Every finding on record at Strasburg Nursing Home

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 14 residents (Resident #21) reviewed for self-administration of medication (SAM). Failure to assist/observe residents who are not SAM take their medications may result in adverse health consequences.Findings include:Review of the facility policy titled Self-Administration of Medications occurred on 04/01/26. This policy, dated 01/16/26, stated, . A licensed nurse will complete the Self-Administration of Medications [SAM] screen . The Interdisciplinary team (IDT) will make a determination based on the screen . Re-assessment will be completed quarterly and PRN [as needed].Review of Resident #21's medical record occurred on all days of survey. A SAM assessment, dated 01/19/26, lacked the resident's choice to not self-administer his medications. A progress note, dated 01/28/26 at 1:54 p.m., stated, . Quarterly hospital return MDS completed . Resident does not wish to participate in SAM.Observation on 04/01/26 at 7:41 a.m. showed Resident #21 seated for the morning meal. A nurse (#5) prepared the resident's medications and stated, He is SAM. The nurse placed a cup of pills on the table, mixed a powdered stool softener in a glass of water, and returned to the medication cart. The nurse (#5) failed to assist/observe Resident #21 with his medications. During an interview on 04/01/26 at 11:40 a.m., a staff nurse (#4) confirmed the nurse should observe/assist Resident #21 taking his medications.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to ensure medication labels and provider's orders matched for 1 of 8 residents (Resident #21) observed during medication pass. Failure to ensure medication labels matched the provider's order placed residents at risk for medication errors.Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 838-840, stated, . Obtain the appropriate medication. Compare the label of the medication container or unit-dose package against the order on the MAR [medication administration record] or computer printout. Rationale: This is a safety check to ensure that the right medication is given. If these are not identical, recheck the prescriber's written order in the client's chart. If there is still a discrepancy, check with the pharmacist. Prepare the medication. While preparing the medication, recheck each prepared drug and container with the MAR again. Rationale: This second safety check reduces the chance of error.Review of Resident #21's medical record occurred on all days of survey. A provider's order, dated 02/11/26, identified to increase dicyclomine (treats irritable bowel) to 20 milligrams (mg) twice a day. Observation on 04/01/26 at 7:41 a.m. showed a nurse (#5) prepared Resident #21's medications. The MAR identified dicyclomine 20 mg twice a day. The medication label indicated to administer half tablet (10 mg) twice a day. The nurse confirmed the provider's order and administered 20 mg.During an interview on 04/01/26 at 10:40 a.m., an administrative nurse (#1) confirmed Resident #21's dicyclomine label did not match Resident #21's MAR.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 sampled residents (Resident #2 and #24) observed during dressing changes. Failure to practice infection control standards related to use of personal protective equipment (PPE) for a resident in enhanced barrier precautions (EBP), hand hygiene, and providing a clean surface area for dressing supplies has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (not regular isolation precautions) occurred on 04/01/26. This policy, dated 04/01/24, stated, . 'Enhanced barrier precautions' refers to use of gown and gloves during high-contact resident care activities . High contact resident care activities do include . Chronic wound care and dressing change . Review of the facility policy titled, Dressing Changes occurred on 04/01/26. This policy, dated 11/25/25, stated, . 1. Wash hands thoroughly 2. [NAME] [apply] clean gloves 3. Remove dressing and discard 4. Remove soiled gloves and discard 5. Perform hand hygiene 6. Put on clean disposable gloves . 8. Apply treatment as ordered 9. Apply dressing as ordered 10. Remove gloves and discard 11. Perform hand hygiene . Dressings, gloves, plastic bags, etc. are never to be placed on the resident's bed; use an over-the bed table to put supplies on, making sure it is left clean and neat. Wipe over-the-bed table off with disinfectant wipe before dressing change and after. -Review of Resident #2's medical record occurred on all days of survey. The care plan identified EBP related to the suprapubic catheter (urine drainage tube inserted through the abdomen) with chronic cellulitis (bacterial skin infection) and wound drainage around the site. Observation on 04/01/26 at 9:58 a.m. showed a sign on Resident #2's door indicating EBP, the resident in bed, and a basket of wound supplies on the bedside table. A nurse (#3) entered the room, performed hand hygiene, applied gloves, and removed a soiled dressing from the resident's suprapubic catheter site. The nurse removed the soiled gloves, and without performing hand hygiene, applied clean gloves. The nurse cleansed the catheter site as ordered and applied a clean dressing. The nurse removed the soiled gloves, and without performing hand hygiene, placed the wound supplies into the basket, placed the basket into the nightstand drawer, and applied the resident's shoes. The nurse (#3) then performed hand hygiene and exited the room. The nurse (#3) failed to apply a gown prior to completing Resident #2's dressing change and use appropriate hand hygiene during the dressing change. During an interview on the morning of 04/01/26, an administrative nurse (#1) stated she expected staff to wear a gown when caring for residents with catheters and utilize proper hand hygiene/glove use during dressing changes. - Review of Resident #24's medical record occurred on all days of survey. The current care plan stated, The resident has a pressure ulcer to right heel . Goal: The resident's pressure ulcer will show signs of healing and remain free from infection.Observation on 04/01/26 at 10:22 a.m. showed Resident #24 in a wheelchair. The nurse (#3) removed dressing supplies from a plastic basin, opened a package of gauze, and placed the gauze directly on a cloth chair. The nurse then placed the scissors, tape, and cleaning solutions on the chair. The nurse failed to use a clean surface for the dressing supplies.

Based on record review, review of facility policy, and resident and family interviews, the facility failed to ensure an alleged violation of misappropriation of resident property was reported within 24 hours to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #20) with a report of missing money. Failure to report the alleged violation to the SSA placed Resident #20 and other residents at risk for misappropriation of property. Findings include: Review of the facility policy titled Abuse, Neglect, Mistreatment, Exploitation &/or Misappropriation of Resident Property occurred on 01/23/25. This policy, dated October 2024, stated, . It is the policy of the facility to provide protections for the health, welfare and rights of each resident by taking appropriate steps to prevent . misappropriation of resident property, regardless of the resident's mental or physical condition. Alleged violations will be reported to . the State Survey & Certification Agency, in accordance with state law through established procedures. Review of Resident #20's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE], identified intact cognition. During an interview on 01/21/25 at 3:43 p.m., Resident #20 stated, I had a check for $100.00 from my wife that she had given to me for a Christmas gift. Last Friday I gave the check to my daughter to take to the bank and cash it for me. My daughter brought the money back to me in a bank envelope and it was five twenties. Then Sunday when I went to take a shower I took the envelope with the money in it and this notepad out of my shirt pocket and put it in this drawer. When I came back to my room after my shower the notepad was in the drawer, but the envelope with the money in was not there. So I told the nurse I was missing my money. When asked if the facility assisted the resident to look for his money, he stated, Yes, I told them they could look all they wanted but I already did and didn't find it. And they couldn't find it either. Review of Resident #20's progress notes included the following: * 1/19/25 at 1:16 p.m. Has been talking about an envelope with 100 dollars that he received the past several days, and lost the money. Nurse phoned [Resident #20's daughter] whom will talk to the resident (nothing mentioned about loosing [sic] money up until today), and then call the nurse back. * 1/19/25 at 2:12 p.m. [Resident #20's daughter] called back, res. [resident] received the 100 dollars on 1-17 [January 17th, 2025]. Res. had told [Resident #20's daughter] he misplaced the money. * 1/19/25 at 5:29 p.m. Res. talked with the bathing CNA [certified nurse aide] from this morning, she explained to resident that he didn't have his shirt or vest on, then res. said 'I misplaced the money in a drawer' . * 1/21/25 at 10:19 a.m. He said he is missing $100.00, said that 'someone had sticky fingers on his bath day, Monday' . During an interview on 01/23/25 at 9:33 a.m., an administrative nurse (#1) verified she had not reported Resident #20's missing money to the SSA.

Based on record review, policy review, and staff, resident and family interviews, the facility failed to initiate an investigation of an alleged violation of misappropriation of resident property for 1 of 1 sampled resident (Resident #20) with reports of missing money. Failure to investigate the alleged misappropriation of the resident's property and ensure all residents are protected placed them at risk for emotional and mental distress. Findings include: Review of the facility policy titled Lost & Missing Items occurred on 01/23/25. This policy, dated January 2025, stated, . This facility maintains a safe and secure environment to minimize lost and/or missing items. When a resident reports a missing item a. Staff will complete the Missing Item form b. Staff will complete a search of the resident's room as well as nearby rooms c. Social Service staff will inform department heads at morning stand up d. A record of areas searched will be kept . Review of the facility policy titled Abuse, Neglect, Mistreatment, Exploitation &/or Misappropriation of Resident Property occurred on 01/23/25. This policy, dated October 2024, stated, . It is the policy of the facility . to prevent . misappropriation of resident property, regardless of the resident's mental or physical condition. The facility will thoroughly investigate all allegations . The facility will immediately engage in efforts to identify, intervene and correct situations in which . misappropriation of resident property have occurred or are more likely to occur. Review of Resident #20's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE], identified intact cognition. During an interview on 01/21/25 at 3:43 p.m., Resident #20 stated, I had a check for $100.00 from my wife that she had given to me for a Christmas gift. Last Friday I gave the check to my daughter to take to the bank and cash it for me. My daughter brought the money back to me in a bank envelope and it was five twenties. Then Sunday when I went to take a shower I took the envelope with the money in it and this notepad out of my shirt pocket and put it in this drawer. When I came back to my room after my shower the notepad was in the drawer, but the envelope with the money in was not there. So I told the nurse I was missing my money. When asked if the facility assisted the resident with looking for his money, he stated, Yes, I told them they could look all they wanted but I already did and didn't find it. And they couldn't find it either. Review of Resident #20's progress notes included the following: * 1/19/25 at 1:16 p.m. Has been talking about an envelope with 100 dollars that he received the past several days,and [sic] lost the money. Nurse phoned [Resident #20's daughter] whom [sic] will talk to the resident (nothing mentioned about loosing [sic] money up until today), and then call the nurse back. * 1/19/25 at 2:12 p.m. [Resident #20's daughter] called back, res. [resident] received the 100 dollars on 1-17 [January 17th, 2025]. Res. had told [Resident #20's daughter] he misplaced the money. * 1/19/25 at 5:29 p.m. Res. talked with the bathing CNA [certified nurse aide] from this morning, she explained to resident that he didn't have his shirt or vest on, then res. said 'I misplaced the money in a drawer'. * 1/21/25 at 10:19 a.m. He said he is missing $100.00, said that 'someone had sticky fingers on his bath day, Monday.' . During an interview on 01/22/25 at 4:23 p.m., Resident #20's daughter, (Family member A), stated, He [Resident #20] might misplace things like we all do for a short time and then find them. It is not normal behavior for my dad to say he is missing things which he is not, and he has a very good mind. During an interview on 01/22/25 at 4:53 p.m., Resident #20's daughter, (Family member B), stated, Last Friday I took the check to the bank for my dad per his request and cashed it. I then took the bank envelope with five twenty dollar bills to me dad. He [Resident #20] didn't go anywhere to spend the money so where did it go? During an interview on 01/23/25 at 9:33 a.m., an administrative nurse (#1) verified the facility had not started and/or completed an investigation for Resident #20's missing money.

Based on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 2 of 3 residents (Resident #9 and #12) observed for insulin preparation and administration. Failure to prime insulin pens correctly may result in residents receiving an inaccurate dose. Findings include: Review of the facility policy titled Insulin Pens occurred on 01/22/25. This policy, dated 01/06/25, stated, . 5. Prime the pen, a. Dial 2 units by turning the dose selector. b. Remove the cover from the needle and hold the pen with needle pointed upward. - Observation on 01/21/25 at 5:23 p.m. showed a nurse (#3) prepared Resident #12's insulin pen for administration. The nurse failed to prime the insulin pen upward. - Observation on 01/22/25 at 7:59 a.m. showed a nurse (#4) prepared Resident #9's insulin pen for administration. The nurse failed to prime the insulin pen upward. During an interview the morning of 01/23/25, an administrative staff member (#1) stated she expected staff to follow the policy for priming insulin pens.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received the necessary service to maintain personal hygiene for 1 of 8 sampled residents (Resident #18) who required staff assistance for personal hygiene. Failure to assist residents who cannot perform personal hygiene independently may result in poor hygiene, skin issues, and decreased self-esteem. Findings include: Review of the facility policy titled ADLs (Activities of Daily Living) occurred on 01/23/25. This policy, dated October 2024, stated, . It is the policy of the facility to provide ADL care to residents as needed to ensure all ADL needs are met are on a daily basis. Review of Resident #18's medical record occurred on all days of survey. The current care plan stated, . The resident has an ADL self-care performance deficit r/t [related to] dementia PERSONAL HYGIENE: she needs set up help and verbal reminders for personal hygiene. Observation on 01/22/25 at 8:17 a.m. showed a nurse (#3) assisted Resident #18 to pick out her clothing, placed the clothing in the bathroom, and asked, Do you want me to help you? The resident answered, yes, and without providing assistance or verbal reminders for personal hygiene, the nurse assisted the resident to remove her pajamas and put on new clothing. After exiting the room, when asked if the resident needs assistance with personal hygiene, the nurse (#3) stated, When she will allow us to help her. During an interview on 01/23/25 at 9:33 a.m., an administrative nurse (#1) stated she expected the nurse (#3) to assist Resident #18 with personal hygiene while she assisted the resident with dressing.

Based on observation, record review, and resident and staff interview, the facility failed to ensure appropriate care and services for 1 of 2 sampled residents (Resident #16) with an indwelling urinary catheter. Failure to empty Resident #16's catheter bag may result in urinary tract infections (UTIs), unnecessary discomfort, and urinary retention and/or obstruction. Findings include: Review of the facility policy titled Catheter Care occurred on 01/23/25. This policy, dated October 2024, stated, . Empty drainage bag at the end of each shift [i.e., three times per day] . Review of Resident #16's medical record occurred on all days of survey. Diagnoses included obstructive and reflux uropathy (blockage that hinders urinary flow), benign prostatic hyperplasia (enlarged prostate that can cause blockage of urine flow from the bladder as well as urinary tract and kidney problems), and history of UTIs. The care plan stated, . The resident has an indwelling suprapubic catheter related to urinary obstruction. Observations on 01/21/25 of Resident #16 showed the following: * 4:43 p.m. Approximately 1200 cubic centimeters (cc) of urine in the catheter bag. The resident stated, It feels like it might explode. * 5:50 p.m. Approximately 1300 cc of urine in the catheter bag. Resident #16's output record showed staff emptied the catheter bag on 01/21/25 at 7:53 p.m., and it contained 2000 cc of urine. The medical record also showed four days from January 6th to January 20th, 2025, staff emptied the resident's catheter bag twice in a 24-hour period. During an interview on 01/23/25 at 9.33 a.m., an administrative staff (#1) confirmed staff should have emptied Resident #16's catheter before 8:00 p.m. on January 21st, and stated she expected certified nurse assistants to empty catheter bags at least once per eight-hour shift.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 2 sampled residents (Resident #9) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP) and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions occurred on 01/22/25. This policy, dated 04/01/24, stated, . It is the policy of this facility to implement enhanced barrier precautions to prevent the transmission of multidrug-resistant organisms (MDRO) during high-contact activities for residents with chronic wound or indwelling medical devices, even if the resident is not known to be infected or colonized with a MDRO. 'Enhanced Barrier Precautions'. refers to the use of gown and gloves during high-contact resident care activities for residents. at increased risk of MDRO acquisition (e.g., .indwelling medical devices). urinary catheters .) . High-Contact Resident Care Activities may include: Transferring. Review of the facility's policy titled Hand Hygiene occurred on 01/21/25. This policy, dated 11/20/24, stated, . Each staff member is responsible to practice hand hygiene. The use of gloves does not replace hand hygiene. perform hand hygiene prior to donning gloves and immediately after removing gloves. - Review of Resident #9's medical record occurred on all days of survey. A current physician's order stated, Enhanced Barrier Precautions every shift for foley catheter. Observations of Resident #9 showed the following: * 01/21/25 at 5:01 p.m., Resident #9 had a catheter drain bag. Two certified nurse aides (CNA) (#6 and #7) transferred Resident #9 from the recliner to the wheelchair. The CNA (#6) moved the catheter bag to the wheelchair. The CNAs (#6 and #7) failed to don a gown or gloves before they transferred Resident #9. * 01/22/25 at 9:13 a.m., Two CNAs (#5 and #8) failed to don a gown or gloves prior to transferring the resident from the toilet to the wheelchair. * 01/22/25 at 4:03 p.m., a CNA (#6) donned a gown and gloves and entered the bathroom where Resident #9 sat on the toilet. The CNA (#6) emptied Resident #9's catheter drainage bag, removed her gloves, and without performing hand hygiene, donned new gloves, raised Resident #9 to a standing position with a mechanical stand lift, and performed bowel movement cares. The CNA removed her gloves, and without performing hand hygiene, donned new gloves, adjusted the resident brief and clothes, and transferred the resident to the recliner. The CNA (#6) removed her right glove, and without performing hand hygiene, applied Resident #9's oxygen cannula. During an interview on 01/23/25 at 11:35 a.m., an administrative nurse (#1) confirmed the facility failed to educate staff on the use of gown and gloves for transfers of residents in enhanced barrier precautions, and stated she expected staff to perform hand hygiene after removing gloves and before putting on new gloves or touching other surfaces per policy.

Based on observation, record review, and staff interview, the facility failed to provide care for 1 of 2 sampled residents (Resident #12) with an indwelling catheter in a manner and environment that maintained, enhanced, and respected the resident's dignity. Failure to cover the resident's catheter drainage bag does not preserve the resident's personal dignity or enhance their quality of life. Findings include: The facility failed to provide a policy for dignity and covering of a catheter drainage bag when requested. Observations of Resident #12 showed the following: * 01/02/24 at 6:00 p.m., Resident returned from the dining room with the catheter drainage bag (containing urine) uncovered and hanging under the wheelchair. * 01/03/24 at 8:54 a.m., Resident returned from the dining room with the catheter drainage bag (containing urine) uncovered and hanging under the wheelchair. * 01/03/24 at 11:48 a.m., Resident sat in the dining room with the catheter draining bag (containing urine) uncovered. During an interview the afternoon of 01/04/23 at 2:00 p.m., an administrative nurse (#1) confirmed she expected urine drainage bags be covered.

Based on record review review of facility policy, and staff interview, the facility failed to provide the resident's representative and/or the State Long Term Care (LTC) Ombudsman a written notice of transfer for 1 of 4 sampled residents (Resident #14) with a recent hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights or inform the Ombudsman of the transfer. Findings include: Review of the facility policy titled Transfer or Discharge occurred on 01/04/24. This policy, dated 10/07/21, stated, . Notice before transfer. Before the facility transfers or discharges a resident, the facility will: Notify the resident and the resident's representative of the transfer or discharge and the reasons for the transfer or discharge in writing and in a language and manner the resident understands and will send a copy of the notified to the Long term Care Ombudsman. Review of Resident #14's medical record occurred on all days of survey and identified a hospital transfer on 12/11/23. The resident's medical record lacked evidence the facility provided a transfer notice to the resident's representative, and/or the ombudsman. During an interview the afternoon of 01/04/24, an administrative staff member (#1) verified the facility did not provide a transfer notice to Resident #14's representative or to the ombudsman.

Based on record review, review of facility policy, and staff interview, the facility failed to provide a bed hold notice upon transfer to the hospital for 1 of 4 sampled residents (Resident #14). Failure to provide a bed hold notice does not allow residents or their legal representatives to make informed choices regarding their readmission rights. Findings include: Review of the facility policy titled Bed Hold occurred on 01/04/24. This policy, dated 08/01/23, stated, It is the policy of the facility to hold a bed for a resident if they or their representative prefer the bed be held when that resident is transferred to an acute setting . Review of Resident #14's medical record occurred on all days of survey and identified a transfer to the hospital on 12/11/23. The record lacked evidence the facility discussed a bed hold with the resident and/or the family/legal representative or provided a bed hold notice. During an interview the afternoon of 01/04/24, an administrative staff member (#1) confirmed the facility failed to provide the bed hold notice.

Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 1 sampled resident (Resident #7). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2019, page J-23 stated, . Current Tobacco Use . Steps for Assessment. Ask the resident if he or she used tobacco in any form during the 7-day look-back period. If the resident states that he or she used tobacco in some from during the 7-day look-back period code 1, yes. Review of Resident #7's medical record occurred on all days of survey. The Annual MDS dated [DATE], identified the facility coded 'no for tobacco use. The care plan stated, . The resident has a need for meaningful activities r/t [related to] psychosocial health. The resident smokes with supervision . A progress note dated 05/25/23 at 7:52 a.m., stated, Annual . MDS completed . Resident continues to choose to smoke cigarettes and requires supervision and a smoking apron when smoking. During an interview on 01/04/24 at 2:21 p.m., an administrative staff member (#1) confirmed staff failed to code the MDS correctly.

Based on observation, record review, and review of facility policy, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 1 sampled resident (Resident #26) observed during a transfer. Failure to provide a gait belt during transfers placed the resident at risk for accidents, falls, or injuries. Findings include: Review of the facility policy titled Gait Belt Use occurred on 01/04/24. This policy, dated 12/06/23, stated,. The facility will provide a gait belt for each resident who is unable to transfer or ambulate without extensive assistance. Do not lift the resident under their arms or by the waistband of their pants during transfer. Review of Resident #26's medical record occurred on all days of survey and included diagnoses of dementia. The current care plan stated, TRANSFER: The resident transfers with assist of one. He will sometimes transfer per self. He does not use his walker. Provide repeated cues encouraging him wait for assistance . Review of Resident 26's activities of daily living charting, dated January 2 and 3, 2024 identified extensive assist to total dependence with transfers. Observation on 01/03/24 at 11:18 a.m., showed a certified nurse aide (CNA) (#3) assisted Resident #26 to stand by grabbing his waist band and lifting under the arm. Observation on 01/03/24 at 1:34 p.m., showed two CNAs (#3 and #4) assisted Resident #26 to stand by grabbing his waist band and lifting under his arm. The CNA (#3) assisted Resident #26 with ambulation by holding on to his shirt and waist band. After toileting, the CNA (#3) assisted the resident from the toilet by lifting under the arm. Facility staff failed to use a gait belt during the transfer with Resident #26.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications during 1 of 2 observations of insulin administration. Failure to store insulin pens securely may result in unauthorized access to the medication. Findings include: Review of the facility policy titled Insulin Pens occurred on 12/04/23. This policy, reviewed 12/06/23, stated after administration to, . Remove the needle from the pen and discard appropriately . Place cap back on the pen and return to storage drawer in med [medication] cart. Observation on 01/03/24 at 11:24 a.m. showed a medication aide (MA) (#2) administered insulin to Resident #12. After completion of administration, the MA laid the insulin pen with the retractable needle in place on the resident's bedside table. The MA then assisted the resident to the dining room. Observation at 11:43 a.m. showed housekeeping staff cleaning the resident's room and the insulin pen on the resident's bedside table. Observation at 1:00 p.m. showed the insulin pen remained on the resident's beside table and the surveyor then gave the pen to the MA (#2) for safe storage. The MA (#2) failed to discard the insulin pen needle and properly store the insulin pen after Resident #12's insulin administered. During an interview the afternoon of 12/04/23, an administrative nurse (#1) confirmed insulin pens are expected to be returned to the medication cart after insulin is administered.

Based on record review, review of facility policy, and staff interviews, the facility failed to ensure all alleged incidents involving possible injury were reported immediately to the State Survey Agency (SSA) for 1 of 4 sampled residents (Resident #4) with an unwitnessed fall. Failure to immediately report alleged incidents to the State Agency placed Resident #4 and other residents at risk for possible abuse and/or further injury. Findings include: Review of the facility policy titled Abuse, Neglect, Mistreatment, Exploitation &/or Misappropriation of Resident Property occurred on 12/21/22. This policy, dated October 2022, stated, . Injuries of unknown source: An injury should be classified as an injury of unknown source . a. The source of the injuring [sic] was not observed . Alleged violations will be reported to other officials, including the State Survey & Certification Agency, in accordance with state law . Resident #4 nurses' notes stated the following: 06/13/22 at 10:19 a.m., CNA [certified nursing assistant] was walking past Res [resident] room and she found [Resident #4] sitting on the floor in front of her recliner with her legs out front turned inward with pain in her Rt [right] hip/knee area. she was left on the floor and ambulance was called . 06/13/22 at 1:53 p.m., . res has small FX [fracture] in ball of her Lt) [left] hip. 06/13/22 at 08:05 p.m., . will be transferred to [name of town] for MRI [magnetic resonance imaging] and evaluation . has small fracture to left hip and to left elbow. 06/15/22 at 09:12 a.m., . received call from [name of facility] that MRI indicated there were no fractures present in elbow or hip as had been previously reported. Resident will be returning . The facility failed to provide evidence of a report or investigation of the incident. During interview on 12/21/22 at 5:21 p.m., two administrative staff members (#1 and #2) confirmed they lacked evidence the facility reported the incident to the SSA and they should have reported this incident.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 5 sampled residents (Resident #11) who required assistance with transfers. Failure to use a gaitbelt when transferring a resident placed Resident #11 at risk for falls and injury. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th edition, eText 2021, [NAME] Boston, Massachusetts, page 1054, stated, Assisting a Client to Ambulate . If the client is a low safety risk . use a gait/transfer belt for standby assist as needed and assistive devices as needed . and 1-2 caregivers. Make sure the belt is pulled snugly around the client's waist and fastened securely. Grasp the belt at the client's back . Review of Resident #11's medical record occurred on all days of survey. The current care plan stated, . At risk for falls . Resident has ADL (activities of daily living) self-care deficit and requires assist of 1 with walker, gait-belt for transfers and ambulation due to weakness and dementia . Observation on 09/27/21 at 11:12 a.m., showed a CNA (certified nursing assistant) (#2)transferred Resident #11 from the bed to standing. During the transfer, the CNA (#2) grabbed on to the waistband of resident #11's pants. pulling them up until almost under her arms. During the transfer the resident appeared unsteady while moving toward the wheelchair. The CNA (#2) failed to use a gait belt during the transfer. During an interview on 09/29/21 at 11:00 a.m., an administrative nurse (#1) stated she would expect staff to use the gait-belt for Resident #11 during a transfer.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure proper respiratory care for 1 of 3 sampled residents (Resident #28) with orders for oxygen (O2) therapy. Failure to provide O2 as ordered may complicate the residents' respiratory status. Findings included: Review of the facility policy titled [NAME] Care Center Oxygen occurred on 09/29/21. This policy, updated June 2021, stated, . to provide oxygen therapy per physician order by O2 concentrator or O2 tank . Review of Resident #28's medical record occurred on all days of survey and included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's order stated, O2 @ [at] 2L[liters]/NC [nasal cannula]- continuous . The current care plan stated, . Oxygen as ordered . Observation on all days of survey showed Resident #28's oxygen concentrator at 2.5 liters. During an interview on 09/29/21 at 10:47 a.m., an administrative nurse (#1) stated she expected staff to follow the current provider order for continuous oxygen. The facility failed to ensure Resident #28 received the correct oxygen flow per physician orders.

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to review/revise the comprehensive care plans to reflect the current status for 2 of 14 sampled residents (Resident #29 and #34) and 2 supplemental residents (Residents (#11 and #30). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled Care Plan Policy occurred on 10/03/18. This policy, dated 09/27/17, stated, . The care plan will be reviewed and revised quarterly and PRN (as needed). - Review of Resident #29's medical record occurred on all days of survey. The current care plan identified, . EZ stand (sit-to-stand mechanical lift) assist (of) 1 . EZ stand 2 assist as needed on pms and nights per nurse's discretion . The current certified nursing assistant (CNA) care sheet identified, EZ stand assist of 1 . EZ stand assist of 2 as needed . Hoyer (full-body mechanical lift) prn (as needed) at nurse's discretion . The current care plan contradicted the CNA care sheet, which directed staff to utilize two staff members on the evening and night shifts and failed to address the use of the Hoyer lift. Observation on 10/01/18 at 11:31 a.m. and 10/02/18 at 4:11 p.m. showed two CNAs transferred Resident #29 utilizing a VERA-Lift II sit-to-stand mechanical lift. Observation on 10/02/18 at 11:25 a.m. showed one CNA transferred Resident #29 utilizing the same VERA-Lift II sit-to-stand mechanical lift. During an interview on 10/03/18 at 9:37 a.m., a nurse (#12) stated, The CNAs should always go by the care plan. (Resident #29) was a one and now she is a two (person assist). The nurse's (#12) comments also contradicted Resident #29's current care plan. - Review of Resident #34's medical record occurred on all days of survey. The current care plan identified, . Thickened liquids, nectar . Eats meals in Dining Room . Cannot be fed by paid feeder . Feeds self Assist with meals, Bedside table at meals . The current CNA care sheet identified, Pureed solids and thin liquids, Feeds Self, Supervision & needs assist w (with)/eating . The weight change history, dated (MONTH) 2, (YEAR)-October 2, (YEAR), identified a 8.33% significant weight loss within a 3 month time span (March 6, (YEAR)-June 5, (YEAR)) and a 12.76% significant weight loss within a 6 month time span (January 2, (YEAR)-July 3, (YEAR)). A nutritional quarterly notes, dated 02/05/18 and 08/06/18, and nutritional risk assessment, dated 05/10/18, identified Resident #34 as uncooperative with or resistive to cares, and very resistive at meals. Observations on 10/01/18 at 11:54 a.m. and 10/02/18 at 8:26 a.m., 11:41 a.m., and 5:38 p.m., showed facility staff fed Resident #34 approximately 75% of each meal. Observation showed Resident #34 seated in a reclined position (at an approximate 70 degree angle with his head tilted slightly back) in his wheelchair, staff feeding him heaping teaspoon-sized bites of pureed foods or using a very rapid rate of presentation, and offering him sips of thickened liquids via a nosey-cup. Resident #34 had a runny nose, spit food out, and/or showed an immediate and/or delayed cough while eating/drinking. During an interview on 10/03/18 at 12:25 p.m., when asked what additional interventions were implemented for Resident #34, the dietitian (#13) stated, We tried a magic cup and he didn't like it. During an interview on 10/03/18 at 8:55 a.m., when asked what additional interventions were implemented for Resident #34, the nurse (#12) reported, High protein jello, something new we just got to the building. I gave him a magic cup at noon and he ate it. During an interview on 10/03/18 at 2:03 p.m. two administrative nurses (#4 and #10) agreed residents should be seated as close to 90 degrees as possible, should be offered small bites of food/sips of liquids at a slow rate of presentation, and staff should be cognizant of/respond to signs/symptoms of dysphagia. The current care plan failed to address Resident #34's gradual, but significant weight loss, various dietary interventions attempted and whether they were successful or needed to be modified, need for proper positioning during meals, dependence on staff for meal intake, need for a controlled bite/sip size and slow rate of presentation, use of nosey cups, the signs/symptoms of dysphagia Resident #34 demonstrates, and/or the type of resistive behaviors he demonstrates. The current care plan also contradicted the CNA care sheet, which directed staff to offer thin liquids versus nectar thickened liquids. - On 10/01/18 the facility identified a paid feeding assistant (PFA) can assist Resident #11 with eating. Review of Resident #11's care plan showed the facility failed to include the determination a PFA can assist the resident. - On 10/01/18 the facility identified a PFA can assist Resident #30 with eating. Review of Resident #30's care plan showed the facility failed to include the determination a PFA can assist the resident.

Based on observation, record review, review of facility policy, resident interview, and staff interview, the facility failed to consistently ensure a code status identification process for 1 of 2 sampled residents (Resident #8) when a full code status reflected the resident's wishes. Failure to ensure facility staff consistently followed the facility's policy regarding code status has the potential to limit access to life-sustaining services for all residents. Findings include: Review of the facility policy titled Code Status occurred on 10/03/18. This policy, dated 04/15/18, stated, . designated sections of documentation are physician orders, MAR (Medication Administration Record), care plan, and on the front of the chart binder and on the resident profile page in the electronic medical record. During an interview on 10/01/18 at 3:44 p.m., a certified nurse aide (CNA) (# 5) indicated a residents' code status was documented in the residents' chart, included a physician's order for a full code, and identified by a heart symbol by the resident's door and assigned seating location in the dining room. Review of Resident #8's record occurred all days of survey. A physician's order, dated 06/13/18, identified a full code. The MAR, care plan, chart binder, and electronic medical record also identified a full code. An observation on 10/01/18 at 4:00 p.m. showed Resident #8's room failed to display a heart symbol on the door indicating a full code status. During an interview on 10/01/18 at 4:50 p.m., when asked the code status of Resident #8 and presence of a heart symbol on the door, the staff nurse (#6) verified the resident's full code status and no heart symbol appeared on the door to identify a full code status. During an interview on the morning of 10/03/18, Resident #8 stated he wished to maintain a full code status. During an interview on 10/03/18 at 2:49 p.m., an administrative nurse (#4) identified no facility policy or procedure required a heart symbol on a resident's door to indicate a full code status. She indicated no awareness of the heart symbol used by by staff. The facility failed to identify a consistent procedure for all staff to identify a resident's code status.

1. Based on observation, record review and staff interview, the facility failed to ensure adequate supervision and assistance to prevent an accident for 1 of 1 sampled resident (Resident #8) with a history of falls who required assistance with transfers and experienced a fracture. Failure to provide supervision during toileting resulted in Resident #8's fall and hip fracture which required surgical repair. Findings include: Review of Resident #8's medical record occurred on August 01-03, 2011. The facility admitted the resident in October 2007. The resident experienced a fall in the bathroom on 07/22/11 and was transferred to an acute care facility for an open reduction internal fixation (ORIF) of a left hip fracture. The resident returned to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. Resident #8's quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment, the resident required limited assistance of one person for transfers, walking in room, toilet use, and experienced two or more falls with injury since the prior MDS. The resident's Fall Risk Assessments, dated 04/04/11 and 07/07/11, identified total Fall Risk scores of "19" and "21," respectively. A resident with a score greater than "10" is considered a fall risk. Resident #8's medical record included memoranda to the resident's responsible parties, dated 04/04/11, stating ". . . Fall Risk Assessment completed. Resident scored 19 - which indicates she is @ (at) high risk for falls. Did fall 04/01/11. Conts. (Continues) to attempt to get up by herself @ times, however calls for assist the majority of the time. Fall Precautions include Chair Check in w/c (wheelchair) & (and) recliner . . .;" and, dated 07/07/11, stating ". . . Fall Risk Assessment completed. Resident scored 21 - which indicates she is @ high risk for falls. She has had 2 falls the past 3 months. Fall Precautions include . . . Chair Check Alarm in the wheelchair & in the recliner. . . ." Resident #8's Fall Tracking Form identified the following: *04/01/11, 4:20 p.m., "Activity . . . Found sitting on the floor in BR (bathroom). Was placed on toilet by staff, call lite (sic) in hand. . . . Plan, Cont. all interventions. . . ." *05/08/11, 9:30 p.m., "Activity . . . Res. (Resident) was found on BR floor, was trasfering (sic) self from toilet to w/c. . . . Plan, Continue with all interventions. Remind Res. to use call lite. (sic) . . ." The resident's Nurse's Notes and the facility's Incident Reports for these dates and times confirm these events and interventions. Resident #8's care plan, dated 10/29/07, stated "Problem . . . Res. is at risk for falls related to weakness, arthritis, and hx (history) of falls . . . Approaches . . . Chair check . . . Problem . . . Resident is continent . . . Approaches . . . Toileted with assist of 1 . . ." Resident #8's Nurse's Notes, dated 07/22/11 at 8:40 p.m., stated "Resident got up per self from toilet & fell in BR. C/o (Complained of) (L) (left) hip/pelvic pain & (R) (right) thigh pain. Resident sent to hospital & was admitted (with) (L) hip fracture. . . ." The facility's Incident Report, dated 07/22/11 at 10:42 p.m., stated ". . . NARRATIVE . . . Called to bathroom in resident room by CNA (certified nursing assistant) who found resident lying on the floor. CNA (name) stated hear (sic) a loud noise and found resident on floor. Resident complains of lefrt (sic) hip/pelvic and right thigh pain. . . . Unable to move legs without severe pain. . . . IMMEDIATE POST-INCIDENT ACTION: Continue to encourage resident to use call light. . . ." Resident #8 returned to the facility on [DATE]. Physician orders [REDACTED]. Observation throughout the survey identified the facility staff transferred the resident to and from her bed, wheelchair, and toilet with a sit to stand lift with limited weight bearing on the left leg. During interview, on 08/02/11 at 10:00 a.m., an administrative nursing staff member (#1) reported Resident #8 usually used the call light to request staff assistance in the bathroom. The facility did not change interventions after the resident's falls in the bathroom on 04/01/11 and 05/08/11. The facility staff identified Resident #8 as cognitively impaired, a high risk for falls, and a history of falls in the bathroom. The facility implemented chair check alarms as a fall prevention intervention and continued to assist Resident #8 to the bathroom without implementing a similar intervention or monitoring while the resident was in the bathroom. Failure to provide interventions and supervision to prevent Resident #8 from attempting self transfers in the bathroom resulted in the resident experiencing recurrent falls, a left hip fracture on 07/22/11, surgical repair, pain, and limited mobility. 2. Based on observation, record review, review of facility policy, and resident, family, and staff interview, the facility failed to ensure staff appropriately used assistive devices to prevent injury for 3 of 6 sampled residents observed during lift transfers (Resident #3, #4, and #11) and 2 of 3 sampled residents observed during gait belt transfers (Resident #5 and #10). Failure to appropriately use assistive devices resulted in Resident #3 experiencing skin tears during lift transfers, may have contributed to Resident #11's skin tear, and placed Resident #4, #5, and #10 at risk of sustaining an injury. Findings include: Review of the facility "Policy and Procedure for EZ Stand" occurred on 08/03/11. The undated policy stated, "The EZ Stand was designed specifically for toileting and changing briefs of patients . . .Transferring the Patient: Apply the Harness 1. Position the top of the harness around the upper body of the patient (Approximately 4-5 inches below the underarm). 2. For the safety of the patient, securely fasten the strap around the patient's chest. 3. On harnesses with the plastic buckles, secure the buckle and pull the loose strap to tighten . . . If necessary to keep patients (sic) shins or feet on the footplate, secure the shin straps around the patients (sic) legs. . . ." - An initial tour of the facility occurred on 08/01/11 at 9:55 a.m. with an administrative nurse (#2). Observation during the tour showed Resident #3 seated in a recliner in his room. Observation showed bruises on the resident's forearms. Resident #3 stated he "bumped" his left elbow going through the bathroom door. The resident stated, "It hurts like a son of a gun." Observation showed steri strips on the left elbow. The resident stated the doors are not wide enough and he bumps his elbows. The nurse (#2) stated staff transfer Resident #3 with an EZ stand lift. Resident #3's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. An annual MDS, dated [DATE], identified Resident #3 with moderate cognitive impairment and required extensive assistance with transfers. An "Interdisciplinary Care Plan Conference Record," dated 06/15/11, stated, "Skin tear to (R) (right) elbow . . . Transfers with EZ stand . . ." Review of Resident #3's Nurse's Notes identified the following: * 02/06/11 at 3:30 a.m.: "resident sustained [REDACTED]. Area cleansed (with) NaCl (sodium chloride) & steri strip applied . . ." * 02/06/11 at 7 a.m.: "Steri strips applied to (R) elbow area, bruising noted . . ." * 06/11/11 at 8 p.m.: "Res went through bathroom door and caught his arm (R elbow) and received a skin tear 1/2 cm (centimeter). Cleansed and steri strips applied . . ." 08/01/11 at 10:30 a.m.: "Taken to bathrm (bathroom) (with) E-Z lift - R & L elbow - bumped wall sm (small) skin tear R & L elbow steri strips applied. Res said 'the bathroom doors are too sm. it would be easy to make them bigger!'" On 08/01/11 at 3:50 p.m., observation showed two Certified Nursing Assistants (CNAs) (#5 and #6) transferred Resident #3 to the bathroom using the EZ stand lift. When the CNAs attached the sling, they failed to tighten the chest strap. During the transfer, the sling slid up under Resident #3's arms, causing the resident's shoulders to rise and his elbows to bow out as the CNAs raised the lift. When the CNAs (#5 and #6) propelled the lift through the bathroom door, a CNA (#5) stated "Watch your elbows." On 08/02/11 at 8:25 a.m., observation showed two CNAs (#7 and #8) transferred Resident #3 to the bathroom using the EZ stand lift. The CNAs attached the sling as in the above observation. As the resident stood in the lift, the sling slid up under his arms, causing his shoulders to rise and his elbows to bow out. The resident's family member (#1), present during the observation, stated, "Put your elbows in so you don't get hurt." After toileting, the CNAs (#7 and #8) assisted Resident #3 to stand for perineal cares using the EZ stand. As he stood, the sling again slid up. Resident #3 stated, "Put me down." The CNAs completed cares and transferred Resident #3 to his wheel chair using the EZ stand. As the CNAs moved Resident #3 across the room in the EZ stand, the sling remained up under his arms, causing his elbows to bow out. Resident #3 stated, "Put me down please." An interview with Resident #3's family member (#1) occurred on 08/02/11 at 8:40 a.m. The family member stated Resident #3 has had skin tears to his elbows from hitting the bathroom door. The family member stated the bathroom door is narrow and "his elbows stick out." An interview occurred with an administrative nurse (#1) on 08/04/11 at 10:30 a.m. When asked how Resident #3 obtained the skin tear on 02/06/11, the nurse stated she would look for information. On 08/04/11 at 1:45 p.m., the administrative nurse (#1) stated she had no further information regarding the skin tear. She stated staff do not complete incident reports "for minor skin tears." - Resident #11's medical record, reviewed on August 2-3, 2011, identified [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], identified Resident #11 with short and long term memory problems, severely impaired decision making skills, and required extensive assistance with transfers. Resident #11's care plan, dated 12/02/07, identified a problem "Resident requires assist with AM (morning) cares. Approaches to the problem included, "Res requires assist of (1) uses Wheelchair, Ez stand." A Nurse's Note, dated 07/01/11 at 7:30 p.m. stated, "CNA informed Res of skin tear to (R) shin w/ (with) transfer & use of standing lift. Skin tear measures 1.5 cm x .25 cm. Cleansed w/ NS (normal saline). Steri Strips & Adaptic/opsite (a type of dressing) applied . . ." On 08/03/11 at 8:35 a.m., observation showed two CNAs (#7 and #9) transferred Resident #11 from the wheel chair to her bed using the EZ stand lift. Observation showed, the CNAs attached the sling, but failed to tighten the chest strap. During the transfer, Resident #11 did not stand erect in the lift. The sling slid up under her arms, causing the resident's shoulders to rise and her elbows to bow out as the CNAs raised the lift. An interview occurred with an administrative nurse (#1) on 08/04/11 at 10:30 a.m. When asked if staff attached the shin straps during the lift transfer on 07/01/11 at 7:30 p.m. or what may have contributed to Resident #11's skin tear, the nurse (#1) stated she would look for information. On 08/04/11 at 1:45 p.m., the administrative nurse (#1) stated she had no further information regarding the lift transfer as staff did not complete an incident report for the skin tear. - Review of Resident #4's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. A quarterly MDSs, dated 07/27/11, identified Resident #4 with moderate cognitive impairment and required extensive assistance with transfers. An "Interdisciplinary Care Plan Conference Record," dated 05/03/11, stated, "Uses EZ stand for transfers." Observation on 08/01/11 at 3:30 p.m. showed two CNAs (#5 and #6) transferred Resident #4 to the bathroom using the EZ stand lift. When the CNAs attached the sling, they failed to tighten the chest strap. After toileting, the CNAs (#5 and #6) assisted Resident #4 to stand using the EZ stand lift. As the CNAs raised the lift, the sling slid up under his arms, causing the resident's shoulders to rise and his elbows to bow out. On 08/02/11 at 8:55 a.m., observation showed two CNAs (#7 and #8) assisted Resident #4 to the bathroom. Again, the CNAs failed to tighten the strap. After toileting the CNAs (#7 and #8) assisted Resident #4 to stand using the EZ stand lift. As the CNAs raised the lift, the resident did not stand erect and the sling slid up under his arms, causing his shoulders to rise and his elbows to bow out. When the CNAs assisted Resident #4 out of the bathroom, his left elbow bumped the door as the CNAs propelled the lift through the bathroom door. During an interview on 08/03/11 at 10:30 a.m. an administrative nurse (#1) stated she expects staff members to tighten the strap when transferring residents with the EZ stand lift to prevent the sling from sliding up under the resident's arms. Failure to ensure staff appropriately utilized the EZ stand lift, including tightening the chest strap, resulted in Resident #3 experiencing skin tears during transfers, may have contributed to Resident #11's skin tear, and placed Resident #4 at risk for an injury during EZ stand transfers. - Review of the facility "Procedure for Use of Transfer Belt" occurred on 08/03/11. The undated procedure stated, "Policy: To be used for all transfers requiring staff assistance unless a lifting device is required. Procedure: . . . Put around waist and pull tight until it is very snug . . . Put your hand under the belt in the back and pull up. Transfer resident. . . ." Review of Resident #5's record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. Quarterly MDSs, dated 04/28/11 and 07/18/11, identified the resident with severe cognitive impairment and required extensive assistance with transfers. A fall risk assessment, dated 07/13/11, stated, "resident scored 24- which indicates he is @ high risk for falls . . . transfers (with) walker - gait belt & assist of (one) . . ." Observation, on 08/01/11 at 2:55 p.m., showed two CNAs (#5 and #6) assisted Resident #5 out of bed. The CNAs assisted Resident #5 to sit at the edge of the bed and applied a gait belt around his waist. The CNAs (#5 and #6) then assisted Resident #5 to stand and walk to the bathroom using a walker and the gait belt. After toileting, the CNAs assisted the resident to stand by holding his left arm, not utilizing the gait belt. The CNAs then assisted Resident #5 to walk from the bathroom to his wheel chair (in his room) by holding onto the back of his pants, and not utilizing the gait belt. The resident walked with a shuffling gait, paused frequently, and required much cueing while ambulating out of the bathroom. On 08/02/11 at 9:15 a.m., observation showed two CNAs (#7 and #8) assisted Resident #5 to the bathroom. The CNAs applied a gait belt loosely around the resident's waist and assisted him to walk from his Merry Walker to the bathroom. Again, Resident #5 walked with a shuffling gait, paused frequently, and required cueing to keep the walker close to his body while ambulating. After toileting, the CNAs (#7 and #8) assisted Resident #5 to walk back to the Merry Walker. The loosely applied gait belt slid up nearly to the resident's under arms as he ambulated across the room. During an interview on 08/03/11 at 10:30 a.m. an administrative nurse (#1) stated she expects staff to apply the gait belt snugly and to use the gait belt when ambulating residents. - Observation on 08/03/11 at 10:20 a.m. showed Resident #10 seated on the toilet in her room and a gait belt around her waist. Two CNAs (#3 and #4) assisted the resident to a standing position, one CNA (#4) utilized the gait belt and the other CNA (#3) lifted Resident #10 under her right arm and failed to utilize the gait belt. During an interview on 08/03/11 at 11:15 a.m., an administrative nurse (#1) agreed the CNAs failed to utilize a gait belt correctly for Resident #10. Failure of facility staff to utilize a gait belt appropriately has the potential for Resident #5 and #10 to experience pain and injury. THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED ON 07/15/09 AND 07/08/10. 3. Based on observation, hot water temperature readings, record review, review of facility policy and procedure, review of professional literature and staff interview, the facility failed to provide an environment as free of accident hazards as possible regarding safe water temperatures in 8 of 8 resident rooms on the South A wing. Failure to maintain safe water temperatures has the potential to result in injuries to the residents. Findings include: Review of the facility "Water Temperature Policy" occurred on 08/03/11. This policy, dated July 2010, stated, "In ensuring that the water temperatures remain within a safe and acceptable level, the Strasburg Care Center (SCC) Maintenance staff will inspect water temperatures weekly, picking two rooms from both wings A & B, and alternating rooms each week. The temperature will be obtained via handheld thermometer, from the appropriate dispensing device. The results will be recorded on a QA (quality assurance) form and addressed at the monthly QA meetings. Should the temperatures obtained be outside of the safe and comfortable range, Maintenance staff will make the necessary adjustments to the hot water system. Also monthly, the Maintenance staff will inspect the mixing valves and circulating pumps to ensure the devices are working properly. . . ." - An interview with Resident #12 occurred on 08/02/11 at 3:55 p.m. in the resident's room in the South A wing. Following the interview, the surveyor identified very hot water during handwashing in the resident's bathroom. On 08/02/11 the water temperatures taken in the following resident bathroom sinks on the South A wing revealed the following hot water temperatures: * Room 118 at 11:00 a.m. - 125 degrees Fahrenheit (F) * Room 119 at 2:00 p.m. - 123.5 degrees F with a facility maintenance staff member (#14) * Room 114 at 4:30 p.m. - 124 degrees F * Room 116 at 4:33 p.m. - 122.6 degrees F * Room 120 at 4:37 p.m. - 126.4 degrees F * Room 117 at 4:40 p.m. - 127.1 degrees F * Room 113 at 4:50 p.m. - 128.1 degrees F * Room 115 at 4:55 p.m. - 130.1 degrees F On 08/03/11 the water temperatures rechecked in the following resident bathroom sinks on the South A wing revealed the following hot water temperatures: * Room 113 at 8:00 a.m. - 116.5 degrees F * Room 115 at 8:07 a.m. - 114.5 degrees F During an interview on 08/02/11 at 1:45 p.m., a maintenance staff member (#14) stated maintenance staff monitor the water temperatures in the resident bathrooms and provided temperature logs. Review of these temperature logs identified on 06/18/11 the hot water temperatures in South A wing Room 113 was 119 degrees F and Room 119 was 118 degrees F. The log also identified the staff turned down the mixing valve on 06/18/11. During an interview on 08/03/11 at 9:30 a.m., a maintenance staff person (#14) stated the water temperature should be around 110 degrees F.