Every finding on record at Tabor Hills Health Care Fac

Based on observation, interview, and record review the facility failed to ensure the hot water dish machine reached 160 degrees Fahrenheit rinse temperature, failed to ensure staff changed gloves between handling soiled and clean dishes and failed to ensure the dry storage area did not contain expired canned food products. This applies to all 63 residents who receive oral diets from the kitchen. The findings include: On [DATE], at 10:11 AM, V6 (Dietary Aide) was washing dishes using the hot water dish machine. V3 (Maintenance Director) and V4 (Dining Room Supervisor) were present and were asked to validate the dish machine temperature, V3 placed the disc thermometer in the dish rack. V3 then placed the rack on the conveyor and ran it through the dish machine. Upon exiting the machine, the thermometer showed a temperature of 153 F (Fahrenheit) degrees. V3 and V4 were both present and aware of the temperature reading. At 10:19 AM, V3 placed the thermometer in the dish rack again, placed the dish rack on the conveyor, and upon exiting the machine the thermometer showed 157.6 F. V6 was placing soiled cups on the dish rack, sending the rack through the dish machine and removed the rack from the machine and touched the clean glasses, without changing gloves. V6 put soiled bowls on the dish rack, put the rack on the conveyor, then retrieved the rack from the clean side and began touching the clean bowls without changing gloves or perform hand hygiene. On [DATE], at 9:40 AM, in the dry storage room canned items were found on the shelf past the expiration dates. There were 5 cans of pineapple tidbits, 107 ounces, with an expiration date of [DATE], and 2 cans of pineapple chunks, 107 ounces, with an expiration date of [DATE]. V3 and V4 were both present in the dry storage room and made aware of the expired products. On [DATE], at 9:45 AM, V4 (Food Service Supervisor) was unable to explain the system he uses for rotating stock. V4 stated he was made aware yesterday of the expired stock, and also stated he does not track food delivery dates and therefore is not able to ensure that food products that are delivered first are used first. The Facility's policy titled Dishwashing Machine Operation, undated, showed Paper thermometers are used to determine correct rinse temperature of the dishwashing machine. The Facility's policy titled Hand Washing, undated, showed Food and nutrition employees will thoroughly wash their hands .after handling soiled equipment and utensils .

Based on interview, and record review, the facility failed to administer the pneumococcal vaccine to residents according to the CDC (Centers for Disease Control and Prevention). This applies to 4 of 5 residents (R8, R13, R17, and R56) in the sample of 19. The findings include: On May 7, 2024, at 1:22 PM, V7 (Infection Preventionist Nurse) said the facility follows CDC recommendations for pneumococcal vaccine timing. 1. R8's EMR (Electronic Medical Record) showed R8 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including hypertension, pneumonia, and anemia. R8's Immunization Record showed R8 received the PCV13 (13-valent pneumococcal conjugate vaccine) on March 15, 2022. R8's undated Consent to Administer Pneumococcal Polysaccharide (PPSV) Vaccine showed R8's Resident Representative consented for R8 to receive the pneumococcal vaccine. On May 8, 2024, at 1:01 PM, V8 (Infection Control Nurse) said R8 should have received the PPSV23 vaccine one year after receiving the PCV13 vaccine. V8 continued to say R8's POA (Power of Attorney) consented to the PPSV23 vaccine, but R8 has not received the vaccine. Facility documentation showed R8's POA consented for R8 to receive the PPSV23 (23-valent pneumococcal polysaccharide vaccine) on April 4, 2024. The facility does not have documentation to show R8 received the PPSV23 vaccine. 2. R13's EMR showed R13 was an [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation, hypertension, and hyperlipidemia. R13's Immunization Record showed as of May 6, 2024, R13 had not received a pneumococcal vaccine. R13's Consent to Administer Pneumococcal Conjugate Prevnar (PCV13) Vaccine showed Check residents medical records first then ask resident if she wants shot. On May 8, 2024, at 12:43 PM, V8 said R13 should have been offered the pneumococcal vaccine before April 2024. The facility does not have documentation to show R13 was offered a pneumococcal vaccine prior to April 4, 2024. 3. R17's EMR showed R17 was an [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, asthma, and dementia. R17's Immunization Record showed R17 received the PCV13 vaccine on August 30, 2017. R17's Consent to Administer Pneumococcal Polysaccharide (PPSV) Vaccine showed Unknown when last received vaccination, but I wish to receive the Pneumococcal Vaccine. R17's consent was signed by R17's Resident Representative on January 31, 2021. As of May 6, 2024, the facility does not have documentation to show R17 received the PPSV23 vaccine. On May 8, 2024, at 12:43 PM, V8 said R17 was eligible for the PPSV23 vaccine one year after receiving the PCV13 vaccine. V8 said R17 should have received the PPSV23 vaccine when she was admitted to the facility. 4. R56's EMR showed R56 was an [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, and tachycardia. R56's Immunization Record showed R56 received the PCV13 vaccine on September 1, 2015. R56's Consent to Administer Pneumococcal Polysaccharide (PPSV) Vaccine showed Unknown when last received vaccination, but I wish to receive the Pneumococcal Vaccine. R56's consent was signed by R56's Resident Representative on June 9, 2022. As of May 6, 2024, the facility does not have documentation to show R56 received the PPSV23 vaccine. On May 8, 2024, at 12:43 PM, V8 said R56 was eligible for the PPSV23 vaccine one year after receiving the PCV13 vaccine. V8 continued to say R56 should have received the PPSV23 vaccine when she was admitted to the facility. The facility's Pneumococcal Vaccination policy dated April 2024, showed, Purpose: All residents are provided the opportunity and encouraged to receive pneumococcal vaccinations. The resident may refuse the offer of the vaccine or may not have the vaccine administered if medically contraindicated. There are currently four types of pneumococcal vaccines: pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20) and pneumococcal polysaccharide vaccine (PPSV23). The numerical value after the letters represents the number of pneumococcal bacteria strains present in a particular vaccine that render protection if a person is exposed to that component strain. CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown. AS such, we adapt the 2022 CDC recommendation for Pneumococcal Vaccination Timing for our residents. Policy: 1. The admitting nurse is responsible to review the medical record and history to determine if any pneumococcal vaccination has been given to the resident. 2. The estimate of the date vaccine as indicated by the resident/responsible party is recorded in the resident's HER (Electronic Health Record). Procedure: .5. For adults less than [AGE] years and older who previously received PCV13 but who have not received all recommended doses of PPSV23, may give one dose of PPSV23 or may use PCV20 if PPSV23 is not available . The CDC's Pneumococcal Vaccine Timing for Adults dated April 1, 2022, showed, Adults [AGE] years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant: CDC recommends one does of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least one year after PCV13 was received .

Based on observation, interview and record review, the facility failed to provide restorative therapies to a resident scheduled for therapies per her plan of care. This applies to 1 of 1 resident (R41) reviewed for rehabilitation in a sample of 19. The findings include: R41's Medical Record, dated May 2024, shows R41's diagnoses included artificial hip, osteoarthritis right and left shoulders, cerebral infarction and transient ischemic attack, osteoarthritis left shoulder, scoliosis, and osteoporosis. Restorative Joint Mobility Evaluation 3/12/24, shows R41 had limited ROM of the front left shoulder related to stiffness, arthritic digits of the left and right hand. The evaluation shows R41 required AROM (Active Range of Motion) of BUE (Bilateral Upper Extremity) and bilateral ankles. R41 had a diagnosis of osteoarthritis of bilateral shoulders and transferred with a standing lift assisted by two staff. Care plan, initiated 3/12/24, shows R41 had a wedge compression fracture of her thoracic 11-12 vertebrae, thoraco-lumbar anterolisthesis of L4 on L5, osteoarthritis of bilateral knees and bilateral shoulders, bilateral hip replacements, lumbar degenerative joint disease, osteoarthritis, pain in the thoracic spine, and left shoulder effusion. The approaches include, Place me in a Range of Motion program. On May 6, 2024, R41 stated she was not sure if she was receiving rehabilitation services. Facility Task Description and Frequency list, undated, shows R41 was to receive restorative sit to stand exercises on days and evenings. POC (Plan of Care) Response History for staff task Restorative - NuStep: Participate NuStep for 15 minutes 3x/wk (three times per week) dated 4/16/24 to 5/7/24, shows R41 received restorative therapy exercises twice and refused twice in 22 days reviewed. The document shows staff responded NA (Not applicable) 30 times regarding R41 being offered NuStep restorative exercise during the time period. POC Response History for staff task Restorative Sit-To Stand: pull self to a standing position at a hall/bathroom railing and balance for 30 seconds x 3 reps (repetitions) with x2 (2 staff) assistance. The report shows R41 received restorative sit to stand exercises on only 7 of 28 days and several days had responses of NA (Not Applicable) or 0. On May 7, 2024, at 1:37 PM with V2 (Director of Nursing, V7 (Restorative Nurse) stated she needed to speak with staff regarding how they were documenting residents' restorative therapies. V7 stated it was her expectation that staff inform her if a resident is not performing restorative exercises so she can reassess the resident. V7 stated she was not aware that R41 was not performing her restorative exercises as staff did not notify her. Facility Policy and Procedure Restorative Services, undated, shows, The objectives of our restorative services are to: . 3. To coordinate rehabilitative services with objectives of the facility and patient's plan of care. 4. To provide and maintain a continuous restorative care program.

Based on observation, interview and record review, the facility failed to apply palm protectors to a resident's contracted hands per her plan of care. This applies to 1 of 3 residents (R14) reviewed for ROM (Range of Motion) in a sample of 19. The findings include: R14's Care Plan, initiated March 20, 2020, shows R14 was at risk for contractures due to decreased strength, impaired coordination, poor endurance and balance, and poor memory. The care plan shows R14 was to wear a palm protector which should be applied in the morning and removed at bedtime. The care plan shows staff should check for redness on the surrounding area. Physician order, dated March 18, 2024, shows R14 was to have Palm Protector applied to her hands every morning and removed before bedtime. The staff were to check for redness in the surrounding areas. On May 6, 2024, at 10:56 AM, R14 was in reclining wheelchair in the dining room. The fingers of both of R14's hands were very contracted and were closing toward palm of each hand. R14 was holding white gauze between her contracted fingers and palm in her left hand. R14 had no gauze or palm protector between her contracted fingers and palm of her right hand. On May 6, 2024, at 11:20 AM with V14 (Registered Nurse), R14 continued to have white gauze only between her contracted fingers and palm of her left hand and no gauze in her right hand between her contracted fingers and palm. V14 (Registered Nurse) stated the staff usually only put a cloth in her left hand between her contracted fingers and palm but no cloth in her right hand. On May 6, 2024, at 11:15 AM, V15 (CNA - Certified Nursing Assistant) stated R14 sometimes refuses to put anything between her contracted fingers and hands. V15 stated in the morning the staff look at both hands and place gauze in the one hand that has redness. V15 stated the staff usually use gauze as the hand protector and no palm protectors. On May 7, 2024, at 1:37 PM, V7 (Restorative Nurse) described a palm protector as sheep skin with and adhesive strap. V7 stated gauze was not considered a palm protector. V7 stated CNA or Restorative staff must do ROM (Range of Motion) exorcizes with R14's hands before they are able to apply her palm protectors to reduce the risk of injury to her contracted hands. V7 stated it was her expectation that R14 wear palm protectors bilaterally in both hands to protect her palms from her contracted fingers. V7 stated the facility should have a physician order if staff use gauze instead of the palm protectors for R14 if she did not tolerate the palm protectors. Facility Response History for Task: Palm Protector on in AM off at HS (bedtime) and check for redness on the surrounding area. Review of responses show R14 received her protector on in AM and off at HS on days including May 6, 2024, AM during which no palm protectors were observed to be applied. Observations on 5/6/24 AM as of 11:15 AM showed R14 did not have her palm protectors in place on either hand.

Based on observation, interview, and record review, the facility failed to ensure a resident was properly positioned in a shower chair during a shower. This applies to 1 of 2 residents (R265) reviewed for falls in the sample of 19. The findings include: R265's EMR (Electronic Medical Record) showed R265 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy, fall, weakness, and dementia. R265's Brief Interview for Mental Status dated May 7, 2024, showed R265 was cognitively intact. R265's Functional Abilities and Goals dated May 1, 2024, showed R265 required maximal assistance from facility staff for transferring to and from the tub/shower. On May 8, 2024, at 11:28 AM, R265 said she got a shower a few days ago and the shower chair tipped over when the CNA (Certified Nursing Assistant) was done washing her. On May 8, 2024, at 11:38 AM, V9 (CNA) said she was giving R265 a shower in her room and R265 attempted to stand up to wash herself. V9 said she instructed R265 to sit back down and R265 was not evenly seated in the chair. V9 said while R265 was unevenly seated in the shower chair, V9 maneuvered the shower chair from the shower stall to the bathroom. V9 continued to say there is an uneven ledge from shower into the bathroom. V9 said since R265 was not properly positioned in the shower chair, R265 fell out of the shower chair when V9 pushed the shower chair over the shower ledge. On May 8, 2024, at 11:53 AM, the shower in R265's bathroom had an approximately one inch raised ledge for the transition from the shower into the bathroom. The facility's fall report dated May 4, 2024, showed V2 (DON/Director of Nursing) documented Upon follow up with the resident and CNA present at the time of fall incident. It was likely the resident was not positioned all the way to the back of the shower chair due to resident scooting forward in the shower chair, attempting to assist the CNA with care, resulting with resident sliding off the chair. Interventions to include providing a larger shower chair, grip strips to shower room floor. OT (Occupational Therapy) to provide positioning education to resident. Staff reeducated on the proper assessment of resident positioning in shower chair. On May 8, 2024, at 1:19 PM, V2 said her expectation is facility staff are to ensure a resident is properly positioned in the shower chair before moving the shower chair.

Based on observation, interview, and record review, the facility failed to store food items in sanitary conditions by having unlabeled and undated food items in dry storage and in a walk-in cooler, and ice buildup on food items and the ceiling in the freezer. This affects all 70 residents consuming food from the kitchen. Findings include: On 6/14/23 at 10:10 AM, V2 (Director of Nursing - DON) stated, We have 70 residents on the certified side. Two are on gastrostomy tube (GT) feeding, but they are also on pleasure feeding. So, all 70 residents are eating from the kitchen. On 6/16/23 at 9:40 AM, during the initial kitchen tour with V5 (Assistant Dietary Manager), the dry kitchen storage was observed with a partially used five-pound Graham Cracker Crumbs with no label or date. On 6/16/23 at 9:45 AM, the kitchen walk-in cooler was observed with two apple pies with no label or date, and two pounds of sliced ham dated 6/5/23 (11 days earlier), partially covered with plastic wrap. On 6/16/23 at 9:45 AM, V5 stated, Sliced hams are good for seven days and should be fully covered . All food items should be labeled and dated. On 6/16/23 at 9:45 AM, the dietary freezer was observed with ice build-up on a five-pound salami, four pizza crusts (no label/date), 90 portions of Turkey and Beef Patties, blueberry bagels, and angel food cake mix. Observed freezer ceiling with ice that had formed throughout the freezer, and food was contained in cardboard boxes that were saggy with ice/condensation. Dripping water was noted at the freezer entry door from condensation that formed on the freezer ceiling. On 06/13/23 at 09:48 AM, V5 added, Ice shouldn't be built up on the freezer, food items, and with the ceiling. The facility presented a policy on storing dry goods/foods (revised 5/20/2014) that showed: Opened products are labeled, dated with the use-by date, and tightly covered to protect against contamination, including from insects and rodents. The facility presented a policy on refrigerated food prepared (revised 5/20/2014) that showed: Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. This includes leftovers. The discard/use-by date will be a maximum of six days after preparation.

Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent cross-contamination from soiled linens, soiled gloves, incontinence wipes, and resident trays. This applies to 11 of 23 residents (R4, R12, R17, R28, R42, R49, R52, R56, R60, R68, and R278) reviewed for infection control. Findings include: 1. On June 13, 2023, at 11:26 am, V7 CNA (Certified Nursing Assistant) placed a disposable incontinence brief and pants on R278 while R278 was in a standing position, V7 threw R278's soiled under pad onto the floor. R278 was assisted to her wheelchair. While still wearing soiled gloves, V7 walked out of R278's bedroom to the clean linen cart in the hallway. V7 lifted the covering of the linen cart wearing the soiled gloves and removed towels and a pillowcase. V7 returned to R278's room, removed the soiled gloves, and used hand sanitizer. R278's room contained three beds and R278 is assigned to bed #3; beds #1 and #2 were both made and ready for new admissions. V7 moved R278's soiled linen and clothing she had previously placed on bed #2, to bed #1, contaminating both beds. V7 picked up the soiled under pad from the floor and placed it on bed #1. V7 collected R278's meal tray and the soiled linen placed on bed #1 and exited the room. V7 placed the dirty meal tray on the clean linen cart before taking soiled linen into the soiled utility room. On June 15, 2023, at 10:58 am, V2 DON (Director of Nursing) stated staff should be removing their gloves and washing their hands after providing care to residents. Staff should not be going into a clean linen cart and removing clean items with gloves they had worn while providing resident care. Staff should not be placing soiled linen and used items on a clean bed. Staff should not place a meal tray that was in a residents room on top of the clean linen cart. It is an infection control issue. On June 15, 2023, at 12:18 pm V7 CNA stated she used the items on the cart for everyone down that hallway (R4, R12, R17, R28, R42, R49, R56, R60, R68, and R278). R278 is in the room by herself, but the other two beds are made and ready for new residents when they come. V7 stated she did not do hand hygiene properly when observed on June 13th. V7 stated she should not have placed the meal tray on the clean linen cart. V7 stated she did not clean the cart after she went through it. V7 stated housekeepers clean the linen carts, but she did not know when. On June 15, 2023, at 12:30 pm V8 Housekeeper stated housekeeping does not clean linen carts or their covers. 46380 2. On June 14,2023 at 08:51 AM, R52 needed to be transferred to the toilet. V4 (CNA- Certified Nurse Assistant) came to the room and applied gloves without doing hand hygiene. V3 (CNA) was already in R52's room. R52 was transferred to the toilet by V3 (CNA) and V4 (CNA). When R52 was done on the toilet, V3 (CNA) took a wet wipe and wiped R52's buttocks. V3 (CNA) proceeded to wipe R52's perineum with the same wet wipe without folding the wet wipe to use the clean side. Without changing gloves, V3 (CNA) proceeded to put on R52's incontinent brief, pulled R52's pants up, assisted with transfer and put a clean shirt on R52. Interview with V2 (DON- Director of Nursing) on June 15,2023 at 10:43 AM, V2 stated during incontinence care, staff are expected to wipe front to back for both male and female residents. V2 (DON) stated wiping back and then front is not acceptable. V2 (DON) stated when using wet wipes, once a wipe is dirty, staff can fold it and use the clean part or discard the wipe and get a new one. This practice should be done to prevent infection. V2 (DON) stated before putting on gloves, staff are expected to wash their hands or apply hand sanitizer. After providing incontinence care to a resident, staff are expected to take gloves off, do hand hygiene and put on new gloves. Staff should change gloves from dirty to clean. Clean gloves should be used after providing incontinent care before touching the resident and clean surfaces. This is done to prevent infection. Facility's undated Hand Hygiene Policy stated the following: . Standard: Proper hand hygiene techniques are used for the prevention of transmission of infectious diseases.Policy: .Facility follows the World Health Organization's Five Moments of Hand Hygiene model . After touching a resident (skin to skin).Hand hygiene is performed before donning PPE, and after doffing PPE. Wearing PPE, especially gloves, is not a substitute for performing hand hygiene. Hand Hygiene must be performed any time a staff member moves from a dirty site to a clean site. Facility's undated Perineal Skin Care Policy stated the following: . 9. Cleanse entire perineal area, moving from front to back, while using a clean area of washcloth for each stroke. 10. Wash entire perineal area with soapy washcloth or pre-moistened wipe, moving from front to back, while using a clean area of the washcloth, new pre-moistened wipe, or clean washcloth for each stroke.11. Remove gloves, sanitize hands and reglove.

Based on observation, interview, and record review the facility failed to ensure the kitchen food storage was free of pests which applies to all 81 residents reviewed for sanitary food storage. The findings include: The CMS-672 dated 8/22/22 showed a census of 81 residents. On 8/22/22 at 10:00 AM, upon entering the kitchen's dry storage area, a swarm of flying insects were concentrated on and around the bread and bread cart in the middle of the storage room. Across the storage room there was a smaller swarm of flying insects centralized around bananas stored on a shelf. On 8/22/22 at 10:15 AM, V17 Dietary Manager and V20 Maintenance/Housekeeping Manager (while on kitchen tour) stated the facility has had problems with drain flies for about 2 months. We have had pest control in, but I am not sure what they have done in the storage area. On 8/23/22 at 9:15 AM, flying insects were in and around the bread cart. The food storage room has no drains, bug zappers lights, or other types of insect pest controls (fly traps) devices in it. On 8/23/22 at 10:10 AM, V21 Pest Control Representative verified the treatments listed on the work invoice dated 7/25/22 were focused on floor drains, sinks, and equipment in the kitchen. V21 stated he was not asked to check or provide any treatments to the food storage area.

Based on observation, interview and record review the facility failed to ensure meal intakes were monitored and ordered interventions were followed through for a resident with significant weight loss, failed to initiate dietary recommendations for a resident with significant weight loss and failed to provide dietary supplements for residents with weight loss. This applies to 4 of 15 residents (R20, R21, R12, R26) reviewed for weight loss in the sample of 20. The findings include: 1. R20's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .S.) dated through August 2022 shows she is a [AGE] year old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The P.O.S. shows orders to give enteral feeding [MEDICATION(S)] 1.5 if 50 % or less of meal consumed and hold if 50 % or more of meal consumed. R20's meal intake report from August 1, 2022 to August 23, 2022 shows 27 out of 69 meals she consumed less than 50%. R20's Medication Administration Record for August 2022 shows she did not receive her enteral feeding of [MEDICATION(S)] 1.5 23 of 27 times based on her meal consumption less than 50 %. The M.A.R. shows 15 of 22 entries of (2) indicating refusals. R20's dietary note dated 7/7/22 documents her weight continues to decline despite fair intake and supplemental enteral nutrition and recommends to add a 240 ml bolus at night. R20's weight report dated 8/23/22 5/17/22- 167 lb (pounds) 6/13/22- 156.6 lb 7/12/22- 153 lb 8/9/22- 150.8 lb (10 % weight loss in three months). On 8/23/22 at 12:13 PM, R20 was in her room during the noon meal feeding her self. She said she had some nausea in the morning, but was feeling better. On 8/23/22 at 12:20 PM, V7 (CNA) said R20 is alert but forgetful and her appetite is good someday's and other days bad. V7 said R20 complains of nausea at times. On 8/23/22 at 1:11 PM, V5 (Dietitian) said R20 should be receiving enteral feedings of [MEDICATION(S)] 1.5 if she consumes less than 50 % of her meals and she added an additional bolus feeding at night due to weight loss. V5 said she does not know why she is losing weight if she is eating and receiving the enternal feedings as ordered. It could be an administration issue (staff not providing the feeding). V5 said R20 is cooperative and not aware of her refusing any feedings. On 8/24/22 at 9:24 AM, V6 (LPN) said R20 is alert, forgetful and can answer questions. V6 said staff should administer her enternal feeding ([MEDICATION(S)]) if she consumes less than 50 % of her meal. V6 said R20 is cooperative with cares and has no refusals of her feedings. On 08/24/22 at 9:27 AM, R20 said she does not refuse her enteral feedings. 2. R21's Weights and Vitals Summary printed on 8/23/22 shows R21's weight on 7/5/22 was 150.4 pounds and R21's weight on 6/7/22 was 162.6 pounds (7.5% loss in 1 month). R21's weight on 8/23/22 was 146.4 pounds. R21's Dietitian Notes dated 7/7/22 shows that she recommended super cereal and yogurt with breakfast, pudding with lunch and a magic cup daily due to her significant weight loss. R21's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/23/22 at 1:11 PM, V5 (Registered Dietitian) said that she saw R21 on 7/7/22 due to a significant weight loss. V5 said that she recommended super cereal and yogurt with breakfast, pudding with lunch and a magic cup daily. V5 said that she emails the recommendations to the Director of Nursing and the Assistant Director of Nursing so they can get an order from the physician. V5 said that she emailed the recommendations on 7/7/22. V5 said that it must have gotten missed. 3. R12's POS printed on 8/24/22 shows that she is on nectar thick liquids and has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Weights and Vitals Summary printed on 8/24/22 shows that her weight was 126.4 pounds on 8/9/22 and 136.8 pounds on 5/1/22 (7.6% weight loss in 3 months). On 8/23/22 at 9:04 AM during morning medication pass, R12 did not receive Med Pass 2.0 (nutritional supplement) as ordered. On 8/23/22 at 9:04 AM, V14, Registered Nurse (RN) said that Med Pass was recalled about a week ago and they do not have anything to replace it with. On 8/23/22 at 1:11 PM, V5 (Registered Dietitian) said that the facility contacted her regarding Med Pass not being available. V5 said that she worked with them to find an alternative. V5 said that she recommended Resource (nutritional supplement) for residents on non-thickened liquids and to use a Magic Cup (frozen nutritional supplement) in place of Med Pass for residents on thickened liquids. On 8/23/22 at 1:50 PM, V2 (Director of Nursing) said that they have been out of Med Pass 2.0 since the recall on 8/10/22. V2 said that they reached out to V5 for recommendations and she said that Resource would be an alternative to order but while waiting to get it, residents on a non-thickened liquid diet should get an Ensure (nutritional drink) daily. V2 said that she did not give any recommendations for residents on a thickened liquid diet. On 8/24/22 at 10:35 AM, V11 (RN) said that she was told that Med Pass has been recalled and not to use it. V11 said that she was not directed to give anything else to replace the supplements that the residents were not receiving. 4. On 8/22/22 at 12:10 PM, R26 was in the dining room eating lunch. R26 ate 25% of her meal. On 8/23/22 at 12:12 PM, R26 was in the dining room eating lunch. R26 ate 25% of her meal. R26's POS printed on 8/24/22 shows an order dated 1/27/20 for magic cup twice a day for supplement post breakfast and dinner. R26's August Medication Administration Record does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/23/22 at 1:55 PM, V14 (Registered Nurse) said that when a magic cup is ordered, it will show on the EMAR (Electronic Medication Administration Record) to be given. V14 viewed R26's EMAR and said that a magic cup was not on the EMAR so it would not be given. On 8/23/22 at 1:50 PM, V3 (Assistant Director of Nursing) said that R26's magic cup was ordered wrong in the system so it will not show up on the EMAR to be given. The facility's Weights: Establishing, Monitoring, and Maintaining Policy dated 1/2019 shows, All significant weight loss and gain (5% in 1 month, 7.5% in 3 months, or 10% in 6 months) are: Reported to the attending physician/nurse practitioner for appropriate orders and interventions. The nurse will document the significant weight change, the notification and interventions in the resident's clinical record. Registered Dietitian will complete a nutritional assessment. The resident's Care Plan will be reviewed and/or updated. The facility's Dietary Supplements Policy dated 4/5/2006 shows, Dietary Supplements are ordered by physician. Residents are regularly assessed by clinical dietitian, dietary manager or physician if and when supplements are needed .Need for supplements is based on weight loss (5%-one month, 7%-3 months, 10%-6 months) Pharmacy lists supplements on Medication Administration Record (MAR).

Based on observation, interview and record review the facility failed to ensure oxygen was applied by a licensed professional as ordered and failed to ensure oxygen tubing was changed as ordered for 5 of 8 residents (R12, R21, R26, R50 and R78) reviewed for respiratory care in the sample of 20. The findings include: 1. R21's Care Plan for oxygen shows, I am currently on O2 at 3L/NC Administer my O2 as MD ordered. The position for the intervention says registered nurse or licensed practical nurse. On 8/22/22 at 12:45 PM, V13, Certified Nursing Assistant (CNA) turned off R21's portable oxygen tank to transfer her to bed for care. R21 was provided care and transferred back to her chair. V13 turned the portable oxygen dial to 2 liters and applied the oxygen to R21. On 8/23/22 at 12:14 PM, V14, Registered Nurse (RN) said that CNA's can adjust the oxygen tubing but they should not be turning on the portable tanks and adjusting the liters of oxygen administered. V14 said that the orders should be checked and followed any time oxygen is administered. The facility's Oxygen Therapy Policy revised 8/2015 does not indicated what staff members are allowed to administer oxygen. 2. R26's POS printed on 8/24/22 shows an order dated 8/28/20 for, Change nasal cannula/mask/tubing/humidifier weekly on Sat. (Saturday) on 11-7 shift-date tubing. On 8/23/22 at 9:10 AM, R26 was wearing oxygen administered by a portable oxygen tank. R26's oxygen tubing for her portable oxygen tank was dated 8/7/22. R26's Oxygen Care Plan shows, Change my nasal cannula, tubing, and humidifier bottle q (every) weekly and PRN (As Needed). 3. On 8/23/22 at 9:10 AM, R12 was wearing oxygen provided by an oxygen concentrator in her room. R12's oxygen tubing was dated 8/14/22. 4. R50's POS printed on 8/24/22 shows an order dated 7/13/21 for, Change mask/cannula/tubing every week on 11-7 shift. On 8/23/22 at 12:47 PM, R50 was wearing oxygen administered by a portable oxygen tank. R50's oxygen tubing for her portable oxygen tank was dated 8/14/22. On 8/23/22 at 12:14 PM, V14 (RN) said that oxygen tubing is changed weekly by the night shift nurses. The facility's Oxygen Therapy Policy revised 8/2015 shows, Oxygen cannula or mask, tubing and humidifier is changed weekly by 11-7 shift staff Regulate flow meter as ordered 5. On 8/22/2022 at 10:20AM, R78 was observed with a nasal cannula in place in her room. On 8/23/2022 at 10:14AM, R78's oxygen tubing was dated 8/6/2022. On 8/24/2022 at 10:40AM, V11 Registered Nurse said oxygen tubing is changed once a week. On 8/24/2022 at 10:40AM, V3 Assistant Director of Nursing said oxygen tubing is to be changed weekly on nights. The facility's Oxygen Therapy policy, revised on 8/15, states .Oxygen cannula or mask, tubing and humidifier is changed weekly by 11-7 shift staff.

Based on interview and record review the facility failed to treat a resident with respect and dignity, affecting one of twenty residents (R40) reviewed for dignity in the sample of twenty. The finding include: R40's Minimum Data Set, dated dated dated , July 1, 2022, shows, Brief Interview for Mental Status 15/15-Cognitively Intact. On 08/22/22 at 10:06 AM, R40 said, I asked V8 CNA-Certified Nursing Assistant to help me get out of bed. She became very irritated. She took my clothing out of the closet and threw them on my bed. She told me I was a racist; She said I was entitled. On 08/24/22 at 10:28 AM, R40 said, V8 CNA called me a racist. I asked her to help me get up. I reported it to the nurse on duty when it happened. I do not remember the date or the nurse that was working that day. I told the nurse when it happened. R40 said, when V8 CNA called me a racist and was speaking to me rudely I was bewildered. I had never treated her poorly. It was like she was having a bad day and decided to take it out on me. The way V8 CNA acted when calling me a racist made me feel bad. On 08/24/22 at 11:51 AM, V3 ADON-Assistant Director of Nursing said, V19 CEO-Chief Executive Officer was the abuse coordinator at the time, he did the investigation. V3 said, V8 CNA was R40's Primary Care Giver at the time of the incident. I attempted to contact V8 CNA today for an interview. I have not been able to reach her. On 08/24/22 at 12:00 PM, V19 CEO-Chief Executive Officer said, I spoke with R40. I also spoke with other residents in the area. I have to look at my notes to see if I interviewed any staff. No staff or resident interviews or other information was provided by V19 prior to exiting the facility. R40's Incident Report initiated 03/11/22 shows, a staff member came into her room, was very quick with her, didn't like answering questions, and seemed like she was in a rush to leave. The 3/11/22 Incident Report shows, no Certified Nursing Assistants were interviewed regarding the incident.

Based on interview and record review the facility failed to verify a resident's code status upon admission to ensure residents wishes were followed for 1 of 20 (R331) reviewed for advance directives in the sample of 12. The findings include: R331's Admission Record dated 8/23/2022 shows an admitted [DATE]. R331's Admission Record dated 8/23/2022 does not have a code status listed under advance directives. R331's Order Summery Report as of 8/23/2022 does not have a code status order in place. On 8/24/2022 at 9:49, V3 Assistant Director of Nursing said the resident's code status should be addressed upon admission and their wishes should be entered in the computer charting system. V3 said the residents code status should match in all places. V3 said the resident's code status is found in the physician orders.

Based on observation, interview and record review the facility failed to ensure staff provided perineal cleansing in a manner to prevent infections for a resident with a history of urinary tract infections. This applies to 1 of 4 residents (R60) reviewed for bladder services in the sample of 20. The findings include: R60's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R60's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, requires extensive assist for toileting and frequently incontinent. On 8/22/22 at 1:19 PM, V8 (CNA) transferred R60 from the wheelchair to the toilet using the mechanical stand lift and removed her soiled incontinent brief. V8 cleansed R60's perineal area from front to back and continued to use the same contaminated area of the wipe to cleanse her. V8 did not use a clean area of the wipe with each swipe. On 8/22/22 at 12:15 PM, V9 (Agency CNA) said perineal cleansing should be from front to back and use a clean area of the wipe with each swipe to prevent infections. The facility's Perineal Skin Care Policy undated policy states, Proper perineal care is essential to protect the perineal skin from damage caused by contact with urine and stool .females: separate the labia, clean front to back using downward strokes. Use a clean area of the cloth with each downward motion .

Based on observation, interview, and record review the facility failed to ensure a resident on contact/droplet isolation remained in the room, and failed to perform hand hygiene and glove exchange during peri care to prevent cross contamination. This applies to 3 of 20 residents (R331, R78, R14) reviewed for infection control in the sample of 20. The findings include: 1. R331's Admission Record shows R331 being admitted to the facility on [DATE]. On 8/22/2022 at 12:15AM, R331 was observed in the communal dining room with her mask off sitting at a table waiting for lunch to be served. There were other residents sitting in the same communal dining room as R331. On 8/22/2022 at 1:29PM, V11 Registered Nurse said R331 was on contact/droplet isolation precautions because she didn't have her boosters and wasn't up to date. V11 said R331 has been eating meals in the dining room. On 8/22/2022 at 1:51PM, V4 Infection Control Preventionist said R331 was on contact/droplet isolation precautions for 10 days because she didn't have her COVID boosters and is not up to date. V4 said no residents on droplet isolation/quarantine should be eating in the common dining areas. V4 said residents on quarantine should be eating all meals in their rooms. V4 said residents on droplet isolation/quarantine who are outside of their rooms put other residents at risk for spreading infections such as COVID to other residents. The facility's CORONAVIRUS (COVID-19)-Staff and Resident Testing policy, revised August 2022, states .If the resident is asymptomatic and not up to date with COVID-19 vaccinations, quarantine for 10 days even if testing negative. 2. On 8/22/2022 at 10:20AM, V16 Certified Nursing Assistant was providing incontinence care to R78. V16 did not change her gloves or perform hand hygiene after wiping R78 and applying a clean brief. On 8/24/2022 at 10:14AM, V4 Infection Control Preventionist said gloves should be changed and hand hygiene should be performed after cleaning up a resident before applying a new brief to the resident. The facility's Incontinent Care policy, not dated, states .Wash your hand before and after changing the resident. 3. On 8/22/22 at 9:58 AM, V7 (CNA) provided perineal care to R14. With the same gloves on, V7 pulled R14's pants up, assisted with the transfer back the wheelchair, took the sit to stand lift sling off from around R14, touched the lift and touched R14's wheelchair. On 8/23/22 at 12:29 PM, V13 (CNA) said that gloves should be removed, and hands sanitized right after providing perineal care and before touching any clean surfaces to prevent the spread of germs. The facility's Hand Hygiene Policy dated 11/2018 shows, Proper hand hygiene techniques are used for the prevention of transmission or infectious diseases. [Facility] follows the World Health Organization's Five Moments of Hand Hygiene model After body fluid exposure risk Hand hygiene must be performed any time a staff member moves from a dirty site to a clean site .

Based on observation, interview, and record review, the facility failed to mitigate the risk of cross contamination during wound care, perineal/catheter care, incontinent care, and handling meal trays preparation. This applies to 6 of 6 residents (R1, R5, R22, R24. R30, and R73) reviewed for infection control in a sample of 20. The Findings include: On October 27, 2021 at 11:56 AM, V13 (Certified Nursing Assistant, CNA) was collecting food trays in the 2nd floor dining room to distribute to R5 and R30 in their rooms. While collecting food trays, V13 dropped utensils on the floor and then picked it off the floor with her bare hand. V13 did not wash her hands then with her bare hands V13 collected meal plates for residents. V13 was touching the inner surface of the plates and then collected few plastic cup lids from the container of cup lids and covered 4 cups filled with liquid for R5's and R30's meal trays. On October 28, 2021 at 12:11 PM, V14 (CNA) opened a straw cover with her bare hands touching both end of a straw and placed in the juice cup of R24. On October 28, at 12:35 PM, V14 said she is aware of handing food in a sanitary manner and her handling of the straw was an accident. On October 28, 2021 at 12:45 PM, V13 said she should have washed her hands after picking the utensils off the floor and she should not have collected cup lids with her bare hand since it touches the resident's mouth. On October 28, 2021 at 1:25 PM, V3 (Assistant Director of Nursing) and V12 (Registered Nurse- infection Control) said all the employees are trained in infection control preventions and employees should wash their hands as needed and handle food, plates, cups and utensils which comes in contact with residents in a sanitary manner. Facility's policy titled Infection Control in the Food Service Department (No date) documents the following: . 1a. staff must wash hands before handling of food . On October 27, 2021 at 10:35 AM, V4 (Wound Care Nurse) and V6 CNA (Certified Nurse Aide) were performing wound care dressing change, catheter care and incontinent care for R1. R1 had an indwelling catheter. V4 was assisted by V6 during the wound dressing change. V4 began the procedure by gathering her supplies and informed the resident of wound dressing change. V6 donned gloves without washing her hands. V4 washed her hands and donned gloves. V4 removed the old dressing on R1's back, removed the soiled gloves, performed hand hygiene and changed gloves. V4 cleansed the wound on R1's back and applied new dressing on the wound. V4 removed soiled gloves, performed hand hygiene and reapplied new gloves. Then V4 removed old dressing on R1's coccyx area, she then removed the soiled gloves, performed hand hygiene and put on new gloves. V4 cleansed the wound on R1's coccyx area, applied treatment and new dressing on the wound. After completing the dressing change, V4 removed garbage, removed her gloves and performed hand hygiene. V4 failed to perform hand hygiene or change her gloves after she cleansed R1's wounds before she applied treatment and new dressing to R1's wound. At 10:50 AM, V6 donned gloves and started providing catheter care on R1. V6 wiped R1's bilateral groin area in a downward motion and wiped around the penis area. V6 changed her gloves and then proceeded to wipe the catheter tubing in downward motion away from the insertion site. V6 changed her gloves after cleaning the catheter tubing, then removed the dirty linen. V6 then turned R1 on his side to change his incontinent brief. V6 removed R1's old incontinent brief and put a new brief on without cleaning R1's anal area, V6 repositioned the resident and removed her gloves. V6 did not perform hand hygiene every time she changed her gloves. R1's Electronic Medical Records shows multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated October 21, 2021 shows R1's BIMS (Brief Interview Mental Status) score of 5, which indicates severe cognitive impairment; and he requires extensive assistance of 2 staff members with transfers and assistance of 1 staff member with personal hygiene. On October 28, 2021 at 8:36 AM, V3 (Assistant Director of Nursing, ADON) said the nurse should change gloves and perform hand hygiene after cleaning wound and before applying treatment and new dressing to the wound. V3 said for incontinence care and catheter care, the staff should perform hand hygiene at the beginning and at the end of the procedure. V3 further said every time there is a glove change, the staff should perform hand hygiene. The facility's undated policy titled Incontinent Care, under Procedure states, 7. Wash your hands before and after changing the resident. The facility's 2018 policy titled Hand Hygiene, under Policy states, Hand hygiene is performed before donning PPE (Personal Protective Equipment), and after doffing PPE. Wearing PPE especially gloves, is not a substitute for performing hand hygiene. Hand hygiene must be performed any time a staff member moves from a dirty site to a clean site. On October 27, 2021 at 10:35 AM, V4 (Wound Care Nurse) and V6 CNA (Certified Nurse Aide) were performing wound care dressing change, catheter care and incontinent care for R1. R1 had an indwelling catheter. V4 was assisted by V6 during the wound dressing change. V4 began the procedure by gathering her supplies and informed the resident of wound dressing change. V6 donned gloves without washing her hands. V4 washed her hands and donned gloves. V4 removed the old dressing on R1's back, removed the soiled gloves, performed hand hygiene and changed gloves. V4 cleansed the wound on R1's back and applied new dressing on the wound. V4 removed soiled gloves, performed hand hygiene and reapplied new gloves. Then V4 removed old dressing on R1's coccyx area, she then removed the soiled gloves, performed hand hygiene and put on new gloves. V4 cleansed the wound on R1's coccyx area, applied treatment and new dressing on the wound. After completing the dressing change, V4 removed garbage, removed her gloves and performed hand hygiene. V4 failed to perform hand hygiene or change her gloves after she cleansed R1's wounds before she applied treatment and new dressing to R1's wound. At 10:50 AM, V6 donned gloves and started providing catheter care on R1. V6 wiped R1's bilateral groin area in a downward motion and wiped around the penis area. V6 changed her gloves and then proceeded to wipe the catheter tubing in downward motion away from the insertion site. V6 changed her gloves after cleaning the catheter tubing, then removed the dirty linen. V6 then turned R1 on his side to change his incontinent brief. V6 removed R1's old incontinent brief and put a new brief on without cleaning R1's anal area, V6 repositioned the resident and removed her gloves. V6 did not perform hand hygiene every time she changed her gloves. R1's Electronic Medical Records shows multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated October 21, 2021 shows R1's BIMS (Brief Interview Mental Status) score of 5, which indicates severe cognitive impairment; and he requires extensive assistance of 2 staff members with transfers and assistance of 1 staff member with personal hygiene. On October 28, 2021 at 8:36 AM, V3 (Assistant Director of Nursing, ADON) said the nurse should change gloves and perform hand hygiene after cleaning wound and before applying treatment and new dressing to the wound. V3 said for incontinence care and catheter care, the staff should perform hand hygiene at the beginning and at the end of the procedure. V3 further said every time there is a glove change, the staff should perform hand hygiene. The facility's undated policy titled Incontinent Care, under Procedure states, 7. Wash your hands before and after changing the resident. The facility's 2018 policy titled Hand Hygiene, under Policy states, Hand hygiene is performed before donning PPE (Personal Protective Equipment), and after doffing PPE. Wearing PPE especially gloves, is not a substitute for performing hand hygiene. Hand hygiene must be performed any time a staff member moves from a dirty site to a clean site.

Based on observation, interview, and record review, the facility failed to promote dignity of a resident with indwelling catheter. This applies to 1 out of 2 residents (R338) reviewed for indwelling catheter in sample size of 20. The findings include: On October 26, 2021 at 12:10 PM, R338 was observed in therapy room during a therapy session. R338's indwelling catheter bag was hanging on the side of his wheelchair. R338's catheter bag was exposed and was not in a privacy bag. R338's Electronic Medical Record shows multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R338's Social Service assessment dated [DATE], Resident is alert and oriented; He scored 13/15 on the BIMS (Brief Interview Mental Status) assessment, indicating he is cognitively intact. On October 27, 2021 at 10:00 AM, V3 (Assistant Director of Nursing) said she was aware that R338's catheter bag was not placed in a privacy bag, therapy staff got the resident out of the room before nursing staff was able to place a privacy bag. She said all residents with indwelling catheters should have a privacy bag regardless of whether the residents were in or out of their rooms; the nurses or the CNAs (Certified Nurse Aide) are responsible for placing the catheter bags in privacy bags. The facility's revised 2017 policy titled Indwelling Catheter/Maintenance shows under procedure, 12. A cover bag is used over a drainage bag when resident is in bed or up in the chair.

Based on observation, interview, and record review, the facility failed to honor resident's food preferences. This applies to 1 out of 1 resident (R332) reviewed for food preferences in the sample size of 20. The findings include: On October 26, 2021 at 11:19 AM, R332 said she had concerns about her food. She does not eat pork due to religious beliefs and the facility did not honor her food preferences. She said she received pork sausage for breakfast the day before. V9 (R332's son) said they had spoken to the dietician about R332's food preferences, they are aware that she does not eat pork due to religious beliefs. On October 27, 2021 at 8:30 AM, V6 (Certified Nurse Aide) served R332's her breakfast tray. R332's tray ticket indicated that her dislikes were fried foods and pork, and she wanted cinnamon swirl French toast, bread, and margarine/jelly for breakfast. R332's breakfast tray had egg sandwich with pork sausage and oatmeal. V6 said she would call the kitchen to send up another tray. R332's Electronic Medical Record shows multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R332's Social Service assessment dated [DATE], Resident is alert and oriented; she scored 15/15 on the BIMS (Brief Interview Mental Status) assessment, indicating she is cognitively intact. On October 27, 2021 at 11:05 AM, V7 (Registered Dietician/Dietary Consultant) confirmed that R332 received sausage that was made of pork for breakfast this morning and on Monday, October 25, 2021, and her tray card did note that her dislikes were pork. On October 27, 2021 at 11:07 AM, V8 (Dietary Supervisor) said they have it on record that R332 did not eat pork due to her religious beliefs, so they have to honor it. She said the dietary staff that assembled the meal trays would have placed the pork sausage on her meal trays. V8 said she will have an in service for her staff to teach them what food items were from pork. She said the facility does not have turkey sausage but will provide it as an option for residents that do not eat pork. The facility's revised 2016 policy titled Resident Rights under Accommodation of Needs states, You have the right to make choices about aspects of your life that are significant to you.

Based on observations, interviews, and record review the facility failed to post the Nursing Staffing daily hours. This applies to all 82 residents who reside in the facility. The Findings include: On 10/26/21, a tour of the facility was made and there was no display of the current nursing staffing posted in the entry or anywhere else in the facility visible to the residents and visitors. On 10/26/21 at 11:30am, V11 (Staffing Coordinator/Licensed Practical Nurse) said that she is the person responsible for posting the daily nursing staffing. She would post it at the receptionist desk at the facility's entry, but she has not posted it since August 2021. On 10/28/21 at 2:15pm, V1 (Administrator) said that the facility's staffing should be posted daily because it is a regulation. The facility's 672 (Resident Census and Conditions of Residents) dated 10/27/21 showed the facility's census at the time of the survey was 82 residents.

Based on observation, interview, and record review, the facility failed to ensure staff were consistently screened at the beginning of their shifts, isolation signage was posted outside the rooms of Covid positive residents, N95 masks were fit-tested prior to use, linens were transported in a sanitary manner, and clean and contaminated staff and resident items were not co-mingled to prevent the spread of Covid-19. This applies to all of the residents residing in the facility. The findings include: 1. On October 28, 2020 during the initial tour beginning at 10:05 AM, V5 Licensed Practical Nurse (LPN) and V6 Certified Nurse Assistant (CNA) were interviewed separately in a non-Covid unit, and each reported that the staff were screened upon entry at the facility's back entrance near the time clock. On October 28, 2020 at 1:00PM, during a tour of the Covid unit V8 (CNA) and V9 Registered Nurse (RN) stated the staff were screened at the facility's back entrance near the time clock, and then enter the Covid Unit from a separate outside entrance. On October 28, 2020 at 1:30 PM, the screening logbooks located at the front and back entrances of the facility were reviewed. It was noted that the logbook screening pages were alphabetized by staff last names in a 3-ring binder, and each binder had pre-printed Employee Screening Questionnaire pages for each staff member with their names pre-printed at the bottom of the page, and pre-dated in the far left column with 1 -15 on the front, and 16-31 on the back. The four questions columns, and columns temperature check, time, and employee initials, provided space for documentation for each date. The month, and year were pre-printed in the lower right border on each page. A sample of nursing departments staff screening forms were reviewed. Two of the staff reviewed, V8 (CNA) and V9 (Registered Nurse), reported they were regularly assigned to the Covid Unit, two staff reviewed, V5 (Licensed Practical Nurse) and V6 (CNA), stated they were regularly assigned to work in non-Covid areas. All four reviews showed inconsistencies in staff screening documentation, which was compared against the employee's payroll time sheets and actual worked schedules provided by the facility. The logbooks at the front, and back facility entrances were reviewed for these four staff screening reviews, and it was noted that both the front and back entrance logbooks had screening forms for these staff. It was also noted that the screening instructions on the bottom of the front side of the pages of the Employee Screening Questionnaire in the facility's front entrance logbook had a line drawn through the instructions with a bold marker, which partially obliterated the instructions. For V5 (LPN)-The payroll time sheet and actual worked schedule showed V5 worked a full shift on October 16, 2020, and screening logbooks for the front and back facility entrances showed no screening documentation for V5 on October 16, 2020. The payroll time sheet and actual worked schedule showed V5 worked a full shift on October 20, 2020, and the screening log for the facility's back entrance for October 20, 2020 showed there was no entry in the Temperature or Employee Initials columns. For nine additional dates (October 2, 3, 4, 21, 23, 24, 25, 27 and 28, 2020) where screening was logged for V5, there was no entry in the Time column. For V6 (CNA)-The payroll time sheet and actual worked schedule showed V6 worked full shifts on October 12 and 13, 2020. Review of the facility's front and back entrance screening logs showed no documentation of screening for V6 on either October 12 or 13, 2020. For 12 additional dates (October 2, 4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16) where screening was logged for V6, there was no entry in the Time column. For V8 (CNA)-The payroll time sheet and actual worked schedule showed V8 worked full shifts on October 12, 13, 14, 22 and 28, 2020. Review of the facility's front and back entrance logbooks showed no documentation of screening for V8 on October 12 or 13, 2020. The front logbook showed V8 did not answer the screening questions on October 14, 2020. The back logbook showed V8 did not record a temperature in the Temperature column on October 22, or 28, 2020. For V9 (Registered Nurse)-The payroll time sheet and actual worked schedule showed V9 worked a full shift on October 23, 2020. Review of the facility's front and back entrance screening logs showed no documentation of screening for V9 on October 23, 2020. On October 28, 2020 at 2:10 PM, V3 (Infection Preventionist) stated the staff enter the facility at the facility's back entrance and V3 demonstrated use of the facility's digital thermometer mounted on the wall near the time clock and the screening logbook on a nearby table. V3 stated the staff enter for clocking-in and screening and write their information in the log on their designated screening page. V3 stated she keeps track of the screening logs and the staff are responsible for recording their screening information. On November 6, 2020 at 12:10 PM, V2 (Director of Nursing) stated she did not know why the instructions on the front side of the screening questionnaire page in the facility's front entrance logbook were blacked out with a marker. The facility's policy, Coronavirus (Covid-19) revised August 21, 2020 stated in part, Prevention 1.a. Upon entering the building for their shift temperature will be recorded, and questionnaire will be filled out . 2. On October 28, 2020 at 11:30 AM during the tour of the Covid-positive Unit with the V3 (Infection Preventionist), the Covid Unit was entered via a separate outdoor entrance/exit with V3. It was noted there was no isolation signage posted at the entry, neither on nor near the interior double doors entering the Covid Unit. All the resident room doors were closed. It was noted that all the resident's room doors were closed, and that several doors did not have isolation signage. The residents who resided in the Covid-positive unit and did not have isolation signage posted outside their rooms were R1, R2, R6, R7, R8, and R9. V3 confirmed these residents should have isolation signage posted outside their rooms for contact and droplet isolation precautions, and stated she could not explain why there was no isolation signage posted outside the resident's rooms. R1 was admitted to the facility on [DATE]. R1's lab results for Covid-19 test taken while at the facility showed a positive result on October 21, 2020, and R1's progress notes showed R1 was transferred to the Covid Unit that same date. R2 was admitted to the facility on [DATE]. R2's progress notes documented R2 showed elevated temperature and possible Covid symptoms at the facility on October 10, 2020 and R2 was sent to the hospital for evaluation and was admitted there. R2's lab results showed that while he was at the facility on October 9, 2020, R2 was tested for Covid-19 and the positive result was determined from that sample while R2 was still in the hospital. R2's progress notes showed he was readmitted to the facility on [DATE], and was admitted directly to the Covid Unit on October 14, 2020. On November 9, 2020 at 11:40 AM, V2 (Director of Nursing) confirmed R2 was admitted to the Covid Unit on October 14, 2020. The facility provided their policy Coronavirus (Covid-19)-Resident Care and Placement revised September 14, 2020, and it stated in part, under the heading, Covid-19 Positive Residents, stated 6. All PPE supplies pertaining to Covid 19 will be set up in the unit and isolation sign will be placed outside the room. 3. On October 28, 2020, during tour of Covid Unit with V3 (Infection Preventionist), V3 introduced the nursing staff present in the unit, V8 (CNA) and V9 (Registered Nurse) and explained they were the assigned for the shift. V3 stated the Covid Unit staff are designated and not assigned elsewhere in the facility as much as possible. On October 28, 2020 at 1:05 PM, V8 (CNA) and V9 (Registered Nurse) were both noted wearing N95 masks and V9 wore a cloth mask over the N95 mask. It was noted that they each wore a different type of N95 mask, and V8 and V9 stated the N95 masks were provided by the facility. V8 and V9 both reported they each received a new N95 mask every day. V9 stated that she receives, .a new one every day when I punch in, and V9 reported that she was not fit-tested for an N95 mask. V9 stated the facility began providing the N95 masks earlier in the year, reporting it was several months ago but she could not remember exactly when. V8 reported she also receives, a new mask everyday at the door, and stated she was not fitted for the N95. On October 28, 2020 at 1:50 PM, V3 (Infection Preventionist) and V10 (Director of Environmental Services) provided a tour of the facility's supplies of PPE including disposable gowns, N95 masks, surgical masks, gloves, face shields, shoe covers. Multiple boxes of the various PPE were noted on the supply room shelves on two supply rooms. V3 and V5 stated the facility does not have a shortage of PPE. V10 stated he manages the Central Supply, and stated the staff are supplied with whatever they need, and confirmed that he provided the staff with the N95 mask on their request. V10 stated he orders PPE to keep the facility fully supplied. On October 28, 2020 at 2:30 PM, V3 (Infection Preventionist) stated the facility did provide staff fit-testing for N95 masks, and that the fit-testing of N95 masks was performed by herself, and the former Director of Nursing for the staff. On November 2, 2020 at 10:15 AM, V3 stated she was mistaken when she reported earlier that fit-testing of N95 masks was performed for staff and stated, We didn't do fit-testing. On November 5, 2020 at 1:50, V3 explained that N95 masks should be worn by staff in the Covid Unit, The PUI (Persons Under Investigation) Unit, and Observation Unit, because they (the residents) are on isolation for Covid and stated that for each of these units there is a specific policy for PPE (Personal Protective Equipment) use. V3 stated it was her expectation that staff wearing N95 have a fit-test before wearing them. On November 5, 2020 at 10:30 AM, V1 (Administrator) stated the facility does not have a shortage of PPE, and added that when staff needs PPE, it is supplied to them, adding We want to keep the staff safe. On November 6, 2020 at 12:00 PM, V2 (Director of Nursing) stated it is her expectation that N95 masks be fit-tested before wearing, and added that it is important to her that staff are kept safe. The facility's policies regarding PPE use which included N95 masks, Coronavirus (Covid-19) PPE in Covid Unit revised October 2020, Coronavirus (Covid-19) PPE in PUI Unit revised September 2020, and Coronavirus (Covid-19) PPE in Observation Unit revised September 2020 were reviewed. They all listed N95 masks as requirements in those areas. None of the policies mentioned N95 fit-testing. Review of the CDC (Centers for Disease Control and Prevention) Strategies for Optimizing the Supply of N95 Respirators updated June 28, 2020 stated in part, N95 respirators are the PPE most often used to control exposures to infections transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use. The CDC guidance referenced the Occupational Safety and Health Administration (OSHA) respiratory precautions which stated in section 1910.134 OSHA's Respiratory Protection Standards, which stated, Section 1910.134(c)(1) In any workplace where respirators are necessary to protect the health of the employee .(Section) 1910.134(c)(1) .The employer shall include .(section)1910.134(c)(1)(i) Procedures for selecting respirators for use in the workplace; (section)1910.134(c)(1)(iii) Fit testing procedures for tight fitting respirators. 4. On October 28, 2020 at 11:30 AM during the tour of the Covid Unit with V3 (Infection Preventionist), the unit was entered though a separate facility entrance/exit which V3 stated staff coming on shift used for access to the unit. Upon entering the building, there was a small vestibule to pass though before reaching the closed double-doors to the Covid Unit. In the vestibule was noted a with a large quantity and variety of co-mingled clean and contaminated, staff and resident items and housekeeping items which included: On the left was a cart with shelves, and on the top shelf were sanitizing products which included disinfecting wipes and hand sanitizer, PPE gloves, clean N95 mask, and on the shelf directly below were personal staff items, which included a purse, a personal beverage container with a lid and exposed straw, and a digital tablet. On the floor directly in front of one of the double-doors were open boxes of patient care items including incontinence pads and incontinence briefs. In the center of the space was a mattress positioned with a long-side on the floor and leaning against a housekeeper's cart which held garbage bags filled with trash. The mattress was not covered in plastic or any covering to identify it as clean or dirty. Along another wall which had windows on the upper half of the wall and furniture below the windows which included patio-type cushioned chairs which were not clearly visible due to a large quantity of personal items and PPE laying askew on top of them. Multiple white hooded isolation jumpsuits with names written on the front were hanging on hangers from the casings of the window coverings and draped over the chairs below the windows. The personal items on the chairs included a jacket and used N95 and facemask with name written in ink. There were 2 floor mats leaning against a wall. There was no signage to identify this as an entryway to an isolation unit. There was a large red garbage container with a lid with a lid that perch askew atop the trash can. A narrow footpath with clutter on either side led the way from the entrance door to the double-doors to the Covid Unit. It took effort to not accidentally touch any items while passing through the space. The remaining floor space was filled with the items mentioned, which were visible. An alarm sounded when the facility entrance door was opened on our entrance, which caused V9 (Registered Nurse) to enter the vestibule from the Covid Unit side. V9 confirmed the personal items belonged to staff, as well as the used PPE that lay on furniture and the isolation suits which hung from the window frames. V9 stated the mattress was clean because she removed it from a room when a resident arrived with a mattress. She confirmed it could not be considered clean because it was sitting on the floor and leaning against the housekeeper's cart, and added she should have notified housekeeping department to remove the mattress. V3 (Infection Preventionist) as present and noted the array of co-mingled staff, patient care, and housekeeping items and confirmed the vestibule was in disarray and most of the items should not be in the entry to the Covid Unit. V3 stated the Rehab staff see their residents in the Covid Unit toward the end of their shift and bring their personal items and leave them in the space so they do not have to walk so far to their cars on the way out. On November 10, 2020 at 12:25 PM, V2 (Director of Nursing) explained it is not her expectation for staff and resident items to co-mingled and left in in the manner and location where they were noted. The facility provided their policy, Infection Control Isolation Techniques (revised June 2016) which stated in part, Standard precautions are for the protection of residents, personnel and visitors from the spread of infection and/or disease. It is performed in a simple but effective manner considering quality of life. When an infection requiring isolation techniques is determined, appropriate measures will be put in place to reduce the potential for further infections. The policy also stated, The facility will follow the Centers for Disease Control and Prevention (CDC) guidelines for Standard Precautions.

Based on interviews, and record review, the facility failed to ensure that contracted staff were tested for Covid 19 according to the positivity rate in their region, and the facility failed to have a documented policy and procedure for testing contracted staff for Covid-19. This applies to all the residents residing in the facility. The findings include: 1. On October 29, 2020 the facility's actual-worked schedule for the nursing department for the previous two weeks was reviewed. Three agency CNA (Certified Nursing Assistant) staff from two agencies were randomly chosen for review of staff testing for Covid-19 (V12, V13, V14). On November 4, 2020 at 1:50 PM, V1 (Administrator) stated the total facility census on October 24, 2020 was 99 residents (9 residents in the Covid positive unit and 90 residents in the non-Covid areas). V1 confirmed the total facility census on October 27, 2020 was 97 (8 residents in the Covid positive unit and 89 residents in the non-Covid areas). The facility provided the Daily Assignment Sheet for October 24, 2020 which showed V14 (CNA/agency staff) worked on a non-Covid unit and was assigned 9 residents. The Daily Assignments Sheet for October 27, 2020 showed V12 (CNA/agency staff) and V13 (CNA/agency staff) were each assigned to work in non-Covid units, and V12 and V13 were each assigned to 9 residents. On November 2, 2020 at 1:30 PM, V1 (Administrator) confirmed these agency (contracted staff) were assigned on the afternoon shift on the dates mentioned above. On November 4, 2020 at 9:16 AM, V1 reported that the facility did not have documentation to prove V12, V13, or V14 were tested for Covid-19 within seven days prior to working the assigned shifts as mentioned above. 2. On October 28, 2020 at 11:15 AM during the initial tour, V7 (Infectious Disease Nurse Practitioner/Consultant) stated she was at the facility to see residents in the Covid unit in her role as a medical provider. V7 stated she began as a consultant with the facility on Friday (October 23, 2020), and she first saw residents the following week on Monday (October 26) and Wednesday (October 28, 2020), and added that her regular days to visit the facility were every Monday and Wednesday. She added that she was requested to render her consulting services to the facility by the facility's medical director. V7 stated she had not been tested for Covid-19 before she began visiting residents at the facility. V7 stated she currently worked at a local hospital where she was told that she did not have to be tested for Covid-19. V7 stated that she also visited 2 or 3 other nursing homes in her role as a medical provider and had been exposed to Covid-19 positive residents. V3 (Infection Preventionist/IP) was present during V7's interview. On October 28, 2020 at 2:30 PM, V3 (Infection Preventionist) confirmed V7 did see residents on V7's visits to the facility on [DATE] and October 28, 2020. V3 confirmed the facility was currently in outbreak status, which she stated began on September 19, 2020. V3 stated the facility's Covid-19 testing policy required consultants to provide proof of Covid testing results to the facility within seven days prior to their visit. V3 stated the facility updated their testing policy within the previous 2 weeks to include the proof of testing requirement. V3 reported she was unaware that V7 had not been tested for Covid-19. The facility provided their policy, Coronavirus (Covid-19) Staff and Resident Testing, Rev: [DATE]. The policy made no reference to contracted staff, and there was no reference for the contracted staff to provide proof of Covid testing and results to the facility before working at the facility. On November 1, 2020 at 10:30 AM, V3 reported she mistakenly stated earlier that there was an update in the facility's Covid-19 policy regarding contracted staff requirements for testing. V3 stated, We didn't write it in the policy, we just tell them.

Based on interview and record review the facility failed to ensure that 2 residents identified as high risk for falls (R25 and R9) were provided with adequate supervision and individualized interventions based on the identified fall risk factors. The facility also failed to analyze the circumstances surrounding the multiple falls. As a result of this failure, R25 sustained a facial laceration and a fractured finger following a fall on [DATE] and with the third fall on [DATE], R25 sustained a subdural hematoma, expiring on [DATE] . R9 sustained 5 falls in 3.5 months resulting in hematomas, bruising, complaints of pain, head laceration and fractured left tibula. E 1(Administrator) & E 2(DON) were notified of an Immediate Jeopardy (IJ) existing at F323 on [DATE] at 9:30am. E1 and E2 were informed the IJ began on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level 2 additional time is needed to monitor and evaluate the effectiveness of the training and education of the staff, policy and procedure. This applies to 2 of 9 residents with falls in a sample 27 residents. This has the potential to affect all 58 residents who are assessed as "high risk for falls". Findings include: Admitting Minimum (MDS) data set [DATE] shows that R25 is [AGE] year old and admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS) dated [DATE] assessed R25 ' s cognitive status as severely impaired due to short term memory impairment. Record review also shows R25 shared the room with his spouse, R17. Incident report dated [DATE] states that a nurse ' s aide heard knocking coming from R25 ' s room around 5:30am and that the door was closed. Per " Occurrence report in detail " R25 said he was in the bathroom, fell in his own urine, hitting his head on the doorway. His hands, lower extremities and floor were covered in blood that appears to have been wiped. R25 had taken off his wet pajamas and left them on the floor at the bedside. R25 sustained a 6cm laceration to the left eye requiring sutures and a fracture to the right 5th finger. The facility QA follow-up form following this fall and dated [DATE] identifies R25 with multiple fall risk factors: diabetes (per blood glucose monitoring log, R25 ranged from 75 to 488 between ,[DATE] and [DATE]), dizziness, history of falls, hypertension, unsteady gait, impaired balance, decreased lower extremity strength, shuffled gait, anemia (nurse ' s notes show R25 was transfused for low hemoglobins and a physician order [REDACTED]. These multiple risk factors were not addressed following this fall and as stated in the facility policy and procedure for their fall program: " Preventative care plan interventions will be developed and implemented based upon the assessment of risk factors. " R25 ' s continence was not reassessed nor were R25 ' s fluctuating blood sugars considered in the analysis. The fact that R25 insisted that his door be closed during the night was not evaluated for safety or supervision interventions either prior to or following this fall. The facility ' s revisions/interventions to R25 ' s fall care plan following this fall were to place non-skid strips to the bathroom floor and by his recliner or night light on in bathroom. R25's fall care plan was not individualized to R25 ' s specific risk factors. R25 ' s Fall Care plan (undated) shows R25 fell again on [DATE] when he " missed chair. " E1 stated on [DATE] that there was no incident report into this fall because it was a chair with wheels and the family removed it from R25 ' s room. E1 (administrator) was asked on [DATE] at 2:00pm and ,[DATE] /11 at 10:10am and again at 1:20pm to provide surveyor with an analysis of the factors surrounding R25 ' s falls and E1 confirmed that everything the facility did could be found in the care plan and in the QA tool referenced above. Review of Investigation Follow-up, incident and Occurrence report forms referencing a third fall on [DATE] fall at 2:08 am, states a nurse ' s aide heard someone screaming for help and found R25 and R17 (R25 ' s spouse and roommate) on the floor, the door was closed. R17 stated that she also slipped in R25 ' s urine trying to help her husband who had fallen. A large amount of urine was found on the floor as was blood from a laceration to back of the head R25 sustained during fall. Both were sent to the hospital. Per nurse ' s note dated [DATE], R17 was admitted to the hospital with [REDACTED]. R25 expired in the hospital on [DATE] from intracranial bleed. These were the same circumstances that caused R25 to fall on [DATE] and sustain serious injury. E2 (director of nurses) stated on [DATE] at 10:20am that R25 was admitted to the facility because it was unsafe for him to remain in the assisted living environment. R25 could be a behavior problem at times by not wanting staff to assist him with necessary care issues. Interview with E9 (nurse's aide) on [DATE] at 12:55pm, stated she had been R25 ' s nurse's aide on a regular basis prior to his death. E9 stated that R25 needed help to the bathroom sometimes. It would depend on how weak he was feeling and how his blood sugars were. R25 was aware of his voiding needs but if he was feeling weak, it would take him too long to get up from the chair and he would wet himself. R25 liked to do things for himself and would refuse to let staff help him sometimes. E9 said R17 (wife) would tell R25 to let staff help him if he needed it and he would. E9 said that R25's door was closed every morning when she came to work. 2. Review of Neuropsychological Evaluation dated [DATE] states that R9 is [AGE] years old and has been a resident at the nursing facility for [AGE] years. R9 has history of a life-long seizure disorder and medical record review shows R9 is very confused at times. [DIAGNOSES REDACTED]. Thought process is impaired secondary to her significant memory impairment. R9 also demonstrated significant impairment of her insight/judgement for health and safety considerations. Incident reports, investigations and corresponding nurses notes show the following falls: [DATE] slid off bed try to put on shoes redness to back, armpit and knee pain to knee [DATE] found on floor by bed hit back of head, 8 x 4 inch bruise to putting self to bed ribs [DATE] fell with walker in hallway ice pack to bump on head [DATE] slid off bed, trying to go to left leg was in a lot of pain at the bathroom at 3:05am thigh and femur area, per nurse's note ,[DATE]. [DATE] lying on floor next bed, trying Laceration to back of head, bleeding to go to the bathroom, lost balance Fracture to left distal fibula at 6:08am. Nurse's note of [DATE] at 8:30am states R9 was "ambulating with walker with slow gait noted." Review of documentation regarding this fall and medical record do not reflect assessment of range of motion for R9 following this fall. It is unclear if the slow gait noted in the nurse's note was a change in condition of R9's ambulation. The nurse's note at 11:00pm on [DATE] state that R9 is complaining of pain to her left ankle and back of head. X-ray revealed a fracture to the left distal fibula. Four of the 5 falls noted above involved R9 being found on the floor next to her bed. Several of the incidents also document that R9 stated she fell because she "lost her balance". The risk factors listed on the QA form following each of R9's falls include factors such as poor standing balance/coordination, decreased lower extremity strength, and unsteady gait. Review of the most recent care plan with original date of [DATE] does not contain clear individualized interventions based on R9's specific fall risk factors, particularly her repeated episodes of balance and coordination issues. There are no supervision measures listed and R9's cognitive issues are not incorporated into her fall care plan. R9's continence program/issues were not reassessed. The approaches listed on the care plan have not been evaluated for their effectiveness after each fall. Interview with E1 and E2 on [DATE]at 11:30am stated they are the only 2 people on the fall committee who evaluate falls. E1 and E2 were asked several times during the course of the survey for documentation showing they analyze the circumstances surrounding the facility of falls and both stated that they meet every morning and review each fall. When asked to provide documentation showing the facility identifies frequent fallers and analyzes the circumstances surrounding those incidents and accidents, E1 and E2 did not provide documentation showing that such a system was in place, either on an individual basis or as a facility wide identification method. The facility does not have a comprehensive method that allows them to analyze the circumstances surrounding resident falls/incidents. The surveyor confirmed the facility took the following actions to remove the immediacy: 1. All residents having a fall within the last 60 days and all high risk residents were reviewed and corresponding care plans were reviewed to assure all appropriate interventions were in place. 2. All staff were inserviced on [DATE] and [DATE] regarding the facility policy and procedure to follow when a fall occurs. 3. The Fall Committee was expanded to include all members of the IDT and will meet after each fall and discuss the most appropriate interventions following a thorough analysis of the circumstances surrounding the falls. 4. Facility Fall Policy and Procedure was reviewed to ensure that it addresses all aspects of fall prevention and revise as appropriate.

Based on observation, interview and record review the facility failed to complete an accurate and thorough assessment of factors for R23 & R 24's urinary incontinence. Identify the causes of R23 & R 24's incontinence and analyze whether these were reversible or irreversible. Develop and implement a specific program based on resident ' s individual assessment. Develop and implement a specific and individualized bowel and bladder plan of care to promote dignity & to improve or maintain R 23& R 24 ' s current bladder functioning. These failures resulted in R 23 decline in bowel & bladder functioning from continent (0) to frequently incontinent (2). This is for 2 (R 23 & R 24) of 2 residents in the sample identified as incontinent of bladder. Findings include: (1) On 05-12-11 at 1:50 PM, R 23 stated " I can feel the urge to use the bathroom; I wear diaper every day for protection because I have accidents at times most specially at night. At night I just pee on my diaper for me to get up at night it will be a lot of work for them. They need to put the prosthesis on my leg then transfer me from bed to my wheelchair, so that ' s probably why they put diaper on me at night too. I just do it while in bed; they didn't ' offer me the option to use the bedpan, I will be willing to try anything. They said when you have babies this things happens (incontinence) when you get old, your bladder weakens. I usually let them know at times that I need to go to the bathroom but the incontinence happens in the process of waiting for help. I am willing to try anything that will help me control my incontinence, it ' s embarrassing I am becoming like a baby. " On 05-12-11 R 23 was toileted by staff at 1:00 PM, R 23 was observed to be able to stand with assist, R 23 " I can clean myself up, just need a little help pulling my pants up. " Review of the admission Minimum (MDS) data set [DATE] showed that cognitively R 23 has some difficulty in new situations only, totally continent in both bladder & bowel. The quarterly Minimum (MDS) data set [DATE] showed a decline in R 23 ' s bowel & bladder function, R 23 was scored 2- frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding.) Staff interviews (C.N.A ' s - E 12 & E13, Nurse- E 14) confirmed that R 23 ' s alert & oriented X3. On 05-12-11 at 1:30 PM, E 13 stated " she's alert & oriented, she's able to tell when she needs to use the bathroom, but she's incontinent. She wears diaper at day time, I don ' t know at night, I don ' t work night shift. Most of her incontinence is after lunch. "When E 13 was asked why would R 23 be incontinent if (R 23) able to verbalize her need to go to the bathroom, E 13 said " that ' s a good question. " On 05-12-11 at 2:13 PM, the Bowel & Bladder Coordinator (E11) presented the B&B assessment/Resident Assessment Protocol sheets dated 06-11-10 that showed R 23 was continent of bowel & bladder. The Bowel & Bladder quarterly note dated 09-04-10 read as follows: declined with Bowel & Bladder. No constipation. Continue to monitor & will start toileting plan. (2) On 05-12-11 at 2:30 PM, the C.N.A (E12 & E13) stated that R 24 is alert & oriented X3, he walks with a walker. He goes to the nursing station to tell the nurses if he wants to go to the bathroom. He wears diaper because he ' s incontinent but he ' s able to pee when taken to the bathroom. He ' s usually wet in the morning & he ' s bed is usually wet in the morning. " At 2:50 PM R 24 stated " I can tell when I need to use the bathroom, I wear diaper because I have accidents, at night I just pee in bed because by the time that help comes I ' m already wet. " At 3:35 PM E 12 added " If you catch him before & after breakfast he ' ll stay dry but that ' s not easy to do with other patients on the floor. " Review of R 24 ' s Bowel & Bladder assessment/ Resident Assessment Protocol sheets presented by E 11 was inaccurate; it showed that R 24 has functional incontinence (in ability to reach the bathroom because of loss of memory or inability to communicate the need to use the toilet due to cognitive impairment.) On 05-12-11 @ 3:15 PM, the Bowel & Bladder Coordinator (E11) disclosed " I don ' t know who ' s on Bowel & Bladder program or how many people I have in the program. " E 11 was unable to present the Bowel & Bladder program list. There were no comprehensive assessments conducted to analyze the causes of R 23 & R24's decline in Bowel & Bladder functioning, this finding was confirmed by E 11. The Bowel & Bladder care plan developed for R 23 & R 24 were not specific & individualize base on their needs.

Based on record review and interview the facility failed to ensure that staff received effective training in the area of staff assisted physical transfers and the usage of mechanical lifts. These failures resulted in 4 of 27 residents inside of the sample (R18, R19,R20 and R21) and 4 residents outside of the sample (R28, R29, R30, and R31) sustaining injuries including, skin tears and bruises. Findings Include: 1) R18 is a right [DIAGNOSES REDACTED] and requires two person staff assisted transfers using a mechanical standing lift. Review of R18's incident report dated 3/20/2011 denotes that there was noted fading bruises to the left lateral forearm. Further documentation denotes that the bruising occurred during the process of staff transferring the resident with the lift. 2) R19 is a [AGE] year old, with [DIAGNOSES REDACTED]. Per MDS and the transfer assessment R19 requires extensive two person plus physical assist with a standing lift. Review of R19's incident report dated 2/14/2011 denotes that R19 sustained a bruise to the right lower leg during a transfer from the bed to the wheelchair by E 17 (CAN) 3) Review of R20's incident report dated 2/19/2011 denotes that during an attempted transfer by E 18(CAN) the sling of the total mechanical lift hit R20 on the left upper arm and a skin tear was sustained. 4) R21 is a [AGE] year old, with [DIAGNOSES REDACTED]. Per MDS and the transfer assessment R21 requires extensive two person plus physical assist with a standing lift. Review of R21's incident report dated 3/16/2011 denotes that E 20 (CAN) bumped R21 with the wheelchair while assisting the resident using the mechanical standing lift. R21 sustained a 2x1.5cm skin tear to the left shin area. 5) R28 is a [AGE] year old, with [DIAGNOSES REDACTED]. Documentation denotes that R28 requires a two person total body mechanical lift for all transfers. Review of the incident report dated 1/3/2011 denotes that R28 sustained a skin tear to the left arm while E 15 (CAN) was putting the sling from the lift onto the resident. 6) R29 is a [AGE] year old with [DIAGNOSES REDACTED]. Documentation (MDS and transfer assessment) denotes that R29 requires a one person physical assist during transfers. Review of the incident report dated 2/13/2011 denotes that R29 sustained a skin tear to the right knee during transfer by E 16 (CAN) while using a gait belt. 7) R30 is a [AGE] year old with [DIAGNOSES REDACTED]. Per MDS R30 is totally dependent and requires a two plus person physical assist in the area of transfers with a total mechanical lift. Review of the incident report dated 3/5/2011 denotes that R30 sustained bruising and a hematoma to the lateral right side of the breast extending to the down the right side of the body. Per documentation the injuries occurred when E 19 (CAN) used the sling to transfer the resident. Further documentation denotes that the bruise line closely matches the where the sling is placed. 8) R31 is a [AGE] year old with [DIAGNOSES REDACTED]. Review of the incident report dated 3/22/2011 denotes that R31 sustained a skin tear to the left leg during a transfer by E 22 (CAN). Per interview on 5/12/11 E1 (administrator) stated that the facility does spot training and inservicing of their staff and CAN's. E1 stated that the inservice is logged but not tracked.