Every finding on record at Sun Terrace Health Care Center

Based on observation, interview, and record review, the facility failed to follow the comprehensive care plan and physician ordered toileting schedule for one (#4) out of four sampled. As a result, Resident #4 experienced overnight incontinence without timely care, and scheduled toileting was not consistently implemented or documented. Findings Include: During an observation and interview on 7/20/26 at 7:15 a.m., Resident #4 was seated in a wheelchair, well groomed and dressed in street clothing. During the interview, the resident became tearful, appeared stressed, and reported having a bad night. Resident #4 stated she was incontinent during the night and staff did not provide incontinent care until she was assisted with getting dressed for the day. Record review showed Resident #4 was admitted on [DATE] with diagnoses including left hemiplegia and hemiparesis, type 2 diabetes mellitus with chronic kidney disease, a need for assistance with personal care, and osteoarthritis of the knee. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed the following: Cognitive Patterns: Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Functional Abilities: Resident #4 required substantial/maximal assistance with toilet transfer and artial/moderate assistance with toileting hygiene. Bowel and Bladder: Resident #4 was frequently incontinent of bladder. Record review showed physician orders dated 2/25/26 directing staff to toilet the resident after each meal, upon rising, and prior to bed. Review of the care plan showed the following focus areas: Resident #4 has impaired visual function related to glaucoma and legal blindness. Resident #4 has bowel and bladder incontinence related to weakness and urinary frequency.Interventions included assessing and anticipating the resident's toileting needs and assisting the resident frequently with toileting. Review of nursing skilled evaluation notes, including a note dated 7/20/26, showed documentation indicating Resident #4 was continent of bladder. Review of Resident #4's Documentation Survey Report V2 showed the ordered toileting schedule of toileting the resident after each meal, upon rising, and prior to bed. Record review found missing documentation indicating the ordered toileting schedule was not consistently implemented or recorded: May 2026: Documentation was missing for 7 of 99 shifts. June 2026: Documentation was missing for 12 of 90 shifts. July 2026: A documentation report was requested by the survey team but was not provided by the facility. During an interview on 7/20/26 at 4:45 p.m., Staff B, Certified Nursing Assistant (CNA), stated that when toileting assistance is provided, it should be documented in the medical record. During an interview and record review on 7/20/26 at 3:28 p.m., the Director of Nursing (DON) stated that toileting documentation was missing and that missing documentation should be assumed to mean the task was not done. She stated she expects staff to complete documentation of assigned tasks each shift. Review of facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018 showed the following: Policy Statement: Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Policy Interpretation and Implementation:Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:Hygiene (bathing, dressing, grooming, and oral care); .Mobility (transfer and ambulation, including walking);Elimination (toileting);Dining (meals and snacks); andCommunication (speech, language, and any functional communication systems).Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions:Independent - Resident completed activity with no help or staff oversight at any time during the last 7 days.Supervision -Oversight, encouragement or cueing provided 3 or more times during the last 7 days. continues on next pageLimited Assistance - Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days.

Based on record review, and interviews, the facility failed to ensure that effective supervision and fall prevention interventions were implemented to prevent an avoidable fall with injury for one (Resident #6) out of three residents sampled.Review of Resident #6's Resident Information Record showed she was originally admitted on [DATE] and readmitted on [DATE]. Her diagnoses included: periprosthetic fracture around an internal prosthetic left knee joint (subsequent encounter) dated 04/30/2026; unspecified fracture of the upper end of the left humerus (subsequent encounter with routine healing) dated 02/20/2026; Type 2 Diabetes Mellitus with diabetic polyneuropathy dated 02/20/2026; fracture of the left shoulder girdle (subsequent encounter with routine healing) dated 02/20/2026; need for assistance with personal care dated 02/20/2026; fall on same level (subsequent encounter) dated 02/20/2026; and mild cognitive impairment of uncertain or unknown etiology. Review of Resident #6's Baseline Care Plan dated 02/20/2026 showed Resident #6 was admitted following hospitalization for a fall resulting in fractures of the left humerus and femur. She required skilled nursing services including physical, occupational, and speech therapy related to gait training, strengthening, and cognition. Review of Resident #6's admission assessment dated [DATE] showed Resident #6 had a history of falls and demonstrated balance problems while standing, sitting, and walking. Review of Resident #6's change in condition note dated 04/27/2026 showed she was found on the bathroom floor after having a bowel movement. Resident #6 sustained a small skin tear on the left shin. Skin prep and thin sterile adhesive skin closures were applied. Resident #6 complained of right knee pain, and an x ray was ordered. The x ray showed an acute distal femur fracture. Resident #6 was sent to the hospital for further evaluation. Review of Resident #6's Activity of Daily Living (ADL) care plan, initiated on 02/21/2026 and revised on 03/03/2026, showed Resident #6 was assessed as having an ADL self care performance deficit related to a fall resulting in fractures of the left femur and left humerus, limited mobility, decreased range of motion, and pain. Review of Resident #6's ADL goals, initiated on 02/21/2026 and revised on 02/27/2026, showed the goal was for her to maintain the current level of function through the review period, with a target date of 07/29/2026. Interventions initiated on 02/21/2026 directed staff to encourage Resident #6 to use the call bell to request assistance and to provide the level of assistance and supervision needed to safely complete ADLs.During an interview on 07/20/2026 at 1:00 PM, Staff D, Certified Nursing Assistant (CNA) stated she cared for Resident #6 on 04/27/2026. Staff D reported the resident had periods of confusion, required two person assistance, and was incontinent. Staff D stated she got Resident #6 dressed and out of bed and then left to assist another resident. When returning down the hall, she saw Resident #6 attempting to wheel herself to her room to use the bathroom. Staff D stated she assisted the resident to the toilet, placed her on it, and instructed her to pull the call light when finished. Staff D stated another CNA later found Resident #6 on the bathroom floor. Staff D could not recall whether the resident used the call light. Staff D, CNA said Resident #6 was not typically left alone in the bathroom. On 07/20/2026 at 2:00 PM, Staff E, Licensed Practical Nurse (LPN) stated Resident #6 was a vulnerable and a high fall risk resident. Staff E, LPN stated she conducted the follow up assessment when Resident #6 complained of leg pain in April. Staff E stated she notified the physician and obtained orders for an x-ray. The x-ray showed an acute fracture, and the resident was transferred to the hospital. Resident #6 returned back to the facility on [DATE] with non-weight bearing orders. During an interview on 07/20/2026 at 2:40 PM, the Director of Nursing (DON) stated she was not present when Resident #6 was originally admitted . The DON stated the facility recently discussed proper mechanical lift and toileting procedures, with the staff. The DON acknowledged Resident #6 was found sitting on the bathroom floor on 04/27/2026 with a skin tear and later complained of knee pain, after which an x ray confirmed an acute distal knee fracture. The DON stated Resident #6 required extensive two person assistance on 02/21/2026, limited one person assistance on 04/22/2026, and mechanical lift use on 05/21/2026 following the fall. The DON stated the care plan was updated on 04/27/2026 after the fall to indicate Resident #6 should not be left alone in the bathroom. The DON stated the facility did not have a fall or supervision policy.

Based on record review and interviews, the facility failed to ensure ostomy care was provided and documented according to the physician's orders for one (Resident #5) out of three residents reviewed for ostomy care. This failure resulted in the inability to determine whether the resident received required ostomy care and hygiene support. Findings include:Record review showed Resident #5 was admitted in October 2021 with multiple diagnoses including partial intestinal obstruction, ileostomy status, Type 2 diabetes mellitus with chronic kidney disease, vascular dementia (moderate), muscle weakness, need for assistance with personal care, hypertensive heart and chronic kidney disease with heart failure, and obstructive sleep apnea. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed Section C Brief Interview for Mental Status (BIMS) score was 06, indicating impaired cognition. Section GG showed the resident required full assistance from staff for toileting, showering/bathing, and personal hygiene. Section H documented the resident was always incontinent of urine, and bowel continence was marked Not rated; resident has an ostomy. A review of Tasks documentation for Resident #5 from 06/21/2026 through 07/20/2026 showed 19 out of 90 expected toileting hygiene tasks were not documented as completed. Record review of the resident's orders showed: Ileostomy care every shift, every day (initiated 05/26/2026). Change ileostomy wafer and pouch using prescribed pouch type. Barrier paste, powder, and skin prep may be used as needed to ensure adhesion of wafer. Change as needed for leaking or non adhering wafer (order dated 05/26/2026). During an interview on 07/20/2026 at 4:13 PM, Staff F, Licensed Practical Nurse (LPN), stated Certified Nursing Assistants (CNAs) are responsible for emptying a resident's ostomy, and nurses are responsible for assessing the ostomy, maintaining cleanliness, and replacing the ostomy appliance as ordered or when issues occur. Staff F stated that assessment and replacement of an ostomy should be documented in the Treatment Administration Record (TAR) or in a progress note. Staff F confirmed Resident #5, and two other residents on the unit, had ostomies. During an interview on 07/20/2026 at 5:17 PM, Staff G, CNA, stated CNAs empty ostomies and check them at least every two hours during toileting or incontinence rounds. Staff G reported they document emptying of ostomies in the Tasks section of the electronic record but do not document each time the ostomy is checked. During an interview on 07/20/2026 at 5:19 PM, the Director of Nursing (DON) stated documentation of ostomy care was completed appropriately in May; however, for June and July, no ostomy care documentation was completed in the Treatment Administration Record (TAR) for Resident #5 on any shift reviewed. The DON confirmed that without documentation of ostomy care or appliance changes, there was no way to determine whether care was completed according to the physician's orders. The DON stated she attempted to locate the documentation but was unable to produce any records by the end of the survey. A review of the May Treatment Administration Record (TAR) for Resident #5 showed order Ileostomy care every shift was documented appropriately for every shift every day with the exception of 2 shifts. A review of the TAR for the months of June and July showed no checks (meaning administered/completed) for any ileostomy care or replacements.The followed to follow their policy Ostomy Care which states:Purpose: To maintain ostomy site integrityProcedure:Assemble equipment.Explain the process and provide privacy.Wash hands.Position the resident in a comfortable position.Expose the abdominal area.Don gloves.Remove sealed bag/appliance & discard appropriately.Remove and discard gloves.Perform hand hygiene and don second gloves.Cleanse stoma and skin surrounding stoma with soap and water (use specific cleanse ordered).Rinse and gently pat dry.Apply bag/appliance.Remove and discard gloves.Reposition for comfort with call light in reach.Wash hands.Discard trash.Documentation:Document in the resident's electronic health record (HER).

Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen, walk-in cooler, walk-in freezer, reach-in freezer, and stock room (Photographic evidence obtained). Findings include: During an observation while conducting a walk-through tour of the kitchen with the Dietary Manager (DM) on 6/3/2024 starting at 8:40 AM, there were one large, perforated pan with raw chicken pieces thawing that was not in running water or covered; one sheet pan with 20 packages containing meat products with no identifying label or date on the pan or packages; three cases of health shakes, each containing 72 individual cartons, that were completely thawed and were in a case that read, Keep Frozen; and three containers containing pesto with no date or identifying label in the walk-in cooler. There was one opened large clear bag of a breaded food product with no label or date on the product in the walk-in freezer. There was French fries left opened and exposed to the elements in the reach-in freezer. During an interview on 6/3/2024 at 8:45 AM, the DM stated that the raw chicken on the large pan should have been submerged under running water. The DM confirmed the large sheet pan with 20 packages of meat product found in the walk-in cooler was deli turkey and did not have a label or date. The DM stated that the cases of health shakes should have been stored in the freezer as marked and the amount pulled to thaw according to the prescribed health shakes needs. The DM confirmed that the pesto containers should have been labeled or kept in the original container and dated. The DM stated that the food product found open in the walk-in, and reach-in freezer should have been closed properly, labeled, and dated according to policy. During an observation while conducting the follow-up kitchen tour with the DM on 6/4/2024 at 6:30 AM, there were one large and uncovered clear container with white dry powdery content with no identifying label or date in the kitchen prep area; one pan with a white substance partially covered in plastic with part of the product exposed with no label or date, on the bottom shelf of the prep table; one opened container of dry instant mashed potatoes; one chemical spray bottle marked heavy duty degreaser on the shelf between the exposed pan and the opened potato container; approximately 190 glass plates and bowls that were not inverted or covered in a shelf in the kitchen; two opened bread packages with use-by dates of 5/26 and 6/02; five pans of food that had no identifying label in the reach-in refrigerator; and one large opened bag of sugar with no opened date. During an interview on 6/4/2024 at 6:45 AM, the DM confirmed that the observed products had no label or date and identified the large clear container with dry powdery content as food thickener. The DM identified the pan with a white substance that was partially exposed as flour. The DM stated that the chemical spray bottle should not have been stored near any food products. The DM stated the glass plates and bowls should have been stored inverted or covered and were not stored properly. The DM verified the bread product was outdated and should have been discarded on the labeled dates of 5/26 and 6/02. Review of the facility policy and procedure titled Thawing with no date read, Purpose: Foods are thawed properly to prevent food borne illness. Procedure . 2. Thaw foods according to one of the following choices as indicated . Submerged under running water. Review of the facility policy and procedure titled Food Storage Overview with no date read, Procedure . 5. Chemicals must be clearly labeled, kept in original containers when possible, and kept in a locked area away from food . 8. All stock is to be rotated . b. Food should be dated with date received as it is placed on the shelves . Refrigerator Storage: 12. Leftover food is stored in covered containers or wrapped securely. Each item is clearly labeled and dated before being refrigerated . 14. Refrigeration . e. Foods are to be covered, labeled, and dated including month, day, and year . Freezer Storage: 15. Frozen Foods . c. All foods should be covered, labeled, and dated including month, day, and year.

Based on observation, record review, and interview, the facility failed to ensure residents received care and services for PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 of 3 reviewed residents with a PICC access device, Resident #104 (Photographic evidence obtained). Findings include: During an observation on 6/3/2024 at 9:52 AM, Resident #104's PICC line was visible in right upper arm. The transparent dressing over the gauze securing PICC and insertion site was not visible. The transparent dressing was peeling off on one side. The dressing was dated 5/28/2024. During an observation on 6/4/2024 at 10:22 AM, Resident #104's PICC line was visible in right upper arm. The transparent dressing over the gauze securing PICC and insertion site was not visible. The transparent dressing was peeling off on one side. The dressing was dated 5/28/2024. During an interview on 6/4/2024 at 10:22 AM, Resident #104 stated, I don't remember exactly when the dressing was changed, but they change the dressing about once a week. Review of Resident #104's physician order dated 5/14/2024 read, Dressing change every week and PRN [as needed]. RUA [Right Upper Arm] Measure length of line and circumference of arm upon admission/insertion then weekly. To measure length start from hub of PICC line to insertion site on forearm, to measure arm circumference measure at the insertion site around the forearm. Continue weekly until line discontinued. Document the length of line & circumference of arm upon admission/insertion below. PICC Line Length [blank] cm [centimeter]. Arm Circumference: [blank] cm, every day shift every 7 day(s) for IV [Intravenous] maintenance, Report s/s [sign and symptom] of infections/infiltration/dislodgement to MD [Medical Doctor]. Change dressing weekly and document measurement of line. During an interview on 6/4/2024 at 11:57 PM, Staff A, Licensed Practical Nurse (LPN), stated, The PICC dressing should have been changed when dressing was observed to be peeling away and within 24 hours since gauze was used under the transparent dressing. During an interview on 6/4/2024 at 11:59 PM, Staff B, Registered Nurse (RN), Unit Manager, stated, The PICC line dressing should have been changed within 24 hours. Gauze cannot be left under the transparent dressing we use bio patches [antibiotic patch] so we can see the site and monitor for signs and symptoms of infection. During an interview on 6/4/2024 at 3:58 PM, the Director of Nursing stated, Gauze should not be placed under the transparent dressing and if gauze is under the transparent dressing, then the dressing has to be changed again within 24 hours. We should not use gauze for our PICC line dressing. We should be using only a transparent dressing applied over a bio patch. Review of the facility policy and procedure titled Catheter Insertion and Care with the last approval date of 2/22/2024 read, Policy: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated loosened or soiled catheter site dressings . General guidelines . 4. Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze with TSM dressing and change the dressing every 48 hours.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 of 3 reviewed residents with PICC (Peripherally Inserted Central Catheter) line, Resident #104. Findings include: Review of Resident #104's physician order dated 5/14/2024 read, Dressing change every week and PRN [as needed]. RUA [Right Upper Arm] Measure length of line and circumference of arm upon admission/insertion then weekly. To measure length start from hub of PICC line to insertion site on forearm, to measure arm circumference measure at the insertion site around the forearm. Continue weekly until line discontinued. Document the length of line & circumference of arm upon admission/insertion below. PICC Line Length [blank] cm [centimeter]. Arm Circumference: [blank] cm, every day shift every 7 day(s) for IV [Intravenous] maintenance, Report s/s [sign and symptom] of infections/infiltration/dislodgement to MD [Medical Doctor]. Change dressing weekly and document measurement of line. Review of Resident #104's Medication Administration Record (MAR) for May 2024 and June 2024 revealed no documentation for PICC line length or arm circumference for 5/14/2024, 5/21/2024, 5/28/2024 and 6/4/2024. During an interview on 6/5/2024 at 11:50 AM, the Director of Nursing stated, I've spoken with those nurses and the measurements were done but not documented. During an interview on 6/5/2024 at 12:00 PM, Staff C, Registered Nurse (RN), stated, I did the dressing changes on 5/14, 5/28 and 6/4 and measured the length of the line and the circumference. I did not document the measurements. During an interview on 6/5/2024 at 12:20 PM, Staff B, RN, stated, I did the dressing change on 5/21/2024 and measured the length of the line and the circumference, but did not document the measurements. During an interview on 6/5/2024 at 12:50 PM, the Director of Nursing stated, PICC lines are to be measured for length and circumference of insertion site are to be measured and documented on the TAR with weekly dressing changes. Review of the facility policy and procedure titled Catheter Insertion and Care with the last review date of 2/22/2024 read, Documentation: 1. The following information should be recorded in the resident's medical record . c. Any complications, interventions that were done.

Based on observation, interview, and record review, the facility failed to ensure staff used proper PPE (Personal Protective Equipment) while providing high-contact care for 1 of 3 residents reviewed for transmission-based precautions, Resident #341, and failed to ensure staff performed hand hygiene between residents during meal tray delivery to help prevent the possible development and transmission of communicable disease and infections. Findings include: Review of Resident #341's physician order dated 6/4/2024 showed that it read, Enhanced Barrier Precautions for Dx [diagnosis] Wound every shift nurse to verify correct door signage and equipment present. During an observation on 6/5/2024 at 8:01 AM, Resident #341's door had a sign posted for Enhanced Barrier Precaution (EBP) use. Staff D, Certified Nursing Assistant (CNA), wore gloves, but no gown, opened Resident #341's shared bathroom door from inside the bathroom and pushed Resident #341 in her wheelchair into the resident's room. After exiting Resident #341's bathroom with the resident, Staff D doffed her gloves and threw them in the trashcan. Without performing hand hygiene or wearing a gown and gloves, Staff D proceeded to wheel the resident to her bedside, helped her adjust positions in the wheelchair and pulled the resident's bedside stand, containing the resident's breakfast tray, to the resident. Without performing hand hygiene or wearing a gown and gloves, Staff D removed the covers from the breakfast item containers and juice drinks and placed the resident's eating utensils on the plate containing the food items. Staff D exited the resident's room, proceeded down the hallway and performed hand hygiene in the dirty utility room sink. Review of the Enhanced Barrier Precautions Sign by the CDC (Centers for Disease Control and Prevention) visibly posted on Resident #341's room door showed that it read, STOP: Enhanced Barrier Precautions. Everyone Must: Clean their hands, including before entering and when leaving a room. Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing. During an observation from 8:01 AM through 8:17 AM, Staff D, CNA, returned from Resident #341's room to the breakfast tray cart and grabbed the breakfast tray for Resident #119 and entered the resident's room. Staff D placed the breakfast tray on the resident's bedside table, removed the food item and drink container covers, opened, and placed the condiments in the resident's coffee cup for Resident #119 and placed the resident's eating utensils onto the plate of food for the resident. Without performing hand hygiene, Staff D proceeded to Resident #339's bed in the same room and touched Resident #339 on the right shoulder, adjusted her top covers, and spoke to her before exiting the room. Without performing hand hygiene before or after direct contact with Resident #339, Staff D then returned to the breakfast tray cart and grabbed the breakfast tray for Resident #342. Staff D proceeded to Resident #342's room and assisted Resident #342 with setting up his tray, moved his food containers and drink containers to within reach of the resident, adjusted his bed height with the remote and moved his bedside table in front of the resident in bed. Staff D exited Resident #342's room without performing hand hygiene, proceeded to the breakfast tray cart, grabbed the dining tray for Resident #339 and entered the resident's room and placed the tray on Resident #339's bedside table. Staff D, without performing hand hygiene, donned a pair of gloves, adjusted Resident #339's pillow, assisted her with repositioning up in bed, elevated the head of the bed, adjusted the resident's covers, removed the lids from the food and drink containers and assisted the resident with her utensils. Without doffing her gloves, Staff D returned to Resident #119's bedside, picked up her tray cover off the floor and set it on Resident #119's bed. Staff D then doffed her gloves in the trashcan and exited the room. During an interview on 6/5/2024 at 8:18 AM, Staff D, CNA, stated, I didn't wash my hands before or after resident care or between moving between residents while delivering their meals or helping with tray set up and care. I should have sanitized my hands before and after each tray delivery before moving on to the next resident. For the resident on Enhanced Barrier Precautions [Resident #341], I should have worn a gown and gloves when I helped her in the bathroom. I only wore gloves. I did not wash my hands after I removed the gloves. I should wear a gown and gloves as soon as I enter the room for a resident on EBP, especially when helping them with toileting or personal care. During an interview on 6/5/2024 at 8:35 AM, the Director of Nursing (DON) stated, The staff should be performing hand hygiene before and after care with each resident, including tray delivery between every resident. The nursing staff should be wearing a gown and gloves when performing her [Resident #341] peri-care and toileting. Review of the facility policy and procedure titled Isolation- Precautions Overview; SNF & ALF with the last review date of 2/22/2024 showed that it read, Purpose: To provide a system of isolation precautions to prevent the transmission of infection. To prevent the transmission of infectious diseases. Procedure: 1. The guidelines contain two tiers of precautions, Standard Precautions and Transmission Based Precautions (Airborne, Enhanced Barrier, Droplet and Contact Precautions) . Enhanced Barrier Precautions- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [Multidrug Resistant Microorganisms] to staff hands and clothing. Review of the facility policy and procedure titled Infection Prevention- Hand Hygiene with the last review date of 2/22/2024 showed that it read, Overview: The facility will follow the Center for Disease Control (CDC) Guidelines for handwashing/hand hygiene. Handwashing/hand hygiene is the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Handwashing is mandated between resident contact in an effort to prevent the spread of infection. Hands must be washed after the following, including, but not limited to . Contact with contaminated items or surfaces . Contact with resident . Removal of gloves.

Based on observations and interviews, the facility failed to maintain an environment that promotes dignity and privacy for one (Resident #87) of thirty five sampled residents. Findings included: A review of Resident #87's Medical Record revealed that Resident #87 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #87's Minimum Data Set (MDS) Assessment revealed, under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14, which indicated that Resident #87 was cognitively intact. An observation of medication administration for Resident #87 was conducted on 03/16/2022 at 09:10 AM with Staff G, Registered Nurse (RN). After pulling Resident #87's medications from the medication cart, Staff G, RN knocked on Resident #87's door and asked permission to enter the room. Resident #87 granted Staff G, RN to enter her room and administer the medications. During the observation, Resident #87 requested that Staff G, RN explain the medications that she was administering to her because there were certain medications that she did not want to take. While Staff G, RN was explaining the medications to Resident #87, Staff H, Licensed Practical Nurse (LPN) knocked on Resident #87's door and entered the room. Staff H, LPN did not ask permission to enter Resident #87's room and did not announce herself while entering Resident #87's room. While Staff H, LPN was speaking to Staff G, RN, Resident #87 asked Staff H, LPN what her purpose was for coming into the room. Staff H, LPN answered Resident #87 by stating I just needed some help. Resident #87 asked Staff H, LPN if there was anything that she needed from her. Staff H, LPN exited the room without answering Resident #87's question. After Staff H, LPN exited the room, Resident #87 became angry and stated that she felt disrespected that Staff H, LPN entered the room while Staff G, RN was explaining medications to her and that the conversation could have waited until she was done speaking to Staff G, RN. An interview was conducted on 03/16/2022 at 09:25 AM with Staff G, RN. Staff G, RN stated when entering a resident's room, staff should knock on the door and announce themselves before entering the resident's room. Staff G, RN also stated she did not hear Staff H, LPN knock before entering Resident #87's room and the conversation could have waited until she was done speaking with Resident #87. An interview was conducted on 03/16/2022 at 02:25 PM with Staff H, LPN. Staff H, LPN stated she entered Resident #87's room because she needed to speak with Staff G, RN about another resident and where to find an item for that resident. Staff H, LPN also stated she did knock on Resident #87's door before entering, but did not ask permission to enter the room. Staff H, LPN stated she was just in a hurry and she did not think about asking for permission to enter the room at the time. An interview was conducted on 03/17/2022 at 08:06 AM with the facility's Director of Nursing (DON). The DON stated multiple staff members enter resident's rooms throughout the day and should knock on the resident's door and ask the resident for permission to enter the room. Staff should respect the resident's dignity and privacy and should only enter the room if the resident states that it is ok. The DON stated that staff should address the resident and inform them if they needed to speak to another staff member in the middle of an interaction or care. A review of the facility policy titled Resident Dignity and Personal Property, with no effective date, revealed under the section titled Policy that the facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. The policy also revealed under the section titled Procedure that staff should care for residents in a manner that maintains dignity and individuality such as knock on doors before entering; announce your presence, and include the resident in conversation.

Based on observation, interview, and record review the facility failed to ensure the care plan was implemented related to preventing skin impairment for one (Resident #25) of three in-house acquired pressure injury residents, and 2. facility did not ensure to implement the plan of care for Resident # 37 regarding placement of an ankle brace and podus boots. Findings included: 1. Medical record review for Resident #37 revealed that the resident was admitted to the facility on [DATE] with a re-admitted [DATE]. Resident #37 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #37 is alert and oriented with a BIMS (Brief Interview for Mental Status) of 14 indicating cognitively intact. A review of Resident #37's plan of care revealed that (Effective date 3/04/22) the resident was care planned for ADL (activities of daily living) self-care performance deficit related to chronic back pain, post laminectomy, impaired ROM (range of motion). Intervention: Bilateral podus boots trial by therapy. Resident utilizes a splint (Bionic Stir up Brace) for right ankle to be worn as tolerated with sneaker. Continual trial being completed with therapy. Once trial is completed nursing staff to complete. During an interview with the resident on 03/15/22 at 10:29 AM Resident #37 reported that she hasn't had her brace for her right ankle that therapy would apply, or a podus boot. On 03/15/22 at 1:05 PM an additional interview with Resident #37 was conducted in her room as she was having lunch. She just had taken off her ankle brace because it was bothering her. She reported that staff does not put on her brace. Usually, staff member (F) will put her ankle brace on, but she hasn't been in. On 03/16/22 09:52 AM resident was observed in bed doing a cross word puzzle, no brace or podus boot on. On 03/17/22 at 9:35 AM Resident #37 reported that her podus boots were on top of the storage bin along with her ankle brace. The resident reported that her ankle brace bothered her and needs high socks, so the brace doesn't rub against her skin. On 03/17/22 09:40 AM an interview was conducted with the Director of Nursing (DON) she was not aware the resident was not wearing podus boots throughout the survey, she stated that she would look into the matter. The DON reported back on 03/17/22 at 10:31 AM, Resident #37's ankle splint should have been applied even though it was on a trial basis. Interview with Staff member (F) was conducted on 03/17/22 at 10:43 AM regarding the ankle brace and podus boots. She reported that when she is here, she will place the ankle brace on the resident which she wears 4-5 hours. Staff member (F) was asked how about when she is not in the building since, she had been on vacation for the last week. She reports that another therapist would place the brace on the resident. She was asked if she could provide documentation that the brace has been placed on the resident since the order of 3/4/22. She was unable to provide documentation that the brace had been placed on the resident or that the resident had refused. 2. A record review of Resident #25's care plan revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's Progress Notes, dated 2/9/22 at 10:23 a.m. revealed . the nursing staff was rounding on the unit the CNA notified the nurse that during transfer of the resident the resident obtained a skin tear to the right lower leg The area was assessed by the nurse and a skin tear measuring 5x3cm [centimeters] was noticed . Resident #25's admission record revealed medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's minimum data set (MDS), dated [DATE], revealed the resident has impaired cognition and requires extensive assistance with two staff members for assistance in bed mobility, and has total dependence on staff for transfers. Resident #25's care plan revealed a focus area of The resident has actual impairment to skin integrity of the . Hx [history] of skin impairments r/t [related to] fragile skin . This focus area was initiated on 1/04/2021 with interventions of applying bilateral lower extremity geri sleeves for protection of paper-thin skin. This intervention was implemented on 01/27/2022. Resident #25's order summary report revealed an active physician order, ordered on 02/10/2022 for Patient to have BLU [Bilateral Lower] BUE [Bilateral Upper] geri-sleeves. Apply in the AM and remove in the PM. every day shift Apply. An observation on 3/14/22 at 10:14 am. of Resident #25 revealed the resident lying in bed with skin discoloration on the arms. No Geri-sleeves were observed on the resident's arms. A follow-up observation of the resident on 03/15/22 at 10:59 a.m. revealed the resident in the same bed position without Geri-sleeves placed on the arms. An interview on 03/15/22 at 1:37 p.m. with Staff B, Certified Nursing Assistance (CNA) revealed the resident has very fragile skin, so it is important to be gentle during care to prevent skin tears and alterations. An observation with Staff A, CNA of the resident revealed the resident lying in bed without bilateral upper or lower extremity Geri-sleeves in place. Staff A stated placing Geri-sleeves onto a resident is a nursing duty, not a CNA duty. An interview on 03/15/22 at 1:44 p.m. with Staff C, Licensed Practical Nurse (LPN) confirmed it was a nursing responsibility to don a resident's Geri-sleeves. Staff B confirmed the resident required Geri-sleeves for both the arms and legs, but the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B stated she was going to don the resident's Geri-sleeves before the end of her shift. The staff member's shift ended at 3p.m. An online medical record task review for the resident with Staff B, LPN confirmed and revealed the start of the task was 7 a.m. and ended at 3 p.m. An interview with the Director of Nursing (DON) on 03/15/22 at 2:06 p.m. confirmed a CNA can place Geri-sleeves onto a resident. A follow-up interview at 2:34 p.m. on 03/15/22 with the DON revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25 is super high risk for skin tears. Therefore, the Geri-sleeves are meant to be donned during care, such as when a Hoyer lift is used, to prevent skin tears and breakage. A follow-up interview on 03/16/22 at 09:55 a.m. with Staff B, LPN confirmed she was the nurse on duty the day the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin tear occurred on the resident's leg. An interview on 03/16/22 at 10:13 a.m. with Staff D, CNA confirmed her presence during the Hoyer lift transfer in which the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C stated herself and another CNA placed the resident into the Hoyer lift sling and got her into the chair. They then noticed blood on the floor and looked around to see where it was coming from. That is when they noticed a skin tear on the resident's leg, so they reported it to the nurse. During this interview, Staff D stated the resident only had Geri-sleeves for arm protection, but not for the legs/lower extremities. Therefore, during this care transfer event, nothing was donned to the resident's legs to prevent skin alteration. Further review of Resident #25's care plan revealed a focus area for The resident has potential for impaired skin integrity, initiated on 2/07/2022. Interventions for this focus area included placing Geri-sleeves to the bilateral lower extremities, initiated on 6/24/2021. An interview with the Director of Nursing (DON) on 03/17/22 at 9:02 a.m. revealed CNAs are allowed to don a resident's Geri-sleeve. the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hoyer lift slings compress the person and move against the skin, so for someone like Resident #25 with very fragile skin, could cause a sheering effect. The Geri-sleeves act as a extra layer of skin to assist in skin protection and skin integrity. The DON confirmed the goal is to implement a resident's care plan. 3. A policy review of Baseline, Resident Centered Comprehensive Care Plans, & Care Plan Summary, copyrighted in 2018, revealed the purpose of the policy is Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuality of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur . Included within the procedures is . Comprehensive Care Plans must be developed within 7 days after completion of the comprehensive assessment . and review and revise the care plan after each assessment . If the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes must be incorporated into an updated summary provided to the resident and his or her representative, if applicable.

Based on observation, interview, and record review the facility failed to implement pressure injury prevention measures for one (Resident #25) of three residents sampled for in-house acquired pressure ulcers. Findings included: Resident #25's admission record revealed medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's minimum data set (MDS), dated [DATE], revealed the resident has impaired cognition and requires extensive assistance with two staff members for assistance in bed mobility, and has total dependence on staff for transfers. Further review of the resident's MDS revealed the resident is at risk for developing pressure ulcers/injuries. The resident has one or more unhealed pressure ulcers/injuries. Resident #25's care plan revealed a focus area for The resident has potential for impaired skin integrity, initiated on 2/07/2022, with interventions of encouraging patient to float heels whenever in the bed, initiated on 5/28/2021 Resident #25's order summary report revealed active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's order summary report revealed an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 3/14/22 at 10:14 am. of Resident #25 revealed the resident lying in bed without pillows in place to float the resident's heels. A follow-up observation of the resident on 03/15/22 at 10:59 a.m. revealed the resident in the same bed position without pillows in place to float the resident's heels. An interview on 03/15/22 at 1:37 p.m. with Staff B, Certified Nursing Assistance (CNA) revealed the resident has very fragile skin, so it is important to be gentle during care to prevent skin tears and alterations. A pillow is placed behind her arm and hip to assist with position. The resident is currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B confirmed the resident did not have pillows underneath her feet. Staff B stated the resident had the pillows underneath her heels at night and so they were removed to give her a break from the elevation. An observation on 03/15/22 at 1:44 p.m. with Staff C, Licensed Practical Nurse (LPN) around Resident #25's room revealed no pillows were available to place underneath the resident's feet/heels. Staff C stated the purpose of floating a resident's heels is to prevent and/or assist in preventing the development of a deep tissue injury/pressure ulcer. An interview on 3/15/22 at 2:06 p.m. with the Director of Nursing (DON) confirmed the resident is at risk for pressure ulcers. The DON confirmed that when a resident is in bed, the expectation would be for the heels to be floated. The DON confirmed the expectation is for pillows to be underneath the resident's heels to float them to reduce the risk of developing a pressure ulcer. A policy review of Skin Integrity, dated 09/2017, revealed the purpose is To provide consistent assessment and evaluation, monitoring, documentation, and implementation of therapeutic interventions to heal and maintain skin integrity, unless clinically unavoidable. To promote the prevention of pressure ulcer/injury development; To promote the healing of existing pressure ulcers/injury (including prevention of infection to the extent possible); and to prevent development of additional pressure ulcer/injury. Underneath the section Assessment/Evaluation, revealed A resident care plan will be created to assist with maintaining intact skin integrity, prevention of pressure ulcers of healing of any non-intact skin. Care plan will include measurable goals and appropriate interventions . treatment orders will be implemented per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, staff interviews, and medical record review the facility failed to ensure care plan interventions were implemented for one (#98) of 54 sampled residents as evidenced by Resident #98 not wearing an abductor wedge pillow between her legs as ordered and care planned. Findings Included: A record review for Resident #98 revealed admission [DIAGNOSES REDACTED]. A review of active physician orders [REDACTED]. Record review of the admission Minimum data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 14, indicating the resident was cognitively intact. Review of the Care Plan for Resident #98 initiated on 12/4/20 revealed a focus area for alteration in musculoskeletal status related to left (L) hip replacement with a goal of remaining free of injuries or complications, and interventions to include hip abductor pillow as ordered. On 01/05/2021 at 09:46 a.m., Resident #98 was observed sitting in a wheelchair and not wearing the abductor wedge pillow between her legs. During an observation on 01/06/2021 at 09:08 a.m., Resident #98 was observed again to not be wearing the abductor wedge pillow between her legs. During an interview with the resident she stated that she was concerned that the abductor wedge was not being put on her. She stated that she was always supposed to be wearing it when up in the wheelchair. Resident #98 further indicated that the Certified Nursing Assistant (CNA) usually puts it on when she assisted her to the wheelchair in the morning, and that she did not want to go back to the hospital with her left hip joint popped out of socket because she crossed her legs while not wearing it. A review of the Medication Administration Record [REDACTED]. On 01/05/2021 evening and night shift had not documented the abductor wedge usage while in the wheelchair, and on 1/06/2021 to 01/07/2021 no documentation was made for all shifts for application of the abductor wedge between legs when in the wheelchair for LE positioning. An interview was conducted on 01/08/2021 at 08:10 a.m. with the Director of Rehabilitation regarding observations of Resident #98 and her concern that she was not wearing the physician ordered abductor wedge pillow between her legs while seated in a wheelchair. The Director of Rehabilitation indicated that if it was a physician order, her expectation was that Resident #98 should be wearing it. The Director of Rehabilitation confirmed the physician order [REDACTED]. An interview was conducted on 01/08/2021 at 09:09 a.m., with Staff M, Licensed Practical Nurse (LPN). Staff M, (LPN) was asked who places the abductor wedge between the resident's legs when in the wheelchair for LE positioning. He indicated that he puts it on the resident and that she has never refused to wear it in all the time he has been the resident's nurse. He was further asked why the resident was not wearing it on 01/06/2020, and also why there was no documentation for that day in the MAR for the device being applied or not applied. Staff M, (LPN) was not able to provide an answer. During an interview with the Director of Nursing (DON) on 01/08/2021 at 9:18 a.m., she was informed of observations made of Resident #98. The DON reported that she was made aware of the situation from the Director of Rehabilitation. The DON stated that the CNA should be putting it on and the nurse should visually inspect that it was on since they are responsible for charting on it, or at lease verify it is place.

Based on record review, observation, and interviews the facility did not ensure appropriate physician's orders were obtained and implemented for nephrostomy tubes for one (#226) of 54 sampled residents. Findings included: A review of Resident #226's clinical record revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission summary dated 12/19/20 reflected a left iliac crest (rear) nephrostomy tube site and right iliac crest (rear) nephrostomy tube site. The 12/19/20 skin check indicated 2. other nephrostomy. Review of the care plan dated 12/22/20 and revised on 12/30/20 showed a Focus area of nephrostomy tubes. The interventions included change tubes as ordered and monitor tubes as ordered. A review of the Minimum Data Set (MDS) assessment, section H, bladder and bowel, dated 1/8/21 reflected an indwelling catheter (including Suprapubic catheter and nephrostomy tube). A review of the physician assistant progress note dated 12/28/20 reflected a hospitalization in October 2020 for AKI (acute kidney injury, large pelvic mass causing bilateral hydro[DIAGNOSES REDACTED] s/p (status [REDACTED]. A review of the physician's orders in the medical record reflected the following: 12/21/20 type of ostomy care every shift as needed for [MEDICAL CONDITION] 12/21/20 type of ostomy care every shift as needed for ostomy care 12/21/20 change [MEDICATION NAME] wafer and pouch every day using (wafer size and type), pouch type (closed or drainable). May use barrier paste/powder and skin prep as needed to ensure adhesion of wafer as needed for [MEDICAL CONDITION] care. Change prn (as needed) for non-adhering wafer. 12/21/20 change ostomy wafer and pouch every day using (wafer size and type), pouch type (closed or drainable). May use barrier paste/powder and skin prep as needed to ensure adhesion of wafer every day shift for ostomy care. A review of the treatment administration record (TAR) for the months of December 2020 and January 2021 reflected the following: The ostomy wafer and pouch treatment for [REDACTED]. The [MEDICAL CONDITION] care was not signed. On 1/08/21 at 10:54 AM, an interview was conducted with Staff J, LPN (licensed practical nurse). Staff J, LPN said Resident #226 has bilateral nephrostomy tubes. The nephrostomy tube care was Q (every) shift. The surveyor asked what type of care was provided to the nephrostomy tubes. Staff J, LPN said she empties it and checks the site daily. Staff J, LPN said she was not sure about the dressing change, she would have to look. She thinks it was daily. Staff J, LPN said she was going in right now to assess the nephrostomy tubes because she heard the stitches were pulling. Staff J, said she wasn't sure when the dressing changes were; it may be on her shift. She just does what was ordered and checks to make sure they were taken care of. On 1/08/21 at 11:05 AM, an observation was conducted with Staff J, LPN and Resident #226. Resident #226 was in her bed with the head of bed elevated to about seventy-five degrees. Resident #226 permitted the nurse to check the nephrostomy tubes. The left flank nephrostomy tube had an undated dressing that was wadded up around the tube near the insertion site with dried reddish-brown moist drainage. The site was slightly red at the insertion site and slightly macerated with sutures holding the tube in place. The right nephrostomy tube adhesive dressing was intact but full of bloody yellowish-clear drainage. The site was macerated and red. The dressing was also undated. Neither dressing was a wafer with pouch as indicated in the physician orders. Staff J, LPN said sometimes the doctors don't want the dressings changed until they see them for the follow up visit. She would have to check and see what the order was. In a follow up interview on 1/08/21 at 11:27 AM with Staff J, LPN she confirmed the dressings were in bad condition. She said she told the unit manager and stated that the order was not appropriate either, so she changed the dressings and the unit manager changed the order. She said she was surprised the dressings were in such bad condition, and she will have to check things herself instead of assuming they were ok. On 1/08/21 at 11:56 AM, an interview was conducted with Staff I, LPN UM (unit manager). She said Staff N, RN (registered nurse) was the unit manager on the hall for Resident #226. Staff I, LPN UM said the nurse (Staff J, LPN) told her about the dressings and asked if she (Staff I, LPN UM) knew when they were last changed. I said I did not. Staff I, LPN UM reported that on admission the UM does the admission, the chart check, the medication, puts the treatment in place, or the UM can call the doctor and get the treatments in place. The admitting nurse does the admission assessment. We do have an admitting nurse who does some of the admission assessments, but usually it was done by the floor nurse. On 1/08/21 at 12:06 PM, an interview was conducted with Staff N, RN UM for Resident #226. Staff N, RN said one of the management team and the unit managers audits the charts. Whoever discovers the area would notify the physician and get treatment orders. Staff N, RN UM confirmed Resident #226 had nephrostomy tubes. Staff N, RN UM said that treatment for [REDACTED]. The treatment was a split dressing and secure with paper tape. The surveyor asked if the treatment that had been ordered was appropriate. Staff N, RN UM said, Not typically, we would use that on an ostomy or [MEDICATION NAME]. Staff N, RN UM also said it was brought to his attention that Resident #226 didn't have a nephrostomy treatment, so he notified the physician and put the treatment order in today. The surveyor asked about the treatments that were signed indicting they were being done and Staff N, RN UM said he would have to look into it. On 1/08/21 at 12:32 PM, an interview was conducted with the DON (director of nursing) and NHA (nursing home administrator). The DON said Staff I, LPN UM reported Resident #226 had a dressing on and the surveyor didn't see an order for [REDACTED]. The DON confirmed the treatment was not an appropriate nephrostomy dressing order. She confirmed the treatments had been signed for a [MEDICAL CONDITION] and [MEDICATION NAME]. When they did her skin check they should have realized she had nephrostomy tubes and put in correct orders for flushing and dressing. On 1/08/21 at 1:43 PM, another interview was conducted with the DON. She said Resident #226 could get an incisional site infection if they don't change the dressings regularly. The DON also said she spoke to the nurses and they said they have been changing the dressings everyday until yesterday when the resident refused.

Based on observation, interview and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure an indwelling urinary catheter bag and tubing was maintained off the floor to prevent potential infection for one resident #(243) during two of two observations, of 5 residents with catheters. Findings included: On 1/05/21 at 4:30 PM, an observation of Resident #243 revealed he was lying in bed with the urinary catheter bag and tubing on the left side of the bed hanging from the bed frame and resting on the floor. The catheter bag was completely on the floor. On 1/07/21 at 8:44 AM, another observation was conducted. Resident #243 was in his bed watching TV. The bed was in the low position near the floor. The catheter bag was sitting completely on the floor near the head of the bed on the resident's left side facing the door. The tubing was also on the floor. On 1/07/21 at 8:46 AM, an interview and observation was conducted with Staff I, LPN UM. Staff I, LPN UM confirmed the catheter bag and tubing were on the floor. A review of Resident #243's clinical record revealed a [DIAGNOSES REDACTED]. On 1/08/21 at 8:55 AM, an interview was conducted with the DON. She said the catheter should not touch the floor. The following information was found at https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html: Catheter-Associated Urinary Tract Infections (CAUTI) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) III. Proper Techniques for Urinary Catheter Maintenance III.B.2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Based on interviews and record review the facility failed to ensure laboratory services were provided in a timely manner in accordance with physician orders [REDACTED].#112) of 54 sampled residents related to a lipid panel. Findings included: A medical record review was conducted for Resident #112 to ensure that the Medication Regimen Review recommendations were being followed. A review of Resident #112's admission record revealed a [DIAGNOSES REDACTED]. There was a physician signature on the form acknowledging the pharmacist recommendation and a signature by Staff C, Registered Nurse (RN) Unit Manager (UM) that documented noted and the date of 11/30/20. Further medical record review revealed a physician's orders [REDACTED]. A review of the lab records, however, revealed that the order was not followed through on and no lipid panel had been conducted. An interview was conducted with Staff C, RN UM on 1/7/2021 who confirmed that the order had not been conducted for the lipid panel until the surveyor asked for the resident's Medication Administration Record [REDACTED] On 01/08/21 at 12:19 P.M., an additional interview was conducted with the DON (Director of Nursing) in regard to following a physician's orders [REDACTED]. Facility then had a STAT order for the labs on 1/6/2021. The DON reports that there is no facility policy for following physicians' orders as this was a standard of care. A telephone call was made to the facility Pharmacist on 1/8/2021 at 1:49 p.m. He was asked if he had expectations of the facility following recommendations. The pharmacist stated that once the physician reviews the recommendation and approves it, the facility must follow through.

Based on resident and staff interviews and record reviews it was determined that the facility failed to ensure residents were treated in a dignified manner related to not responding in a timely to call lights for five residents (#102, #3, #64, #93, and #78) out of 38 sampled residents. Findings included: 1. On 03/27/19 at 10:08 a.m., Resident #102 was observed in her room lying in bed on her back. The resident reported that she had to wait almost two hours for help last night. The resident reported that she had pressed the call light at about 9:00 p.m. because she was itching badly and could not sleep. Resident #102 reported that someone came and reported that they would go find her nurse, but the nurse did not come until about 11:00 p.m. She stated that the time she had to wait was unacceptable and she only needed cream for the itching and a sleeping pill to go to sleep. She reported that she needed the sleeping pill to go to sleep due to all of the itching. The Admission Record revealed that Resident #102 was initially admitted into the facility on [DATE] with a readmission date of [DATE]. The resident had a principal [DIAGNOSES REDACTED]. Section C of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that she was cognitively intact. The resident had the following physician orders [REDACTED]. [MEDICATION NAME] Allergy Tablet 25 MG (milligram) - 1 tablet po (by mouth) every 6 hours as needed for rash (start date 3/27/19) [MEDICATION NAME] Cream 1%- Apply to left scapula, chest topically every shift for itching/redness (start date 3/22/19) [MEDICATION NAME] Capsule 15 MG- Give 1 capsule by mouth every 24 hours as needed for sleep for 14 days at bedtime (start date 3/21/19) [MEDICATION NAME] Tablet 3 MG- Give 1 tablet by mouth at bedtime for nutritional support/age related deficiency at bed time (start date 3/21/19) A review of a health status note dated 03/27/19 at 11:56 a.m. revealed the following, Resident complains of itching. Resident has non distinct rash to face, chest, bilateral arms. She is taking [MEDICATION NAME] and using [MEDICATION NAME] cream but states, it does not last to relieve itching. Call placed to DR (doctor). A review of a health status note dated 03/27/19 at 10:10 a.m. revealed the following, MD (doctor) called R/T (related to) the patient rash to her chest, c/o (complaint of) itching. The patient has [MEDICATION NAME] Cream 1% and patient states it helps but this itching. New orders for [MEDICATION NAME] 25 mg po q (every) 6 hours PRN (as needed) for rash. A review of the Medication Administration Record [REDACTED] On 03/29/19 at 12:44 p.m., an interview with the Director of Nursing (DON) revealed that she (Resident #102) mentioned that she itches and the doctor was informed that the cream was not working. 2. On 03/28/19 at 9:45 a.m., Resident #3 reported that she did not feel safe in the facility because she had a lot of falls. Resident #3 reported that she had a fall a few days ago and pressed the call light for help and no one came. Resident #3 stated that she initially pressed the call light because she needed to go to the bathroom. The resident reported that she fell to the floor because she had difficulty sitting up on her own. She stated that after about 25 minutes she yelled, Patient (room number and bed) on the floor. The resident reported that she wet her pants. A review of a facility report revealed that Resident #3 had a fall on 03/26/19, 03/24/19, 03/22/19, 03/17/19, 03/12/19, and 03/11/19. The resident had also reported this concern to another surveyor verbatim in the Resident Council Meeting held on 03/27/19. On 03/29/19 at 12:45 p.m., the DON was asked if Resident #3 had a fall due to her call light not being answered timely. She stated that recently, we have had a lot of call light concerns. We have been trying to make sure everyone was involved with answering call lights no matter what department they worked for. The Admission Record revealed that Resident #3 was initially admitted into the facility on [DATE] with a readmission date of [DATE]. Resident #3's had a principal [DIAGNOSES REDACTED]. Section C of the MDS dated [DATE] revealed that the resident had a BIMS score of 15 out of 15 indicating that she was cognitively intact. Section G revealed that the resident needed supervision with one-person physical assistance for toileting. The care plan for falls initiated on 03/08/19 and revised on 3/28/19 revealed that the resident had falls that were reviewed on 3/10, 3/12, 3/17, 3/24 and 3/26/19. The focus revealed that the resident is at risk for falls r/t activity intolerance, poor balance, poor safety awareness r/t closed head injury, [MEDICAL CONDITION]. (Resident #3) is aware that she needs to ask for assistance but chooses not to do so. The interventions included but were not limited, place frequently used items within easy reach and encourage the use of call light for assistance as needed. 3. On 03/26/19 at 10:53 a.m., Resident #64 was observed sitting in the room next to the bed in a recliner chair. The resident reported that there was not enough staff in the facility. She reported that she pressed the call light 12 times last night because she had to use the restroom. She reported that she had to wet her pants due to waiting for so long. She reported that staff never answer the call light timely. She reported that the concern was reported, but she does not remember to who. The Admission Record revealed that Resident #64 was initially admitted into the facility on [DATE] with a readmission date of [DATE] with a principal [DIAGNOSES REDACTED]. Section C of the MDS dated [DATE] indicated that the resident had a BIMS score of 14 out of 15 indicating that she was cognitively intact. Section G revealed that she needed extensive assistance with one-person physical assistance for toileting. The ADL self-care performance deficit r/t activity intolerance care plan initiated on 03/08/19 revealed that the resident required extensive assistance by one staff for toileting. The bowel incontinence r/t immobility care plan initiated on 03/08/19 revealed that interventions included but were not limited to check resident frequently during each shift and assist with toileting as needed. The falls r/t history of falls care plan initiated on 03/08/19 revealed that interventions included but were not limited to encourage the resident to use call light for assistance as needed. On 03/27/19 at 10:48 a.m., Staff H, Certified Nursing Assistant (CNA) reported that there was not enough staff and the residents had to wait a while for call lights to be answered. She reported that several residents had wet and pooped their pants because it was taking a while to answer the call lights. It has been kind of rough for a minute, stated Staff H. We need more help we really do, stated Staff H. On 03/29/19 at 11:35 p.m., grievances on the Concern Log were reviewed with the Social Services Director (SSD) related to call lights. There were three grievances on the Concern Log related to the amount of time it took staff to answer call lights during the month of (MONTH) 2019. There was one grievance related to the amount of time it took staff to answer call lights during the month of (MONTH) 2019. Further review revealed that education was provided to the staff related to answering call lights as the resolution. On 03/29/19 at 12:47 p.m., an interview with the DON revealed that her expectations for answering the call lights were to answer them timely. Five minutes is a long time, stated the DON. She stated that the call lights should be answered within five to 10 minutes. On 03/29/19 at 2:32 p.m., the Regional Director of Clinical Services reported that there was not a policy on call lights or ADLs. 4. On 03/26/19 at 11:42 a.m., an observation and interview was conducted with Resident # 78, who was in his room, sitting in a wheelchair. Resident #78 was asked about patient care related to activities of daily living provided by the facility staff. Resident #78 very pleasantly stated, I have to wait many times for staff to answer the call light. Recently I had to wait a half an hour for them to answer the call light, and I wound up peeing in my brief, I wet myself. A record review for Resident #78 revealed an admission date of [DATE] and a re-admission date of [DATE] with multiple [DIAGNOSES REDACTED]. Review of the Quarterly Minimum data Set (MDS) dated identified in Section C, indicated the BIMS score was 14, (on a 1-15 score range) indicating the resident was cognitively intact. Record review of the care plan for Resident # 78, revealed a focus area of Activities of Daily Living Performance Self-Care Deficit related to activity intolerance, initiated on 03/04/19. The interventions revised on 03/13/2019, indicated, Toilet Use: The resident requires extensive assistance by one (1) staff for toileting. Record review of the care plan revealed a focus area of falls related to impaired balance, initiated on 2/27/19. The one of the interventions indicated, Encourage the resident to use call light for assistance as needed. 5. An interview was conducted with Resident #93 on 03/27/19 at 10:00 a.m., during a Resident Council Meeting. The resident stated, One time I did sit on the toilet for a half an hour till the staff came and got me off. I did put my call light on. Review of Section C of the current Quarterly MDS indicated the BIMS score for Resident #93 was a 15; (on a 1-15 score range) indicating the resident was cognitively intact. Clinical record review of Resident #93's face sheet indicated an admission date of [DATE] with a re-admission date of [DATE] with multiple [DIAGNOSES REDACTED]. Clinical record review of the care plan for Resident #93 indicated a focus area of activities of daily living self-care performance, self-care deficit related to activity intolerance, initiated on 11/27/17. The interventions were revised on 12/11/18, an indicated, Toilet use: the resident requires extensive assistance by one (1) staff for toileting. Transfer: The resident requires assistance to include by one (1) staff to move between surfaces as necessary. Further review of the care plan revealed a focus related to the resident was at risk for falls related to gait/balance problems and required assistance for transfers with an initiated date of 11/27/17. The interventions included but not limited to (initiated on 11/27/17 and revised 9/24/18), Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.

Based on staff and resident interview, and record review the facility failed to provide sufficient staffing to respond to call lights in a timely manner to provide toileting, incontinence care, medication assistance and assistance following a fall for five (Resident #102, #3, #64, #93, and #78) of 38 residents sampled. Findings included: 1. On 03/27/19 at 10:08 a.m., Resident #102 was observed in her room lying in bed on her back. The resident reported that she had to wait almost two hours for help last night. The resident reported that she had pressed the call light at about 9:00 p.m. because she was itching badly and could not sleep. Resident #102 reported that someone came and reported that they would go find her nurse, but the nurse did not come until about 11:00 p.m. She stated that the time she had to wait was unacceptable and she only needed cream for the itching and a sleeping pill to go to sleep. She reported that she needed the sleeping pill to go to sleep due to all of the itching. The Admission Record revealed that Resident #102 was initially admitted into the facility on [DATE] with a readmission date of [DATE]. The resident had a principal [DIAGNOSES REDACTED]. The resident had the following physician orders [REDACTED]. [MEDICATION NAME] Allergy Tablet 25 MG (milligram) - 1 tablet po (by mouth) every 6 hours as needed for rash (start date 3/27/19) [MEDICATION NAME] Cream 1%- Apply to left scapula, chest topically every shift for itching/redness (start date 3/22/19) [MEDICATION NAME] Capsule 15 MG- Give 1 capsule by mouth every 24 hours as needed for sleep for 14 days at bedtime (start date 3/21/19) [MEDICATION NAME] Tablet 3 MG- Give 1 tablet by mouth at bedtime for nutritional support/age related deficiency at bed time (start date 3/21/19) A review of a health status note dated 03/27/19 at 11:56 a.m. revealed the following, Resident complains of itching. Resident has non distinct rash to face, chest, bilateral arms. She is taking [MEDICATION NAME] and using [MEDICATION NAME] cream but states, it does not last to relieve itching. Call placed to DR (doctor). A review of a health status note dated 03/27/19 at 10:10 a.m. revealed the following, MD (doctor) called R/T (related to) the patient rash to her chest, c/o (complaint of) itching. The patient has [MEDICATION NAME] Cream 1% and patient states it helps but this itching. New orders for [MEDICATION NAME] 25 mg po q (every) 6 hours PRN (as needed) for rash. Section C of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that she was cognitively intact. A review of the Medication Administration Record [REDACTED] On 03/29/19 at 12:44 p.m., an interview with the Director of Nursing (DON) revealed that she (Resident #102) mentioned that she itches and the doctor was informed that the cream was not working. 2. On 03/28/19 at 9:45 a.m., Resident #3 reported that she did not feel safe in the facility because she had a lot of falls. Resident #3 reported that she had a fall a few days ago and pressed the call light for help and no one came. Resident #3 stated that she initially pressed the call light because she needed to go to the bathroom. The resident reported that she fell to the floor because she had difficulty sitting up on her own. She stated that after about 25 minutes she yelled, Patient (room number and bed) on the floor. The resident reported that she wet her pants. A review of a facility report revealed that Resident #3 had a fall on 03/26/19, 03/24/19, 03/22/19, 03/17/19, 03/12/19, and 03/11/19. The resident had also reported this concern to another surveyor verbatim in the Resident Council Meeting held on 03/27/19. On 03/29/19 at 12:45 p.m., the DON was asked if Resident #3 had a fall due to her call light not being answered timely. She stated that recently, we have had a lot of call light concerns. We have been trying to make sure everyone was involved with answering call lights no matter what department they worked for. The Admission Record revealed that Resident #3 was initially admitted into the facility on [DATE] with a readmission date of [DATE]. Resident #3's had a principal [DIAGNOSES REDACTED]. The resident had the following current physician orders [REDACTED]. [MEDICATION NAME] Chloride ER Tablet Extended Release 24 Hours 15 MG- Give 1 tablet po two times a day for over active bladder (start date of 3/8/19) Ropinirole HCI Tablet 1 MG- Give 1 tablet by mouth two times a day for [MEDICAL CONDITION] (start date of 3/8/19) [MEDICATION NAME] Tablet 25-100 MG- Give 1 table by mouth three times a day for [MEDICAL CONDITION]. (start date 3/7/19) The care plan for Activities of Daily Living (ADLs) initiated on 03/27/19 revealed that Resident #3 required limited assistance by one staff for toileting. The care plan for falls initiated on 03/08/19 and revised on 3/28/19 revealed that the resident had falls that were reviewed on 3/10, 3/12, 3/17, 3/24 and 3/26/19. The focus revealed that the resident is at risk for falls r/t activity intolerance, poor balance, poor safety awareness r/t closed head injury, [MEDICAL CONDITION]. (Resident #3) is aware that she needs to ask for assistance but chooses not to do so. The interventions included but were not limited, place frequently used items within easy reach and encourage the use of call light for assistance as needed. Section C of the MDS dated [DATE] revealed that the resident had a BIMS score of 15 out of 15 indicating that she was cognitively intact. Section G revealed that the resident needed supervision with one-person physical assistance for toileting. 3. On 03/26/19 at 10:53 a.m., Resident #64 was observed sitting in the room next to the bed in a recliner chair. The resident reported that there was not enough staff in the facility. She reported that she pressed the call light 12 times last night because she had to use the restroom. She reported that she had to wet her pants due to waiting for so long. She reported that staff never answer the call light timely. She reported that the concern was reported, but she does not remember to who. The Admission Record revealed that Resident #64 was initially admitted into the facility on [DATE] with a readmission date of [DATE] with a principal [DIAGNOSES REDACTED]. The ADL self-care performance deficit r/t activity intolerance care plan initiated on 03/08/19 revealed that the resident required extensive assistance by one staff for toileting. The bowel incontinence r/t immobility care plan initiated on 03/08/19 revealed that interventions included but were not limited to check resident frequently during each shift and assist with toileting as needed. The falls r/t history of falls care plan initiated on 03/08/19 revealed that interventions included but were not limited to encourage the resident to use call light for assistance as needed. Section C of the MDS dated [DATE] indicated that the resident had a BIMS score of 14 out of 15 indicating that she was cognitively intact. Section G revealed that she needed extensive assistance with one-person physical assistance for toileting. On 03/27/19 at 10:48 a.m., Staff H, Certified Nursing Assistant (CNA) reported that there was not enough staff and the residents had to wait a while for call lights to be answered. She reported that several residents had wet and pooped their pants because it was taking a while to answer the call lights. It has been kind of rough for a minute, stated Staff H. We need more help we really do, stated Staff H. On 03/29/19 at 11:35 p.m., grievances on the Concern Log were reviewed with the Social Services Director (SSD) related to call lights. There were three grievances on the Concern Log related to the amount of time it took staff to answer call lights during the month of (MONTH) 2019. There was one grievance related to the amount of time it took staff to answer call lights during the month of (MONTH) 2019. Further review revealed that education was provided to the staff related to answering call lights as the resolution. On 03/29/19 at 12:47 p.m., an interview with the DON revealed that her expectations for answering the call lights were to answer them timely. 5 minutes is a long time, stated the DON. She stated that the call lights should be answered within 5 to 10 minutes. On 03/29/19 at 2:32 p.m., the Regional Director of Clinical Services reported that there was not a policy on call lights or ADLs. 4. On 03/26/19 at 11:42 a.m., an observation and interview was conducted with Resident # 78, who was in his room, sitting in a wheelchair. Resident #78 was asked about patient care related to activities of daily living provided by the facility staff. Resident #78 very pleasantly stated, I have to wait many times for staff to answer the call light. Recently I had to wait a half an hour for them to answer the call light, and I wound up peeing in my brief, I wet myself. A record review for Resident #78 revealed an admission date of [DATE] and a re-admission date of [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the care plan for Resident # 78, revealed a focus area of Activities of Daily Living Performance Self-Care Deficit related to activity intolerance, initiated on 03/04/19. The interventions revised on 03/13/2019, indicated, Toilet Use: The resident requires extensive assistance by one (1) staff for toileting. Record review of the care plan revealed a focus area of falls related to impaired balance, initiated on 2/27/19. The one of the interventions indicated, Encourage the resident to use call light for assistance as needed. Review of the Quarterly Minimum data Set (MDS) dated identified in Section C, indicated the BIMS score was 14, (on a 1-15 score range) indicating the resident was cognitively intact. An interview was conducted with Resident #93 on 03/27/19 at 10:00 a.m., during a Resident Council Meeting. The resident stated, One time I did sit on the toilet for a half an hour till the staff came and got me off. I did put my call light on. 5. Clinical record review of Resident #93's face sheet indicated an admission date of [DATE] with a re-admission date of [DATE] with multiple [DIAGNOSES REDACTED]. Clinical record review of the care plan for Resident #93 indicated a focus area of activities of daily living self-care performance, self-care deficit related to activity intolerance, initiated on 11/27/17. The interventions were revised on 12/11/18, an indicated, Toilet use: the resident requires extensive assistance by one (1) staff for toileting. Transfer: The resident requires assistance to include by one (1) staff to move between surfaces as necessary. Further review of the care plan revealed a focus related to the resident was at risk for falls related to gait/balance problems and required assistance for transfers with an initiated date of 11/27/17. The interventions included but not limited to (initiated on 11/27/17 and revised 9/24/18), Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of Section C of the current Quarterly MDS indicated the BIMS score for Resident #93 was a 15; (on a 1-15 score range) indicating the resident was cognitively intact. An interview on 03/28/19 2:45 p.m. was conducted with Staff D, LPN she stated, They hire people, they come here and leave . most CNAs have a second job . We are short on staff, and it's a issue with consistency of staff, makes it harder for me to do my job. Staff confirmed that the staffing issue had caused her to do extra work, and she stated, I cannot do it all, I have to do extra when we are short on CNAs and do my job and the CNA job, and I can't answer the lights or take care of the residents, and it's not fair to them.

Based on resident observation, medical record review and interviews with staff the facility failed to ensure that one (#23) out of thirty eight sampled residents was properly assessed and monitored for self-administration of a nebulizer treatment. Findings included: On 3/28/19 at 11:20 a.m. Staff B, Licensed Practical Nurse (LPN) was observed at the nurse's station. A resident called for help from the bathroom and Staff B got up from the nurse's station and went to assist a resident in the bathroom located in the hallway across from the nurse's station. On 3/28/19 at 11:23 a.m. Resident #23 was observed sitting in her room in a wheelchair at the bedside. She appeared to be dozing with her head slumped forward toward her chest. Resident #23 had a nebulizer mask on with the strap stretched around her head. A respiratory treatment was in progress delivered by a nebulizer machine located behind the resident on the bedside table. Staff B, LPN quickly entered the room and woke up the resident to remove the nebulizer mask and turn off the respiratory treatment. On 3/28/19 at 11:25 a.m. an interview was conducted with Staff B, LPN as she exited Resident #23's room. The nurse stated that Resident #23 was not supposed to be left unattended during the nebulizer treatment. She stated that Resident #23 was not assessed for self-administration of medications. Staff B, LPN confirmed that she left the resident alone during the treatment. A review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Determination of Incapacity was present in the record dated 5/18/18 and signed by the attending physician. A review of the physician orders for (MONTH) 2019 revealed Resident #23 had an active order for [MEDICATION NAME] Nebulization Solution to be inhaled orally via a nebulizer every six hours for cough/congestion and initiated on 12/7/18. The Medication Administration Record [REDACTED]. A review of the Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 06, indicating severe cognitive impairment. A review of the care plan revealed the following focus area for Resident #23: Focus: The resident has altered respiratory status/difficulty breathing related to [MEDICAL CONDITION]. (Initiated 3/26/18 and Revision 2/24/19) Goal: The resident will have no complications related to shortness of breath (SOB) through the review date. Interventions included but not limited to: Nebulizer treatments as ordered, oxygen as ordered.(Initiated 10/16/18) The medical record review revealed no physician order for [REDACTED]. On 3/28/19 at 4:30 p.m. an interview was conducted with the Director of Nursing (DON). The DON confirmed that nursing is to remain in the room during nebulizer treatments for residents who are not assessed to self-administer medications. She confirmed that no assessment had been completed for Resident #23. She stated that Resident #23 had no ability to self-administer medications. She was made aware of the observation that occurred with Resident #23. A review of the facility provided policy titled, Self-Administration of Medication, (limited liability corporation) 0115 with no date indicated, revealed the following: Purpose: (one of four bulleted items) To provide evaluation process to determine if a resident is capable of self-administration Procedure: 3. Based on the interdisciplinary team's assessment, a decision is made as to whether or not the resident is a candidate for self-administration. This will be recorded on the Self-Administration of Medication Evaluation. 4. The nurse will obtain a physician's order for each resident conducting self-administration of medications. A review of the facility provided policy titled, Oral Inhalation Administration, revised (MONTH) 2014 revealed the following: Purpose: To allow for safe, accurate, and effective administration of medication using an oral inhaler or nebulizer. Procedure: Nebulizer C. Position the resident in semi-Fowler's position K. Instruct the resident to take a deep breath, pause briefly and then exhale normally. Repeat pattern throughout treatment.

Based on observations, record reviews, and interviews, the facility failed to ensure that infection control practices were maintained related to isolation precautions by not ensuring visitors and staff wore personal protective equipment (PPE) when entering two of nine rooms that were on isolation for four residents (#94, #71, #101, and #308) for three of four days. Findings included: The facility policy titled, SUBJECT: Infectious Diseases- [MEDICAL CONDITION], with a copyright date of 2013 revealed the following overview: . Advise families, visitors, and residents about the importance of handwashing or hand hygiene to minimize the spread of fecal contamination to surfaces. The Procedure revealed, 4. Wear clean non sterile gowns and shoe covers when entering the room of a [MEDICAL CONDITION] of a resident due to the environmental significance of the organisms spores. *If no contact with the resident, environmental surfaces, or items in the room is anticipated, gowns are not necessary, and Activities/Movements Of Resident, 11. Notify receiving hospital/health care facility prior to the transfer, of [MEDICAL CONDITION] colonized or infection. On 03/26/19 at 12:17 p.m., a visitor for Resident #94 was observed sitting in the room in a chair at the foot of the bed. The visitor was not wearing PPE. There was a sign posted on the door to the room of Resident #94 and #71 that revealed, Please lift the sheet and read the instructions prior to entering the room. Contact isolation has been indicated for the resident in A bed. This resident must not leave the room (unless approval from Nursing). Visitors 1. Wash your hands with soap and water before exiting the room even if you did not have contact with the resident. 2. Gloves and gowns MUST be worn while in the room. 3. Do not sit on the resident's bed or use the resident's bathroom. 4. Remove glove and gowns prior to leaving the room and dispose of in the trash can. 5. Wash your hands with soap and water prior to leaving the room. On 03/27/19 at 9:32 a.m., the surveyor went to the room to speak to Resident #71 and observed the door to the room no longer had the caddy up that held the PPE and the signs related to the isolation were no longer on the door. On 03/27/19 at 10:21 a.m., Resident #71 was observed in the Resident Council Meeting. On 03/27/19 at 10:40 a.m., Resident #94 was asked why his roommate was on isolation and he reported that he did not know but he was concerned. He stated that he was asking everyone why and they could not tell him anything. The resident reported that he was worried because everybody was coming in the room with the gowns on and his neighbors and family would come to visit him, and they did not put on the gowns. A review of the Admission Record for Resident #94 revealed that he was admitted into the facility on [DATE] with a principal [DIAGNOSES REDACTED]. Further review of the record revealed that this resident did not have a [DIAGNOSES REDACTED]. Section C of the current Minimum Data Set (MDS) revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderately impaired. On 03/27/19 at 10:50 a.m., Resident #71 was observed coming down the hallway and this surveyor asked the resident if they could speak in his room. The resident reported that he was on contact isolation, and they did not tell him why at first and they later told him it was because of [MEDICAL CONDITION]. The resident reported that he had been on isolation for about a week. On 03/27/19 at 2:30 p.m., Resident #71 was observed in his room and there was no PPE equipment on the door at this time. A review of the Admission Record revealed that Resident #71 was initially admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Section C of the most recent Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. A review of Resident #71's current physician orders [REDACTED]. A review of the Medication Administration Record [REDACTED] *[MEDICATION NAME] Tablet 500 MG- Give 500 mg by mouth three times a day for Cdiff for 14 days start date of 3/27/19 at 2100 (9:00 p.m.) *[MEDICATION NAME] Tablet 500 MG- Give 500 mg by mouth three times a day for [MEDICATION NAME], start date of 3/22/19 at 2100 (9:00 p.m.) and discontinued date of 3/27/19 at 1549 (3:49 p.m.) *[MEDICATION NAME] Tablet 500 MG- Give 500 mg by mouth three times a day for possible infection, start date of 3/21/19 at 2100 (9:00 p.m.) and discontinued date of 3/22/19 at 1059 (10:59 a.m.) *[MEDICATION NAME] Tablet 500 MG- Give 500 mg by mouth three times a day for possible infection, start date of 3/20/19 at 2100 (9:00 p.m.) and discontinued date of 3/21/19 at 1320 (1:20 p.m.) A review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed that Resident #71 had the following orders: 03/26/19 Send stool to lab to rule out [MEDICAL CONDITION] every night shift for monitoring for 1 day discontinued 3/26/19 03/25/19 Schedule CT (computerized tomography) scan of Abdomen and Pelvis with PO (oral/by mouth) contrast Dx. (diagnosis) Diarrhea 03/23/19 Contact isolation every shift discontinued 3/26/19 03/23/19 Collect stool sample every shift. Reason to rule out C.Diff discontinued 3/24/19 03/21/19 [MEDICATION NAME] Tablet 500 MG- Give 500 mg po three times a day for possible infection 03/21/19 Contact Precautions for DX (diagnosis) Cdiff discontinued 3/21/19 A review of the progress notes for Resident #71 revealed: A progress note dated 03/28/19 at 11:30 a.m. written by the Director of Nursing (DON) revealed that the resident was no longer having loose stools. Resident treated for [REDACTED]. A progress note dated 03/27/19 at 18:46 (6:46 p.m.) written by the Social Services Director (SSD) revealed that the resident was scheduled to discharge home but the results for his stool sample came back positive for [MEDICAL CONDITION]. SSD explained that once his medication regimen was completed, and as long as he was asymptomatic he could discharge at that time. A progress note dated 03/27/19 at 15:59 (3:59 p.m.) written by Staff J, Licensed Practical Nurse (LPN), revealed that the [MEDICAL CONDITION] results was showing positive. MD (Medical Director) called made aware of orders to continue [MEDICATION NAME] for 14 days and place on contact isolation. [MEDICAL TREATMENT] called made aware that the patient was [MEDICAL CONDITION] positive. A progress note dated 03/23/19 at 23:08 (11:08 p.m.) revealed that the resident remained on contact precaution. A progress note dated 03/23/19 at 20:52 (8:52 p.m.) revealed that patient currently on po abt (antibiotics) for loose stools. A progress note dated 03/22/19 at 23:32 (11:32 p.m.) revealed that the resident remained on contact isolation dx [MEDICAL CONDITION]. A progress note dated 03/22/19 at 18:35 (6:35 p.m.) revealed that the resident was noted having new order from MD, CT scan abd (abdominal) and pelvis with po contrast dx diarrhea. A progress note dated 03/21/19 17:57 (5:57 p.m.) revealed that the MD notified of patient not having diarrhea. MD ordered to continue antibiotic [MEDICATION NAME] and discontinue contact isolation. The Lab Results for Resident #71 dated 03/27/19 revealed that the test was positive for[DIAGNOSES REDACTED]icile. The resident had a care plan in place with a focus that revealed, The resident continues on antifungal for [MEDICAL CONDITION], initiated on 03/21/19 and revised on 3/27/19. Interventions included but were not limited to contact isolation and educate resident/family/staff regarding preventive measures to contain infection initiated on 3/21/19 with a revision on 3/25/19. On 03/28/19 at 10:00 a.m., Staff J, Licensed Practical Nurse (LPN) was asked why the contact isolation precaution was removed yesterday (03/27/19) and the resident was now back on contact precautions. She reported that Resident #71's stool sample that was pending came back yesterday, and it was positive for [MEDICAL CONDITION]. Staff J reported at 10:06 a.m., that Resident #71 had formed stool. She reported that they had to do a re-culture and the culture was sent off on Monday. She stated that the doctor wrote an order to discontinue the contact isolation yesterday. The culture came back yesterday at about 4:00 p.m. and it was positive so he ordered the resident to remain on contact precautions. He had been having formed stools, but the doctor order a CT scan of the abdominal because of the loose stool. She stated that Resident #94, the roommate, was educated to use the bedside commode for preventive measure. Staff J reported that Resident #94 was educated on [MEDICAL CONDITION] and anyone entering the room should be wearing PPE. Staff J stated that the Social Services Director (SSD) was looking to rooming Resident #71 in a private room. Staff J reported that the SSD wanted to move him now because he was positive for [MEDICAL CONDITION]. On 03/28/19 at 10:51 a.m., Staff J reported that the physician was aware that the culture was still pending. She stated that she removed the caddy from the door because the stool was formed. On 03/28/19 at 10:20 a.m., the DON reported that Resident #71 had a stool sent out Tuesday morning and the results came back yesterday. The DON was asked why was the resident taken off contact isolation, and she stated that she thought he was on contact isolation. She stated, I'm going to have to look. The DON stated that visitors should be wearing PPE when they were in the room. She was asked if it was okay for him to have a roommate, and she stated if he needs to be moved then I would move him. On 03/28/19 at 5:30 p.m., the DON reported that the resident (#71) had [MEDICAL CONDITION] prior to him arriving to us. She reported that he came to the facility on [DATE]. The DON was asked if the [MEDICAL TREATMENT] center was notified about Resident #71 having [MEDICAL CONDITION] and she stated, I believe they were notified prior. The DON reported that Resident #94 was educated about [MEDICAL CONDITION], but she could not find anything about the family being educated. A progress note dated 03/27/19 at 16:59 (4:59 p.m.) written by the DON revealed that the [MEDICAL TREATMENT] center was contacted in regards to the resident having [MEDICAL CONDITION]. There were no other progress notes found in the medical record to document the [MEDICAL TREATMENT] center was notified of the resident having [MEDICAL CONDITION] prior to 3/27/19. On 3/28/19 at 10:20 a.m. while conducting a medication administration observation with Staff A, Registered Nurse (RN) it was noted that Resident #71 was on isolation precautions. An isolation precaution bin was hanging on the door to the room. Personal protective equipment (PPE) was stocked in the isolation bin. A sign was included on the door indicating the resident was on isolation precautions. A visitor approached the room and was observed going into the room to visit the resident. The visitor did not stop to speak with staff regarding the isolation bin and proceeded into the resident room without putting on PPE. The observation was brought to the attention of Staff A, RN. She observed the visitor in the room with the Resident #71 with no PPE in place. She stated that all visitors should be educated on what PPE equipment to put on when they visit a resident who is on isolation precautions. She confirmed that the visitor should have on PPE when in the room. The visitor spent five minutes with the resident then kissed and hugged the resident and left the room. Staff A stated that the visitor should have had on gown and gloves due to the resident being on active isolation precautions for [MEDICAL CONDITIONS] ([MEDICAL CONDITION]). An observation was conducted of Resident #101's and Resident # 308's room on 03/26/19 at 9:47 am. Staff C, Director of Environmental Services was observed to enter the residents' room without donning PPE. Staff C was observed to take from each resident their personal items of covered drinking cups out of the room, touching both of them with her bare hands. The staff member was not observed to wash her hands when leaving the residents' room. Facility signage hanging that was hanging on the door to Resident #101's and Resident # 308's room titled, Contact Isolation, read as follows, Transmission is by person to person contact or by contact with items in the environment that may be contaminated. Nursing/Rehab Staff/Housekeeping: 1.) wash your hands with soap and water before exiting the room and not alcohol gels, 2.) Gloves and gowns MUST be worn at all times when in the room. An interview was conducted immediately with Staff C, while she was in the hall outside of the room, on 03/26/19 at 9:50 am. Staff C stated, We do not have to gown up, only if we do patient care. I was told that from a nurse. I have been working here for 4 years now. I don't know who told me it, but it is what we do. Staff C left the 200 hall with both personal items, walking through the hall, dining area and into the kitchen to deliver the personal cups to be washed for Resident # 101 and Resident #308. An interview was conducted with Staff D, Licensed Practical Nurse (LPN) on 03/26/19 at 9:53 a.m. Staff D confirmed that she saw Staff C leave Resident #101's and Resident #308's room with personal cups, as she was right outside of the residents' room by her medication cart. Staff D stated, Everyone is supposed to gown up and no one should take anything out of a precaution room, and that is the policy of the facility. On 03/26/19 at 12:30 p.m. Staff E, Certified Nursing Assistant (CNA) was observed entering Resident #101's and Resident # 308's room without first donning PPE. Staff E did a meal tray set up for Resident #308. Staff E confirmed she did not don PPE, and stated, I usually have another person helping me, and I did not so I had to go put the tray down first. The policy says to put everything on before you enter the room. Review of the medical records for Resident #101 and Resident #308 revealed that both residents were identified through present medical status as at risk of transmitting Extended-Spectrum Beta-Lactamase (ESBL) organisms resistant to antibiotic treatment to other people. An interview was conducted with the DON on 03/28/19 at 11:07 a.m. The DON confirmed that both Resident #101 and Resident # 308 were on contact isolation, and that contact isolation for both residents required gowns and gloves for anyone entering the room. She stated, My expectation would be that you don't come out of the room with personal items. Review of the physician orders [REDACTED]. Nurse is to verify correct door signage. A review of physician orders [REDACTED]. Review of the care plan dated 03/08/19 with a revision date of 03/21/19, indicated that Resident # 101 was on contact isolation for treatment of [REDACTED]. A medical record review for Resident #308 indicated multiple diagnoses, which included urinary tract infection. Review of the care plan dated 03/26/19 revealed contact isolation precautions, and a focus area of ESBL in the urine. Review of the facility's policy and procedure titled, SECTION: Infection Control Manual, SUBJECT: Isolation - Contact Precautions, copyright date of 2013 reads as follows: Overview The facility will utilize Contact Precautions in addition to Standard Precautions, or the equivalent, for specified resident known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident environment. The procedure revealed: 1. Implement Standard Precautions Gloves and Hand Washing, 5.) Remove gloves before leaving room and wash hands immediately with an antimicrobial agent or waterless antiseptic agent. Ensure hands do not touch potentially contaminated environmental surfaces or items in the room after glove removal. Gown, 6.) Wear a gown (clean, nonsterile) when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident room. 7.) Wear a gown if the resident is incontinent or has diarrhea, an [MEDICAL CONDITION], a [MEDICAL CONDITION], or wound drainage not contained by a dressing.

Based on observation, interview, and record review the facility failed to ensure call bells were accessible for use for two residents (#143, #144) of 19 sampled residents assessed as being at risk for falls. Findings included: 1. A review of Resident #143's clinical record revealed she was recently admitted to the facility after a hospitalization for a fall that she sustained at home. Observation of the resident, on 12/11/17 at approximately 1:00 p.m. revealed a large yellow green bruise on her forehead. The resident reported that she had been sitting at home, reached over to pick something up and fell on her face. During the interview the resident was sitting in her wheelchair next to her bed. At 2:00 p.m. on 12/11/17, the resident was observed in bed resting. The resident's call bell was observed lying on the floor, next to the bed. The resident opened her eyes and when asked where her call bell was, if she should need to call for something, the resident responded, it's somewhere here. When it was pointed out that it was on the floor, the resident responded that she wouldn't be able to use it. At that time, a Respiratory Therapist, Staff B, was passing in the hall. When asked if she could assist, the staff member entered the room and confirmed that the resident's call bell was on the floor, inaccessible to the resident. 2. On 12/11/2017 during the initial observations which began at approximately 11:00 a.m., the resident was approached for an interview. The resident was non-verbal but could nod his head yes or no to answer questions. The resident indicated with a nod 'yes' that he understood what was said to him and he answered simple questions appropriately. The resident had paper communication devices on his over bed table with which he could further communicate in a nonverbal manner. During an interview with Resident #144's roommate on 12/12/17 beginning at 8:50 a.m., an aide brought in the breakfast for Resident #144. She spent a few minutes setting up the tray and ensuring that the resident had what he needed to eat. At 9:10 a.m., the call bell for Resident #144 was noted to be lying on the floor, between the two beds. The resident's nurse, (Staff H) came into the room when asked, and confirmed that the call bell would not be accessible to the resident should he need assistance.

Based on review of the residents' medical records and interview with facility staff, the facility failed to ensure that the resident or responsible parties for three (#11, #142, #146) of three residents sampled for emergency transfer, were provided with a Bed Hold notice. Findings included: 1. A review of the clinical record for Resident # 142 revealed the resident was transferred to the hospital under a Baker Act 52 order (BA-52) on 10/18/2017. Continued review of the medical record revealed no documentation to indicate that the resident or the responsible party had been provided with the Bed Hold policy upon transfer. An interview with the Social Services Director (SSD) on 12/12/17 beginning at 3:45 p.m. revealed that the Bed Hold notice had not been given to the resident as they knew the resident would be returning to the facility. 2. Clinical record review for Resident #11 revealed a transfer to the hospital under a BA-52 order on 05/30/17. Continued review of the medical record did not locate a copy of the Bed Hold policy that had been provided to the resident upon transfer. The Assistant Director of Nurses (ADON) was asked about the Bed Hold form on 12/14/17 at approximately 10:00 a.m. Later that morning she provided a copy of the Bed Hold form that had been faxed from the hospital. The form had a line at the top of the page noting Fax Server 12/14/2017 8:41:25 AM. The ADON reported that they did not have a copy of the Bed Hold form and had called the hospital to get a copy of the form. A review of the faxed copy revealed the form was not dated, did not indicate whether or not the facility met the 95% occupancy requirement and the form did not indicate whether the Bed Hold would be offered. 3. Resident # 146's clinical record revealed a transfer to the hospital under a BA-52 order on 07/07/2017. Review of the medical record did not reveal a bed hold policy had been completed. The ADON reported, on 12/14/2017 at 12:30 p.m. that she was not sure if it had been completed or not.