Every finding on record at Terrace of St Cloud, The

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 out of 2 residents, of a total sample of 7 residents, (#2, and #6).Findings:1.Resident #2 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, anxiety disorder and seizures.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident # 2's cognition was severely impaired, and she was dependent on two or more staff for assistance with activities of daily living (ADL) and transfers.Review of resident #2's care plan initiated on 10/27/23 and most recently revised on 10/01/25 indicated the resident required two-person assistance for transfers via mechanical lift, bed mobility and ADLs. On 11/04/25 at 10:23AM, resident # 2 was in bed and had a small, round, bluish mark on her left cheek. She was calm but did not answer any questions when asked. Later in the morning at 11:48 AM, her husband stated a few weeks ago on 10/01/25, his wife got the bruise to her face while she was on another unit. He explained a nurse had called him during the night to inform him of the bruise and because the facility could not tell him what happened, he called the police to report an allegation of abuse.On 11/05/25 at 9:16 AM, Certified Nursing Assistant (CNA) C said he took care of resident #2 while she resided on Unit 2. He remembered working the morning as well as the evening shift and reported to the nurse the bruise on her face an hour before his shift ended. He recalled he had not noticed any bruises on her before. CNA C acknowledged sometimes he provided ADL care to resident #2 without the assistance of another staff member but could not remember if he had assistance on that day. CNA C conveyed he knew what care the resident required from the care plan. He said he knew resident #2 required two persons to assist with ADLs and transfers but explained he still sometimes provided care by himself. CNA C did not give a reason why he did not follow the care plan for two staff for ADL care when caring for resident #2. He explained he might have asked for assistance but could not remember if anyone helped him that day.On 11/04/25 at 3:52 PM, in a telephone interview, CNA A said she learned from report that resident #2 had a bruise to her face. The CNA acknowledged she had assisted resident #2 on 10/01/25, the night the bruise was found. CNA A expressed she changed the resident herself, and stated, I've changed her by myself before, she does not fight, she is calm.On 11/04/25 at 4:07 PM, CNA B stated she had assisted resident #2 when she was on Unit 2 but did not recall her having any bruises on her body. CNA B acknowledged she had provided ADL care to resident #2 by herself previously. On 11/05/25 at 11:15 AM, the lead MDS Coordinator said that resident #2 moved around a lot and it was hard for one staff member to assist her. She explained that resident #2 was very fragile, and CNAs should not decide to assist her by themselves. She stated that care plan interventions for two staff were put in place to minimize bruising and the only time it would have changed was if the resident had a physical therapist evaluation. She continued to explain that unless the resident was improving or if there was some other change in the care plan, those interventions would not change.On 11/04/25 at 1:25 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) acknowledged that the incident resulted in a federal report for abuse filed on 10/01/25. The DON continued to explain that from their investigation, the assigned Certified Nursing Assistant (CNA) C did not follow the resident's care plan for assistance of two persons with ADL care which resulted in bruises to her leg and face.2. Resident #6 was admitted to the facility on [DATE] with diagnoses that included unspecified congestive heart failure, malignant neoplasm of the colon, Alzheimer's disease, unspecified dementia, and generalized anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #6's cognition was severely impaired. The assessment indicated resident #6 required two or more staff for care and was dependent on staff for ADL care.Review of resident #6's plan of care initiated on 10/09/25, revealed the resident was at risk for easy bruising due to fragile skin, unsafe hand movement behaviors, impulsively grabbing items on the floor or surroundings, combative behaviors, and flings and swings her hands. Resident #6 also had a care plan for risk for skin breakdown and pressure injuries related to combative behaviors, impaired cognition, decreased mobility, incontinence, require assist with care, poor oral intake, daily use of psychiatric medications, fragile skin, impulsive body movement behaviors when in bed or chair. Interventions included the use of two staff members as needed to prevent shearing during positioning. In contradiction to the MDS of 10/09/25, the plan of care indicated resident #6 required one person assistance with transfers, bed mobility and ADL care.On 11/05/25 at 12:46 PM, resident # 6 was in bed with torn pool noodles on the side rails of her bed. The assigned CNA D said that resident #6 tried to get out of bed, constantly tore the pool noodles off the rails, and bumped into the rail.On 11/05/25 at 1:48 PM, CNA E looked in the Kardex to determine if a resident was a one- or two-person assistance with ADLs and transfers. She logged into her computer but could not find the desired information. At 1:51 PM, the Unit Manager (UM) for Unit 2 arrived and confirmed CNA E was unable to find the information in the computer for how many staff were needed by the resident for assistance without the UM's help. The UM acknowledged CNA E was unable to navigate the facility's electronic system and stated the CNAs relied on verbal reporting instead of what was in the care plan. The UM's said the expectation was for CNAs to know how to look up the information from the care plan.On 11/05/25 at 1:56 PM, in a joint interview with CNA D and CNA F, resident #6's assigned CNA D said that resident #6 required one person to assist with ADLs and transfers. She was unable to verify the information in the electronic charting system because, she explained, she did not have computer access. The CNA said she had to speak with the DON to give her access. CNA F said the information she saw in the electronic system seemed confusing. Both CNAs said they didn't usually access the electronic system for that information but instead relied on verbal reports from the nurse or other staff to update them of any changes with the resident. On 11/05/25 at 2:34 PM, in a joint interview with the NHA and DON, the DON stated her expectation was all staff would know how to access the residents' care plans, follow the care plan interventions and ask for help if needed. She acknowledged recent education on care plans did not ensure staff understood how to navigate or access the care plans on the computer. The facility's policy statement for Care Plans, Comprehensive Person-Centered, revised on January 2025 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy interpretation and implementation in section 4 g. detailed, Each resident's comprehensive person-centered care plan will be consistent with the resident's rights .including the right to receive the services and or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent the development, transmission and potential spread of infection by not adhering to proper contact precautions for 1 of 2 residents reviewed for isolation precautions, (#56); and failed to ensure acceptable standards of practice were implemented when performing blood glucose monitoring and administration of injectable medication for 1 of 6 residents observed during medication administration, (#64); of a total sample of 49 residents. Findings: 1. On 4/21/25 at 11:25 AM, resident #56's door had a sign indicating contact isolation precautions were implemented. Inside the resident's room, the biohazard waste receptacle for used personal protective equipment (PPE) was located in the middle of the resident's room between resident #56's and her roommate's dressers. In order to dispose of soiled PPE, the wearer would have to walk past resident #56's bed and dresser in order to dispose of soiled PPE. Personal protective equipment refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness, (retrieved on 5/02/25 from www.fda.gov/medical). Resident #56 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Hospital paperwork dated 3/20/25 revealed swelling, a rash and fluid-filled blister like formation to her right upper extremity due to possible infiltration of a corrosive IV medication. An admission note from 3/28/25 listed a wound to the inside bend of resident #56's right elbow. Review of the results for a lab test of resident #56's right arm wound dated 4/15/25 revealed multiple microorganisms identified inside the wound including staphylococcus aureus (staph). A nursing progress note from 4/16/25 revealed the resident was placed on contact precautions due to staph in her right middle arm wound. Staph or a Staph infection is caused by staphylococcus bacteria. This bacteria can cause a staph infection which can be deadly if the bacteria invade deeper into your body. The Centers for Disease Control recommend that nursing home residents with multi-drug resistant organisms such as staph be placed on contact isolation to prevent further transmission of the bacteria, (retrieved on 5/02/25 from www.mayoclinic.org). On 04/23/25 at 11:48 AM, the Infection Preventionist (IP) nurse revealed disposal for soiled PPE should be located near the resident's exit door. The IP nurse confirmed resident #56's biohazard waste disposal box was located in the middle of the resident's room between the two residents. She confirmed contact precautions for resident #56 were to prevent the transmission of the staph organism from her to other residents. She acknowledged removing PPE and walking back through the resident's environment for disposal was a break in isolation. The facility policy revised October 2018 entitled, Infection Prevention and Control Program indicated an infection prevention and control program was established and maintained to provide a safe, and sanitary environment. The policy detailed the program should help prevent the development and transmission of communicable disease and infections. A facility policy revised on March 2024 with information for different types of isolation indicated under the section for contact precautions, a gown and gloves were required on every entry into the resident's room and waste disposal for PPE should be located near the exit of the resident's room. 2. Resident #64 was admitted to the facility on [DATE] with an admitting diagnosis of end stage renal disease with dependence on dialysis, hypertension, and type 2 diabetes mellitus. On 4/23/25 at 8:57 AM, Licensed Practical Nurse (LPN) A prepared to perform medication administration for resident #64. LPN A entered the room and swabbed resident #64's finger with an alcohol swab. The nurse pricked resident #64's finger with a lancet, obtained a drop of blood from the finger and placed it on the test strip which was previously inserted into the glucometer. LPN A did not don gloves when he performed the blood sugar check. LPN A then removed the cap of the insulin pen, swabbed the rubber seal, and attached the needle to the pen. LPN A swabbed the site on resident #64's abdomen and administered the injection, without sanitizing his hands or applying gloves. LPN A then disposed of the lancet, the bloody test strip and the used needle in the sharps container. He left the resident's room without sanitizing his hands and proceeded to his medication cart where he placed the glucometer back into the top drawer of the medication cart without disinfecting the device. The Centers for Disease Control, recommended health care providers should wear gloves during blood glucose testing or any other procedure that involved potential exposure to blood or bodily fluids. They recommended if blood glucose meters were used to test multiple patients the device should be cleaned and disinfected after every use to prevent the spread of blood and infectious agents, (retrieved on 5/02/25 from www.cdc.gov/injection-safety). On 4/23/25 at 9:38 AM, the Director of Nursing (DON) explained they did not have individual glucometers for each resident and expected nurses to disinfect the glucometers after each resident. Nurses should use the appropriate cleaning solution prior to placing the glucometer back on the cart. The DON confirmed nurses were expected to wear gloves as best practice when checking blood sugars and/or administering injections, as they had potential to encounter blood and bodily fluids. She acknowledged LPN A did not follow this policy/procedure and required re-education. On 4/23/25 at 1:21 PM, LPN A confirmed he did not wear gloves when checking resident #64's blood sugar or when he administered insulin by injection. He acknowledged he knew the proper infection control procedure for blood glucose monitoring and insulin injection required the use of gloves when potentially encountering bodily fluids. He stated he should have disinfected the glucometer before placing it back into the medication cart. The facility's policy and procedure revised September 2014 entitled, Blood Sampling - Capillary (finger stick) indicated the purpose of the procedure was to guide the safe handling of capillary-blood sampling devices to prevent the transmission of bloodborne diseases to residents and employees. The section titled, General Guidelines detailed that blood glucose meters should always be cleaned and disinfected between use. The section entitled, Steps in the Procedure, listed the steps including, wash hands, don gloves, clean and disinfect reusable equipment after each use. The procedure continued, remove gloves, and wash hands. The facility policy dated 2024 entitled Administering Medications indicated staff were to follow established facility infection control procedures such as hand washing and wearing gloves during the administration of medications.

Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care, and failed to obtain physician orders for the care and maintenance of a peripheral IV for 3 of 3 residents reviewed for IV care, of a total sample of 49 residents, (#466, #106 and #520). Findings: 1. Resident #466 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of fracture of unspecified metatarsal left foot, peripheral vascular disease, Type 2 diabetes mellitus, urinary tract infection and sepsis. Current physician's orders indicated resident #466 had a midline IV line in his right upper arm for administration of IV antibiotics. The physician orders showed he received 1 gram (gm) of Ertapenem solution (antibiotic) intravenously daily at 9:00 PM from 4/17/25 until 4/27/25 for a bloodstream infection. A midline catheter is put into a vein by the bend in the elbow or the upper arm . a midline catheter may allow you to receive long-term intravenous medicine or treatments (retrieved on 5/02/25 from www.drugs.com). On 4/21/25 at 10:29 AM, resident #466 was sitting up in bed, an undated, transparent midline IV dressing was seen on his right upper arm. The resident stated the midline was inserted at the hospital but was unsure when. On 4/22/25 at 9:44 AM, assigned Registered Nurse (RN) C verified resident #466's IV midline dressing was undated. He explained dressing changes were based on the physician's order, usually the order was to change the dressing every week or as needed. The nurse verified the physician's order indicated the dressing was to be changed weekly on Wednesday evening. The nurse acknowledged the resident's midline dressing should have been dated with the date of the last dressing change. He acknowledged the importance of dating the dressing in preventing infection and complications. On 4/22/25 at 10:56 AM, with the Director of Nursing (DON) present, resident #466 stated his IV midline dressing had just been changed and dated with today's date. The DON stated her expectation was IV midline dressings should always be dated. 2. Resident #106 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of left femur fracture, chronic obstructive pulmonary disease and chronic respiratory failure. Review of current physician's orders revealed she had a midline IV line in her left upper arm for administration of IV antibiotics. The orders specified 1 gm of Vancomycin solution (antibiotic) intravenously twice a day at 9:00 AM and 9:00 PM, from 4/17/25 to 4/23/25, then once a day at 9:00 AM until 5/01/25 for a wound infection of her lower left leg. Another physician order indicated, IV midline left upper arm dressing change every week, remove old dressing cleanse site with alcohol or Betadine cover with transparent dressing weekly and as needed. Monitor for s/s of infection, phlebitis, or bleeding at IV site. Once a day on Tuesday 7 AM- 3 PM. On 4/21/25 at 11:13 AM, resident #106 was in bed, a midline IV was on her left upper arm. She stated she received IV antibiotics for a wound infection on her left leg. Resident #106's midline IV dressing was undated, and loose with the edges of the dressing lifted up from the skin. The resident stated she did not remember when the IV was inserted nor the last time the dressing was changed. On 4/22/25 at approximately 9:54 AM, RN C entered resident #106's room and confirmed the midline IV dressing now with a date of 4/16/25 written on it. The dressing was still loose at the edges lifting up from the skin, and the resident explained another nurse came in and wrote the date, but did not change the dressing. RN C acknowledged the midline IV dressing needed to be changed. On 4/22/25 at 10:50 AM, the DON stated IV midline insertions were ordered through the pharmacy and facility nurses changed the IV midline dressings based on the physician's order. She explained the facility's protocol was to change any IV dressings every Tuesday. The DON confirmed the midline IV dressing should have been dated when first inserted. She acknowledged the nurse should have changed the IV midline dressing instead of writing a date on it when they saw the dressings were undated as they would not be sure as to how long it had been in place. The Facility's Policy on Central Venous Catheter Care and Dressing Changes revised October 2024 stated in the Procedure section- to apply sterile dressing section 6 e, Label with initials and date. 45646 3. Resident #520 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type 2 diabetes, and pneumonia. A care plan for the presence of peripheral IV catheter was initiated on 4/23/25. The care plan indicated resident #520 was at risk for localized infection or complications. Interventions included dressing changes to IV site per orders and to observe IV site for swelling, redness, patency, leaking around site, pain and/or coolness to touch. Review of resident #520's electronic medical record (EMR) revealed a communication form from a vascular access company which indicated a peripheral IV had been placed in the resident's left arm on 4/21/25. Review of physician orders for resident #520 revealed an order dated 4/21/25 which read, May place peripheral IV line. No orders were present for monitoring or maintenance of the peripheral IV and dressing. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2025 revealed no documentation to indicate the peripheral IV and dressing had been monitored or maintained. On 4/22/25 at 10:16 AM, resident #520 was observed in bed with a transparent IV dressing on her left arm. No date was present on the dressing. Resident #520 stated she received an IV solution because she was dehydrated. On 4/23/25 at 2:44 PM, resident #520 was observed in bed, the transparent IV dressing remained in place. The dressing was now dated 4/22/25. On 4/24/25 at 10:13 AM, resident #520 was observed in bed with her husband at bedside. The IV dressing remained in place. Resident #520 stated the IV infusion had been discontinued but she was not aware why she still had the IV. On 4/24/25 at 10:14 AM, RN B and the Assistant Director of Nursing (ADON) confirmed resident #520 had a peripheral IV. RN B and the ADON could not locate physician orders to monitor and/or maintain the IV. On 4/24/25 at 10:22 AM, the DON stated a peripheral IV was usually removed within 72 hours of insertion. She could not locate an order for care, maintenance nor for removal of the IV. The DON confirmed resident #520 should have a physician's order for monitoring and maintenance of the IV and IV site. At 10:40 AM, the DON acknowledged the peripheral IV should have been removed and there should have been an order to monitor the IV and change the dressing as needed. The DON acknowledged without orders, nurses would not be prompted to check the IV site and dressing, including documentation of their findings.

Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe environment to prevent accidents for 1 of 1 resident reviewed for falls with injuries, out of 2 sampled residents, (#1). The facility's failure to ensure nursing staff were knowledgeable to utilize the required transfer sling and ensure proper positioning of the resident during transfers to prevent fall with injury and transfer to a higher level of care for treatment, resulted in isolated actual harm at F689, for resident #1. Findings: Resident #1 was admitted to the facility on [DATE], with diagnoses that included dysarthria following cerebral infarction, muscle weakness, bradycardia, hypertension (HTN), non-ST-elevation myocardial infarction (NSTEMI), type 2 diabetes, chronic obstructive pulmonary disease (COPD), dementia, abnormal posture, difficulty walking, atrial fibrillation (AFIB), polyosteoarthritis, and cognitive communication deficit. Review of the medical record revealed physician orders for a Hoyer lift for all transfers and Eliquis 2.5 milligrams (mg) twice a day for AFIB. Eliquis is a medication used to lower the risk of stroke or a blood clot in people with a heart rhythm disorder called atrial fibrillation. Eliquis can make it easier for you to bleed, even from a minor injury, (retrieved on 8/02/24 from www.drugs.com) Review of a Physical Therapy evaluation dated 1/12/2024 revealed resident #1 was dependent on staff for transfers and required the use of a Hoyer lift for bed to wheelchair transfers. Review of the admission care plan revealed resident #1 required 2 people to assist with transfers using the Hoyer lift. Review of a progress note dated 7/04/2024 at 5:20 PM, revealed the nurse was notified resident #1 had fallen while being transferred to bed from her wheelchair. Upon entering the room, the nurse noted the resident lying on the floor, on the right side of her bed with her feet pointed towards the door. The nurse noted a small amount of blood coming from the back of her head. The note indicated the resident was fully conscious and denied pain. The nurse noted a 2-centimeter-long laceration on the back of her head. She documented resident #1 was transferred to the emergency room (ER) for evaluation and treatment. Hospital paperwork from 7/04/24 revealed resident #1 presented to the ER with a small abrasion to her right occiput (back of scalp). A computerized tomography (CT) scan, labs and electrocardiogram performed in the emergency department were all negative for acute diagnoses and the resident returned to the facility 7/04/24 at 10:45 PM. A progress note dated 7/08/24 revealed an Interdisciplinary team meeting was held to discuss the fall from the mechanical lift. The note indicated: Two staff members utilized the mechanical lift to assist the resident to transfer from the wheelchair to the bed. The resident slipped through the opening in which her buttocks should be placed when transferring. She bumped her head when she landed on the floor. Neuro checks were initiated. She was sent to the ER and returned with no new orders. The mechanical lift sling has been changed, as the prior sling was too large for her and allowed room to slip out. In a witness statement dated 7/08/24 by Certified Nursing Assistant B (CNA B) and presented by the Director of Nursing (DON) on 7/24/24 at approximately 9:55 AM, he stated the resident slid out of the sling feet first and landed on her buttocks. In the statement she indicated CNA B admitted he didn't ensure the sling was the correct size for the resident nor did he know what the correct size was supposed to be. On 7/24/24 at approximately 10:00 AM, the DON stated on 7/08/24, she had interviewed CNA C who was assigned to resident #1 on the date of the fall. She stated the day shift CNA would have been the person to transfer the resident into the wheelchair in the morning. The DON described that CNA C stated she was assigned to the resident on the 7 AM to 3 PM shift but was unsure whether she used the Hoyer lift to get the resident up that day. She also didn't recall who assisted her with the transfer but said if she did get Resident #1 up that day she would have a sling under her and ready for the next CNA to put her back into bed. The DON explained the CNA would have gotten the sling out of the resident's room and if it wasn't there, she would have gotten one from laundry or central supply. CNA A's witness statement from 7/04/24 revealed at approximately 5:20 PM, she and CNA B transferred the resident from the chair to the bed with a mechanical lift. She detailed CNA B was in the front, and she was positioned in back to transfer her to the bed. Her statement described how she saw the resident sliding down, but said the wheelchair was locked and she couldn't move it quickly enough to catch resident #1 and she ended up on the floor. On 7/24/24 at 9:53 AM, the DON revealed that after she read the witness statements from the two CNAs involved on the fall on 7/04/24, she felt she needed to conduct follow up interviews with them to obtain more information about the incident. The DON stated that following her interview with CNA A on 7/05/2024, she asked her which type of sling they used at the time. CNA A confirmed they had used a sling referred to as a 'shower or toilet' sling which had a hole towards the bottom of the sling where a resident's buttocks should be. The DON explained this type of sling was designed so the resident could be transferred onto the toilet with their buttocks positioned through the hole so the resident could sit onto the toilet. The sling was designed so the resident was positioned in more of a sitting position to make it easier to transfer onto the toilet. CNA A told her they didn't notice the residents' buttocks weren't positioned over the hole until they had started to raise the arm of the mechanical lift. Instead, the resident's feet were positioned by the hole and when they lifted her up, she went feet first through the hole since the sling positioned the resident in a seated position. The DON said she concluded the CNAs had incorrectly used a shower/toilet sling when they should have used a regular sling. The DON also concluded the shower/toilet sling used was too large for the resident. On 7/23/24 at 3:00 PM, CNA A revealed CNA B was assigned to Resident #1, but she assisted her to transfer the resident on 7/04/24. She stated CNA B had asked for her help to transfer the resident from the wheelchair to her bed. CNA B explained the resident already had a sling under her from her transfer earlier in the day from her bed to the wheelchair. She stated when they lifted the resident out of the wheelchair with the mechanical lift, she fell and hit her head on the floor. CNA B recalled she then called a nurse to assess the resident who was sent out to the hospital. She stated the day after the incident she received one on one training on safe transfers with the Director of Rehabilitation. On 7/24/24 at 12:18 PM, CNA B revealed when he and CNA A transferred the resident from the wheelchair to the bed he made sure the colors on each strap lined up. He recalled the sling was too big for the resident. CNA B stated when they lifted the resident up, she slid out of the sling feet first thru the hole where the buttocks normally went in the shower sling. CNA B explained after the fall, the facility trained him on safe transfers and mechanical lifts. He explained after the training he realized he needed to check to make sure the resident had the correct type of sling and the correct size of sling before using the lift. In the facility's policy with most recent review dated 02/23, titled, 'Lifting machine, using a mechanical' it states that the purpose is to establish the general principles of safe lifting using a mechanical lifting device. Under the section Procedure Guide, one of the steps is to visually check the size of the sling to ensure it is not too large or too small.

Based on interview, and record review, the facility failed to implement their abuse policy to fully investigate and provide education for injury of unknown origin for 1 of 2 residents, of a total sample of 4 residents, (#2). Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, heart failure, stroke, dementia, and left-hand contracture. The resident received hospice services. Review of resident #2's medical record revealed a nurse's Progress note dated 9/17/23 at 4:51 AM, which indicated a purple discoloration was noted to the top of the resident's right hand, but no swelling or redness was noted. A few hours later another Progress note indicated the nurse was notified by the Certified Nursing Assistant (CNA) that the resident's right arm was swollen with a faint yellowish discoloration, and he complained of pain. The nurse noted the medical provider and resident Power of Attorney were contacted and a STAT radiograph of the right arm was ordered. On 9/17/23 an Immediate Investigation report was submitted by the facility for an injury of unknown origin to resident #2. The report described an X-ray report from 9/17/23 which indicated an acute spiral fracture of the right proximal humerus (upper arm bone). The document revealed an investigation was initiated by the facility. In interviews on 5/30/24 at 2:11 PM, and on 5/31/24 at 6:02 PM, the Director of Nursing (DON) revealed the facility obtained statements and performed record review as part of their investigation. Review of the facility investigation with the DON revealed conflicting information regarding how and when resident #2's injuries occurred. A witness statement from Licensed Practical Nurse (LPN) B indicated resident #2 complained of pain to his right arm when CNA A provided incontinence care on 9/16/23. Various other staff statements and a statement from resident #2's daughter indicated he had bruising, swelling and complained of pain to his right arm and hand before 9/16/23. The DON explained any abuse or neglect allegation should be reported immediately and if after investigation it was found to be an adverse event that should be reported as well. She stated individuals involved in the incident should receive education immediately, and then all other staff to ensure no one else made the same mistakes. The DON stated the facility was unable to provide a Root Cause Analysis of the event, nor could they provide a timeline completed during the investigation. The DON said the expectation was after the facility learned of an alleged incident, the Administrator would write up the report and they would do an in-service for all staff regarding the injury or incident. The DON confirmed for this incident not all facility staff received in-service. The DON said she could not find any written evidence the steps were completed.

Based on interview, and record review, the facility failed to demonstrate the effectiveness of a Performance Improvement Plan (PIP) for timely transmissions of Minimum Data Set (MDS) assessments. Findings: On 08/24/23 at 11:00 AM, the MDS Regional Nurse Consultant stated the facility had an employee turnover at the end of May 2023, and an entire facility MDS assessment audit was conducted. She noted a problem was identified for late transmittals of MDS assessments. She explained a Quality Assurance and Performance Improvement Plan (QAPI) plan was discussed and the Regional Nurse presented the MDS plan to the monthly QAPI team in the August 2023 meeting. On 08/23/23 at 5:12 PM, during an interview, the MDS Director was unable to answer if a Performance Improvement Plan (PIP) was currently in place for Minimum Data Set (MDS) assessment transmittals. She noted she was unsure of what a PIP was. The Administrator was present and noted there was no PIP in place for MDS assessments. On 08/24/23 at 1:35 PM, the DON stated there was a discussion at the last QAPI meeting about PIP and MDS submissions. She recalled they reviewed the PIP. On 08/24/23 at 7:59 PM, the Administrator, and Regional Nurse, acknowledged the root cause for the MDS PIP was a transmittal issue. Review of MDS PIP read, Opportunities to Improve Quality 2023-2024, with a date of 8/9/23, with goal to transmit MDS assessments timely ., it showed a performance improvement indication related to employee turnover, and a plan for the MDS Coordinator to electronically submit, within 14 days of completion of a resident's assessment. The plan was dated for one month and included the MDS Corporate Nurse Consultant to in-service, and educate the MDS Coordinators, and the DON to conduct weekly reviews. The actions noted the Corporate Nurse Consultant to complete a two-week audit of all MDS residents assessments to ensure assessments had been submitted timely, provide assessments to the DON to conduct weekly reviews and then report findings to the QAPI committee. The MDS Corporate Nurse Consultant provided a copy of the first facility wide audit dated 8/9/23. On 8/24/23 at 11:00 AM, the MDS Corporate Nurse Consultant was unable to provide a copy of a second facility audit and stated, have not done it yet. It was noted that MDS assessments identified as not transmitted timely still had not been transmitted after the first audit was completed. Review of facility Quality Assurance and Performance Improvement (QAPI) Plan Policy dated revised 4/2014 showed the facility shall develop, implement and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of residents care, pursue methods to improve care quality, and resolve identified problems. Under the section of authority, it revealed the Administrator is responsible assuring the QAPI Program complies with Federal, State and local regulatory requirements. Listed under the section for implementation it showed the QAPI Committee oversee the implementation of QAPI Plans.

Based on observation, interview, and record review, the facility failed to develop and implement an indwelling urinary catheter plan of care for 1 of 1 resident reviewed for Urinary Catheters from a total sample of 41 residents, (#110). Finding: Review of resident #110's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital and had diagnoses that included urinary tract infection (UTI), multiple sclerosis, Bell's Palsy, Vestibular Schwannoma (brain tumor), pressure ulcer of sacral region, gastrostomy (feeding tube), and muscle weakness. The Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) 6/16/2023 noted the resident scored 12 out of 15 on the Brief Interview for Mental Status that indicated the resident was not cognitively impaired. The Functional Status on the assessment showed she required extensive staff assistance to complete Activities of Daily Living (ADL). Bladder and Bowel section noted the resident had frequent urinary incontinence during the 7 day look back period. On 8/21/2023 at 10:51 AM, resident #110 was observed awake and lying in bed. A urinary catheter bag was noted on the left side of the bed. The resident said she was upset because the nursing staff had not assisted her with the urinary catheter. She said the catheter felt uncomfortable, and she wasn't sure the catheter was fully inserted in her bladder. She indicated, I keep telling them, and it's not checked by nurses or CNAs (Certified Nursing Assistants) . Review of the Nursing Progress Notes dated 6/10/2023 noted the resident was admitted to the facility with an indwelling urinary catheter. The Matrix CMS-802 (10/2022) provided to the survey team on 8/21/2023 included resident #110 but there was no indication that the resident had an indwelling urinary catheter in place. The Physician Order Report from 6/09/2023 to 8/22/2023 did not include orders for care, services, or monitoring of the urinary catheter. The report showed medications for antibiotics were ordered to treat urinary tract infections that included Macrobid 100 milligrams (MG) twice daily for UTI from 6/18/2023 to 6/24/2023, and Cipro 750 MG every 12 hours from 7/05/2023 to 7/14/2023. The Comprehensive Care Plan included monitoring for the use of antibiotic medications to treat UTIs. It did not include care, services, or monitoring of an indwelling urinary catheter. On 8/23/2023 at 10:56 AM, Certified Nursing Assistant (CNA) B said her duties included checking residents' catheters to make sure they were draining properly, and emptying and measuring the urine. She explained CNAs recorded their completed assignment tasks in the Point of Care program. She said the computer software told CNAs everything about the resident and what care and services were to be provided. She said she was not sure if resident #110 had a catheter. On 8/23/2023 at 12:31 PM, the Regional Nurse Consultant said all CNA tasks were located in the Point of Care medical record and recorded through the program when CNAs entered the information into the system. She explained CNA tasks were imported there from physician's orders, and that is where CNAs obtained information for the care needs of a resident. Review of the Point of Care History report did not include tasks or information for CNAs to indicate resident #110 had a urinary catheter. On 8/23/2023 at 12:34 PM, Registered Nurse (RN) A said all treatments and medication were included on the Electronic Medication Administration Record (EMAR) for nurses to see the resident's status and plan of care. She said care, services, and monitoring were documented by nurses and recorded on the EMAR. She explained that nurses entered orders when residents were admitted , and then they were updated as needed. She said she was not sure if resident #110 had a urinary catheter. She checked the resident's medical record and acknowledged there were no orders for care and services for the urinary catheter. During a joint observation on 8/23/2023 at 12:38 PM, RN A checked resident #110 while she was lying in bed. RN A acknowledged the resident had an indwelling urinary catheter in place with a collection bag hooked to the left side of the bed. She said, it should have been in the computer. On 8/24/2023 at 3:33 PM, the MDS Director said resident #110's MDS admission assessment with ARD 6/16/2023 was coded incorrectly for bladder function and did not include the resident's urinary catheter. On 8/23/2023 at 12:51 PM, the MDS Director stated she was responsible for coordinating and ensuring comprehensive care plans were up to date and information was obtained from the medical record, Interdisciplinary Team (IDT), and from her own physical assessment. She explained the facility had multiple processes in place to retrieve updated information and ensure care plans were inclusive and comprehensive. She checked resident #110's medical record and acknowledged there was not a plan of care for an indwelling urinary catheter. She said the resident's active orders did not include care and services for the catheter. She said orders were entered when residents were admitted by nurses, and they must have missed it. She stated she had not implemented the plan of care because she did not know the resident had a catheter. She could not explain why it had been missed for over 2 months through the processes the facility had in place. Review of the nursing Progress Notes dated 6/21/2023, completed by the Assistant Director of Nursing read, (Late Entry on 7/07/2023 at 08:42 PM) SOC (Standards of Care) meeting was held to discuss 6/19-24 (6/19/2023 through 6/-24/2023) Ms. (resident name) utilization of Macrobid 100 mg for her UTI .The care plan has been reviewed by the IDT and deemed appropriate at this time. On 8/24/2023 at 9:27 AM, the Director of Nursing (DON) said resident #110 had an indwelling urinary catheter in place since she was admitted to the facility on [DATE]. She stated the MDS Director was responsible for updating the comprehensive care plans. She explained the facility processes for reviewing residents' plan of care done during Standards of Care meetings and order reviews. She stated the resident had a history of UTIs, and it was important that proper care and services were provided to reduce the risk of complications. She said it should have been addressed throughout the review process and could not explain why the resident's comprehensive care plan had not included monitoring of an indwelling urinary catheter for over 2 months. The facility's Care Plans Comprehensive Person-Centered policy dated November 2020 read, The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . g. Incorporate identified problem areas; incorporate risk factors associated with identified problems; . l. Identify the professional services that are responsible for each element of care .

Based on interview and record review, the facility failed to provide timely notice of right to appeal for 1 of 4 residents reviewed for Beneficiary Notification out of a total sample of 41 residents, (#265). Findings: Resident #265 was admitted to the facility on [DATE] with diagnoses including syncope and collapse, dementia, difficulty in walking and history of falls. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 7/06/23 revealed resident #265 had a Brief Interview for Mental Status score of 09 out of 15 that indicated she had moderate cognitive impairment. The document indicated resident #265 expected to return to the community. Resident #265's medical record contained a Notice of Medicare Non-Coverage (NOMNC) which indicated coverage of skilled nursing facility services for resident #265 would end 7/07/23. The form was signed by resident #265's daughter on 7/06/23. Review of resident #265's Electronic Medical Record (EMR) revealed a social services progress noted dated 7/06/23 that read read social services issued a Notice of Medicare Non-Coverage and discharge notice. However, resident #265's daughter refused to give verbal consent over the phone and stated she would be at the facility on 7/06/23 to sign paperwork. On 8/23/23 at 12:20 PM, the Social Services Director (SSD) stated resident #265's daughter was contacted by phone on 7/05/23 to issue the NOMNC with a discharge date of [DATE]. She explained the Social Services Assistant (SSA) spoke to resident #265's daughter who refused to give verbal consent over the phone and wanted to come into the facility to sign the NOMNC. The SSD explained resident #265's daughter came to the facility at about 5:30 PM on 7/06/23 to view and sign the NOMNC. She reported the daughter filed an appeal but lost the appeal due to timely filing. The SSD verified the resident's daughter only had until noon on 7/06/23 to file the appeal but could not explain why the discharge date was not changed in order to allow the family member time to file an appeal. On 8/23/23 at 12:32 PM, the SSA confirmed she spoke to resident #265's daughter on 7/05/23. She explained she tried to review the NOMNC over the phone, but the daughter wanted to come into the facility to see the form before she signed it. The SSA stated she informed the family of their right to appeal but did not provide information regarding how to file an appeal. The SSA stated resident #265's daughter informed her she lost the appeal as she was past the deadline to file for appeal. On 8/23/23 at 3:33 PM, the Administrator recalled resident #265's daughter coming to the facility on [DATE] to sign paperwork. She stated the daughter had planned to be at the facility in the morning but did not come in until the afternoon. She reviewed resident #265's EMR and verified it did not contain any documentation regarding appeal information being provided to the daughter prior to her coming to the facility on [DATE]. The Administrator reviewed the contents of the NOMNC and acknowledged the form was provided after the deadline which did not provide the daughter the opportunity to appeal.

Based on interview, and record review, the facility failed to prevent abuse, accurately report allegation of abuse to the Agency for Health Care Administration (AHCA) and thoroughly investigate an allegation of abuse for 1 of 2 residents reviewed for abuse of a total sample of 6 residents, (#1). Findings: Review of resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, Alzheimer's disease, and dementia. Review of resident #1's admission Minimum Data Set assessment with Assessment Reference Date of 4/13/23 revealed a Brief Interview for Mental Status score of 6 out of 15 which indicated she was severely cognitively impaired. The assessment showed resident #1 required extensive assistance with Activities of Daily Living. The assessment indicated resident #1 did not reject evaluation or care needed to achieve her goals for health and well-being. Review of resident #1's medical record revealed Weekly Skin Audit was performed on 4/24/23, 5/02/23, 5/22/23 and 6/05/23. Review of the Nursing Homes Federal Reporting Five Day Report submitted to AHCA on 5/15/23 revealed an alleged abuse incident for resident #1 on 5/15/23 at 1:30 PM. The AHCA report was completed by the Administrator. The report noted resident #1 reported in Spanish that a staff member in scrubs rushed her during her meal, slapped her in the face, and punched her in her belly. The report included resident #1 was unable to describe the meal, the day it occurred or the person, and she only knew it was a female staff member. The report indicated the Interim Director of Nursing (DON) and the Administrator were notified on 5/15/23 at approximately 1:30 PM. The Investigative Findings section of the report noted resident #1 ate a type of meat and rice on the day of the incident and the facility looked at the Certified Nursing Assistants (CNAs) and nurses assigned to resident #1 on those days, 5/7/23 and 5/10/23 but they did not match the description of a light complexioned black young lady. The report included that when resident #1 was asked by the DON if she had seen the staff member in question since the incident, she responded she had not. The report showed this allegation of abuse was not substantiated and staff were provided in-service on abuse and neglect and the reporting of such. The following Witness Statements, collected during the investigation, were reviewed: CNA F - On 5/14/23 she was in resident #1's room where the resident was with her daughter and she was told a CNA, name starting with an E, had slapped her. CNA F wrote, (resident #1's name) speaks Spanish so her daughter was translating but she was also using hand gestures to demonstrate what had happened. She went into details stating that she had used the call button and a CNA came in and snatched it from her and slapped her in the face. Resident could not recall date and time of the incident and her story had been consistent. I advised her CNA (name of CNA) and acting DON (name). CNA G wrote, On 5/14 at around 4:30 PM I (his full name) spoke with (resident #1's name) in room (number) and her daughter regarding a complaint that the resident had been slapped in the face by an employee in a scrub outfit. The resident is Spanish speaking, so the daughter was translating. The resident could not recall accurately the date and time of the incident but only that it occurred at a mealtime. According to the daughter the resident stated that a lady fed her quickly and that the same woman fed her quickly and responded to call light. The woman was described as wearing scrubs, came into room hit the button to turn off the call light and slapped the resident on the face. The daughter asked the resident to recall the incident multiple times and the resident story was consistent other than recalling the date and time of incident. I concluded the conversation and reported the incident to my supervisor. On 6/21/23 at 5:05 PM, the Administrator explained she interviewed CNA H over the phone. She was the CNA assigned on 11 PM to 7 AM shift on 5/14/23. CNA H told the Administrator resident #1 was provided incontinent care during her shift and she did not notice any marks or bruises during her shift. CNA I wrote the statement and signed it on 5/19/23. She noted she was resident #1's CNA for two shifts, 7 AM to 3 PM and 3 PM to 11 PM on Saturday 5/13/23. She wrote she left resident #1 well, not blue or swollen nose. She was OK. I have no schedule on Sunday and then on Tuesday family came to visit her to ask me to see the head of unit, the family stated looks like someone hit my mother and resident said the person who hit me has lighter skin than you. On 6/21/23 at 5:05 PM, the Administrator indicated the Social Services Director (SSD) was the Abuse Coordinator, but the current SSD was new to her role. The Administrator indicated resident #1's family had visited the resident on Friday 5/12/23 and expressed no concerns during their visit. She stated as far as she remembered no family visited resident #1 on Saturday. She indicated the family came on Sunday 5/14/23. She explained they reviewed the staff assignments from Saturday and Sunday and recalled the former DON was working on this investigation. When asked for the nurses' statements who had been assigned to resident #1, she stated she had to see if she could find the folder from the the former DON for additional statements, as they were not in her investigation folder. She stated they spoke to the staff, and explained CNA I, whose name begins with an E, was resident #1's regularly assigned CNA. She is also very dark. The CNA on Saturday night 11-7 was an agency CNA. The Administrator recalled speaking to an agency CNA on the phone, but the CNA did not remember resident #1. The Administrator could not provide the witness statement for that interview. She stated some documents from the investigation were not in her folder. A copy of the visitor log from 5/12-5/15/23 was requested but not provided by the Administrator. The Administrator acknowledged residents assigned to the same nurses and CNAs as resident #1 were not interviewed as part of the investigation. On 6/21/23 at 6:21 PM, the Regional Nurse Consultant stated she was involved in the investigation. She recalled resident #1's daughter was upset on 5/15/23 and the Unit Manager for unit 2 called her and asked to speak with her. She interviewed resident #1 but could not recall what she told her. She remembered learning the incident happened on a day resident #1 was served rice and meat and talking to the kitchen to determine which days they served those items. She stated she had pictures of staff ready to show resident #1, but the resident could not recall more details. She said she did not write a statement of her interview with resident #1. She explained she learned about the incident on 5/15/23 and she performed a head-to-toe assessment that day and noted no skin tears or bruises. She could not explain why witness statements dated 5/14/23 and CNA F's statement mentioned she was informed about the abuse allegation on 5/14/23. The Regional Nurse Consultant then stated she spoke with resident #1's daughter on Monday 5/15/23 and she performed the assessment, but she would have to look at everything before she responded to any other questions. I cannot tell if I spoke directly to the resident. Review of the facility's Abuse Prevention Program policy and procedure, revised on 01/2022, read As part of the resident abuse prevention, the administration will 1. Protect our residents from abuse by anyone . 6. Identify and assess all possible incidents of abuse . 7. Thoroughly investigate and document . 8. Report all allegations of abuse within timeframes as required by federal requirements . 9. Protect residents during abuse investigations and protect resident(s) from further harm during the investigation by providing resident(s) with a safe environment . The document revealed the Administrator was responsible for the overall implementation of the policies and procedures that prohibited abuse. Review of the facility Assessment Tool dated 6/05/23 revealed the staff received education and competency on Mandatory State & Federal training including abuse, neglect, and exploitation. The document read, Training that a minimum educates staff on - (1) Activities that constitute abuse, neglect . (2) Procedures for reporting incidents, of abuse . ; and (3) Care/management for persons with dementia and resident abuse prevention.

Based on observation, interview, and record review, the facility failed to implement policies and procedures to ensure a reasonable suspicion of crime was reported for 1 of 2 residents reviewed for abuse, of a total sample of 6 residents, (#3). Findings: Review of resident #3's medical record revealed she was admitted to the facility on [DATE] with diagnoses of anemia and depression. Review of resident #3's quarterly Minimum Data Set assessment with Assessment Reference Date of 4/16/23 revealed a Brief Interview for Mental Status score of 15 which indicated intact cognition. The assessment showed resident #3 required extensive assistance with Activities of Daily Living. The assessment indicated resident #3 did not reject evaluation or care needed to achieve her goals for health and well-being. On 6/20/23 at 12:21 PM, resident #3 stated some Certified Nursing Assistants (CNAs) were really rough when providing care to her. She explained CNAs had pushed her hard on her head and pulled her arm. She explained when this happened, she reported it to the Unit Manager (UM) but she did not know what they did after that. She shared she liked to do things her way when being dressed or moved but she could not stand up by herself and CNAs did not always want her to do as much as she could. She recalled a few weeks ago, she reported this during a Resident Council meeting. She stated this issue was still ongoing with CNAs. Review of the Grievance Log for March 2023 revealed resident #3 had filed a grievance on 3/21/23. On 6/20/23 at 1:23 PM, the Unit Manager (UM) explained his responsibilities included to mediate between nurses and family members when issues arise. He stated when he learned about a resident or representative concern, he discussed it with them directly. He indicated resident #3 had not discussed concerns with him but he recalled a couple of residents who mentioned CNAs were a little rough during care. He stated he addressed the residents' concerns with their assigned CNAs directly. He noted the CNAs told him residents were too heavy and one CNA was petite and did not have the strength, which came across as rough. He recalled telling the CNA to find help from other staff when needing assistance with a resident because it was not acceptable to be rough. He indicated he had reported this to the Director of Nursing (DON). On 6/21/23 at 12:00 PM, the Social Services Director (SSD) stated she started working at the facility about 2 months ago. She explained as the grievance officer, she was responsible for handling the grievances. She indicated grievances were discussed with the interdisciplinary team. On 6/21/23 at 12:05 PM, the Administrator stated on 3/21/23, resident #3 filed a grievance because the 11 PM to 7 AM shift did not provide proper care and staff did not listen to her preferences. Review of the grievance forms showed two grievance forms dated the same day for the same issue but different wording. One form included CNAs were rough and On 3/19/23 during ADL care part of the bandage was ripped. The Administrator stated the former DON provided education to the 11 PM to 7 AM shift staff, but she could not provide evidence of the education. She recalled speaking to resident #3 to get additional details and clarify what the resident meant but did not recall the details. She stated the resident told her care had improved but the CNAs were not consistent. She stated it was not like abuse or neglect or she would have taken it a step further because they self-report. The Administrator read out loud the Physical Abuse description included in the facility's Abuse Prevention Program policy, used to educate their employees. She read, Physical Abuse: Physically harming a person through such actions as slapping, bruising, cutting, burning, physically restraining, pushing, shoving, or even rough handling. The Administrator stated this was handled as a grievance and it was not reported as abuse. Review of the Abuse Prevention Program policy and procedure, revised on 01/2022, read As part of the resident abuse prevention, the administration will 1. Protect our residents from abuse by anyone . 6. Identify and assess all possible incidents of abuse . 7. Thoroughly investigate and document . 8. Report all allegations of abuse within timeframes as required by federal requirements . 9. Protect residents during abuse investigations and protect resident(s) from further harm during the investigation by providing resident(s) with a safe environment . The document revealed the Administrator was responsible for the overall implementation of the policies and procedures that prohibited abuse. Review of the Facility Assessment Tool dated 6/05/23 revealed the staff received education and competency on Mandatory State & Federal training including abuse, neglect, and exploitation. The document read, Training that a minimum educates staff on - (1) Activities that constitute abuse, neglect . (2) Procedures for reporting incidents, of abuse . ; and (3) Care/management for persons with dementia and resident abuse prevention.

Based on observation, interview and record review, the facility failed to follow appropriate infection control precautions when moving between resident rooms to prevent cross-contamination and exposure to infectious microorganisms according to established guidelines, (room [ROOM NUMBER] and #104). Findings: On 6/20/23 at 10:30 AM, during tour of the facility, Personal Care Attendant (PCA) A entered room [ROOM NUMBER] which had a sign on the door indicating contact isolation. PCA A did not perform hand hygiene nor donned a gown and gloves. She grabbed a plastic clear bag which contained linens, towels and gowns, removed it from room [ROOM NUMBER], exited the room, and entered room [ROOM NUMBER] with the bag. On 6/20/23 at 10:46 AM, PCA A stated she was required to perform hand hygiene and don personal protective equipment (PPE) when she entered an isolation room. She stated she needed to wear the PPE only when providing care. She acknowledged she was not supposed to take items from one isolation room into any other room because that is considered cross contamination. She said, Stuff like this I can do because it is clean linens that was inside of the bag. She stated she had provided personal care to residents in room [ROOM NUMBER] and she took the bag to room [ROOM NUMBER] to provide care to both residents in that room. She indicated the resident on precautions in room [ROOM NUMBER] returned from the hospital the day before and was not on isolation before going to the hospital. She recalled the Unit Manager told her when she went into room [ROOM NUMBER] to provide care, she needed to wear PPE. When asked when she received infection prevention and control training, she stated she had not received training in this facility. On 6/20/23 at 12:09 PM, PCA B indicated she began working at the facility on June 1st, 2023. She stated she had not received training on Infection Prevention and Control. On 6/20/23 at 4:26 PM, the Infection Preventionist (IP) stated her responsibilities included prevention of infections by following the facility's Infection Prevention and Control Program policy and procedure. She explained she educated staff on any infections residents had. She stated her emphasis was on hand washing to prevent infections. She explained the type of isolation a resident had was based on the type of infection identified on the laboratory results and in consultation with the physician. The IP stated she had not had a chance to review the resident's chart from room [ROOM NUMBER] but knew the resident was readmitted the previous night with Methicillin-Resistant Staphylococcus Aureus (MRSA) and were awaiting physician's response on the course of treatment and isolation precautions. She shared the facility had a lot of new staff and they provided brief training on isolation precautions. She indicated she had not performed any audits on isolation rooms. She explained when entering a contact isolation room, she expected staff to first perform hand hygiene, don gown, gloves, and mask when providing direct care to the resident. She indicated it was not acceptable to remove a bag from an isolation room and take it to another resident's rooms as it was considered contaminated. She stated PCAs were not supposed to be assigned to residents in isolation rooms. On 6/21/23 at 1:51 PM, the Director of Nursing (DON) confirmed PCAs were not supposed to be assigned to any resident on isolation precautions. She explained staff were expected to follow infection prevention and control policy. Review of the policy and procedure titled Infection Prevention and Control Program, dated 2017, read, The primary mission is to establish and maintain and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. It included, Standard and transmission-based precautions to be follow to prevent the spread of infections. Facility Assessment reviewed 1/02/23 read, Infection Control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program. The form listed Competencies which included, Infection Control - hand hygiene, isolation, standard universal precautions included use of personal protective equipment, MRSA . precautions .

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected health conditions for 1 of 3 residents reviewed for falls out of a total sample of 5 residents, (#4). Findings: Review of resident #4's medical record revealed she was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated 6/14/22 at 4:39 PM revealed resident #4 was found on the floor in her room. The document read, When we attempted to do a skin check resident was in a lot of pain to her right hip and knee. The note indicated the resident was transferred to the hospital emergency room via ambulance. On 8/02/22 at 12:04 PM, the facility's Risk Manager (RM) confirmed resident #4 fell on [DATE]. She recalled staff found the resident on the floor, and on assessment noted she complained of pain that worsened with movement. The RM stated resident #4 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS Discharge assessment - return anticipated, with assessment reference date of 6/14/22, revealed resident #4 had an unplanned discharge to an acute hospital. Section J1800 indicated the resident had no falls since the most recent admission, entry, reentry or prior assessment. Section Z Assessment Administration revealed the Licensed Practical Nurse MDS Coordinator completed and signed Section J to .certify the accompanying information accurately reflects resident assessment information for this resident. On 8/02/22 at 5:27 PM, the Lead MDS Coordinator reviewed resident #4's MDS Discharge assessment and verified the document was inaccurate as it did not reflect the resident's fall on 6/14/22. She explained Section J1800 should read, Yes to note the resident's fall, and Section J1900 should read, B. Injury (except major) as the resident complained of pain after the fall. The Lead MDS Coordinator stated MDS staff were made aware of residents' falls in daily clinical team meeting discussions and also by reviewing nursing and event reports. She stated she was not sure how resident #4's fall with injury was overlooked. Review of the Centers for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0 Manual instructions for MDS Section J1800 read, Code 1, yes: if the resident has fallen since the last assessment. The manual directed MDS staff to utilize multiple sources including physician and nursing notes, incident reports, and fall logs, and interview staff and/or family to identify any falls that may have occurred during the look back period.

Based on observation, interview, and record review, the facility failed to implement care plan interventions to minimize the risk for fall-related injuries and promote optimal respiratory status for 1 of 3 residents reviewed for falls of a total sample of 5 residents, (#4). Findings: Review of resident #4's medical record revealed she was admitted to the facility on [DATE] and had re-admissions on 6/22/22 and 7/28/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note dated 6/14/22 at 4:39 PM, revealed resident #4 was found on the floor in her room. The document indicated the resident was transferred to the hospital by emergency medical services (EMS) after she complained of right knee and right hip pain. A nursing note dated 6/22/22 at 11:56 PM, showed the resident was readmitted to the facility with new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A note from an interdisciplinary team meeting dated 7/06/22, revealed fall prevention and safety measures were in place for resident #4 including padded side rails for her bed and floor mats. Review of a nursing note dated 7/18/22 at approximately 2:50 AM, revealed resident #4 was transported to the hospital by EMS for signs and symptoms of respiratory distress and low oxygen levels. The medical record showed she was readmitted from the hospital on 7/22/22 at approximately 6:00 PM with orders for oxygen at 3 liters per minute via nasal cannula. A few hours later, on 7/23/22 at 2:45 AM, a nursing note indicated resident #4 experienced symptoms of respiratory distress and low oxygen levels and was again transferred to the hospital. The medical record showed resident #4 was readmitted to the facility on [DATE]. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's care plan for risk for falls and related injuries due to impaired cognition, poor safety awareness and unsteady balance was initiated on 4/09/21. The care plan goal noted the resident's safety would be maintained through implemented interventions. The document directed staff to ensure side rails were in place at all times per family request and observe the resident for safe positioning when in bed or chair. An approach dated 6/28/22 directed staff to ensure resident had fall prevention interventions including a low bed, floor mats, bed alarm and a scoop mattress. A care plan for use of padded side rails on resident #4's bed, as requested by her family, was initiated on 6/24/22. The goal reflected the resident would not have any injuries. Resident #4 had a care plan for risk for respiratory distress initiated on 4/09/21. The goal noted the resident would maintain adequate gas exchange as evidenced by no respiratory or cardiac distress. Interventions directed nursing staff to keep the head of resident #4's bed elevated at 45 degrees while she was in bed. On 8/02/22 at 11:20 AM, resident #4 was in bed in a supine position. The head of her bed was flat and her lower legs were elevated above the level of her head. There was one floor mat on the right side of bed, between the bed and the wall. Folded side rail pads were noted on the bedside table approximately four feet away from the resident's bed. On 8/02/22 at 11:23 AM, the Unit 1 Licensed Practical Nurse (LPN) Unit Manager (UM) validated the head of resident #4's bed was flat, and her legs were elevated. The UM explained the resident had two, recent back-to back transfers to the hospital for respiratory distress. She acknowledged lying flat in bed was not the appropriate position for a resident who had acute and chronic respiratory issues. The UM stated she was not sure if there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM was asked to identify the folded items on the bedside table, and she confirmed they were the pads for the resident's side rails. She explained resident #4's family requested padded side rails after the resident fell . The UM said, I'm not sure if it's on the care plan. I would have to check. On 8/02/22 at 11:30 AM, the UM reviewed resident #4's medical record and noted a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/22 at 11:41 AM, LPN A confirmed she was assigned to care for resident #4 for the day shift. She stated she saw the resident twice today, during change of shift rounds and when she administered morning medications. LPN A acknowledged she did not realize the side rail pads were not in place and said, They are for protection. She was informed the resident was discovered with the head of her bed flat. LPN A said, She should be up to breathe better. On 8/02/22 at 11:46 AM, Personal Care Attendant (PCA) B stated resident #4's side rail pads were not on the bed when she arrived at the start of the shift. When asked if she knew why the pads were necessary, PCA A said, I guess it's for her not to fall off the bed. She confirmed she neither attempted to attach the side rail pads nor inform the nurse or any other staff member. On 8/02/22 at 2:34 PM, in a telephone interview, resident #4's daughter explained her mother was at risk for falls. She stated her mother fell from her bed in June 2022, which resulted in bone fractures. The daughter stated after that fall, the Director of Nursing (DON) reassured her the facility would provide all the necessary fall prevention equipment to keep her mother safe. The daughter stated when she visited the facility approximately four days ago, last Friday, she found the side rail pads on the floor in front of the chest of drawers. She said, I folded them and put them on the nightstand. I saw her on Saturday, and they were still on the nightstand. On 8/02/22 at 2:17 PM, the DON was informed resident #4 was observed with only one floor mat beside her bed and no padded side rails. The Risk Manager (RM) validated only one floor mat was in place. The DON and RM confirmed if a floor mat had to be removed for cleaning, staff should replace it with another mat as the intervention was necessary to prevent injury if resident #4 fell . The RM verified side rail pads and floor mats should have been in place as ordered and noted in the care plan. On 8/02/22 at 5:17 PM, the Social Services Director (SSD) recalled resident #4's daughter made a grievance regarding her mother's fall with fracture, and the facility's resolution was implementation of specific fall prevention interventions agreed upon by the daughter and the DON. The SSD confirmed floor mats and padded side rails were two of the items promised to the daughter. When she was informed these interventions were not in place today, the SSD described the situation as a major concern. The facility's policy and procedure Comprehensive Assessment and the Care Delivery Process revised in December 2016, revealed a person-centered care plan involved the selection and implementation of interventions that reflected overall care goals.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record according to accepted professional standards and practices for 1 of 3 residents reviewed for falls of a total sample of 5 residents, (#4). Findings: Review of resident #4's medical record revealed she was admitted to the facility on [DATE] and had re-admissions on 1/13/22, 6/22/22, and 7/28/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note dated 6/14/22 at 4:39 PM, revealed resident #4 was found on the floor in her room. The document indicated the resident was transferred to the hospital by emergency medical services (EMS) after she complained of right knee and right hip pain. On 8/02/22 at 12:04 PM, the facility's Risk Manager (RM) discussed the facility's investigative findings regarding the resident's fall on 6/14/22. The RM stated the facility's investigation showed at the time resident #4 fell in June 2022, all interventions included in the plan of care were in place. The RM provided witness statements written by staff who saw the resident before and after she was found on the floor. The statements indicated resident #4 was observed sleeping in bed with side rails in place and the bed in low position within the hour before her fall. On 8/02/22 at 1:05 PM, Licensed Practical Nurse (LPN) C stated she was assigned to resident #4 on the day she fell , and last saw her at about 3:15 PM. She recalled the resident's side rails and two floor mats were in place. She said, Those were always there. On 8/02/22 at 2:06 PM, the Unit 2 LPN Unit Manager (UM) stated on 6/14/22, staff notified her resident #4 was found on the floor. She recalled when she arrived at the room, the resident lay on the floor next to her floor mat. The UM said, I am certain the floor mat was there. She explained the side rails were still in place, there was a scoop mattress on the bed, and all care plan interventions were implemented at the time. On 8/02/22 at 2:17 PM, the Director of Nursing (DON) stated all fall prevention interventions ordered for resident #4 were in place when she fell on [DATE]. The RM and DON were informed review of resident #4's medical record revealed there was no documentation of active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They were apprised the medical record showed orders for the devices and equipment were discontinued in December 2021 and re-ordered on 7/28/22 when resident #4 was most recently readmitted to the facility. The DON and RM reiterated the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/22 at 3:25 PM, the RM provided resident #4's Order History List for the period 3/01/22 to 8/02/22. The document showed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In a column on the left side of the page, an X indicated none of these orders were signed by the physician. Review of order details with the RM revealed resident #4's medical record now included General Order forms for the following: 1) A physician's verbal order for a scoop mattress with a received and start date of 1/13/22 and an end date of 6/14/22. The order was received by the DON and also created and verified by the DON on 8/02/22 at 3:14 PM. 2) A physician's verbal order for bilateral floor mats with received and start date of 1/13/22 and an end date of 6/14/22. The order was received by the DON and also created and verified by the DON on 8/02/22 at 3:15 PM. 3) A physician's verbal order for side rails in the down position with received and start date of 1/13/22 and an end date of 6/14/22. The order was received by the Unit 2 LPN UM and also created and verified by the LPN UM on 8/02/22 at 3:17 PM. 4) A physician's verbal order for bed in lowest possible position with received and start date of 1/13/22 and an end date of 6/14/22. The order was received by the Unit 2 LPN UM and was created and verified by the DON on 8/02/22 at 3:20 PM. The RM was informed these four orders were not noted in the medical record an hour ago. She could not explain why the orders were dated 1/13/22, and created within the last 30 minutes on 8/02/22 between 3:14 PM and 3:20 PM. On 8/02/22 at 3:52 PM, the Unit 2 LPN UM stated sometime within the past hour, the RM informed her resident #4's medical record did not include a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN UM stated that was the only order she entered. She was shown an order dated 1/13/22 which identified her as the recipient, regarding keeping resident #4's bed in the lowest position The LPN UM examined the order, confirmed it was signed by the DON, and stated she had no knowledge of that order. The LPN UM verified the medical record was supposed to be accurate and reflect the resident's care at that time. She confirmed the accepted standard of practice for late documentation was to make a late entry note on the actual date documentation was entered, and not to backdate information. On 8/02/22 at 4:09 PM, the RM explained accuracy of the medical record was important as it ultimately ensured residents received the best quality care. She verified a late entry note was the appropriate way to identify and add information that had been omitted from the medical record. On 8/02/22 at 4:18 PM, the DON acknowledged the General Order forms for resident #4's fall prevention devices in place on 6/14/22 were not signed by the physician and showed she created and verified them today, 8/02/22. The DON explained resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON did not respond when asked why she opened the orders if she noted they already existed. She stated she did not alter or backdate any orders in the resident's medical record. She said, It is impossible to backdate an order in this system as it will always show the original date. The DON stated she had not instructed the Unit 2 LPN UM to enter any orders that afternoon. On 8/02/22 at approximately 4:25 PM, the Unit 2 LPN UM confirmed earlier that afternoon, the DON and the RM asked her to enter an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON contradicted the LPN UM, and stated she did not instruct her to enter any orders. The DON said, I simply asked about the order and why it had not been entered. The DON reiterated she did not enter any orders today and explained she could run a report to show that many orders were never signed by physicians. The DON was asked how residents' medical records could be deemed accurate and complete if physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said, That's just the way [name of electronic medical record] is. She confirmed the facility was aware of these issues but they had not been addressed by administration or the Quality Assurance and Performance Improvement committee. The DON stated the software's manufacturer had not been contacted regarding a solution. On 8/02/22 at 4:42 PM, the Unit 2 LPN UM provided a copy of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The RM and DON acknowledged the LPN UM was able to enter an order with start and end dates in the past. The RM and DON stated they were not aware orders could be backdated in that manner. On 8/02/22 at 4:56 PM, the Regional Nurse Consultant (RNC) was informed the Unit 2 LPN UM was able to enter a backdated order. She said, It is possible to backdate an order, but we do not let the staff know how to do it. I have [access], but I would have to look at her access. The RNC explained different levels of access or authorization within residents' electronic medical records were provided to nursing staff depending on their positions. The DON interjected and explained she did not have access to backdate orders and did not even know it could be done. She said, I just learned today that orders can be backdated. The RM stated she did not know this could be done. The RNC could not explain why the LPN UM would have system authorizations equivalent to a RNC, while the facility's nursing administration, the DON and RM, did not have the same level of access. Review of the facility's policy and procedure for Charting and Documentation revised on 3/25/21, revealed treatments and services provided to residents should be documented in the medical record. The policy read, Documentation in the medical record will be completed as necessary to accurately and objectively reflect resident's status. The document indicated security rights should be granted based on the minimum required access necessary to care for the resident.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan for smoking with appropriate interventions to minimize risks and ensure the safety of 1 of 2 residents reviewed for accidents, of 51 sampled residents, (#61). This failure contributed to resident #61 smoking inside his room and placed him and others at risk for serious injury/impairment/death. While resident #61 smoked in his room with an oxygen concentrator nearby, there was likelihood he could have suffered and/or caused burn injuries and/or death from unsafe smoking practices or oxygen combustion. On 12/06/21 at 12:35 PM, resident #61 informed a staff member he wanted to smoke. He was instructed to wait until someone was available to supervise him in the smoking area. Although the staff member was aware resident #61 habitually kept a cigar in his pocket and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Approximately 40 minutes later, a strong smell of smoke was noted in the hallway outside the resident's room. Resident #61 was inside his room, seated in a wheelchair with a lighter on his lap. He was a few feet away from his wife who had oxygen infusing, and a distinct odor of cigar smoke emanated from the partially open bathroom door. The facility's failure to develop and implement appropriate interventions for known noncompliance with safe smoking practices placed all nearby residents at risk. This failure resulted in Immediate Jeopardy starting on 12/06/21. The Immediate Jeopardy was removed on 12/08/21. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy, after verification of the facility's immediate corrective actions. Findings: Cross reference F689 Resident #61, an [AGE] year-old male, was admitted to the facility from the hospital on 7/09/21. His primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .webmd.com). Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Observation dated 7/09/21 revealed resident #61's history was obtained from the medical record. There was no documentation by the admission nurse or input from his family regarding the resident's social or medical history. The admission evaluation data for resident #61 did not include a smoking risk assessment despite his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Admission assessment with assessment reference date of 7/16/21 revealed resident #61 had a Brief Interview for Mental Status score of 8, which indicated he had moderate cognitive impairment. Section F of the MDS assessment showed resident #61 felt it was very important to participate in his favorite activities and Section J1300 Current Tobacco Use was answered affirmatively. Review of the medical record revealed a care plan for smoking was initiated on 7/09/21 with a goal that resident #61's risk for smoking-related injuries would be minimized by compliance with the smoking policy. The approaches directed staff to complete scheduled smoking assessments, inform the resident and responsible party of the smoking policy, observe for compliance, and ensure the resident smoked safely in the designated area. Resident #61's initial Smoking Risk (Acuity) evaluation was done on 10/14/21, approximately three months after he was admitted to the facility. A care plan initiated on 10/14/21 indicated the resident chose to continue smoking and was at risk for health complications and injury. The approaches remained the same as those noted on the admission care plan dated 7/09/21 and did not reflect any increased knowledge of resident #61's preferences and care needs. On 12/06/21 at 1:52 PM, after the discovery of resident #61 smoking in his room, the Unit 1 Unit Manger (UM) explained she was aware of past issues related to resident #61's access to smoking materials. She said, Previously, when he was first admitted , the family would leave matches and lighter with him after they visited. She stated the family was reminded not to provide the resident with smoking materials. On 12/07/21 at 11:13 AM, the UM confirmed there was an incident when a staff member gave her matches which had been retrieved from resident #61. She recalled educating the resident's daughter about not providing matches and also informed his granddaughter, the previous Director of Nursing (DON). She explained the previous DON permitted her grandfather to keep his cigars. The UM stated she could not explain why resident #61's care plan had never been updated to include interventions to keep the resident safe, such as checking his room for smoking materials. She did not recall writing a progress note or an incident report, nor participating in Interdisciplinary Team (IDT) discussion about the resident's access to matches. On 12/07/21 at 11:57 AM, the MDS Coordinator reviewed the process for development of a smoking care plan. She explained a nurse or Unit Manager would complete a smoking evaluation for every newly admitted resident. The admission data would be discussed the following day by the IDT in the scheduled daily clinical meeting. The MDS Coordinator stated she would create a smoking care plan during that meeting. She stated the IDT would determine the level of supervision the resident needed and communicate information to the assigned members of the nursing team via the care plan. The MDS Coordinator stated she did not know resident #61 smoked until she conducted his care conference in October 2021. She could not explain why resident #61 had a care plan for smoking created on admission if there was no smoking evaluation done at that time. The MDS Coordinator stated resident #61's granddaughter, the previous DON, was present at the care conference meeting and there was no mention of safety issues or noncompliance with the smoking policy. On 12/07/21 at 12:17 PM, the Lead MDS Coordinator explained resident #61 had a care plan for smoking created on admission because he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated nurses could not revise or update care plans, but if they wrote a progress note, created an incident report, or provided information verbally, MDS staff would make revisions to address identified concerns. The Lead MDS Coordinator confirmed a care plan was important to provide the correct, appropriate interventions for each resident. When informed resident #61 had cigars in his room, she said, If I knew before, I would have put in an intervention to check his room. The job description for Resident Assessment/Care Plan Coordinator (undated) revealed functions included coordinating the development of a written plan of care that involved input from residents and/or their family members, and ensuring all assigned staff were aware of the care plan and checked it prior to administering daily care. Review of the policy and procedure Care Plans, Comprehensive Person-Centered revised in November 2020, revealed the IDT would develop and implement a person-centered care plan in conjunction with the resident and family. The care plan should include personal preferences, necessary services to maintain the resident's highest practicable well-being, and identify problem areas with associated risk factors. The policy read, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. On 12/08/21 at 11:02 AM, in a telephone interview, resident #61's daughter M, stated prior to admission to the facility, her father lived at home and his regular daily routine included smoking after every meal. On 12/08/21 at 11:15 AM, in a telephone interview, resident #61's daughter N stated to her knowledge, her father smoked almost every day. She confirmed her father kept his cigars in the drawer of his bedside table. Daughter N did not recall any conversation or education from the facility regarding her father not being allowed to keep cigars in his room. She stated her father might have taken a lighter from her purse, which she left open on his bed during her last visit. Review of resident #61's medical record revealed no progress notes by nursing, social services, activities or administrative staff that addressed the confirmed violations of the smoking policy, education provided for family members and the resident, nor interventions to prevent continued noncompliance and promote safe smoking. The medical record did not include documentation of interviews with the family regarding the resident's preferred smoking schedule nor collaboration with family to develop interventions that ensured he smoked safely. On 12/09/21 at 2:21, the Director of Nursing (DON) acknowledged there was no documentation regarding resident #61's noncompliance with the facility's smoking policy related to keeping smoking materials in his room. She stated staff should have created progress notes if smoking materials were observed in the room and also when they were confiscated. The DON stated resident #61's care plan should reflect behaviors and communicate appropriate approaches and intervention. She stated his smoking safety concerns had not been brought to the IDT before he smoked in his room. Review of the facility's Assessment Tool updated on 11/02/21, indicated facility staff would provide person-centered care such as getting to know residents, identifying preferences and routines, and ensuring assigned staff had this information. The Assessment Tool revealed the facility would identify hazards and risks that were unique to each resident. Review of immediate measures implemented by the facility revealed the following, which were verified by the survey team: * On 12/06/21 at 1:15 PM, facility staff responded to a report of resident #61 smoking in his room. The smoking paraphernalia was removed, and the resident's room searched for additional smoking materials. The smoking policy was reiterated to the resident and his representative/family. *On 12/06/21, resident #61 was re-assessed and his smoking risk score increased from 1 to 8. The facility revoked his smoking privileges for noncompliance with the smoking policy. *On 12/07/21, the Assistant Director of Nursing (ADON) initiated an in-service for licensed nurses on the accurate completion of assessments. There were 25 of 34 licensed nurses (73%) who had received the education as of 12/08/21. The ADON and Staff Coordinator will ensure any licensed nurse who has not received the education will not be permitted to work until the education is completed. Review of in-service attendance sheets and reconciliation with staff roster validated education was completed. *On 12/08/21, the facility held a Quality Assurance meeting, attended by the Medical Director, Administrator, DON, ADON/Risk Manager and nine additional committee members. Performance Improvement Plans were developed by the committee and approved by the Medical Director. The MDS Coordinator will conduct daily audits from a random list of residents to monitor the facilities compliance with the accuracy and completion of assessments. * On 12/08/21, Social Services assisted with resident #61's discharge placement to another facility at the request of his family. *On 12/08/21, a facility-wide baseline smoking questionnaire was completed on all residents to ensure all smokers were identified. One additional resident was identified as a smoker. The resident was re-assessed for smoking risk, provided with another copy of the facility's smoking policy, and the care plan was updated. *On 12/09/21, interviews conducted with 2 Licensed Practical Nurses, and 3 RNs revealed they were knowledgeable of the smoking risk assessments and required documentation standards. *The sample was expanded to include the only additional smoker, resident #262. Interview and record review revealed no concerns related to accuracy of the resident's smoking risk evaluation and appropriateness of care plan interventions.

Based on observation, interview and record review, the facility failed to conduct an admission smoking risk evaluation; failed to maintain smoking materials in a secure location to ensure a safe environment; and failed to provide appropriate supervision for 1 of 2 residents reviewed for accidents, of a total sample of 51 residents, (#61). These failures contributed to resident #61 smoking inside his room and placed him and others at risk for serious injury/impairment/death. While resident #61 smoked in his room with an oxygen concentrator nearby, there was likelihood he could have suffered and/or caused burn injuries and/or death from unsafe smoking practices or oxygen combustion. On 12/06/21 at 12:35 PM, resident #61 informed a staff member he wanted to smoke. He was instructed to wait until someone was available to supervise him in the smoking area. Although the staff member was aware resident #61 habitually kept a cigar in his pocket and had a history of inappropriate access to smoking materials including matches and lighters, she left the resident to wait unattended. Approximately 40 minutes later, a strong smell of smoke was noted in the hallway outside the resident's room. Resident #61 was inside his room, seated in a wheelchair with a lighter on his lap. He was a few feet away from his wife who had oxygen infusing, and a distinct odor of cigar smoke emanated from the partially open bathroom door. The facility's failure to evaluate smoking risk on admission and ensure a physically and cognitively impaired resident did not have access to smoking materials placed all nearby residents at risk. This failure resulted in Immediate Jeopardy starting on 12/06/21. The Immediate Jeopardy was removed on 12/08/21. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy, after verification of the facility's immediate actions. Findings: Cross reference F656 Resident #61, an [AGE] year-old male, was admitted to the facility from the hospital on 7/09/21. His primary diagnosis was metabolic [CONDITION(S)], which is brain damage or disease that can lead to an altered mental state and confusion (retrieved on 12/21/21 from WebMD at www.webmd.com). Additional diagnoses included [MEDICATION(S)] dependence, dementia, [CONDITION(S)], and Chronic Obstructive Pulmonary Disease. The Admission Observation dated 7/09/21 revealed resident #61's history was obtained from the medical record. There was no documentation by the admission nurse of input from his family regarding the resident's social or medical history. The admission evaluation data for resident #61 did not include a smoking risk assessment despite his diagnosis of [MEDICATION(S)] dependence. Review of resident #61's medical record revealed a Resident Face Sheet with demographic information that read, Smoking Status: Current every day smoker. The Minimum Data Set Admission assessment with assessment reference date (ARD) of 7/16/21 revealed resident #61 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated he had moderate cognitive impairment. The MDS assessment showed the resident had highly impaired hearing, unclear speech, difficulty communicating some words and he missed some part or intent of messages. Section F indicated resident #61 felt it was very important to participate in his favorite activities. He required extensive assistance for bed mobility, transfers and locomotion around his room and in the hallway. The resident did not walk and used a wheelchair for mobility. The MDS assessment Section J1300 Current Tobacco Use was answered affirmatively. Review of the medical record revealed a care plan for smoking was initiated on 7/09/21 with a goal that resident #61's risk for smoking-related injuries would be minimized by compliance with the smoking policy. The approaches directed staff to complete scheduled smoking assessments, inform the resident and responsible party of the smoking policy, observe for compliance, and ensure the resident smoked safely in the designated area. Resident #61's initial Smoking Risk (Acuity) evaluation was done on 10/14/21, approximately three months after he was admitted to the facility. The evaluation revealed resident #61 smoked cigars less than daily, did not beg, steal, or borrow smoking materials from others, nor smoke in unauthorized areas. The document indicated the resident had a minimal problem related to Careless with Smoking Materials - Drops cigarette/cigar butts or matches on the floor, furniture, self, or others; [CONDITION(S)] finger tips; smokes near oxygen. Despite resident #61's diagnoses of [CONDITION(S)] and dementia, and BIMS score of 8, the evaluation showed he had no problem understanding the facility's smoking policy and was capable of following the requirements. The section of the document for mobility indicated resident #1 had no problems although he required extensive assistance for mobility, transfers, and locomotion. The evaluation resulted in a smoking risk score of 1 on a scale which showed scores of 0 to 9 denoted a safe smoker. On 12/06/21 at 12:35 PM, resident #61 propelled himself in his wheelchair from his room towards the Unit 1 nurses' station. He got the attention of the Unit 1 Unit Manager (UM) and was able to communicate that he wanted to be taken outside to smoke. Resident #61 requested assistance by using hand motions in combination with Spanish words. The UM informed the resident there were no staff members available to accompany him to the smoking area at that time and instructed him to wait near the nurses' station. The UM explained resident #61 was the only Unit 1 resident who smoked, and she would ask a Certified Nursing Assistant (CNA) who smoked to take him outside after lunch. The UM stated the resident was not an independent smoker but was permitted to smoke with supervision. She explained resident #61 always carried a cigar in the pocket of his shirt and pointed to the resident's chest. When asked if the resident was allowed to keep his smoking materials, the UM stated he kept his cigars but did not have access to a lighter. She stated there had been issues in the past related to resident #61's family members leaving smoking materials with him. On 12/06/21 at 1:14 PM, a strong smell of smoke was noted outside resident #61's room. On entering the room, State Survey Agency staff observed the resident seated in his wheelchair with a pink lighter on his lap, partially hidden by a surgical mask. He was approximately six to eight feet away from an oxygen concentrator that provided oxygen for his wife who was in bed. The UM was alerted, entered the room and frantically began searching for a possible smoldering cigar as the source of the smell. She opened the bathroom door, and the distinct odor of cigar smoke escaped into the room. While the UM searched the room, the Assistant Director of Nursing (ADON) removed resident #61 from the room and asked him to hand over the lighter. The resident had a tightly clenched fist and initially denied having a lighter. He then defiantly refused to give the lighter to the ADON and repeated, It's mine! It's mine! several times in Spanish. Resident #61 agreed to relinquish the lighter only after the ADON emphasized how dangerous it was to smoke near oxygen, and that he could have caused great harm to his wife. Inside the room, the Unit Manager removed ten cigars from the resident's bedside table drawer, one of which was partially smoked and had a black burnt end. Photographic evidence was obtained. Review of the Smoking Policy and Procedure revised in March 2020 revealed the facility's goal to maintain . a healthy and safe environment for its residents, staff and visitors while respecting individual choice. The procedure provided instructions for administration and all nursing personnel regarding completion of smoking assessments to determine safe smoking status, the need to escort and supervise any resident who wanted to smoke, and the designation of a lock box to store smoking materials. The policy read, All residents must forfeit all smoking materials, including, but not limited to cigarettes, cigars, lighters, matches . Smoking paraphernalia stored in residents' rooms is strictly prohibited. The procedure revealed smoking materials provided by family were to be delivered to staff, and the facility retained the right to conduct regular room inspections for potential fire hazards. The policy indicated violations could result in discharge from the facility, notification to appropriate governing agencies, and loss of attending physician services. On 12/06/21 at 1:52 PM, the UM stated resident #61's smoking evaluation form indicated he was a safe smoker but even if deemed safe, the facility's policy was all residents should be supervised when smoking. The UM explained resident #61 was the grandfather of the facility's previous Director of Nursing (DON) and he also had two daughters who visited on the weekends. When asked about issues related to resident #61's access to smoking materials, the UM said, Previously, when he was first admitted , the family would leave matches and lighter with him after they visited. She stated the family was reminded not to provide the resident with smoking materials. The UM validated the potential for fire and burn injuries to occur from smoking near oxygen. She stated resident #61's wife shared his room, and she was one of the four residents on Unit 1 who used oxygen. The UM confirmed the resident was not assisted outside to smoke at lunchtime when he asked, as the staff member who was to supervise him was on lunch break. The UM said, I can't believe he lights up a cigar on the day the surveyors are in the building. On 12/07/21 at 10:18 AM, the Activities Director stated the facility's smoking schedule was dependent on the number of smokers in the building and the frequency they desired. She confirmed resident #61's family usually visited on one to two days every weekend. The Activities Director acknowledged she had seen resident with a cigar in his shirt pocket as he headed towards the smoking area. On 12/07/21 at 10:33 AM, CNA G stated she confiscated resident #61's smoking materials on two or three occasions and gave them to the weekend supervisor and the UM. CNA G said, The [resident's] family are very difficult, and they keep bringing in cigars. I saw cigars and lighter about three months ago. I took a full packet of cigars and a lighter to the Unit Manger. She explained despite education, the resident's family continued to leave smoking materials with him. CNA G was aware resident #61 carried a cigar in the pocket of his shirt. On 12/07/21 at 10:49 AM, CNA H stated she had occasionally been assigned to care for resident #61 but was never informed he smoked. On 12/07/21 at 11:03 AM, CNA I confirmed she was regularly assigned to care for resident #61 during the past couple months but never knew he smoked. She stated neither his assigned nurse nor the off going CNA informed her during shift change report that the resident lit a cigar in his room the previous day. CNA I stated she did not know where the facility secured residents' smoking materials. On 12/07/21 at 11:13 AM, the UM confirmed there was an incident when a staff member gave her matches retrieved from resident #61. She recalled educating the resident's daughter about not providing matches and also informed his granddaughter, the previous DON. When asked why she allowed the resident to keep cigars in his room and on his person, the UM stated she was previously under the impression that matches and lighters were the only items prohibited in rooms. She explained the previous DON was her supervisor, so she never challenged the decision to allow resident #61 to keep cigars. The UM said, Since yesterday I was educated that cigars are also categorized as smoking materials. The UM confirmed she conducted a smoking risk assessment after resident #61 smoked in his room. During review of the Smoking Risk (Acuity) form dated 12/06/21 at 2:56 PM, the UM verified she obtained a score of 8 that still deemed him to be a safe smoker. The UM stated the result did not make sense to her as the resident's actions on the previous day did not support that conclusion. A detailed review of the UM's responses on the form revealed she did not select risk factors such as the resident carried a lighter, stole smoking materials from others, did not understood the smoking policy and had mobility issues. Review of resident #61's medical record revealed no progress notes by nursing, social services, activities or administrative staff that addressed the confirmed violations of the smoking policy, education provided for family members and the resident, nor interventions to prevent continued noncompliance and promote safe smoking. On 12/07/21 at 1:58 PM, the Social Services Director stated she reviewed the department's records and grievance log but did not encounter any grievances filed or education provided regarding the failure of resident #61 and his family members to adhere to the requirements of the smoking policy. On 12/08/21 the resident's two daughters were interviewed by telephone. At 11:02 AM, the first daughter explained her father had dementia and behavioral problems. She stated prior to admission to the facility, her father lived at home and his regular daily routine included smoking after every meal. She acknowledged her father's access to cigars and lighters could have resulted in a serious incident. At 11:15 AM, the second daughter stated to her knowledge, her father smoked almost every day. She stated she visited her parents on the weekends and her last visit was the previous Saturday. She confirmed her father kept his cigars in the drawer of his bedside table. She did not recall any conversation or education from the facility regarding her father not being allowed to keep cigars in his room. She denied providing her father with a lighter but stated he might easily have taken one from her purse, which she left open on his bed during her last visit. On 12/08/21 at 2:29 PM, Registered Nurse (RN) J stated resident #61's family situation posed challenges for staff such as demands that nothing in his room be touched. RN J described constant tension surrounding issues with resident #61 because the previous DON was his granddaughter. RN J stated the resident openly carried a cigar in his pocket or held it between his fingers and said, The family used to dare staff to do anything if they complained. He acknowledged resident #61 smoking in his room near the wife's oxygen concentrator was very dangerous and could be like a bomb. On 12/08/21 at 3:55 PM, the ADON stated on the day of admission, the facility was not aware resident #61 smoked. She explained staff were surprised on the following day when the previous DON stated she was going to take her grandfather outside to smoke. The ADON said, This was a complicated situation because of the resident's relationship with the previous DON. The ADON confirmed all smoking materials should be secured in a lock box, retrieved at residents' request and used under staff or family supervision. She stated she provided verbal education to staff on how to monitor smokers but had no written documentation of this training. The ADON explained all CNAs, especially those assigned to care for smokers should be aware of the need to escort and supervise them when requested. She validated on the day resident #61 smoked in his room he should not have been asked to wait. Instead, any available staff including CNAs, managers or housekeeping staff could have taken him to the designated smoking area on the patio. On 12/08/21 at 6:11 PM, CNA O stated she was not aware resident #61 smoked although she was occasionally assigned to care for him. She stated she relied on nurses to provide that information. On 12/09/21 at 12:42 PM, the facility's Medical Director stated she was informed that resident #61 lit a cigar in his room with oxygen nearby. She validated the dangers of smoking near oxygen and stated her expectation was staff would follow the facility's safe smoking policy. On 12/09/21 at 2:21 PM, the Administrator and DON discussed the facility's investigation related to resident #61 smoking in his room. The DON stated the resident explained daughter M provided him with cigars and a lighter. The DON confirmed a CNA confiscated smoking materials from resident #61 in the past, but there was no documentation of the incident. She stated her investigation showed staff were uncomfortable challenging the previous DON. However, she acknowledged nobody had brought the smoking safety issue and policy violations to her attention in the month since the previous DON left. She stated her expectation was staff should have notified her or any member of administration about prohibited items in resident #61's room, and progress notes should have been created to reflect any noncompliance or incidents. The DON stated all staff received mandatory education and additional in-services on smoking safety. However, she acknowledged they failed to implement the policy did not demonstrate understanding and competency. The DON confirmed the facility did not complete a smoking risk evaluation for resident #61 on admission and he therefore smoked for three months before being assessed for safety. Review of the job description for Nurse Supervisor/Unit Manager (undated), revealed a primary purpose of assisting with supervision of the day-to-day activities of the facility. Responsibilities included reviewing nurses' notes to ensure they were informative, accurate and descriptive; implementing procedures for reporting hazardous conditions; and ensuring all staff involved in providing care were aware of residents' care plans. Review of the job description for Registered Nurse/Floor Nurse (undated), revealed responsibilities included completing and submitting incident reports as necessary; conducting thorough admission assessments; promptly responding to requests for assistance; and ensuring CNAs were aware of and implemented residents' care plans. Review of the job description for Nursing Home Administrator (undated) revealed duties and responsibilities included ensuring facility staff, residents and visitors followed safety regulations including those related to smoking. Review of the facility's Assessment Tool updated on 11/02/21, revealed the facility was able to care for residents with common conditions including dementia and behaviors that required interventions. The document indicated staff would provide person-centered care such as getting to know residents, identifying preferences and routines, and ensuring assigned staff had this information. The Assessment Tool revealed the facility would identify hazards and risks that were unique to each resident. Review of immediate measures implemented by the facility revealed the following, which were verified by the survey team: * On 12/06/21 at 1:15 PM, facility staff responded to a report of resident #61 smoking in his room. The smoking paraphernalia was removed, and the resident's room searched for additional smoking materials. The smoking policy was reiterated to the resident and his representative/family. *On 12/06/21, resident #61 was re-assessed and his smoking risk score increased from 1 to 8. The facility revoked his smoking privileges for noncompliance with the smoking policy. *On 12/07/21, the facility initiated in-services to cover the following information: Facility's smoking policy; Requirement to respond to a resident's request to smoke timely; Notification of management of any problems or change in condition that would affect the Resident's ability to smoke safely; Non-compliance with the smoking policy. A total of 136 Employees will be educated; A total of 68 % were educated as of 12/08/21. The ADON and Staff Coordinator will ensure any employee who has not received education will not be permitted to work until the education is completed. Review of in-service attendance sheets and reconciliation with staff roster validated education was completed using the facility's smoking policy. The policy was made available in English and Spanish to promote optimal comprehension. *On 12/08/21, the facility held a Quality Assurance meeting, attended by the Medical Director, Administrator, DON, ADON/Risk Manager and nine additional committee members. Performance Improvement Plans were developed by the committee and approved by the Medical Director. Topics include: All residents will be assessed on admission to identify if they smoke; Residents identified to be smokers will be provided a copy of the Facility's Smoking Policy; The Unit Managers will conduct audits weekly to ensure smoking assessments are complete and accurate. Findings will be submitted to the DON; Residents known to smoke will be re-assessed monthly and as necessary; Residents who smoke will have room searches for smoking paraphernalia Q shift, with Resident/Representative permission, as specified in the Facility Smoking policy; Room audit documentation will be collected by the DON daily for review and tracking of resident compliance with the smoking policy. * On 12/08/21, Social Services assisted with resident #61's discharge placement to another facility at the request of his family. *On 12/08/21, a facility-wide baseline smoking questionnaire was completed on all residents to ensure all smokers were identified. One additional resident was identified as a smoker. The resident was re-assessed for smoking risk and provided with another copy of the facility's smoking policy. *On 12/09/21, interviews conducted with 21 facility staff including 12 CNAs, 2 Licensed Practical Nurses, 3 RNs, 2 Patient Care Attendants, 1 Physical Therapist and 1 housekeeper revealed they were knowledgeable of the smoking policy and procedure, including the need to respond to residents' requests in a timely manner and report any unsecured smoking materials. *The sample was expanded to include the only additional smoker, resident #262. Interview and record review revealed no concerns related to accuracy of the resident's smoking risk evaluation and appropriateness of care plan interventions.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate related to administration of anticoagulant medication (#26, #29, #74 N), discharge location (#112), and hospice services (#41), for 6 of 51 sampled residents. Findings: 1. Resident #78's Quarterly MDS assessment with assessment reference date (ARD) of 11/04/21 indicated the resident received an anticoagulant or blood thinner medication on six days during the seven day lookback period. Review of resident #78's medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This drug is classified as a platelet aggregation inhibitor, not an anticoagulant, since it prevents platelet adhesion that causes blood clots (retrieved on 12/20/21 from Drugs.com at www.drugs.com). Review of the Centers for Medicare & Medicaid Services MDS Resident Assessment Instrument (RAI) Version 3.0 Manual v.1.17. October 2019 revealed instructions for MDS staff related to recording anticoagulant use in Section N041E of the MDS assessment. The document read, Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION(S)], or [MEDICATION(S)] here. On 12/08/21 at 5:43 PM, the Lead MDS Coordinator reviewed Section N of resident #78's MDS assessment and confirmed it reflected anticoagulant administration on six days. She explained resident #78 received [MEDICATION(S)] which was an anticoagulant. When the Lead MDS Coordinator was prompted to read the instructions in the MDS RAI Manual, she discovered [MEDICATION(S)] or [MEDICATION(S)] was not classified as an anticoagulant. 2. Resident #29's 5-day Medicare MDS assessment with ARD of 9/19/21 revealed the resident received anticoagulant medication on 7 days in the lookback period. Review of the resident's medical record showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #74's Quarterly MDS assessment with ARD of 10/30/21 revealed the resident received anticoagulant medication on 6 days in the lookback period. Review of the resident's medical record showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident #26's Quarterly MDS assessment with ARD of 9/18/21 revealed the resident received anticoagulant medication on 7 days in the lookback period. Review of the resident's medical record showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/09/21 at 11:43 AM, the MDS Coordinator confirmed she completed section N of the MDS assessments for residents #26, #29, #74 and #78. She explained she reviewed the residents' physician orders, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator stated she was not aware [MEDICATION(S)] was not an anticoagulant. She acknowledged the drug should not have been recorded in Section N of the MDS assessments. 5. Resident #112's Discharge - return not anticipated MDS assessment with ARD of 11/14/21 revealed the resident had an unplanned discharge to the community. The Lead MDS Coordinator completed Section A which included the discharge information. Review of resident #112's medical record revealed a nursing progress note dated 11/14/21 at 3:14 PM that read, Resident was transport to [the hospital] via 911. On 12/09/21 at 4:47 PM, the Lead MDS Coordinator confirmed resident #112's MDS assessment reflected a discharge to the community rather than the hospital. She said, It is an error. The policy and procedure Certifying Accuracy of the Resident Assessment revised in December 2009, revealed all staff who complete any portion of the MDS assessment must sign to certify the accuracy of that portion of the assessment. 6. Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly MDS assessment with assessment reference date of 9/29/21 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 06/15. Section J1400 question Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was answered yes. On 12/06/21 at 2:20 PM, resident #41 stated he did not receive hospice services. On 12/08/21 at 9:31 AM, Registered Nurse (RN) E stated resident #41 did not have a life expectancy of less than six months and did not receive hospice services. On 12/08/21 at 9:44 AM, Wing 2 Unit Manager (UM) said resident #41 was assessed by hospice, however, the resident was being evaluated for a procedure. The UM noted if the resident was on hospice he could not have the procedure done, so the resident's wife declined hospice services. The UM stated resident #41 was never on hospice caseload. On 12/08/21 at 10:59 AM, the Lead MDS Coordinator stated MDS assessment was completed by doing a seven day look back of the resident's clinical records, hospital documents, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator explained that approximately four to five months ago, hospice services were requested, but was declined by the resident's wife. The resident's quarterly MDS Section J1400 was reviewed with the MDS Coordinator. She acknowledged the assessment was not accurate, and the question should have been answered no. Review of the Centers for Medicare & Medicaid Services' (CMS) Long-Term Care Facility RAI User's Manual, v.1.17 (October 2019) revealed instructions for completion of Section J regarding life expectancy. The Steps for Assessment included reviewing the medical record for documentation by the physician that the resident's condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness. Reviewing the medical record to determine whether the resident is receiving hospice services. The Manual instructed to Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.

Based on observation and interview, the facility failed to properly secure 2 of 2 medication carts on 1 of 2 units, (Unit 1). Findings: 1. On 12/06/21 at 10:00 AM, a medication cart was parked on Unit 1, 300 hallway with the lock in the open position. The nurse for the cart was not seen anywhere in the hall or near the cart. The drawers were tested and access was available to the medications inside the cart. Several residents were observed nearby, wandering in the hallway and seated in wheelchairs a few rooms away. A few minutes later RN B came out of a resident room and acknowledged her medication cart was unlocked. The Unit 1 manager approached and stated the medication carts should be locked, but that she borrowed RN B's medication cart keys. The Unit 1 manager acknowledged the medication carts could still be locked by RN B without having the key. She stated nurses are expected to lock the medication carts when they are not in immediate use by the nurse. On 12/06/21 at 12:14 PM, with translation provided by Advance Practice Registered Nurse D, RN B stated she knew she was supposed to lock the medication cart. She stated it should be locked to prevent any confused residents who could be wandering around or others from accessing the medication cart. On 12/06/21 at 4:53 PM, a medication cart parked halfway down the 100 hall on Unit 1 was observed with the lock [NAME] out indicating it was unlocked. No nurse was seen in the hallway or anywhere nearby. The drawers were tested and able to be pulled open revealing medications inside them. Confused residents were wandering nearby and sitting near the Unit 1 nurses station. On 12/06/21 at 4:55PM, RN A stated she was the evening supervisor. She confirmed the medication cart was left unlocked by LPN C who had gone to the other unit. She stated LPN C should have locked the cart and could not explain why it was unattended. On 12/06/21 at 4:58 PM, LPN C came back to Unit 1 and was unable to say why she left her medication cart unlocked. She said the medication cart, needed to be locked because there were confused patients and they could get into it. On 12/09/21 at 5:56 PM, The Staff Development Coordinator (SDC) stated both RN B and LPN C received training during initial orientation that included securing the medication carts. She confirmed the competencies completed by the nurses did not include education on locking the medication cart. The SDC stated that locking the medication carts would be a standard of practice for nurses to prevent accidents. She explained at least 75 percent of the Unit 1 residents were confused, wandered in the hallway and touched everything including the medication carts. She stated locking the medication carts could prevent accidents, and it would definitely prevent anyone from having access to the medications inside. 2. On 12/06/21 at 11:32 AM, the 100 hallway medication cart was against the wall between rooms [ROOM NUMBERS]. Residents walked aimlessly along the hallway past the medication cart and occasionally paused to touch the rails and activity stations on the walls nearby. A female resident approached the medication cart, then stopped to place trash in the bin on the side of the cart. The lock projected from the medication cart to indicate the drawers were unlocked, and when drawer handles were pulled, they opened without difficulty. The medication cart was unattended and there was no nurse in the hallway. On 12/06/21 at 11:36 AM, Registered Nurse (RN) J exited a resident's room and walked towards the medication cart. He was shown the open drawers and informed the cart had been found unlocked. RN J acknowledged he was assigned to the 100 hallway medication cart and stated he had walked away and left it unlocked. RN J looked around the 100 hallway and confirmed all the residents in the vicinity of his medication cart were wandering, confused and had dementia. He confirmed the contents of the unlocked medication cart were accessible to confused residents and anyone else who passed by. On 12/06/21 at 11:38 AM, the Unit 1 Unit Manager (UM) was informed the 100 hallway medication cart had been left unlocked and unattended by the nurse. She acknowledged a significant number of residents on Unit 1 had dementia and/or cognitive impairment including the resident who accessed the medication cart's trash bin. The UM explained confused residents continuously wandered along the length of the 100 hallway and walked past the medication cart. She said, They wander in and out of rooms, along the hallways, touching lots of things. The UM confirmed medication carts should be locked to prevent unauthorized access, and acknowledged it was standard nursing practice. She explained this incident was the second for the day as the 300 hallway medication cart, assigned to another nurse, was found unlocked and unattended earlier that morning. On 12/08/21 at 2:38 PM, RN J explained he frequently had to re-direct residents as they often touched containers of pudding and the jug of water kept on top of the medication cart. He acknowledged an unlocked medication cart posed a danger to these confused residents for this reason. The policy and procedure Storage of Medications revised in April 2019, revealed the facility would store all drugs in a safe and secure manner. The document indicated drugs would be stored in locked compartments, and nursing staff were responsible for maintaining safety in medication storage and preparation areas. The policy and procedure revealed compartments including drawers containing drugs would be locked when not in use and Unlocked medication carts are not left unattended.

Based on observation, record review and interview the failed to provide and promote dignity during meals for 1 of 51 sampled residents, (#17). Finding: Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 0. The assessment also noted the resident required extensive assistance from staff for eating. On 12/7/21 at 12:34 PM, resident #17 was in bed. The resident was not able to answer any questions and did not respond to his name. The resident's roommate was seated in a wheelchair near the foot of the resident #17's bed and was eating his lunch on an over bed table in sight of resident #17. Resident #17 did not have his meal at this time and staff were in the hallway passing out meal trays to other residents. On 12/9/21 at 12:30 PM, resident #17 was observed in bed and did not have his meal tray. His roommate was eating his lunch near the foot of resident #17's bed. The roommate had eaten half of his meal and was in sight of resident #17. Registered Nurse (RN) L was asked why resident #17 and his roommate were not served meals together. She stated resident #17 can't feed himself and referred to resident #17 as a feeder. Approximately 1-2 minutes later, the Wing 1 Unit Manager stated resident #17 required staff assistance with meals and explained the staff had been educated on meal service in regard to resident dignity. She stated there was no excuse for resident #17 not to have had his meal while his roommate ate in front of him.

Based on observation, interview, and record review, the facility failed to provide wound dressing per physician's order for 1 of 4 residents reviewed for non-pressure related skin condition of a total sample of 51 residents, (#30). Findings: Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order dated 12/07/21 for [MEDICATION(S)] read, Cleanse right distal lateral foot with normal saline, apply thin layer to wound bed, apply skin prep to peri wound area and cover with dry dressing and gauze wrap two times daily (BID). On 12/09/21 at 11:30 AM, resident #30 was in bed positioned to her right side. A dressing to her right foot was dated 12/07/21. On 12/09/21 at 11:36 AM, Licensed Practical Nurse (LPN) C stated all the resident's dressings were to be done daily. Observation of the dressing to resident #30's right foot was conducted with LPN C. The LPN acknowledged the dressing was dated two days ago, 12/07/21. A review of the resident's physician's orders conducted with LPN C revealed orders for dressing to the resident's right foot was to be completed twice daily. LPN C stated the expectation was that staff followed the physician's orders. On 12/09/21 at 11:42 AM, an observation of the resident's dressing was conducted with Wing 2 Unit Manager (UM). She confirmed the dressing was dated 12/07/21, and after review of the resident's physician's order, she verified the dressing was ordered BID. The UM verbalized that staff should follow physician orders, and the resident's dressing should have been changed twice daily. On 12/09/21 at 12:44 PM, resident #30's physician's order was reviewed with the Director of Nursing (DON). She verified dressing for the resident's right foot was BID, and stated the expectation was that nurses should follow the physician orders for treatment. The policy Wound Care Revised October 2010 read, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order for this procedure.