) for 30 seconds. The contact times for other bacteria, viruses, and fungi may differ. See product label for contact times. Other bacteria and virus listed directed kill times were between 30 seconds to one minute.

Based on observation, clinical record review, and staff interview the facility failed to properly administer insulin from a Kwik pen for 2 out of 2 residents reviewed (Resident #174, Resident #175), resulting in a facility medication error rate of 8%. The facility identified a census of 158 residents.Findings include: 1.) Review of the Medication Administration Record for Resident #174 revealed an order for sliding scale insulin. On 08/06/2025 at 8:05 AM Staff A, Registered Nurse (RN) administered 2 units Lispro insulin via Kwik pen to Resident #174 and did not prime the needle prior to administration. 2.) Review of the Medication Administration Record for Resident #175 revealed a sliding scale order for Lispro Kwik pen insulin. On 08/06/2025 at 9:16 AM Staff A, RN administered 8 units Lispro insulin via a Kwik pen to Resident #175 and she failed to prime the insulin pen prior to medication administration. On 08/04/2025 at 11:59 AM Staff D, Licensed Practical Nurse (LPN) stated to administer insulin from a Kwik pen, clean the tip of the pen, put on the needle, prime the needle with 2 units and then administer the medication. On 08/06/2025 at 3:58 PM Staff A, RN stated should prime the insulin pen with 1 or 2 units and then after it is primed, verify the needle is working. Then could draw up the prescribed dose and then administer. Staff A explained she did not prime the insulin pen for either resident because she was nervous. On 08/07/2025 at 12:29 PM Staff G, RN, Co Director of Nursing (Co DON) stated would expect staff to prime the insulin needle with minimum 2 units prior to drawing up the ordered dose of insulin, and had provided education on this last week. Review of the package insert for Lispro insulin Kwik pen directed to prime before each injection. Priming your pen means removing the air from the needles and the cartridge that may collect during normal use and ensures the pen is working correctly. If you do not prime before each injection you may get too little or too much insulin.

Based on clinical record review, family and staff interviews, and facility policy review the facility failed to follow the care plan which directed the staff to follow the resident with a wheelchair during staff assisted ambulation which resulted in a fall with minor injuries for 1 of 3 residents' sample for fall care plans (Resident #217). The facility identified a census of 156 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #217 documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points indicating mild cognitive loss. The MDS documented the resident required extensive assistance of two staff with transfers and extensive assistance of one staff for assistance walking in the corridor and locomotion on the unit. The MDS listed diagnoses of heart failure, anemia, hypertension, end stage renal disease, hyperkalemia (a medical problem in which you have too much potassium in your blood) and documented shortness of breath with exertion. The MDS documented the resident had falls prior to admission and one fall since admission to the facility that resulted in injury (except major- skin tears, abrasions, lacerations, superficial bruises, hematomas (a hematoma is usually caused by a broken blood vessel that was damaged by surgery or an injury) and sprains; or any fall-related injury that causes the resident to complain of pain. The Care Plan dated 1/17/23 documented Resident #217 at risk of falls with a goal to remain free of injury/major injury and directed the staff to provide non-skid footwear to prevent falls. The Care Plan updated on 1/19/23 directed staff to provide 1 assist for ambulation using a forward wheeled walker (FWW) followed by a wheelchair in the hall twice a day. An Office Clinic Note dated 1/18/23 detailed the resident had several falls over the last several months and had gotten progressively weaker. A Physical Therapy Plan of Care dated 1/18/23 documented the resident presented to therapy with a decline in functional mobility tolerance due to congestive heart failure and progressive weakness. The resident and family noted a decrease in his independence with mobility resulting in decreased safety and increased need for assistance. A Therapy Communication Email dated 1/18/23 documented the resident required an assist of one with a FWW followed by a wheelchair for ambulation. The Therapy Communication Email had been directed to Staff D, RN, Skilled Coordinator. A Fall Event Report dated 1/23/23 at 5:05 p.m. documented Resident #217 had an unwitnessed fall while walking in the hallway with a C.N.A. The resident utilized a walker and one assist. The resident reported he just fell forward. The Report documented he hit his head and experienced a split lip that Staff A, Registered Nurse (RN) had to stop the bleeding to. The report further detailed they assisted the resident up off the floor with a mechanical lift and 3 staff. The Fall Event Report documented a family representative had been notified on 1/23/23 and the facility would provide 2 staff assist with ambulation using a FWW and following the resident with a wheelchair to prevent future falls from occurring. An observation of the resident's room that he had resided in while at the facility revealed Staff B had walked him approximately 30 feet out of the room. During an interview on 6/6/23 at 1:07 p.m. Staff B, Certified Nursing Assistant (C.N.A.) reported she walked Resident #217 out of his room toward the dining room. She stated she assisted him with one assist, gait belt and his walker. She stated the resident voiced he started to get weak and tired. She asked him twice if he would be okay if she went back to his room to get his wheelchair and he reported he would be fine. He stood in the hallway, approximately two room doors up from his room at that time. He had been standing fine with his walker when she left him to go get his walker. She stated when she came out of his room, Resident #217 lay face down on the floor. He voiced his legs had gave out, and his nose hurt. She stated he had blood coming out of his nose. She stated it had been the first time that she had worked with the resident. She stated the facility provides a C.N.A. guide that lists the resident's name, how they transfer, as well as why they are at the facility. There is also a white board in the resident's room that lists how they transfer. She stated his white board had listed to walk him with a one assist and a FWW. On 6/6/23 at 2:55 p.m. Staff C, RN, reported the aide had walked him in the hallway, she did not have a wheelchair behind him and he ended up on the floor. She stated he had a bloody nose. She stated his family requested to have him sent to the emergency room for evaluation because they were concerned about his general health. She stated he had a decline since he had been admitted and the fall had just been a tipping point as the resident was always on the weaker side. She stated they were supposed to follow him with the wheelchair and that is pretty much a standard of practice. She thought his care plan listed to follow him with the wheelchair. She stated he required assist of one and a gait belt for walking and he had a gait belt on at the time of the fall. She stated the aide should not have left the resident on his own since he needed a one assist and she should have had the wheelchair behind him. She stated the aide should not have just left him like that. On 6/6/23 at 4:59 p.m. Staff A reported she didn't recall much about the resident's fall. She did remember he voiced his weakness to the C.N.A. The C.N.A. asked him if he was okay to stand while she went to his room to get his wheelchair. She stated his room at the time had been about two doors down from where she had him standing. She stated he had been alert and oriented and able to make his own decisions. The C.N.A. felt he had been safe to leave while she went to get his wheelchair. Staff A couldn't recall the care planned level of assistance needed or if staff needed to follow him with a wheelchair. She stated he fell between 5:30 p.m. - 6:00 p.m and he had a bloody nose and split lip. During an interview on 6/6/23 at 5:24 p.m. a family member reported he had split both of his lips and had a black eye from the fall. They chose to take him to the emergency room since he had hit his head in the fall. He had never been a one assist. The family member stated he required the assistance of two people when he walked, one person to walk with him and another to follow behind him with the wheelchair. On 6/6/23 at 5:28 p.m. a family member voiced regarding the fall on 1/23/23, she had been upset with the aide. The family stated the aide made the choice not to use the wheelchair. She had been upset the aide left him totally unattended in the hallway where he fell . The family stated the aide could have lowered him to the ground to keep him from getting injured. On 6/7/23 at 4:39 p.m. Staff B reported the evening of the resident's fall on 1/23/23 she looked around but all the other staff were on the other hallway or in the dining room. She stated she didn't try to call out or flag anyone else down to assist her. She left the resident standing in the hallway with his walker to go back to his room and get his wheelchair. During an interview on 6/7/23 at 4:50 p.m., the Director of Nursing, reported he would expect the plan of care to be followed. He reported he would expect the resident's choices to be honored as part of the plan of care. On 6/8/23 at 8:30 a.m. Staff D, Post Acute Nursing Manager, reported the resident's assistance level would have been documented on the whiteboard in the resident's room and they do not keep those. A picture of the whiteboard from Resident #217's room on 1/23/23 provided by the family directed the staff to provide one assist with ambulation and follow the resident with the wheelchair. The Comprehensive Care Plan Policy revised 10/2022 detailed the care plan would include the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The Policy specified qualified staff would be responsible for carrying out interventions specified in the care plan and would be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical record review, family and staff interviews, resident images and facililty policy review the facility failed to provide adequate supervision when an aide left a resident that required staff assistance standing in the hallway with his walker unassisted while she went back to his room to get his wheelchair, resulting in a fall with minor injury for 1 of 3 residents reviewed (Resident #217). The facility identified a census of 156 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #217 documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points indicating mild cognitive loss. The MDS documented the resident required extensive assistance of two staff with transfers and extensive assistance of one staff for assistance walking in the corridor and locomotion on the unit. The MDS listed diagnoses of heart failure, anemia, hypertension, end stage renal disease, hyperkalemia (a medical problem in which you have too much potassium in your blood) and documented shortness of breath with exertion. The MDS documented the resident had falls prior to admission and one fall since admission to the facility that resulted in injury (except major- skin tears, abrasions, lacerations, superficial bruises, hematomas (a hematoma is usually caused by a broken blood vessel that was damaged by surgery or an injury) and sprains; or any fall-related injury that causes the resident to complain of pain. The Care Plan dated 1/17/23 documented Resident #217 at risk of falls with a goal to remain free of injury/major injury and directed the staff to provide non-skid footwear to prevent falls. The Care Plan updated on 1/19/23 directed staff to provide 1 assist for ambulation using a forward wheeled walker (FWW) followed by a wheelchair in the hall twice a day. An Office Clinic Note dated 1/18/23 detailed the resident had several falls over the last several months and had gotten progressively weaker. A Physical Therapy Plan of Care dated 1/18/23 documented the resident presented to therapy with a decline in functional mobility tolerance due to congestive heart failure and progressive weakness. The resident and family noted a decrease in his independence with mobility resulting in decreased safety and increased need for assistance. A Therapy Communication Email dated 1/18/23 documented the resident required an assist of one with a FWW followed by a wheelchair for ambulation. The Therapy Communication Email had been directed to Staff D, RN, Skilled Coordinator. A Physical Therapy Treatment Note dated 1/20/23 at 4:02 p.m. documented the resident had been able to ambulate 50 feet with a FWW and contact guard assist. The resident required moderate verbal cues on step quality but struggled to correct due to level of fatigue. A Fall Event Report dated 1/23/23 at 5:05 p.m. documented Resident #217 had an unwitnessed fall while walking in the hallway with a C.N.A. The resident utilized a walker and one assist. The resident reported he just fell forward. The Report documented he hit his head and experienced a split lip that Staff A, Registered Nurse (RN) had to stop the bleeding to. The report further detailed they assisted the resident up off the floor with a mechanical lift and 3 staff. The Fall Event Report documented a family representative had been notified on 1/23/23 and the facility would provide 2 staff assist with ambulation using a FWW and following the resident with a wheelchair to prevent future falls from occurring. An observation of the resident's room that he had resided in while at the facility revealed Staff B had walked him approximately 30 feet out of the room. During an interview on 6/6/23 at 1:07 p.m. Staff B, Certified Nursing Assistant (C.N.A.) reported she walked Resident #217 out of his room toward the dining room. She stated she assisted him with one assist, gait belt and his walker. She stated the resident voiced he started to get weak and tired. She asked him twice if he would be okay if she went back to his room to get his wheelchair and he reported he would be fine. He stood in the hallway, approximately two room doors up from his room at that time. He had been standing fine with his walker when she left him to go get his walker. She stated when she came out of his room, Resident #217 lay face down on the floor. He voiced his legs had gave out, and his nose hurt. She stated he had blood coming out of his nose. She stated it had been the first time that she had worked with the resident. She stated the facility provides a C.N.A. guide that lists the resident's name, how they transfer, as well as why they are at the facility. There is also a white board in the resident's room that lists how they transfer. She stated his white board had listed to walk him with a one assist and a FWW. On 6/6/23 at 2:55 p.m. Staff C, RN, reported the aide had walked him in the hallway, she did not have a wheelchair behind him and he ended up on the floor. She stated he had a bloody nose. She stated his family requested to have him sent to the emergency room for evaluation because they were concerned about his general health. She stated he had a decline since he had been admitted and the fall had just been a tipping point as the resident was always on the weaker side. She stated they were supposed to follow him with the wheelchair and that is pretty much a standard of practice. She thought his care plan listed to follow him with the wheelchair. She stated he required assist of one and a gait belt for walking and he had a gait belt on at the time of the fall. She stated the aide should not have left the resident on his own since he needed a one assist and she should have had the wheelchair behind him. She stated the aide should not have just left him like that. On 6/6/23 at 4:59 p.m. Staff A reported she didn't recall much about the resident's fall. She did remember he voiced his weakness to the C.N.A. The C.N.A. asked him if he was okay to stand while she went to his room to get his wheelchair. She stated his room at the time had been about two doors down from where she had him standing. She stated he had been alert and oriented and able to make his own decisions. The C.N.A. felt he had been safe to leave while she went to get his wheelchair. Staff A couldn't recall the care planned level of assistance needed or if staff needed to follow him with a wheelchair. She stated he fell between 5:30 p.m. - 6:00 p.m and he had a bloody nose and split lip. During an interview on 6/6/23 at 5:24 p.m. a family member reported he had split both of his lips and had a black eye from the fall. They chose to take him to the emergency room since he had hit his head in the fall. He had never been a one assist. The family member stated he required the assistance of two people when he walked, one person to walk with him and another to follow behind him with the wheelchair. On 6/6/23 at 5:28 p.m. a family member voiced regarding the fall on 1/23/23, she had been upset with the aide. The family stated the aide made the choice not to use the wheelchair. She had been upset the aide left him totally unattended in the hallway where he fell . The family stated the aide could have lowered him to the ground to keep him from getting injured. The family who is Power of Attorney provided pictures of the resident's injuries. The family stated the pictures were taken during the hospital stay after the fall on 1/23/23. On 6/7/23 at 4:39 p.m. Staff B reported the evening of the resident's fall on 1/23/23 she looked around but all the other staff were on the other hallway or in the dining room. She stated she didn't try to call out or flag anyone else down to assist her. She left the resident standing in the hallway with his walker to go back to his room and get his wheelchair. During an interview on 6/7/23 at 4:50 p.m. the Director of Nursing reported he would expect the plan of care to be followed. He reported he would expect the resident's choices to be honored as part of the plan of care. On 6/8/23 at 8:30 a.m. Staff D, Post Acute Nursing Manager reported the resident's assistance level would have been documented on the whiteboard in the resident's room and they do not keep those. A picture of the whiteboard from Resident #217's room on 1/23/23 provided by the family directed the staff to provide one assist with ambulation and follow the resident with the wheelchair. The Adverse Events Policy, revised 12/2022, provided by the facility directed the staff not to leave a person involved in a critical situation unattended unless it is absolutely necessary to summon additional assistance.

Based on observation, facility policy review, manufacturers recommendations and staff interviews, the facility failed to ensure all facility dishmachine's met requirements to adequately sanitize the facility dishes in order to reduce the risk of contamination and food-borne illness. The facility census was 199 residents. Findings include: Observation on 10/22/19, at 8:10 a.m., revealed Staff I, homemaker/cook, prepared to run the first floor skilled household dishmachine. Upon request, Staff I performed a chemical sanitizer check of the dishmachine using a Hydrion QT-10 test strip (used to measure the concentration of quaternary sanitizers to ensure proper concentration as specified by the individual chemical manufacturer). Staff I dipped the test strip into the dishmachine rinse water and held it up to the container to show the color of the strip, compared to the colors on the test strip container. The test strip displayed multiple colors from blue to a blue green and failed to match any of the colors on the strip comparison chart, which would indicate if it met the required sanitizer level. Staff I performed a second test, which also failed to match any of the comparison colors, but she reported it was ok and should be between about 200-300 ppm (parts per million). Review of the manufacturer information on the Hydrion QT-10 test strip container stated in part .Dip paper in Quat solution. During interview on 10/22/19, at 8:25 a.m., the Director of Dining Services verified the dishmachine in the first floor skilled household is a low temperature machine that utilizes a chemical to sanitize the dishes. She reported they have been using the same chemical test strip for a long time, and believed it was the right one. She verified the dishmachine sanitizer used is a chlorine solution, SparChlor chlorinated sanitizer, and will contact their current chemical representative and determine if the strip they are using is the correct one for their product. During a follow-up interview on 10/22/19, 2:45 p.m., the Director of Dining Services reported she talked with their current dishmachine chemical supply representative and the Hydrion QT-10 test strips they are currently using for the first floor skilled household dishmachine are not the correct ones. She reported they changed chemical suppliers last fall and the company representative at the time, told her the QT-10 strips were the appropriate ones to use for the chlorine solution used in that dishmachine. Their current chemical company representative informed her of the correct strips, which she has obtained. Review of an undated facility policy titled Dishwashing Procedures, revealed in part . Low Temperature Dish Machines . The concentration of the sanitary solution during the rinse cycle is 50 ppm (parts per million). A Chlorine test strip kit is used at each meal and may be obtained from the chemical supplier or food vendor . Review of the manufacturer information on the SparChlor chlorinated sanitizer revealed in part . Solutions containing an initial concentration of 100 ppm available chlorine must be tested and adjusted periodically to ensure the available chlorine does not drop below 50 ppm . The 2013 Food Code published by the Food and Drug Administration and considered a standard of practice for the food service industry, requires food contact surfaces and utensils must be santized and the concentration of the sanitizing solution must be accurately determined by using a test kit.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to properly sanitize the blood glucose machine between residents during two of four observations (Resident #15 & #168) and failed to ensure the Foley catheter bag did not touch the floor for one resident with a Foley (Resident #32) The facility census was 199 residents. Findings include: 1. During interview on 10/22/19 at 10:50 a.m., Staff H, Certified Medication Aide, CMA, revealed the facility had two types of glucose monitoring devices (glucometer). Staff H indicated the Evencare Proview glucose monitoring device (glucometer) was not owned by individual residents therefore it was designated as the device that could be used for multiple residents. Staff H stated the device was used for Resident #15. 2. Observation on 10/23/19 at 7:19 a.m., Staff I, CMA, tested Resident #15's blood glucose level with a multi user glucose monitoring device. Staff I wiped the glucometer with 70% alcohol prep pads until it was wet, then set it on a napkin on top of the medication cart to dry. 3. Observation on 10/22/19 at 8:44 a.m., Staff G, Registered Nurse, RN, tested Resident #168's blood glucose level with a Evancare Proview device, wiped the device with Clorox Healthcare Hydrogen Peroxide wipes. Staff G placed the device into a plastic bag and placed it into a drawer in the medication cart. Staff G identified the device was used for more than one resident. 4. During interview on 10/23/19 at 9:13 a.m., Staff I stated he was not taught to use a certain disinfectant product to clean a multi user glucometer. Staff I stated he usually uses alcohol wipes. Staff I stated he was told the most important thing was to let the device air dry, which usually takes at least 30 seconds. Staff I stated he was not taught to wipe down the glucometer itself for a certain amount of time. 5. During observation on 10//23/19 8:52 a.m., Staff G, tested Resident #168's blood glucose level with a Evancare Proview device. Staff G wiped the device with Clorox Healthcare Hydrogen Peroxide Disinfectant wipes for approximately 30 seconds and placed the device into a plastic baggie and sat into one of the medication cart's drawers. During interview directly following the observation, Staff G stated she was taught to disinfect multi use devices by wiping the devices off with Clorox Healthcare Hydrogen Peroxide wipes for 30 seconds. Staff G said she did wipe the device off for 30 seconds, but admitted she did not wipe the device off for 30 seconds during observation the day before on 10/22/19 at 8:44 a.m. Staff G had identified the device used by for Resident #168 as a multi user device. During interview on 10/23/19 at 9:27 a.m., the Director of Nursing (DON), stated his expectations would be to disinfect between uses of the multi user glucometers. DON stated the facility uses disinfectant wipes with a green cap on it. DON said staff were trained on disinfecting glucometers at the skills fair. DON stated he did not know drying or cleaning times for disinfecting glucometers. DON stated the facility would go by the manufacturer's guidelines for the Evencare Proview glucometer. DON stated CMA's are trained by the facility to do blood glucose monitoring. A Skills Validation Day educational resource provided by the facility dated 5/6/2019, showed Blood Glucose Checks listed under Booth 1- Medication Administration. An undated Performance Checklist for Blood Glucose Monitoring showed staff are to perform hand hygiene after turning meter (glucometer) off, disposing of test strip, lancet, and gloves. This checklist did not include disinfecting of the glucometer. A protocol titled Blood Glucose Check dated 9/2018, directed staff to disinfect glucometer with disinfect wipe. During interview on 10/23/19 at 1:10 p.m., the DON stated the facility used a training video for the Evencare Proview glucometer. DON stated the video was available to all staff but the facility did not track the employees whom have viewed the video. During interview on 10/23/19 at 1:13 p.m., Staff J stated she taught the skills fair portion on disinfecting the glucometers. Staff J directed the Clorox Healthcare Hydrogen Peroxide wipes was to be used to disinfect glucometers and demonstrated the proper use of the wipes. Staff J stated alcohol wipes are not acceptable to use for disinfecting glucometers and she would have directed staff not to use them if she would have been asked. An EvenCare Proview User's Guide provided by the facility, instructed an EPA-registered disinfecting wipe be used on the glucometer in between patients and be cleaned prior to disinfecting. The undated Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Portfolio stated wet-contact time is critical because if the product evaporates too quickly, it will not remain in contact with the microorganisms for the necessary kill/contact time and hence the desired antimicrobial effect will not be achieved. The Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes updated (MONTH) (YEAR), stated the wipes are EPA-registered and they kill most bacteria [MEDICAL CONDITION] on a variety of hard, nonporous surfaces with contact times of 30 seconds to 1 minute. Disinfection efficacy showed a 1 minute kill time for staphylococcus Aureus, [MEDICAL CONDITION]-resistant Staphylococcus Aureus, and Avian Influenza [MEDICAL CONDITION]. 3. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #32 with [DIAGNOSES REDACTED]. The resident required extensive assist with activities of daily living and required an indwelling catheter for bladder functions. Observation on 10/21/19 at 11:25 a.m. revealed the resident rested in bed with the Foley catheter bag attached to the bed frame and rested directly on the floor. During interview on 10/23/19 at 11:42 a.m. Staff A, Certified Nurse Aide, CNA, reported for a resident with a catheter sitting in the wheelchair the catheter bag should be secured under the chair in a privacy bag. Staff A reported when the resident was lying in bed the Foley catheter bag should be placed in a privacy bag secured to the bed rail and not touching the floor. During interview on 10/23/19 at 3:49 p.m., the Director of Nursing reported he expected staff to position a catheter bag under the wheelchair in a cloth bag if the resident was in the wheelchair. He reported staff should position the Foley catheter bag attached to any portion of the bed as long as the catheter bag does not touch the floor when a resident is in bed. The DON reported it was not acceptable for a Foley catheter bag to touch the floor. Record review of the Urinary Catheter Care Policy, revised 9/2018, showed the purpose is to prevent urinary tract infection and provide routine catheter care. The procedure section of the policy showed: 9. Ensure the catheter tubing and drainage bag are kept off the floor.

Based on observation, clinical record review and staff interview, the facility failed to revise the care plan for two of 35 residents reviewed. (Resident #178 & #51) The facility census was 199 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #178 required extensive assist with activities of daily living and had [DIAGNOSES REDACTED]. Observation on 10/21/19 at 11:21 a.m., revealed the resident sat in the wheelchair in the hallway with gray cloth mittens in place on bilateral hands. Observation on 10/21/19 at 4:39 p.m., revealed the resident sat in the wheelchair near the nurses station with gray cloth mittens on both hands. Observation on 10/22/19 at 12:57 p.m., revealed the resident sat in the wheelchair in the dining room with black cloth gloves to both hands. Observation on 10/23/19 at 7:29 a.m., revealed the resident sat in the dining room in the wheelchair and wore a pair of black cloth gloves on both hands. During interview on 10/23/19 at 9:07 a.m., Staff E, Certified Medication Aide, CMA, reported the family requested the resident wear gloves due to a history of grabbing and causing skin concerns during cares when the resident became combative. Staff [NAME] reported the resident preferred to have the gloves on as a sense of security as well. Staff [NAME] reported the family purchased many pairs of gloves for the resident to use. During interview on 10/23/19 at 10:27 a.m., Staff F, CMA, reported the reason the resident wore gloves was to protect both the resident and staff as at times the resident can grab out at staff or family during care. Staff F reported the gloves were discussed with the daughter and the daughter preferred for the resident to wear them. During interview on 10/23/19 at 11:48 a.m., Staff C, Licensed Practical Nurse, LPN, reported she was not sure why the resident wore gloves. Staff C reviewed the Resident Profile Sheet and could not locate the use of gloves on the sheet. Staff C asked Staff [NAME] to return to the computer and reported Staff [NAME] did not find any events that would indicate the use of the gloves so it had to be due to family preference. Staff [NAME] reported staff have always passed on by word of mouth that the resident wore gloves. During interview on 10/23/19 at 2:32 p.m., the Director of Nursing (DON) reported not being familiar with the reason the resident wore gloves. The DON reported staff would find the resident's need to wear gloves on the care plan. The DON reported he expected the care plan to be revised at the initiation of the glove use. Record review of the resident's Care Plan failed to show the use of gloves. Record review of the Resident Profile Sheet failed to show the use of gloves. 2. The MDS assessment dated [DATE], documented Resident #51 had [DIAGNOSES REDACTED]. A care plan for Resident #51 dated 8/16/19, did not address a problem, goal or approaches concerning [MEDICAL CONDITION] or use of a [MEDICAL CONDITION] drug. During interview on 10/23/19 at 3:11 p.m., Staff K, MDS Nurse stated the resident received Keytruda ([MEDICAL CONDITION] drug) outside of the facility [MEDICAL CONDITION] of the rectum. Staff K stated the facility did not care plan the addition of the [DIAGNOSES REDACTED]. During interview on 10/24/19 at 10: 53 a.m., the Director of Nursing (DON), confirmed the [DIAGNOSES REDACTED].

Based on clinical record review and staff interview, the facility failed to identify a skin condition on the Minimum Data Set (MDS) assessment for one of two residents. (Resident # 172) The facility census was 199 residents. Findings include: 1. A History and Physical dated 8/30/19, listed Resident #172 had chronic stasis ulcers and chronic venous stasis [MEDICAL CONDITION]. The Body Check sheet dated 9/6/19, identified skin areas to the residents right lower extremity (RLE). The Wound Condition Update report dated 9/11/19, identified chronic non-healing ulcers to the residents right lower extremity measuring 2.9 centimeters (cm) by 0.9 cm and 0.1 cm deep posterior calf. A cluster of wounds to the lateral right calf 13 cm by 1 cm and 0.1 cm deep. The MDS assessment dated [DATE], 9/19/19 10/2/19 & 10/6/19, failed to identify the non-healing ulcers to the residents RLE. During interview on 10/23/19 at 1:25 p.m., Staff L, MDS nurse reported missing the ulcers on the MDS.

Based on clinical record review and staff interview, the facility failed to comply with all applicable Federal Regulations regarding Medicare requirements governing billing practices for two of three residents reviewed for beneficiary notification protection. (Residents #54 & #162) The facility census was 199 residents. Findings include: 1. Resident #54 received Medicare benefits for skilled services from 7/15/19 to 7/22/19 and remained in the facility. The facility provided documentation to show they initiated a planned discharge from skilled care. The facility failed to provide the resident/resident representative with information regarding appeal rights, (Notice of Medicare Provider Non-Coverage, CMS ) and the correct form to provide information regarding potential financial liability (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, CMS ) if the skilled care continued. 2. Resident #162 received Medicare benefits for skilled services from 6/7/19 to 7/5/19 and remained in the facility. The facility provided documentation to show they initiated a planned discharge from skilled care. The facility failed to provide the resident with the correct form and options to provide information regarding the potential financial liability (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, CMS ), if the skilled care continued. During interview on 10/23/19, at 10:00 a.m., the Director of Social Services acknowledged she did not find any documented evidence Resident #54 or the representative received information regarding appeal rights or potential financial liability previous to discharge from skilled care. The Director of Social Services reported she did not realize the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form had changed, with different options to select, and believed she had been using the correct one.

Based on clinical record review and staff interview, the facility failed to submit one Minimum Data Set (MDS) assessment timely. The facility census was 199 resident. Findings include: 1. The Transmission File Listing Report dated 9/6/19, lacked the MDS file for Resident # 1 dated 9/3/19. During interview on 10/23/19 at 9:37 a.m., Staff K, MDS nurse confirmed failing to submit the MDS dated [DATE]. During interview on 10/23/19 at 2:11 p.m., the Director Of Nursing (DON) reported expecting the MDS to be transmitted timely.

Based on observation, facility menu review and staff interview, the facility failed to ensure residents on mechanical soft and pureed texture diets received the proper portion size for five of five residents on a pureed diet and for six of seven residents on a mechanical soft diet on the 3rd floor dining room. The facility census was 189 residents. Findings include: 1. The facility's Week 5 menu identified 1 pork chop for residents receiving pureed and mechanical soft texture diet for the lunch service on 5/22/18. The facility diet order report and daily diet accounts revealed five residents on a pureed diet and seven residents on a mechanical soft diet (6 regular portion and 1 small portion) in the 3rd floor dining room. Observation on 5/22/18 at 8:30 a.m., revealed Staff T, Cook, assigned to prepare the main menu items for the lunch meal which included a pork chop. Staff T reported he would grind the pork chops needed for the mechanical soft and pureed diets together and separate out what was needed for the mechanical soft diets and puree the amount required for the pureed diets. Staff T ground 27 pork chops into a large pan. He explained (as he showed the planned menu) the pork chop portion is 1 each and reported the pork chops are a 4 ounce (oz.), but they use 3 oz portion of meat for the mechanical soft diets. He identified on the scoop conversion chart a #10 scoop equivalent to about 3 oz. Staff T put 7 - #10 scoops in a pan for the 3rd floor dining room and dished the number of portions needed for the other service areas with the #10 scoop. He reported some residents on a mechanical soft and pureed diets received small portions, which would be a #16 scoop, referencing the scoop conversion chart for a 2 oz portion. He proceeded to pureed preparation, reported he needed a total of 8 pureed servings and scooped 8 - #10 scoops into the large Robo Coupe plus 1 extra scoop. He processed the meat, with the glaze and used the posted pureed diet portion/scoops chart and determined the portion size of a #8 scoop. He portioned 5 - #8 scoops into a pan for 3rd flood dining room and dished the number of portions needed for the other service areas with the #8 scoop. Observation at the end of the process revealed there was a large amount of ground meat left in the pan, given he reported he needed 25 portions and portioned out 25 portions between the ground and pureed. Staff T contributed the extra due to the fact the pork chops were 4 oz and he used a 3 oz portion scoop. Observation in the 3rd floor dining room on 5/22/18 at 11:55 a.m., revealed Staff S, dietary aide, assigned to serve the lunch meal. Staff S used the #8 scoop, identified as the pureed portion by Staff T, to serve the pureed pork to 5 of 5 residents on a pureed diet. She used the #10 scoop, as identified as the mechanical soft portion by Staff T, to serve ground pork to 6 of 7 residents on a mechanical soft diet, as one resident chose the alternate entree. During interview on 5/22/18, at 1:30 p.m., the consultant dietitian obtain a weight of a #10 scoop of the ground pork. She retrieved the leftover ground pork from the morning preparation, zeroed the scale and placed 1 - #10 scoop on the scale. Observation revealed the weight was 1 3/4 oz. The consultant dietitian acknowledged she questioned and had concerns with the process Staff T used to prepare the ground and pureed pork. She confirmed the #10 scoop did not yield the correct portion for the ground and pureed diets. During interview on 5/23/18, at 10:40 a.m., the Consultant Dietitian reported she believed Staff T did not normally grind the meat needed for the mechanical soft and pureed together and then struggled to determined how much to use for each batch. The Lead Supervisor reported their pork chops are 4 oz, but they reinforce to staff that a standard portion is 3 oz, which is probably why Staff T thought he should calculate his servings on 3 oz. The Lead Supervisor described the best process for pureed and ground preparation would be to grind the number of portions needed for the mechanical soft and pureed separately. Then for the ground meat, put a pan on a scale, zero it out, measure the total amount and divide by the number of servings. This would result in the ounces needed for each portion, and the appropriate scoop could be determined using the scoop conversion chart. The Consultant Dietitian and Lead Supervisor confirmed they expect a minimum portion size of 3 oz and the #10 scoop did not yield the intended minimum of 3 ounces. During an interview on 5/23/18, at 12:30 p.m., the Lead Supervisor reported she talked with Staff T regarding the process he used for the pork yesterday and confirmed that he does not normally grind the meat for the mechanical soft diets and pureed diets together and would normally do them separately, but thought it might be a faster process to use for a surveyor observation. Review of a facility policy, titled Mechanical Soft Meat Procedure, identified the portions to be placed in the food processor, ground to appropriate texture and the volume of the product measured. The policy identifies the Altered Texture Portion Chart will be used to determine the portion size based on the yield and number of servings. Review of a facility policy, titled Guidelines for Pureed Diets identified the portions to be placed in the food processor with appropriate liquid. The contents should then be measured and the Altered Texture Portion Chart

Based on observation, clinical record review, resident and staff interviews, the facility failed to answer resident call lights in a timely manner for six of 35 residents reviewed. (Resident #201 & #184). The facility census was 189 residents. Findings include: 1. The Minimum Data Set (MDS) assessment completed 5/10/18, documented Resident #201 had [DIAGNOSES REDACTED]. Observation on 5/22/18 at 7:35 a.m., revealed a white call light on above the resident's room that was audible from nurse's station. No staff was currently in the hallway. Staff H, certified nurse aide, CNA and Staff I, registered nurse, RN stood at nurses station. At 7:41 a.m., the call light remained on, housekeeping was the only staff in the hallway. At 7:45 a.m., the call light remained on, two staff was noted at the nurses station At 7:53 a.m., the call light remained on for 18 minutes, Staff H and Staff I stood at the nurses station with no other nursing staff in the hallway During interview on 5/23/18 12:02 p.m., Staff H, CNA reported call lights should be answered within 15 minutes. The system had the capability to see how long the call light was on at a box at the nurses station and print out reports that management could print off. During interview on 5/23/18 12:32 p.m., Staff K, CNA reported call lights should be answered within a few minutes, we should check in with the resident and acknowledge them and if staff are in the middle of something, tell the resident you are in the middle of something and will come back as soon possible, or find another staff member to help the resident. There is a computer at the desk that shows what room has the call light on and how long the call light has been on. If standing in the hallway, staff can not tell how long the light has been on. If the red light is flashing, that means the resident needs assistance in the bathroom, if the white light is on, this means the resident has pushed the call light. During interview on 5/23/18 12:44 p.m., Staff J, CNA reported call lights should be answered within 15 minutes. If staff was standing in the hall, there was no way to know how long the light had been on. At the nurses station, a little box will show the room number and how long the light has been on. During interview on 5/24/18 at 8:15 a.m., the director of nursing reported he expected staff to answer call lights within 15 minutes. He also reported there was a device at the desk that shows the room number and the length of time the light had been on. There was no way for staff to tell how long a call light had been on if they were standing in the hallway There are devices in all the dining rooms to show the that there are call lights on. The facility based staffing on our scheduling software that integrates with Matrix which looks at our population from census and computes the acuity for us, and shows how many staff per day per day per unit. 3. Observation on 5/22/18 at 6:25 a.m., revealed a call light on in a room down the E Hallway. Staff answered the call light at 6:44 a.m., 19 minutes after the call light had been initiated. 4. During interview on 5/21/18 at 10:42 a.m., Resident #184 reported sometimes it will take staff over 15 minutes to answer the call light. The resident noted it can happen for any shift, especially when they are busy, and it might happen 1-3 times week. The resident noted it happens a lot around mealtimes and the call light can go on over 30 minutes before it is answered. The resident nodded to the clock on the wall across from the recliner and bed as knowing the timeframe to notice for call lights. The resident noted sometimes they answer the light, leave say they will be back and sometimes they forget to come back. Call light activity for 2 call lights in S Hallway showed residents waited for the call light on 5/16/18 to present from 20 minutes to 31 minutes. 2. During resident group meeting on 5/21/18 at 3:10 p.m., three of eight residents present complained of issues with timely response to the call lights. They reported they often wait greater than 15 minutes and it may take up to 30 minutes. The residents expressed frustration regarding staff answering a call light, being told they will be right back and then may not return for up to an hour or sometimes more. The residents reported they have a watch or clock, so they are able to keep track of how long it takes to get help. The group agreed they felt as if the facility needed more staff to assist them with their needs and 2 of the 3 believed some of the longest wait times are in the afternoon.

Based on observation, facility policy review and staff interviews, the facility failed to transport resident clothing using proper infection control technique for two of four floors. The facility census was 189 residents. Findings include: 1. During observation on 5/23/18 at 8:17 a.m., Staff F, Laundry aid pushed the uncovered laundry cart by the 3rd floor nurses station delivering clothes on the South Hall. At 8:18 a.m., Staff F dropped a hanger bent to it pick up, dragging pants hung on a hanger on the floor. Staff F took the pants into room [ROOM NUMBER]. At 8:21 a.m., Staff F pushed the uncovered hanging laundry cart past housekeeping cart on the South Hall. At 8:28 a.m., Staff F pushed uncovered hanging laundry cart down the East Hall delivering clothes. During observation on 5/23/18 at 1:42 p.m., Staff N, Laundry walked by the 1st floor front entry way with an uncovered 5 rack folded laundry cart. During interview on 5/23/18 2:37 p.m., Staff M, Laundry stated day staff deliver the hanging clothing we never have covered it and do not cover the folded carts. During interview on 5/23/18 2:52 p.m., Staff O, Laundry expected clothing to be neat and clean when delivered. Have never put covers on the folded or hanging personal clothes. During interview on 5/23/18 at 3:29 p.m., the Environmental Supervisor reported not knowing the clean personal laundry needed covered. Policy titled Handling Soiled Linen provided by the facility stated All used linen should be handled using standard precautions (i.e., gloves) and treated as potentially contaminated: Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. During an interview on 5/24/18 at 8:15 a.m., the director of nursing reported he would expect the staff who delivered laundry an picked up soiled item from the floor to wash hands or use hand sanitizer

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure the comprehensive care plan included all services required to ensure the residents needs were met for 4 of 35 residents reviewed. (Resident #28, #73, #88 & #127 ) The facility census was 189 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #73 had [DIAGNOSES REDACTED]. The Care Plan dated 3/21/18, did not identify the use of [MEDICAL CONDITION] medication as a problem. The care plan lacked direction to staff for monitoring for side effects of medication. The physician orders [REDACTED].> 2. Observation on 5/21/18 at 11:13 a.m., revealed a container outside the room for Resident #127, that contained isolation supplies. During interview on 5/21/18 at 12:02 p.m. Staff G, Certified Medication Aide reported the resident was on isolation precautions for [MEDICAL CONDITIONS] ([MEDICAL CONDITION]). The Admission Minimum Data Set (MDS) Resident assessment dated [DATE], documented the resident had the [DIAGNOSES REDACTED]. The lab report dated 4/9/18, documented the resident as positive for C- Difficile. During interview on 5/23/18 at 10:15 a.m., the Director of Nursing reported the isolation information for a resident would be found on the Huddle Boards at the nurses stations. Observation on 5/23/18 at 10:27 a.m., revealed the Huddle Board on the second floor did not contain isolation information for any residents. The residents Care Plan did not address the residents isolation status. 3. During observation on 5/21/18 at 10:40 a.m., isolation supplies and a sign was observed outside the room for Resident #28. During interview on 5/21/18 at 12:02 p.m. Staff G, Certified Medication Aide (CMA) reported the resident was on isolation precautions for (MRSA) [MEDICAL CONDITION]-resistant Staphylococcus Aureus (bacterial skin infection), to his leg. During an interview on 5/22/18 at 8:01 a.m., Staff B, CMA reported the resident [MEDICAL CONDITION] to his lower leg and the facility did not do the dressing change, but the resident had taken the dressing off before, so they kept the isolation supplies available. Lab Report dated 2/24/18 documented the resident was confirmed [MEDICAL CONDITION] to the right lower extremity wound. The Care Plan failed to address the residents isolation status. 4. The Medication. Record dated the month of (MONTH) (YEAR) documented Resident #88 was on [MEDICATION NAME] (antidepressant) 10 mg by mouth daily, with the start date of 11/14/17. Medication Record documented the resident was on [MEDICATION NAME] (antipsychotic) 0.5 mg by mouth 30 to 60 minutes prior to meals with the start date of 3/15/18. The Care Plan did not address the use of [MEDICATION NAME] and [MEDICATION NAME]. During interview on 5/23/18 at 2:40 p.m., Staff Q, MDS Coordinator reported she completed care plans for residents on 3NW, 3SE, and the 3rd floor Household. Staff Q stated care plans updated when MDS completed every 92 days, when a resident had a significant change, after resident hospitalized , change in skilled care or hospice services. Staff Q reported she tried to update the care plan if a resident on an antipsychotic or antidepressant and worked with therapy and staff on communication for care plan updates. Staff Q advised nurses on each unit developed 48 hour care plan when she had been absent after hours or weekends. During an interview 5/23/18 at 2:55 PM, Staff R, Certified Nursing Assistant (CNA) reported she used the computer kiosk to check what cares were needed for each resident. Staff R reported staff nurses communicated to CNA and information relayed during shift report. During an interview on 5/23/18 12:02 p.m., Staff H, CNA/CMA reported the MDS coordinators had the responsibility of developing and updating the care plans. A review of the undated facility policy titled: comprehensive care planning and the care plan conference had documentation of the following: The care plan is developed by utilizing the RAI manual. The working comprehensive care plan is maintained in the resident's electronic record . The care plan will be updated as needed. Care plan information is documented and distributed so that all disciplines have access to it. The interdisciplinary team shall be responsible for assuring that the care plan is updated and reflects medical and nursing assessment: is oriented toward preventing declines in functioning and/or functioning levels. attempts to manage risk factors reflect standards of current professional practice contain objectives with measurable outcomes reflect an interdisciplinary approach to maintain or improve functional abilities involves resident and family input, and when not able to attend, will inform the resident and/or representative of any changes in condition or care plan goals

Based on observation, record review and staff interviews the facility failed to follow the care plan for ambulation, range of motion, and restorative care for 4 of 18 residents (Resident #4, 5, 7 and 8 ). The facility identified a census of 204 residents. Findings include: 1. Resident #4's MDS assessment dated [DATE] showed the resident had short and long term memory loss, required assistance of one staff for ambulation in the hallway, which only occurred once or twice in a 2 week reporting period. The MDS showed the resident had [DIAGNOSES REDACTED]. The Care Plan with a start date of 1/11/16 identified a problem with mobility and directed staff to assist the resident with ambulation in the hall with a wheeled walker twice daily. An interview on 3/29/17 at 12:50 p.m. Staff A, CNA, reported there is a 'Walk List' is in the bath book. Staff A reported the general rule is to walk any resident who is ambulatory at least once on day shift and once on second shift. The CNA staff is responsible for doing the ambulation. Staff A noted the resident can refuse a lot. An interview on 3/29/17 at 1:05 p.m. Staff D, RN, showed the Walk List (found at the nursing station) and noted Resident #4's name not present. Staff D reported not knowing why the resident hadn't been listed. Staff D also noted if the care plan stated to ambulate twice a day, then the resident should be ambulated as planned. Staff D also reported if a resident refused, that should be documented in the computer program as a refusal. The Computer Task for ambulation in the hall documented the following: -1/11/17 through 1/30/17-did not occur or not recorded. There were no refusals. -2/1/17 through 27/17-did not occur or not recorded. There were no refusals. -3/1/17 occurred one time. 3/2 through 29/17-did not occur or not recorded. There were no refusals. 2. Residents #5's Minimum (MDS) data set [DATE] identified the resident as severely cognitively impaired and required extensive staff assistance of two with all activities of daily living. According to the face sheet dated 1/8/16 Resident #5 had [DIAGNOSES REDACTED]. A review of the care plan dated 3/8/17 titled Nursing Restorative Therapy (Mobility) identified the the following approaches: Seated Therapeutic Exercise to include marching, knee extension, hip adduction, using ball squeezes and hip abduction and knee flexion with use of red theraband. All exercise to be completed with 2 sets of 10 repetitions each. Standing therapeutic exercises including squats and marching in place for 2 x 10 repetitions. Review of discharge summary dated 3/8/17 from physical therapy states caregivers instructed in restorative nursing program and gait with patient. A review of the restorative aides notes revealed the resident received active range of motion 8 out of 22 days since 3/9/17. 3. Review of Resident #7's MDS dated [DATE] had documentation of the following Diagnoses: [REDACTED]. It also identified the resident as cognitively intact and required extensive assist with all activities of daily living. A review of the Nursing Restorative Therapy (Mobility) care plan dated 1/5/17, revealed the following approaches to maintain current range of motion (ROM) to upper extremity: Omnicycle, seated exercises, standing with PAL, Cooking, kickball, Passive ROM to right hand, pulleys, and upper extremity and indicated the certified nurse aide are responsible for the therapeutic exercise program. Review of the Occupational Therapy plan of of care dated 12/9/17 indicated a Restorative program will be put in place to maintain progress once long term goals are met. Observation of Resident #7 on 3/29/17 at 9:45 AM noted the resident sitting in main dining area of household drinking cup of coffee with their left hand. Right fingers and wrist were contracted with functional limitations in range of motion. Interview with Resident # 7 on 3/29/17 at 10:00 AM stated they have not been receiving restorative nursing at all they do not come to offer at all and if they would come to offer they would do range of motion. The Resident also stated he/she does like to use the Omnicyle but sometimes has to wait for staff to assist to use it and can take up to an hour. Review of the Point of Care documentation dated 1/1/17 through 3/29/17 for Restorative Nursing revealed the resident received passive range of motion 45 out of 88 days with four refusals documented. 4. Review of Resident #8's MDS completed 2/11/17 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident as moderately cognitively impaired and needs extensive assist of one staff with all activities of daily living. A review of the care plan dated 2/23/17 titled Nursing Restorative Therapy revealed the following approaches: Daily Low Back Stretching, Seated trunk flexion, Supine knee rocking side to side, Supine knee to chest stretch, Nu Step 15 minutes at 4 level, standing therapeutic exercises 2 pounds 2 x 15 repetitions. Review of Restorative Nursing Documentation revealed from 12/29/16 through 3/29/2017 the resident had restorative range of motion or walking only 3 times during this time frame. Interview with Staff F, Registered Nurse (RN) 3/29/17 at 10:15 AM revealed the ideal frequency of restorative nursing for residents would be 6 x weekly. Staff F indicated they cannot get the exercise done due to short staffing. Interview with Director of Nursing (DON) 3/29/17 at 11:30 AM stated the care plan is a suggestion of what they can do for restorative nursing and should be done 6 x weekly ideally. Interview with the Director of Rehab. on 3/30/17 at 9:40 AM, the Director stated when therapy nears the end of therapy services, they will meet with restorative staff and direct them on program for resident. Therapist will then enter the program into the facility care plan.

Based on record review, facility policy review and staff interview, the facility failed to ensure that 1 of 10 new employees reviewed received the mandatory 2 hour dependent adult abuse training within six months of hire date (Staff G). The facility identified a census of 204 residents. Findings include: Review of Staff G- Certified Nurses Aide's personnel file revealed a hire date of 8/17/16. The personnel file contained a document titled Single Contact License and Background Check (SING) dated 6/28/16. During an interview on 3/29/17, at 1:00 p.m., Staff H, Human Resources Generalist, acknowledged the date documented on the SING check exceeded 30 days prior to the hire date. The Human Resources Department stated they knew the background checks were only good for 30 days and Staff G's should have been repeated when her start date exceeded that time frame. Review of an undated document titled Abuse Policy indicated staff and volunteers will receive education about resident mistreatment, neglect and abuse upon first employment.

Based on record review and interviews, the facility failed to protect 1 of 4 residents from environmental hazards (Resident #4). On 5/4/16, Resident #4 slid out of the wheelchair while being transported in the facility van when the driver stopped abruptly. Resident #4 sustained a large laceration to his/her right leg. Staff interviews revealed the seat belt had not been tightly placed prior to this incident, and now staff slip the right and left belts through the wheelchair arm rests for residents safety. The facility reported a census of 98 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had no cognitive impairment, required extensive assistance of two staff to transfer from one surface to another, failed to ambulate and used a wheel chair for locomotion. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS identified Resident #4's weight at 210 pounds. The Care Plan revealed Resident #4 required assistance with activities of daily living and directed staff to provide a wheel chair with extended brakes and foot pedals. The facility Accident Report dated 5/4/2016 and signed by Staff D included: Description of Accident: Driving shuttle van north on Elm Street at 14th, slowed for intersection and passenger slipped out of wheel chair and onto floor. Immediate Action Taken: Stopped van, went to rear, opened door and Resident #4 reported pain. Staff D pulled over to the curb and called the ambulance and contacted the facility. All restraints and seat belts were in place and correctly fastened. The hospital History and Physical dated 5/4/2016 revealed Resident #4 had a large open laceration wound, right leg on fall. The patient slid out of the chair today, sustaining a large open wound on the right leg. Extremities: Shows large gaping wound over the anteromedial aspect of the proximal third of the leg. No knee effusion present. There is some necrotic skin present, it goes down to bone at least 15 cm (centimeters) by probably 30 cm with a deep laceration, no gross contamination is present. Impression: large gaping laceration wound on the right leg. Plan: Irrigation, debridement, closure as much as possible. The hospital Preliminary Report dated 5/5/2016 included: Subjective: Resident #4 fell out of wheel chair, had seen a large laceration to the right leg. Resident is status [REDACTED]. Working with wound care. The facility investigation of the incident on 5/4/16 included : Resident #4 slid out of the wheel chair while being transported in the facility van and the driver had to stop abruptly. The driver called 911 and transferred the resident to the emergency room for evaluation. When the van and driver returned, the facility inspected the van and received a statement from the driver. According to the driver, the seatbelt and wheelchair were fastened correctly. Staff D drove the van and secured the resident. Staff D demonstrated how he/she secured the resident. Staff D secured the seatbelts, straps and clamps. Staff D placed the seatbelt over the wheelchair to fasten the seatbelt. Staff D indicated the seatbelt remained fastened after Resident #4 slid out. Staff D signed the Van Driver Orientation on 4/25/2016 that included: A. Proper use of seatbelts and clamps/straps to secure wheelchairs if applicable, safely and according to policy and procedure. B. All drivers will be instructed to call 911 in an emergency, i.e. resident unresponsive, fell out of chair, chair tipped over, etc. The facility Maintenance Slip completed on 5/14/2016 indicated the Dodge van had all items functioning well except the left head light. During an interview on 6/1/2016 at 1 o'clock p.m., Staff D, Van Driver reported working part time for approximately six weeks. Staff D indicated the incident occurred due to a conglomeration of things. During orientation the instructions included direction to bring the seat belt across the resident while seated in the wheelchair. The van had two belts, one on each side and one shoulder strap that hook together in the middle. Now, they slip the right and left belts through the wheelchair arm rests. When Resident #4 slid from the wheelchair, Staff D had to suddenly brake and the resident sustained [REDACTED]. The resident had a large build and wore slippery clothing which may have contributed to the accident. Staff D indicated the resident injured the lower leg when he/she hit the wheelchair in front. During an interview on 6/1/2016 at 3:30 p.m., Staff E, Van Driver reported working full time for approximately six weeks. Staff E indicated since the incident involving Resident #4, staff now ensure that the wheelchair had no wobble room. Staff E inspected the equipment and found no faulty parts. Staff E provided a copy of the inspection performed on 5/14/2016. The van had been checked prior to the incident. Staff E reported he never observed Staff D when on the van prior to the incident. If able, they weave the seat belt through the wheelchair arms. During an interview on 6/3/2016 at 9:55 a.m., the Administrator revealed van drivers watch two videos during orientation related to using the lift and straps and clamps. The Administrator reported the auto dealership told him sometimes you cannot weave the seat belt through the wheelchair and to just make sure it's snug. Resident #4 had a large frame (too large) and it was not an option with him/her. The Administrator presented the QRTMAX lesson plan which had not been in the van and referred to the Combination Lap and Shoulder with 3 Retractors instructions. The Administrator indicated they planned to add the instruction manual to van driver orientation moving forward. The QRTMAX Lesson Plan for Trainers (Q'Straint) received from the Administrator on 6/2/2016 included: Forward: The Q'Straint training program and this training kit have been developed in order to assist you and your organization in training your drivers, operators and attendants safely and properly use the Q'Straint wheelchair and occupant securement systems. The Company: Q'Straint is a world renowned, international company, marketing wheelchair and occupant securement systems throughout USA, Canada, Australia and Europe, as the leader in wheelchair and occupant securement's systems. Goal: The goal of any transportation system is to transport their passengers from the pick up point to the drop off point in the safest and most efficient manner possible. Combination Lap and Shoulder Belt with Three Retractors-Type 3: 1. We have the three-retractor combination occupant restraint system. I am sure you are aware that with this system there are no loose belts in the vehicle. 2. To secure the passenger, pull the belt from the retractor and thread the female portion of the lap belt, which is the one closest to the aisle, up through the opening between the seat back and bottom or between the seat back and armrest of the chair and around the occupant. 3. The belt will remain locked in this position. 4. Then Pull the male belt from retractor and thread it up through the opening between the seat back and bottom or between the seat back and armrest of the chair and around the occupant. 5. Attach the two belts by inserting the male portion into the female buckle. 6. Next, pull the belt from the shoulder belt retractor and attach the loose end of the belt to the pin connector on the lap belt. On 5/5/2016 Staff D received re-education on properly securing a resident in a wheelchair in the transport van. The review included placement of straps, clamps and seatbelts. On 6/3/2016 at 8 o'clock a.m., Staff D did not recall of the video observed upon hire instructed staff to thread the seat belts through the wheelchair. The orientation also included driving along with another van driver for a day. Now, Staff D finds a place on the wheelchair that he/she can thread the belts through. Staff D reported the van failed to include a QRTMAX manual and could not recall if the video corresponded with the manual.

Based on resident and staff interviews, clinical record review and facility policy, the facility failed to ensure that each resident remained free from abuse. (Resident #5) The facility reported a census of 209 residents. Findings include: According to the MDS (Minimum Data Set) dated 3/22/2016, Resident #5 had no cognitive impairment and required the assistance of one staff for transfers and ambulation in the room. The resident had [DIAGNOSES REDACTED]. The Care Plan indicated Resident #5 had ADL (Activities of Daily Living) needs and instructed staff to allow the resident to sleep in the recliner, stay with the resident while in the bathroom and transfer with the assistance of 1 - 2 staff. The facility investigation dated 5/20/2016 included: Staff C, CNA (Certified Nurse's Aide) assisted Resident #5 to the bathroom and the resident again requested to use the bathroom shortly after because he/she had an itch. Staff C told the resident no, you just went to the bathroom. Staff C asked Staff A, LPN (Licensed Practical Nurse) if the resident had an order for [REDACTED]. Staff A overheard Staff C say no to the resident and to stand up from the chair. Staff A also heard the resident's walker get moved and set forcefully down. At that point, the facility sent Staff C home. During an interview on 6/1/2016 at 2:45 p.m. Resident #5 sat in the recliner in the room with call light and phone nearby. The resident indicated Staff C treated him/her verbally in a bad and rude manner. At times the resident had an itch and required assistance to the bathroom. Staff C informed the resident the nurse would be gone for a half hour. The resident put the call light on and said Can you please do something?. Staff C told the resident to go into the bathroom and itch his/her bottom with a loud voice. Staff C pushed the walker in a rough manner. It made the resident tearful. The resident had concerns about Staff C prior to that night and told Staff if he/she did not want to provide care to just say so. The resident said actions speak louder than words, and evidently, the nurse overheard Staff C and sent him/her home. The resident reported Staff C's treatment upset him/her and thought it cruel and mean. The resident expressed fear of retaliation but staff assured him/her that Staff C would not return. During the interview the resident described Staff C and knew his/her name. During an interview on 6/2/2016 at 7:00 a.m., Staff A, LPN reported working on third floor on the night shift. Staff A revealed Resident #5 had restless behaviors. Staff C answered the resident's call light, took the resident to the bathroom and back to the recliner. A short while later the resident had the call light on. Staff C answered it, came out and reported the resident wanted to scratch his/her buttocks. Staff C asked Staff A if he/she had to scratch the resident's bottom. Staff A told Staff C to take the resident to the bathroom so he/she could scratch the area per self, and Staff C could offer to wash the area or apply lotion. Staff C asked if the resident could stand by the recliner as opposed to going to the bathroom. Staff A informed Staff C to ask the resident. Staff A overheard Staff C in Resident #5's room and heard Staff C tell the resident to do it right here. The tone of voice started to change and then Staff C told the resident well then sit back down. The resident said why are you so mean to me? Staff A heard the resident's walker be set down forcefully. Staff C came out of the resident's room, failed to say anything and began charting on the kiosk. Staff A notified the house supervisor and administrator and sent Staff C home. During an interview on 6/2/2016 at 9:20 a.m., Staff B, CNA reported working on 3rd floor, the night of the incident. Staff C came to the nurse's station and said No way, I'm not going to scratch him/her. Staff A told Staff C the resident could do it per self and that Staff C should take the resident to the bathroom. Staff C repeated I'm not going to scratch him/her in an irritated voice. Staff A again told Staff C that the resident could scratch the area per self. During an interview on 6/2/2016 at 11:05 a.m., Staff C reported working the night shift on 5/19/2016. Resident #5 wanted someone to scratch him/her. Staff C asked Staff A if the resident had a prescription for ointment. Staff A told Staff C the resident took too many medications and was psycho and had no prescription for the itch. Staff C said Staff B witnessed the interaction. The Corrective Action form dated 5/23/2016 revealed Staff C made several comments regarding resident's care. The resident asked Staff C why he/she talked so mean. The charge nurse also overheard Staff C become very short and discourteous with the resident. Staff C shoved the resident's walker across the room in an abrupt manner. The resident confirmed unpleasant encounter. The facility Abuse policy updated on 3/30/16 included: All residents of Stonehill Franciscan Services have the right to be free of abuse. Review of the policy indicated all residents of Stonehill Franciscan Services have the right to be free of abuse. Abuse may be classified as verbal abuse. Verbal abuse is described as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or their disability.

Based on resident and staff interviews and clinical record review the facility failed to care for one of five residents reviewed in a manner and environment that maintains or enhances each resident's dignity and respect. (Resident #5). The facility reported a census of 209 residents. Findings include: According to the MDS (Minimum Data Set) dated 3/22/2016, Resident #5 had no cognitive impairment and required the assistance of one staff for transfers and ambulation in the room. The resident had [DIAGNOSES REDACTED]. The Care Plan indicated Resident #5 had ADL (Activities of Daily Living) needs and instructed staff to allow the resident to sleep in the recliner, stay with the resident while in the bathroom and transfer with the assistance of 1 - 2. The facility investigation dated 5/20/2016 included: Staff C, CNA (Certified Nurse's Aide) assisted Resident #5 to the bathroom and the resident again requested to use the bathroom shortly after because he/she had an itch. Staff C told the resident no, you just went to the bathroom. Staff C asked Staff A, LPN (Licensed Practical Nurse) if the resident had an order for [REDACTED]. Staff A overheard Staff C say no to the resident and to stand up from the chair. Staff A also heard the resident's walker get moved and set forcefully down. At that point, the facility sent Staff C home. During an interview on 6/1/2016 at 2:45 p.m. Resident #5 sat in the recliner in the room with call light and phone nearby. The resident indicated Staff C treated him/her verbally in a bad and rude manner. At times the resident had an itch and it required assistance to the bathroom. Staff C informed the resident the nurse would be gone for a half hour. The resident put the call light on and said Can you please do something?. Staff C told the resident to go into the bathroom and itch his/her bottom with a loud voice. Staff C pushed the walker in a rough manner. It made the resident tearful. The resident had concerns about Staff C prior to that night and had told Staff if he/she did not want to provide care to just say so. The resident said actions speak louder than words, and evidently, the nurse overheard Staff C and sent him/her home. The resident reported Staff C's treatment upset him/her and thought it cruel and mean. The resident expressed fear of retaliation but staff assured him/her that Staff C would not return. During the interview the resident described Staff C and knew his/her name. During an interview on 6/2/2016 at 7:00 a.m., Staff A, LPN reported working on third floor on the night shift. Staff A revealed Resident #5 had restless behaviors. Staff C answered the resident's call light, took the resident to the bathroom and back to the recliner. A short while later the resident had the call light on. Staff C answered it, came out and reported the resident wanted to scratch his/her buttocks. Staff C asked Staff A if he/she had to scratch the resident's bottom. Staff A told Staff C to take the resident to the bathroom so he/she could scratch the area per self, and Staff C could offer to wash the area or apply lotion. Staff C asked if the resident could stand by the recliner as opposed to going to the bathroom. Staff A informed Staff C to ask the resident. Staff A overheard Staff C in Resident #5's room and heard Staff C tell the resident to do it right here. The tone of voice started to change and then Staff C told the resident well then sit back down. The resident said why are you so mean to me? Then Staff A heard the resident's walker be set down forcefully. Staff C came out of the resident's room, failed to say anything and began charting on the kiosk. Staff A notified the house supervisor and the administrator and sent Staff C home. During an interview on 6/2/2016 at 9:20 a.m., Staff B, CNA reported working on 3rd floor, the night of the incident. Staff C came to the nurse's station and said No way, I'm not going to scratch him/her. Staff A told Staff C the resident could do it per self and that Staff C should take the resident to the bathroom. Staff C repeated I'm not going to scratch him/her in an irritated voice. Staff A again told Staff C that the resident could scratch the area per self. During an interview on 6/2/2016 at 11:05 a.m., Staff C reported working the night shift on 5/19/2016. Resident #5 wanted someone to scratch him/her. Staff C asked Staff A if the resident had a prescription for ointment. Staff A told Staff C the resident took too many medications and was psycho and had no prescription for the itch. Staff C said Staff B witnessed the interaction.

Based on observation, record review and staff and resident interviews, the facility failed to prevent the development of a heel pressure ulcer for 1 of 3 residents reviewed (Resident #9). The facility identified a census of 201 residents. Findings include: 1. Resident #9 had an admission MDS (Minimum Data Set), dated 3/12/15. The MDS identified the resident required extensive assistance of 2 staff persons for bed mobility. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) score of 10. A score of 10 determined the resident had a moderately impaired cognitive status. The MDS indicated the resident to be at risk for the development of pressure ulcers but did not have pressure ulcers. The resident had a pressure reducing device on the bed but did not have a turning and repositioning program nor a pressure reducing device for the chair seat. The Interdisciplinary Resident Admit assessment dated [DATE] indicated the resident had a trace of dependent [MEDICAL CONDITION] to both lower legs, with palpable and posterior tibia pulses. The Assessment showed no open areas to the lower extremities and the skin was described as cool and dry. The assessment indicated the resident had an open area located on the coccyx area measuring 1.5 centimeter by 0.1 centimeter. The Progress Notes dated 9/16/15 at 3:42 p.m. indicated the treatment nurse asked the registered nurse to assess the resident ' s right heel wound. Documentation identified the wound on the right heel as a pressure ulcer and suspected deep tissue injury. The wound was consistent with a partially de- roofed blister. The wound base of 80 percent appeared white in color with 20 percent deep purple in color. The wound measured 3 centimeters by 4 centimeters and the depth could not be measured. The registered nurse instructed the treatment nurse that the resident should not wear shoe on right foot and the restorative nurse would be contacted in order to request a Prevalon boot to be worn in bed. The resident ' s heel would be kept off the surface of the bed. The nurse sent a fax to the physician with a request for a treatment to the heel. The physician ordered [MEDICATION NAME] ointment (antibacterial) to the open area on the right heel and cover with [MEDICATION NAME] and gauze. On 9/22/15 the nurse assessed the skin integrity per the Observation Report. The resident had non-[MEDICAL CONDITION], exudate scant and serosanguinous (serous and bloody) drainage. The nurse documented this to be a suspected deep tissue pressure ulcer and measured 3 centimeters by 4 centimeters and slough present. The interventions included a pressure relieving device on the bed and elevate the [MEDICAL CONDITION]/affected area and apply heel protectors. The physician's order [REDACTED]. Apply a non-stick dressing and gauze wrap. The MDS assessment with a reference date of 1/13/16 indicated the resident required extensive assistance of 2 staff persons with bed mobility. The resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no memory loss. The resident did not walk and used a wheelchair. The MDS indicated the resident to be at risk for pressure ulcers and had 1 unstageable pressure ulcer with suspected deep tissue injury in evolution. The resident continued to have a pressure relieving mattress on the bed and chair but did not have a turning/repositioning program. The Resident's Care Plan identified the resident had a problem due to a right heel pressure ulcer dated 1/13/16. The approach with a start date of 1/13/16 directed the nursing staff that the resident would have heel boots on at all times except for bathing. The resident would wear no shoes and to elevate both feet on pillows to keep the feet off of the surface of the bed. The approaches included the resident would receive a house supplement and a multivitamin each day. Observation on 3/29/16 at 7:05 a.m. Staff B, Registered Nurse, performed wound cares to the resident's right heel. The outer soiled gauze dressing had small amount of yellow drainage and the [MEDICATION NAME] next to the wound had moderate amount of gray and serosanguinous drainage. The wound opened at the base of the heel up the backside of the foot, approximately 4 to 5 cm. in length, approximately 3 to 3.5 cm. with .2 or .3 in depth. The wound had an inner, small amount of granulation, with yellow and gray tissue surrounding the inside granulation. Staff B cleansed the wound with normal saline and applied Solosite to the [MEDICATION NAME], placed it on the wound and then wrapped the area with gauze and tape. A fax dated 2/03/16 to the physician showed an update on the pressure ulcer with suspected deep tissue stage. The wound measured 4.4 cm. by 4 cm. by less than 0.3 cm. depth. A fax dated 3/24/16 to the physician showed the right heel pressure ulcer measured 4.5 cm. by 3.6 cm. by 0.2 cm. An interview on 3/30/16 at 7:00 a.m. the resident reported of not knowing how the pressure ulcer developed, but didn't think the shoes caused it. An interview on 3/30/16 at 7:06 a.m. Staff B thought the resident's shoes and TED hose caused the pressure ulcer. Staff B noted the resident dug his/her heels into the bed. The pressure ulcer started on the heel and migrated up the back of the foot. On 3/30/16 at 9:03 a.m. Staff A, registered nurse/treatment nurse was interviewed and reported the resident received the pressure ulcer here at the facility, as the resident didn't have it when admitted . She reported the pressure ulcer began when the resident transferred to long term care after being on the skilled unit. Staff A noted the pressure began due to the resident's feet rubbing on the bed and not wearing heel protectors. The pressure ulcer started as a blister on the right heel. On 3/31/16 at 2:50 p.m. the resident reported the wound foot hurts but not all the time. The resident noted it hurts during the night at times and a little bit during the dressing change.

Based on observation, record review and staff and resident interviews, the facility failed to provide adequate supervision and assistive devices to prevent the occurrence of a fall (Resident #1). The facility reported a census of 169 residents. The sample consisted of 4 residents. Resident #1 required extensive assistance with transfers and did not ambulate. The resident used a wheelchair and propelled self to meals. The facility staff failed to ensure the resident had access to the call light for assistance. The resident attempted to obtain a cane to release the call light from the wall and fell from the wheelchair. The fall resulted in a spiral fracture of the femur (thigh bone). Findings include: Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 10/12/2011, which identified the resident had a BIMS (Brief Interview for Mental Status) score of 8. The score of 8 indicated moderate cognitive impairment. The MDS indicated Resident #1 required extensive staff assistance with bed mobility, transferring, dressing, toilet use, personal hygiene; total assistance with bathing, and did not ambulate. Resident #1 required staff supervision with locomotion on the unit. The Client [DIAGNOSES REDACTED]. The Plan Of Care dated October 2011 identified Resident #1's need for staff assistance to complete the activities of daily living. The plan directed staff to do the following: * clip light to gown at night * provide "trough" for left upper arm * non skid mat in place in lift chair * Vanderlift for transfers with assist of two * wheel chair with right lateral, tall reclined back, upper back support, and left swing away arm trough for positioning During an interview on 01/11/2012 at 2:35 p.m. Staff A indicated he/she assisted Resident #1 with getting up from the bed and ready for supper between 3:00 and 4:00 p.m. on 12/28/2011. Staff A stated during the process of assisting the resident he/she "protected" the call light by attaching the call light clip to the cord at the level of the wall, so it would not be pulled out, run over, or otherwise damaged. Staff A stated Resident #1 independently propelled self to the ground level of the facility (via the elevator) for the supper meal. Staff A stated about 6:00 p.m. that evening, he/she peeked in Resident #1's room, and made a remark to Resident #1 that he would return shortly (or something to that effect). Staff A stated minutes later he heard "help' and when he responded to Resident #1's room, found Resident #1 on the floor, with the wheelchair tipped over on top of him/her. Staff A stated he immediately summoned assistance. During the interview, Staff A also stated that it was his responsibility to have placed the call light in reach of the resident, but had failed to do so. During an interview on 01/11/2012 at 4:40 p.m. Resident #1 stated he/she recalled the event of the fall, and described he/she leaned forward and downward in the wheelchair in an attempt to reach and untangle a cord around a quad cane, located in the corner of the room. Resident #1 stated had intended to use the quad cane to reach the call light attached to the wall. Resident #1 did not recall why or for what reason had needed to use the call light. During an interview on 01/11/2012 at 11:23 a.m. Staff B stated the staffs are very good at ensuring call lights are within reach for all residents. Staff B indicated staff are to complete a "5 point inspection" when they leave a resident ' s room, which included to ensure a light is on, alarm on (if applicable) call light is in place, bed is in correct position and the floor is clutter free. Staff B indicated that even if a resident is out of his/her room, things (i.e. the call light and other personal items) are to be in reach of the resident if and when the resident returns to their room. The hospital history and physical report dated 12/28/2011, indicated Resident #1 informed hospital personal that he/she leaned forward out of the wheelchair to grab something when and he/she leaned too far and twisted, fell to the floor and doing what he/she calls the splits. The resident had an immediate onset of pain. The hospital report indicated the x-rays showed severe osteopenia and a spiral fracture beginning in the mid shaft of the femur extending distally. The report indicated the resident would be placed in traction for comfort and surgery would be required. During an interview on 01/11/2012 at 3:24 p.m., the facility Director of Nursing stated all nursing staff received ongoing education for fall prevention designed as an "ABC Checklist" which prompted all staff to ensure the call light is within the resident's reach and functioning properly.