Every finding on record at The Ambassador Sidney Inc

Based on facility document review, clinical record review, staff interview, and policy review the facility failed to provide residents and families with 48 hour notification of financial responsibility when Medicare Part A services were scheduled to be discontinued for 1of 3 residents reviewed (Resident #53). The facility reported a census of 43 residents.Past non-compliance achieved through the following:On 3/11/26 at 11:50 AM the Administrator stated the facility had identified a concern regarding Advanced Beneficiary Notice (ABN) in 1/26 and as part of their Quality Assurance had developed a Performance Improvement Plan (PIP). The Social Services Director stated she typically received a notice from therapy regarding planned discharge 72 hours to a week in advance. The Administrator stated the facility also has weekly Medicare Meetings and as part of the morning Stand Up meeting of the Leadership Team they go over the therapy caseload and planned/potential discharges. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #53 had a Brief Interview for Mental Status (BIMS) score of 8/15 indicating moderate cognitive impairment. The document revealed the resident had diagnoses of stroke, atrial fibrillation (irregular heart rhythm), and paralysis of one of his body. The clinical record census revealed Resident #53 admitted to the facility on [DATE] with Medicare A as a payor source and on 12/30/25 the resident was discharged from Medicare A services. The Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, Form Center for Medicare Services (CMS)-20052 (2/2017), provided by the facility revealed Resident #3 did not receive the Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123-NOMNC and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024).The facility failed to provide the resident and/or family with 48 hour advance notice of discharge from Medicare A services and allow the resident and/or family time to follow the process of appeal if desired. On 3/11/26 at 11:50 AM the Administrator and Social Services Director acknowledged Resident #53 had not received the proper documents for signature prior to discharge from Skilled Medicare A services. The facility's Notice of Medicare Provider Non-Coverage and Verification of Receipt Notice Policy, updated 9/5/23, disclosed the residents would be provided with notification of the ending of Medicare services no later than 48 hours before the termination of services.

Based on clinical record review, resident interview, staff interviews, and policy review the facility failed to develop programs maintaining residents strength, range of motion (ROM), communication needs based on the comprehensive assessment for 1 of 14 residents reviewed (Resident #3). The facility reported a census of 43. Findings include:The Minimum Data Set (MDS) for Resident #3 dated 12/16/25 provided a Brief Interview for Mental Status (BIMS) score of 14/15 indicating normal cognition. The document revealed the resident had diagnoses of quadriplegia, anxiety disorder and depression. The document included the resident had functional limitations of ROM in all extremities. The document disclosed that the resident received 1 day of passive range of motion (PROM) and 1 day of communication of at least 15 minutes in the last 7 calendar days.Resident #26's Care Plan dated 3/11/26 identified a problem area for contractures related to quadriplegia post spine injury dated 9/29/25 and reviewed/revised 12/26/25 with staff interventions of PROM exercises for hand, wrist, elbows and shoulders daily. The resident's Care Plan failed to address the resident's restorative programs for PROM to the lower extremities and communication. The clinical record contained a nursing order dated 9/26/25 for Restorative PROM - to follow the instructions on the handout in the resident's room for PROM. Perform PROM daily, go slowly and gently (never force a joint past natural ROM). Support each limb fully (especially at joints). Observe pain/intolerance, resistance, or spasm. Use clean hands and explain each movement (person may not have feeling in extremity). Frequency once a day. The clinical record contained a nursing order dated 9/26/25 for Restorative Communication - general conversation about current events, reminiscing, orientation while speaking in slow, clear, loud and concise manner. Frequency once a day. The Restorative Treatment Administration Record (TAR) Administration History for 2/9/26 - 3/11/26 provided the resident received both the communication and PROM restorative programs 8/30 days. The document contained documentation that on 3 days the staff ran out of time, 1 entry for the resident sleeping, 1 entry for the resident having visitors and 1 entry for staff not being available. The document revealed 14 days of no entries. On 3/9/26 at 4:24 PM Resident #3 stated she did receive Restorative Nursing services, but hadn't received them in the past 3 days. The resident stated she felt it was related to the facility not having enough staff.On 3/11/26 at 8:41 AM Staff A, Certified Nurse Aide (CNA)/Restorative Nursing Assistant (RNA) stated she was primarily assigned to Restorative Nursing; however if there was a staff shortage she will be pulled to the floor. The staff stated when the RNA was pulled to the floor residents may have missed programs or decreased time. Staff A stated in the past 3 months she had been pulled to the floor more frequently. The staff stated there were 2 other staff that were assigned to Restorative Nursing to complete the programs when she was off. The staff stated she was unsure if other staff completed the Restorative Nursing programs when she was pulled to the floor. On 3/11/26 at 2:56 PM the Assistant Director of Nursing (ADON)/MDS Coordinator/Restorative Nurse stated that staffing has varied and when there was a shortage of staff on the floor, the RNA will be pulled from Restorative Nursing to work the floor. The staff acknowledged there were 3 staff that had been trained to work in Restorative Nursing but no more than 1 was assigned to it at a time. The staff stated if a program was written for daily then the facility should try to meet that goal. On 3/11/26 at 3:55 PM the Administrator and Director of Nursing (DON) stated the residents had nursing orders for completion of their programs. The Administrator and DON both stated they felt Resident #3 received more than 8 days of Restorative Nursing in the past 30 days, but acknowledged that without documentation on Restorative TAR there was no evidence of completion. The facility's Restorative Nursing Services Policy, approved 1/29/24, revealed the resident's restorative goals and objectives were individualized, resident-centered and outlined in the resident's plan of care. The document included documentation of completed restorative therapy and/or refusals would be documented in the medical record.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to apply foot pedals to a resident's wheelchair during transport for 1 of 3 residents (#22) reviewed. The facility reported a census of 43 residents.Findings include: Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses of diabetes mellitus, non-Alzheimer's dementia, and osteoporosis. It also revealed the resident required supervision with eating, required moderate assistance with oral and personal hygiene, upper body dressing, tub and toilet transfers, rolling left-to-right, and sitting-to-lying, and maximal assistance with all other Activities of Daily Living (ADLs) and other forms of mobility. It also indicated the resident used a wheelchair and walker in the 7-day look-back period.The Care Plan dated 8/07/23 indicated the resident was independent with locomotion in his wheelchair and staff helps him at times.On 3/10/26 at 8:06 AM, Staff A, Certified Nurse Aide (CNA) transported Resident #22 in his wheelchair from the dining room to the lobby without foot pedals.On 3/10/26 at 9:19 AM, Staff A stated she should not have pushed the resident in his wheelchair because it didn't have foot pedals attached.On 3/11/26 at 10:32 AM, Staff B, Certified Medication Aide (CMA) stated staff should make sure the foot pedals are on a resident's wheelchair before transporting them in it.A policy titled Wheelchair General Guidelines dated 10/2025 indicated the purpose of the policy was to ensure wheelchairs used by residents are safe, properly maintained, and appropriate for each resident's needs in order to promote mobility, independence, and injury prevention. It also directed staff to ensure residents' feet are positioned properly on footrests when seated.On 3/12/26 at 9:30 AM, the Director of Nursing (DON) stated if the resident asked to be pushed in the wheelchair, staff should've reminded the resident they can't be pushed without pedals. If the resident did not ask to be pushed, staff should not have pushed him.

Based on observation, clinical record review, resident and staff interviews, and policy review, the facility failed to consistently perform required pre-hemodialysis and post-hemodialysis assessments for 1 of 1 resident (#2) reviewed. The facility reported a census of 43 residents.Findings include:Resident #2's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of atrial fibrillation (irregular heartbeat), hypertension, End-Stage Renal Disease (ESRD), and thyroid disorder. It also revealed the resident was independent with eating, required supervision with oral hygiene, moderate assistance with personal hygiene, sitting-to-lying, and lying-to-sitting, maximal assistance with bathing, upper body dressing, and bed mobility, and was dependent with all other Activities of Daily Living (ADLs) and mobility. eating and oral hygiene, and was dependent with all other Activities of Daily Living (ADLs). It indicated the resident received hemodialysis upon admission and within the previous 14 days.The Care Plan dated 2/03/26 included a dialysis focus and directed staff to coordinate dialysis schedule and transportation for the resident's time at dialysis.The Progress Notes and Vital Signs documentation revealed the resident's Monday, Wednesday, and Friday pre-dialysis and post-dialysis site assessments and vital signs were not consistently documented between 1/28/26 to 3/09/26.On 3/10/2026 at 11:10 AM, the resident stated staff doesn't always take vital signs before she goes to dialysis because she usually leaves at 5:20 AM.The Electronic Health Record (EHR) included orders dated 3/10/26 for staff to complete a pre-dialysis and post-dialysis assessment and to send the communication form to the hemodialysis facility every Monday, Wednesday, and Friday.The EHR staff Task List revealed a dialysis pre-assessment and dialysis post-assessment entry dated 3/11/26 at 5:00 AM that directed staff to ensure assessment and communication completion on the resident's dialysis days.The EHR's 14-day Administration History lacked documented pre-dialysis and post-dialysis site assessments and vital signs until 3/11/26.A policy titled Dialysis (Hemo) Patient Care dated 10/01/25 directed staff to complete appropriate dialysis forms with pertinent resident information to send with resident.On 3/12/26 at 9:30 AM, the Director of Nursing (DON) stated staff should've been ensuring the assessments were consistently completed and sent with the resident and returned.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to implement infection control practices by lifting an indwelling catheter drainage bag above the resident's bladder during perineal care for 1 of 1 resident (#7) reviewed and by carrying Personal Protective Equipment (PPE) out of the resident's room after it was used. The facility reported a census of 43 residents.Findings include:Resident #7's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of obstructive uropathy (urine unable to drain normally), diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. It indicated the resident was independent with eating, required setup assistance oral hygiene, moderate assistance with upper body dressing, maximal assistance with bathing, lower body dressing, personal hygiene, and bed mobility, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It also indicated the resident had an indwelling catheter (urinary catheter) in the 7-day look-back period.The Care Plan revised 4/19/24 indicated the resident had an indwelling catheter and a history of UTIs (urinary tract infections). The Care Plan directed staff to provide catheter care on rounds and as needed.During a continuous observation on 3/11/25 that began at 7:00 AM, Staff C, Certified Nurse Aide (CNA) and Staff D, CNA performed Resident #7's hygiene and urinary catheter care. Both staff performed hand hygiene and put on PPE in the resident's room. No concerns were identified during hygiene or catheter care. After hygiene care was completed, Staff B, Certified Medication Aide (CMA) entered the resident's room and Staff C removed her PPE and took it out of the resident's room without performing hand hygiene. Staff E, Registered Nurse (RN) entered Resident #7's room and performed catheter care without observed concerns. Staff E completed catheter care and left the resident's room while Staff A and Staff B proceeded to dress the resident for breakfast. While Staff A and Staff B gathered the resident's clothes, the resident's urinary catheter drainage bag was observed lying on the floor beside the resident's bed. Staff A picked up the urinary drainage bag and hung it on the bedframe. While the resident lied in bed, she lifted the urinary catheter drainage bag above the resident and threaded it through the left pantleg before putting the pants on the resident. They dressed the resident and transferred him into a wheelchair and transported him to the dining room for breakfast.On 3/11/2026 at 7:35 AM, Staff C stated she shouldn't have taken the gown out of the room. She added that staff normally discard PPE and perform hand hygiene in the resident's room prior to leaving.On 3/11/26 at 9:35 am, Staff A stated she should not have raised the resident's urine catheter bag above his body when she was putting his pants on.A policy titled Standard Precautions dated 10/25 indicated soiled gowns are removed as promptly as possible and hands washed to avoid transfer of microorganisms to other residents or environments. On 3/12/26 at 9:30 AM, the Director of Nursing (DON) stated staff should've disposed of the gown in the resident's room and performed hand hygiene immediately afterward. She also stated staff should've put the resident's leg and bag through the pantleg together at the resident's level.

Based on observation, interview and policy review the facility failed to ensure that staff used adequate infection control practices during meal service. The facility reported a census of 40 residents. Findings include: In an observation of the lunch meal on 3/17/25 at 11:45 AM, Staff G, Dietary Aide (DA) prepared a peanut butter and jelly sandwich for a resident. Staff G first donned gloves, then touched the bread bag, grabbed two slices of bread, grabbed a utensil and held the bread with one gloved hand and spread with other. At 12:02 PM, Staff G prepare a cheese sandwich. The staff member first donned gloves, opened the lid on the container, bread bag, touched the pan, then with the same gloved hands, grabbed out a couple slices of cheese. On 3/18/25 at 12:51 PM the Dietician said that she would do more education on hand hygiene. On 3/20/25 at 8:48 AM, the Dietary Manager (DM) said that she understood that having the gloves on does tend to make a person feel as if they can touch anything. She said that she would provide education and talk to the Dietician about hand hygiene/glove use processes. According to the facility policy dated 11/2019 and titled: Gloves. When gloves are indicated they shall be used only once and discarded.

Based on observations, staff interviews, facility protocol and clinical record review the facility failed to implement interventions for 1 of 13 residents reviewed. Staff failed to use the As Needed (PRN) suctioning treatment and failed to complete regular vitals when Resident #16 was experiencing increased secretions. The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) dated [DATE], showed that Resident #16 was rarely/never able to make himself understood, and rarely/never understood by others. He was totally dependent on staff for eating, hygiene, transferring and toileting. The resident had shortness of breath or trouble breathing when lying flat, and he was on a mechanically altered diet. Diagnoses for Resident #16 included; cerebral palsy, seizure disorder, gastro-esophageal, reflux disease without esophagitis and dysphagia, The Care Plan last reviewed on 1/10/25, showed that Resident #16 had self-care deficits related to cerebral palsy, cognitive impairment, contractures, impaired communication and immobility. He had a potential for seizures related to seizure disorder and nurses were directed to administer medications as ordered, monitor vials and to suction secretions PRN. In an observation on 3/17/25 at 11:54 AM, Resident #16 was in the dining room getting assists with his lunch. He had a lot of coughing and spilling out of food. On 3/18/25 at 8:04 AM, at breakfast the resident was observed to be coughing and sneezing throughout the meal. The following documentation was found in the Nursing Notes for Resident #16: a. 12/28/24 at 5:41 AM, resident was very congested and had been given Mucinex on the overnight shift. He coughed so much that he had vomited twice. Nasal drainage white and thick, lung sound congested and he was up all night. Doctor notified b. 12/28/24 at 11:21 AM, the resident refused morning medications and did not eat breakfast. Had emesis again. c. 12/29/24 at 6:26 AM, had one emesis with phlegm on the overnight shift. Refused his medications, food and drink. Did not sleep all night. Loose cough. d. 12/29/24 at 11:43 AM one emesis prior to lunch. e. 12/30/24 at 5:24 AM resident had one emesis prior to going to bed, refused medications. f. 12/30/24 at 1:34 PM provider notified regarding congestion and emesis. Started on an antibiotic for sinusitis (inflammation of the sinuses.) The fax sent to the doctor on 12/28/24 included a set of vitals that included an oxygen saturation of 89-92%. The chart lacked any follow up vitals on 12/28/24 or 12/29/25. The chart included a temperature ready only, on 12/30/24. The following documentation was found on the Medication Administration Record/Treatment Administration Record (MAR/TAR) a. An open ended order dated 12/11/22, showed a PRN order to suction with Yankauer (suctioning catheter used to remove secretions from airway) for secretions that the resident was unable to clear. The TAR showed that the PRN order was not used in December or January. b. On 12/31/24 a Respiratory Protocol was added to the TAR for staff to monitor lung sounds, respiration, shortness of breath, cough, vitals, encourage deep breath and cough and encourage fluids. On 3/18/25 at 8:57 AM, Staff A, Licensed Practical Nurse (LPN) was caring for Resident #16 on that day. She said that she was not aware of a PRN order for suctioning and she wasn't sure where the supplies were kept. The Director of Nursing (DON) checked the MAR/TAR to see if the resident had an order for suctioning and said that he was able to clear secretions by coughing on his own. On 3/19/25 at 5:15 AM, Staff B, LPN, said that she did not remember specifically back in December when Resident #16 was having increased secretions and emesis. She said, he does that a lot but she did not remember when it got to the point of upper respiratory infection. Staff B did not have any knowledge of a suctioning machine or an order for suctioning as needed. Staff B said that if the resident had extreme gurgling, the suctioning would probably be helpful. She added that Resident #16 did not follow directions very well and just makes different sounds to communicate. On 3/19/25 at 2:30 PM the Director of Nursing (DON) said that the order that was in the chart for suctioning was an old order from when Resident #16 had a sinus infection in 2022. She understood that the nurses probably didn't know it was there because they didn't use it and the resident was usually able to clear and cough secretions on his own. She said there were vital signs included on the fax to the doctor on 12/28/25. A facility generated undated form titled: Respiratory Protocol showed that as a nursing order to monitoring respiratory symptoms included; monitoring lung sounds, respirations, shortness of breath, cough, and vitals.

Based on observation, clinical record review, staff interviews, and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares for 2/12 residents (Resident #33, Resident #91). The facility failed to utilize hand hygiene, appropriate glove use, and Enhanced Barrier Precautions (EBP). The facility reported a census of 40. Findings include: 1. The Minimum Data Set (MDS) of Resident #33 dated 12/31/24 reflected the Brief Interview for Mental Status (BIMS) score of 7/15 indicating severe cognitive impairment. The document revealed diagnoses of renal insufficiency and obstructive uropathy, and the resident had an indwelling catheter. The Electronic Health Record (EHR) revealed an order dated 2/5/25 to document suprapubic catheter cares and output at the end of each shift. The Care Plan dated 3/18/25 identified a problem area of indwelling catheter. Approaches identified for the problem area included Methicillin-resistant Staphylococcus aureus (MRSA+), EBP, and report output with catheter care to charge nurses each shift. An additional problem area identified was risk for infection of MDRO related to suprapubic catheter. The approaches identified included EBP with identified areas to be used, precautions required, and completion of hand hygiene prior to and during care. Observed Staff H, Certified Nursing Assistant (CNA) on 3/18/25 at 6:37 AM complete personal care and catheter care with Resident #33. Staff H completed hand hygiene and donned personal protective equipment (PPE), gown and gloves, to initiate care. The staff placed a barrier down, obtained alcohol wipes, and a leg bag to complete the change from the overnight drainage bag. Alcohol wipes utilized to cleanse the tubing before changing the drainage bags. The staff completed drainage and measuring of the overnight bag into a graduated cylinder. Staff H completed emptying the cylinder and placed it on a barrier, rinsed the tubing of the overnight bag, emptied, and placed it in the bag. The staff removed gloves and donned new gloves. The staff proceeded to assist the resident with dressing, grooming, and hygiene tasks. Staff H failed to complete hand hygiene between changing of gloves during the resident's personal care. On 3/18/25 at 8:00 AM the Director of Nursing (DON) stated staff should change gloves anytime between dirty and clean tasks, as well as anytime necessary. The DON expected staff to complete hand hygiene between glove changes. On 3/18/25 at 8:15 AM the Administrator acknowledged she was aware of the lack of hand hygiene between glove changes, and expected hand hygiene to be completed when removing dirty gloves and prior to donning new gloves. 41785 2. According to a nursing note dated 3/12/25 at 4:37 PM, Resident #91 was admitted to the facility after a hospitalization for traumatic subdural hemorrhage. The resident presented with a pressure sore to the coccyx and standard treatment orders were initiated. The Baseline Care Plan initiated on 3/12/25, showed that the resident had a Stage II pressure sore, on the coccyx with a goal to prevent/heal sores with treatments, positioning and pressure relieving cushion in the wheel chair. The Facesheet for Resident #19, Custom Banner Flags; showed that Enhanced Barrier Precautions would be used in cares. The Medication Administration Record/Treatment Administration Record (MAR TAR) for March 2025 showed an order initiated on 3/13/25 for Calmoseptine (menthol-zinc oxide) ointment 0.44 - 20.6 %, apply three times a day to the pressure ulcer of the sacral region. In an observation on 3/18/25 at 7:09 AM, Staff D was in the room of Resident #91. The resident was in bed and the CNA provided cares. With gloved hands, she started to remove the soiled brief, unhooked the Velcro sides and pulled it down off of the front of the resident. She then decided that she would wait for another CNA to come in and help her, so she reached into her pocket with the same gloved hand, and got a walkie talkie and called for assistance. On 3/19/25 at 2:29 PM, the Director of Nursing (DON) said that she would have expected the CNA to change her gloves and perform hand hygiene before reaching in her pocket. According to the facility policy dated 11/1019, and titled: Gloves; when gloves are indicated they shall be used only once and discarded. A facility policy titled: Enhanced Barrier Precautions (EBP) dated 4/2024, showed that EBP would be used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for the transfer of Mulitdrug-resistant organisms to staff hands and clothing. High contact resident care activities include wound care.

Based on observations, staff interviews and clinical record review the facility failed to accurately document treatments provided for 1 of 13 residents reviewed. Nursing staff documented that a wound treatment for Resident #91 had been done over two hours before it was actually completed. The facility reported a census of 40 residents. Findings include: According to a nursing note dated 3/12/25 at 4:37 PM, Resident #91 was admitted to the facility after a hospitalization for traumatic subdural hemorrhage. The resident presented with a pressure sore to the coccyx and standard treatment orders were initiated. The Medication Administration Record/Treatment Administration Record (MAR TAR) for March 2025 showed an order initiated on 3/13/25 for Calmoseptine (menthol-zinc oxide) ointment 0.44 - 20.6 %, apply three times a day to the pressure ulcer of the sacral region. In an observation on 3/18/25 at 7:09 AM, Staff D Certified Nurse Aide (CNA) and Staff E, CNA provided peri care and brief change for Resident #91. The resident was found to have an open area on the coccyx. The CNA's applied a new brief without having applied a barrier cream or contacting the nurse to complete the treatment. They transferred him into the wheel chair and took him out to the dining room for breakfast. At 8:00 AM the Resident was not back in his room and the bed was stripped. The MAR TAR printed on 3/18/25 at 9:39 AM, showed that the wound treatment had been completed. The scheduled time for the morning treatment was 8:00 AM, and the charted time was at 9:10 AM. The Reason/Comments column included documentation that the treatment was charted late; done on time At 9:47 AM, the Resident was not in his room and the bed was made. On 3/18/25 at 9:48 AM, when asked about the condition of the coccyx wound on Resident #91, Staff A, Licensed Practical Nurse (LPN) said she hadn't done the morning treatment yet. On 3/18/25 at 10:11 AM, Staff A asked a CNA to assist her as she provided the morning wound treatment. On 3/20/25 at 6:50 AM the Director of Nursing (DON) said that the nurses are taught to document after treatments have been completed She said that on 3/12/2025, they had discussed concerns with documentation accuracy and treatments and planned education due at the end of this month for all nursing staff. A facility policy titled Documentation: General Principles, dated 6/2016, showed that the facility would ensure that staff accurately and thoroughly documented all care provided. The correct date and time would be included with each entry in the medical record.

Based on observations, clinical record review, and staff interviews, the facility failed to protect a resident from a possible accident and injury by not following the prevention of fall interventions for 1 of 12 residents (#14) reviewed. The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) for Resident #14 dated 2/4/25 identified a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the assessment. A cognitive assessment completed by the staff identified short term memory problems, long term memory problems, severely impaired cognitive skills for daily decision making, and behaviors consistently present included inattention, disorganized thinking, and altered level of consciousness. The document revealed the resident was dependent on staff for all activities of daily living (ADLs) and mobility, had diagnoses of cerebrovascular disease (CVA)/stroke, anxiety, and a below the knee amputation (BKA) on the left. The document included the resident took antipsychotic and opioid medications, had no falls during the past reporting period, and received hospice services. Resident #14's Care Plan dated 2/17/25 contained a problem area indicating the resident was at risk for falling related to BKA, weakness, confusion, history of falls, and required staff assistance with care with a start date of 6/14/23 and last review on 1/31/25. The document revealed approaches for staff to follow included a fall mat placed next to the bed dated 1/10/24, and the wheelchair (w/c) to be placed next to the bed and locked dated 8/26/23. The Electronic Health Record (EHR) Fall Risk assessment dated [DATE] revealed a score of 16 indicating at risk. The document identified the resident was disoriented x3, chair bound, not able to perform ambulation, had poor vision, took medications, and other conditions including loss of limb, osteoporosis, CVA, and hospice. Interventions identified in the document included a floor mat, and dependent for ADL's. On 3/17/25 at 11:58 AM observed Resident #14 sleeping in bed with the w/c positioned near the recliner and the fall pad folded against a wall on the other side of the room. On 3/17/25 at 3:30 PM observed the resident was sleeping in bed with the fall mat next to the bed and the w/c across the room. On 3/18/25 at 3:30 PM observed Resident #14 sleeping in bed with the fall mat beside the bed and the w/c between the foot of the bed and the recliner. On 3/20/25 at 7:29 AM Staff I, Certified Nursing Assistant (CNA) stated to find fall interventions, she would check Care Plans, look for notes inside of the resident's room, and the nurses told staff about interventions. The staff stated interventions for Resident #14 included a blue mat put in front of the bed, lower the bed, and side rails up. On 3/20/25 at 7:53 AM Staff J, CNA, stated fall interventions were found in the resident's Care Plan on the computer. The staff stated signs may also be on the walls in the resident's room or stickers on the door. Staff J stated for Resident #14 positioning was the key to preventing falls. The staff stated interventions included tilting the w/c, fall mat on the floor by the bed, and usually keeping the w/c near the foot of the bed in the locked position. On 3/20/25 at 8:10 AM Staff K, Certified Medication Aide (CMA), stated she thought there was a binder at the nurses station with fall interventions for residents. The staff stated a fall intervention for Staff #14 included a blue fall pad on the floor when the resident was in bed. On 3/20/25 at 8:13 AM, Staff L, CNA, stated fall interventions were located in the computer and in the binder. The staff stated a fall intervention for Resident #14 was a mat beside the bed and/or recliner. On 3/20/25 at 8:15 AM the Director of Nursing (DON) stated new fall interventions were discussed during the twice daily Huddle Meetings for all staff. The notes from those meetings were placed in the Scoop Binder for staff reference. The staff stated additionally new interventions may be posted on the board in the staff breakroom. The DON stated fall interventions would also be found in the Care Plans and Pocket Care Plans. The DON expected staff to follow a resident's fall interventions found in the Care Plan. The facility did not have a policy related to following the Care Plan.

Based on observations, clinical record review, resident interview, staff interviews, and facility policy review, the facility failed to provide adequate fluids and failed to monitor and report intake and output for 1 of 1 residents reviewed for urinary tract infections and urinary catheter use (Resident #41). Resident #41 had a history of acute kidney injury and chronic urinary tract infections. He was found to have inadequate fluid intake and urine output and staff failed to monitor and report. The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #41 had a Brief Interview for Mental Status score of 8 (severe cognitive deficit). He needed supervision with eating, and was dependent on staff for toileting and showering. He was admitted to the facility with a urinary indwelling catheter. The Care Plan updated on 5/28/24, showed that he had developed a urinary tract infection (UTI) related to foul odor and cloudy urine in his catheter, staff were to monitor and encourage fluid intake. The resident had a recent hospital stay for urosepsis and aspiration pneumonia and he was at risk for aspiration, staff were directed to encourage intake of fluids (honey thicken). The Nursing Notes documented the following: a. on 4/4/24 at 3:03 PM Resident #41 admitted to the facility from the hospital after having urosepsis. b. on 4/6/24 at 4:05 AM an order to discontinue the Foley catheter due to urosepsis resolved. c. on 4/9/24 at 2:00 PM in the dining room for meals and taking in small amounts of fluids, refused meal intake. d. on 4/10/24 at 1:42 AM moist cough with crackles bilateral lungs. Fax sent to the physician. Elevated head of bed. e. on 4/10/24 at 9:20 AM drank 200 cc of thick liquids from table mate and had a small emesis. f. on 4/11/24 at 3:20 AM vomited X 2 rattling in bilateral lobes temperature of 101.4 oxygen saturation 79%. Sent to the emergency room . According to the Continuum of Care Transfer Report from the hospital, date 4/18/24, Resident #41 admitted to the hospital on 4/11/24 with the primary reason for admission Acute Kidney Injury (AKI) with complicated urinary tract infection and aspiration pneumonia. The following is observed in an ongoing observation: a. On 5/29/24 at 10:04 AM Resident #41 in the recliner sleeping in his room. The catheter bag hanging from the walker next to his recliner. The urine was dark. No fluids in his room. b. On 5/29/24 at 11:25 AM, resident in his room, no fluids in his room. He has some pudding cups but no liquids. c. On 5/29/24 at 11:41 AM, the resident was at the lunch table, two small glasses of fluid in front of him. d. On 5/29/24 at 1:07 PM, he was sitting in the wheelchair in front of the nurses station. e. On 5/29/24 at 1:56 PM, the catheter tubing has sediment. f. On 5/29/24 at 2:56 PM, no fluids in his room. g. On 5/30/24 at 7:45 AM, the resident sitting at the breakfast table, other residents around him were eating but he didn't have anything in front of him for breakfast yet. No fluids in his room. h. On 5/30/24 at 8:05 AM, he was feeding himself and his thickened water was almost gone, has a juice also. i. On 5/30/24 at 8:23 AM, the resident back in his room, both of his thickened liquids from breakfast had been consumed. According to a dietician note dated 5/13/24 at 9:15 AM, the required amount of daily fluid was between 1795 and 2155 cubic centimeters (cc). Fluid intake should be encouraged. The following was found in the Vitals tab, Fluid intake and Urine Output: from 4/1/24 - 5/30/24 a. From 4/8 - 4/10/24 the average daily fluid intake was 350 cc. of fluid daily. (the census tab showed that the resident was hospitalized from 4/11 - 4/18) b. No fluids documented from 4/18 - 4/21. c. From 4/22 - 4/30/24, the daily average fluid intake was 500 cc. d. From 4/22 - 4/30/24 the average output was 253 cc a day (normal output for adults is 800-2,000 cc a day) e. From 5/1 - 5/28/24 intake average was 252 cc. a day f. From 5/1 - 5/28/24 the average output was 525 cc. a day. On 5/30/24 at 8:28 AM, Staff D, CNA stated Resident #41 did not get fluids in his room because he was on thickened liquids. She said that water was passed after breakfast and at second shift but he didn't get anything. On 5/30/24 at 8:38 AM Staff C, CNA stated the resident didn't have much urine in his catheter bag that morning. They wanted to get a sample of the urine because they suspect he may have a UTI. On 5/30/24 08:46 AM, Resident #41 said the staff did not bring him any liquids in his room. He said that he would like to have fluids in his room and he drank both liquids offered to him this morning at breakfast. On 5/30/24 at 9:07 AM, Staff E, CNA stated Resident #41 did not get water in his room because he was on thickened liquids. She said that she did do the water pass on occasion but she said that she hadn't ever given him a cup of thickened water. On 5/30/24 at 9:57 AM, the Director of Nursing (DON) stated they didn't leave thickened liquids in the resident's room because he would take the glass and try to fill it up with regular water. She said that at times, he would sit out by the nurse's station and they would give him the liquids out there so they can watch him. She said that she would look at the intake and output record but was not aware that the averages had been low. On 5/30/24 at 10:09 AM, Staff A, CNA, stated she hadn't ever brought thickened liquids to the resident in his room but they would bring him some if he asked. When they passed water to the residents, they just skipped his room. She said that he needs to be encouraged to drink. On 5/30/24 at 10:10 AM, Staff B, CNA, stated she hadn't ever brought fluids to Resident #41's room but sometimes he would be sitting out by the nurse's station and the nurses will ask her to get a small glass of thickened liquid for him. She said that she had seen a glass of thickened liquids in his room at times but she hadn't ever seen him try to go fill it up with water himself. According to a facility policy titled: Intake and Output dated 6/2016 it was the policy of the facility to provide adequate fluids to each resident. Nursing personnel would provide and monitor the resident's intake and output based on condition and or physicians order.

Based on observation, staff interview, clinical record review and facility policy review, the facility failed to provide wound care treatments as ordered for 1 of 3 residents reviewed. Resident #6 had pressure wounds on her coccyx and inner ankle, in an observation it was discovered that the treatments were not in place. The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #6 was unable to complete a Brief Interview for Mental Status, indicating severe cognitive deficits. She had limited range of motion in the lower extremities and was totally dependent on staff for toileting hygiene, dressing, transfers and bed mobility. She was always incontinent of bowel and bladder. The Care Plan last reviewed on 5/1/24, showed that Resident #6 had self-care deficits related to intellectual disability, and she had poor balance with bilateral lower extremity deformity and weakness. The resident was unable to ambulate. She had the potential for pressure ulcers with impaired skin integrity and a history of resolved pressure ulcers. Resident #6 had an unstageable area to right inner foot with a treatment order for calcium alginate and Tegaderm every 3 days and as need to pressure wound on right ankle. According to the order tab in the electronic chart, Resident #6 had a treatment order dated 12/11/23 to apply Calmoseptine and cover with Mepilex every other day, and as needed, to the coccyx. The resident also had an order dated 4/26/24, for calcium alginate and Tegaderm (transparent medical dressing used to cover and protect wounds) every 3 days and as needed to the right inner ankle. According to the Treatment Administration Record (TAR) the treatment to the coccyx had been changed on 5/27/24. On 5/29/24 at 9:38 AM, observed Staff A Certified Nurse Aide (CNA) and Staff B, CNA changing the soiled brief for Resident #6. The resident had two treatment patches on her bottom, one on the coccyx dated 5/25 and the written date on the patch on the gluteal was faded and not readable. Staff A and Staff B removed the protective boots and socks from the resident's feet and the sore on the inside of her right ankle was not covered with a bandage. On 5/30/24 at 9:57 AM, the Director of Nursing (DON) stated Resident #6 should have had the Tegaderm on her ankle. She acknowledged that it had been documented that the Mepilex on her coccyx was changed on 5/27 and said she that would talk to the nurse who had documented as completed. According to a facility policy titled: Wound Care: Prevention, Assessment, Treatment and Documentation dated 9/2020. Treatment and intervention would be established according to facility wound protocols and physician order and documented. For example: turning schedule, dressing type, topical antibiotic powder/aerosol/ointment, antibiotic systemic, or other treatments.

Based on observation, interview, record review, and policy review, the facility failed to ensure menus were followed related to consistency. This failure had the potential to affect up to 9 residents who received a mechanical soft diet or a pureed diet and could result in unintentional weight loss for those residents who were nutritionally at risk and who may have difficulty with swallowing. Findings include: Review of a document provided by the facility titled Menus-Regular and Modified, dated 01/2020 indicated . Menus are planned and followed to meet the nutritional needs of residents in accordance with physician's orders . The menus are planned to meet the needs of the residents, based on acceptability and within the budget of the facility . Review of a document provided by the facility titled Diet Spreadsheet .Week 1 indicated the menu served for the residents served a ground meal was ground chicken and broccoli stir fry and steamed rice with gravy. Residents served pureed chicken and broccoli and rice with gravy. 1. Review of Resident (R) 21 electronic medical record (EMR) titled Active Orders, located under the Resident tab dated 10/27/21 indicated the resident was ordered a regular pureed diet with honey thickened liquids. Review of a document provided by the facility titled Lunch -Day 5 dated 02/23/23 indicated R21 was to be served a pureed diet. 2. Review of R11 EMR titled Active Orders, located under the Resident tab dated 12/28/22 indicated the resident was ordered a mechanical soft diet with extra sauces and gravy. Review of a document provided by the facility titled Lunch-Day 5 dated 02/23/23 indicated R11 was to be served a mechanical soft diet. 3. Review of R16 EMR titled Active Orders, located under the Resident tab dated 02/04/22 indicated the resident was ordered a pureed diet. Review of a document provided by the facility titled Lunch-Day 5 dated 02/23/23 indicated R16 was to be served a pureed diet. 4. Review of R9's EMR titled Active Orders, located under the Resident tab dated 04/20/22, the resident was ordered a pureed diet. Review of a document provided by the facility titled Lunch-Day 5 dated 02/23/23 indicated R9 was to be served a pureed diet. A tray line observation conducted on 02/23/23 at 11:15 AM, and the Dietary Aide (DA) 1 took temperatures of the food which was held in the steam table. There was no gravy observed in the steam table. During a random observation conducted on 02/23/23 at 11:42 AM, the following trays were prepared by DA1: R21, R16, and R9 were each served a pureed diet and R11 was served a mechanical soft diet. Staff failed to place gravy on the rice before delivering the four meals trays to R21, R16, R9, and R11 in the main dining room. During an interview on 02/23/23 at 11:46 AM, the Dietary Manager stated she expected the cook to follow the menu and confirmed nine residents had mechanical soft and/or pureed meals that had gravy per the menu.

Based on observation, interview, and record review, the facility failed to ensure the food a resident brought in from the outside was dated and labeled. The facility further failed to ensure residents' personal refrigerators were routinely cleaned. This had the potential to affect 5 of 13 (Resident (R) 18, R24, R5, R23, and R19) residents reviewed with personal refrigerators in their rooms. Findings include: Review of a document provided by the facility titled Room Refrigerators dated ,d+[DATE] indicated . It is the policy of this facility to promote cleanliness while providing residents/patients access to food brought into the facility by family . All resident/patient room refrigerators will be provided and stocked by family . Refrigerators will be cleaned weekly and PRN [as needed] by family or facility staff . Opened items must be used within time frame . All food will be kept in closed container with date food has been opened . Perishables will be destroyed PRN by family or facility staff . During a random observation on [DATE] at 8:55 AM, R24's personal refrigerator had a jar of Ranch dressing, French dressing, and a partially empty jar of mayonnaise. R24 stated the facility staff never cleaned his refrigerator. There was no date of when the products were opened. During an interview on [DATE] at 9:29 AM, the Maintenance Director stated the housekeeping staff were responsible for cleaning the residents' personal refrigerators. The Maintenance Director was present during the following observations: During an observation on [DATE] at 9:31 AM, R24 allowed his refrigerator contents to be examined. The Maintenance Director stated he had been in the resident's room previously and tossed the partially emptied jar of mayonnaise out since it was ready to be expired. During an observation on [DATE] at 9:33 AM, R19 allowed her refrigerator contents to be examined. The Maintenance Director pulled out three partially emptied individual serving cups of applesauce. The Maintenance Director pulled out an individual serving of melted vanilla ice cream. In the small freezer section was a disposable bowl full of dried out vanilla pudding. The aluminum cover had ice crystals on the inside when the aluminum was pulled from the disposable bowl. None of the food items were dated. R19 stated the facility staff did not clean her refrigerator. During an observation on [DATE] at 9:35 AM, R5 allowed her refrigerator contents to be examined. There was a small bag of fresh grapes. There was no date. On the bottom door shelf of the refrigerator were raised white and yellow stains in the plastic crevasses. Also present was a small jar of mayonnaise, approximately one third remaining in the jar. The jar had date of when the product was opened. During an observation on [DATE] at 9:40 AM, R18 allowed her refrigerator contents to be examined. The bottom drawer of the refrigerator contained multiple slices of yellow cheese with several of the pieces had heavy mold. There was shelf just above the drawer and a small disposable dish contained hard yellow cheese, processed meat, and two pink frosted cupcakes. The frosting was cracked and dry. The items were covered with another disposable dish. There was no date on these items. The Maintenance Director stated the items were from the previous week's Valentine activity. During an observation on [DATE] at 9:41 AM, R23 allowed her the refrigerator contents to be examined. There were two opened cans of Shasta, one diet cola, and the other a Twist flavor. There were raised crusty spots on the bottom shelf of the refrigerator. R23 stated the freezer needed to be defrosted. The small freezer located at the top of the refrigerator had a frozen area which was approximately two inches thick on the outside of the freezer. During an interview on [DATE] at 10:13 AM, the Administrator stated there was no cleaning schedule for the residents' personal refrigerators.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 1 of 5 residents (Resident (R) 2) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R2 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Prevnar 20 (PCV20) in accordance with nationally recognized standards. The facility failed to offer R2 the opportunity to be vaccinated with Pneumococcal conjugate vaccine PCV13 (Prevnar13), prior to 10/21/21. This practice had the potential to increase the risk for these residents to contract pneumonia. Findings include: Review of a document provided by the facility titled Pneumococcal Vaccine, dated 02/2023 indicated .It is the policy of this facility to provide pneumococcal vaccination to residents/patients and to promote immunity to pneumococcal disease at the appropriate intervals. Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, last reviewed 02/13/23, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older . For adults [AGE] years or older who have only received a PPSV23 [Pneumococcal Polysaccharide Vaccine], CDC recommends you . May give 1 dose of PCV15 [Pneumococcal Conjugate Vaccine] or PCV20 [PCV13 was previously recommended by the CDC prior to 10/21/21] . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. Review of R2's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. The resident was over the age of 65. Review of a document provided by the facility indicated R2 received PNEUMOVAX(R)23 (PPSV23) on 08/22/13. There was no indication the resident was offered the opportunity for PVC13 prior to 10/21/21. During an interview on 02/24/23 at 8:50 AM, the Director of Nursing (DON) confirmed the facility missed offering R2 the PCV13 and did not identify offering the resident Prevnar 20.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that 1 of 25 sampled residents (Resident (R) 19) did not have unsecured medication at their bedside. The facility failed to ensure the resident was assessed for the safe self-administration of an inhaler. This deficient practice has the potential for medication errors related to the inappropriate self-administration of medications and unsecured medications could potential be accessed by individuals other than the intended user. Findings include: Review of a document provided by the facility titled Medication-Self Administration, dated 10/2017 indicated . It is the policy of this facility to permit residents/patients to self-administer their drugs and medications unless such practice for the resident/patient is deemed unsafe . Residents/patients will not be permitted to administer or retain medications in their rooms unless so ordered by the attending physician and approved by the inter-disciplinary team in writing . Medications for the self-administration will be stored at the nurse's carts and/or in the resident's room in a marked medication drawer, medication bin or other storage area of resident's choice in their room . The nurse will document that medications were self-administered by the resident/patient . Review of a document provided by the facility titled Medication Self Administration, dated 05/24/22 indicated R 19 was safe to administer medications. The form indicated the resident was assessed to the safe administration of albuterol one vial, to be administered via a nebulizer machine, as needed four times per day. There was no information which would indicate the resident was assessed for the self-administration of an albuterol inhaler. Review of R19's electronic medical record (EMR) titled Resident Face Sheet, located under the Resident tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure. Review of R19's EMR titled Active Orders located under the Resident tab indicated the resident was ordered ProAir albuterol inhaler 90 micrograms (mcg) to administer two puffs three times a day as needed. During an interview on 02/21/23 at 12:20 PM, R19 stated she takes her own albuterol inhaler and pointed to the inhaler located on her bedside. The inhaler was labeled albuterol and was a yellow container. During an interview on 02/23/23 at 8:05 AM, R19 stated she was safe to self-administer her albuterol inhaler and use her nebulizer machine. The handheld albuterol was observed on her bedside table. During an interview on 02/23/23 at 1:59 PM, the Director of Nursing (DON) stated she was not aware R19 had her ProAir at the bedside. During an interview on 02/24/23 at 8:50 AM, the DON stated she needed to complete an assessment for self-administration of mediation for the albuterol inhaler since R19 would like to administer the ProAir inhaler.

Based on interviews, record review, and facility policy review, the facility failed to ensure one resident 1 of 25 sampled residents (Resident (R) 31) was given advanced notice and a reason for her room change. Findings include: Review of the facility policy titled Room Change/Roommate Assignment, revised on 08/22/22, revealed: Policy Interpretation and Implementation . 4. Advance written notice of a room and/or roommate change will include why the change is being made and any information that will assist the resident in becoming acquainted with his or her new room and/or roommate . Review of R31's electronic medical record (EMR) Admission Record indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of Chronic obstructive pulmonary disease. Review of R31's last Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/22 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. During an interview on 02/21/23 at 1:30 PM, R31 stated the only problem she had with this place is They threw me in here with a roommate, with no notice at all. They just told me I had to move. The resident stated she felt like she was being strong-armed into the move. During an interview on 02/22/23 at 11:30 AM, the Director of Nursing (DON) stated she could not remember the reason for the move, she looked up the reason for the move and stated that the facility had a new admit that qualified for a private room. Review of a document provided by the facility titled Room/Roommate Change, Advance Notice for R31 dated 01/06/23 at 11:05 AM, the space for reason for room change comments was left blank. Review of R26's EMR Admission Record indicated the resident was admitted to the facility on [DATE] at 3:55 PM to R31's previous private room.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff maintained appropriate infection control measures for the safe handling, cleaning, and storage of respiratory equipment for one resident (Resident (R) 24) reviewed for respiratory care. R24 had the potential to develop a serious respiratory infection due to the lack of maintenance and sanitation of the components (face mask, hose, and filter) to the continuous positive airway pressure (CPAP) machine. Findings include: Review of a document provided by the facility titled [NAME] Dreamstation.2 CPAP () Advanced .Auto CPAP Advanced, dated 2021, indicated . Clean the device with a cloth dampened with an approved cleaner. Empty and clean the humidifier water tank daily to prevent mold and bacteria growth .Water tank seal Provides a seal between the water tank lid and base. Removable for ease of cleaning . Home cleaning: tubing Hand wash the tubing, mask adapter (if included), and connectors (if included) before first use and weekly. Discard and replace the tubing every 6 months. Review of a document provided by the facility titled Cleaning Respiratory Equipment, dated 02/2017 indicated . It is the policy of this facility to maintain clean and functional respiratory equipment. All respiratory equipment will be cleaned once a week and PRN (as needed) . Review of R24's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility 08/29/22 with a diagnosis of obstructive sleep apnea. Review of R24's EMR titled Care Plan located under the RAI (Resident Assessment Instrument) tab dated 08/29/22 indicated the resident was at pulmonary risk for impaired breathing pattern related to pulmonary hypertension and shortness of breath. There was no indication identified the resident was responsible for the maintenance and sanitation of his CPAP machine. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/22 located under the RAI tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. The assessment indicated the resident used a CPAP machine. During an interview on 02/21/23 at 10:08 AM, R19 stated he did not clean his CPAP machine and neither did the facility staff. The resident was observed wearing a CPAP device during this interview. During an observation on 02/23/23 at 8:05 AM, R19 was observed sleeping in bed and wearing his CPAP device. During an interview on 02/23/23 at 8:07 AM, Certified Nursing Assistant (CNA) 1 stated she did not clean R19's CPAP since that was something nurses completed. During an interview on 02/23/23 at 8:10 AM, Registered Nurse (RN) 1 stated she did not clean R19's CPAP since this was something the resident was responsible for. During an interview on 02/23/23 at 8:11 AM, the Director of Nursing (DON) stated it was her understanding R19 took care of his own CPAP. During an interview on 02/23/23 at 8:54 AM, R19 stated he would not even know how to change the filters or clean his CPAP. During an observation on 02/23/23 at 9:04 AM, the resident gave permission for RN1 to take off his face mask which was attached to a hose and attached to the CPAP machine. RN1 performed hand hygiene and donned (put on) gloves prior to taking off the resident's mask. RN1 stated there was nasal drainage and skin particles on the inside of the resident's mask. The resident stated during this observation, staff never cleaned his CPAP since he was first admitted to the facility. RN1 then took the face mask, and the mask was connected to the hose. There was a clip connector which secured the face mask to the hose. The clip had heavy yellow residue present. RN1 confirmed the observations and asked the resident permission to clean the components to the CPAP. During an interview on 02/23/23 at 2:06 PM, the DON stated her expectation was for the mask and the hose were to be washed.

Based on observation, interview, record review, and review of manufacturer's manual, the facility failed ensure a staff member sanitized glucometers between uses for 3 of 3 residents (Resident (R) 13, R40, and R93) observed receiving finger stick blood glucose test. This failure to sanitize glucometers between residents has the potential for cross contamination of blood-borne pathogens. Findings include: Review of the manual for the Assure Platinum Blood Glucose Monitor System that was used by the facility revealed . The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed . We have validated . Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the Assure Platinum multi meter . Contact time 2 minutes . dry time of one minute Observation and interview on 02/23/23 at 11:05 AM, revealed one glucometer loosely wrapped in four not separated loosely rolled up Super Sani-Cloth Germicidal Disposable Wipe on top of the medication cart assigned to Certified Medication Aide (CMA) 1 in hall 300. CMA 1 removed the glucometer from the wrapped-up wipes, entered R13's room, and tested the resident's blood glucose with the glucometer without allowing for required dry time. CMA1 returned to the medication cart, without sanitizing the meter, placed the glucometer back into the same loosely rolled up not separated Super Sani-Cloth Germicidal Disposable Wipes on the medication cart. CMA1 gathered more supplies, removed the meter from the same loosely rolled up not separated Super Sani-Cloth Germicidal Disposable Wipes and proceeded to use the meter for R40's glucose test, again not allowing for dry time. CMA1 returned to medication cart, inserted the meter, into the same wipes as used for the previous two residents and started to gather supplies. When CMA1 removed the meter from the rolled up wipes prior to going into the next residents room, she stated she did not know the wet or dry time. CMA1 stated she was sanitizing the meter by placing it in wipes. Ended observation and asked Registered Nurse (RN) 1 to assist CMA1 in sanitizing glucometer prior to use on R93. Review of R13's Face Sheet, located under the Resident tab of the electronic medical record (EMR) revealed R13 had diagnoses that included diabetes mellitus type 2. Review of R13's Physician Order, dated 11/01/16 and located under the Orders tab of the EMR revealed R13 was to receive a Blood Glucose Monitoring four times a day 7:30 AM, 11:30 AM, 5:30 PM and 8:00 PM. Review of R40's Face Sheet, located under the Resident tab of the electronic medical record (EMR) revealed R40 had diagnoses that included diabetes mellitus type 2. Review of R40's Physician Order, dated 01/31/23 and located under the Orders tab of the EMR revealed may check blood glucose levels as needed up to three times a day for hypo/hyper glycemic symptoms. Review of R93's Face Sheet, located under the Resident tab of the electronic medical record (EMR) revealed R93 had diagnoses that included diabetes mellitus type 2. Review of R93's Physician Order, dated 11/01/16 and located under the Orders tab of the EMR revealed R93 was to receive a Blood Glucose Monitoring before meals and at bedtime 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM. During an interview 02/23/23 at 2:38 PM with the Administrator and Director of Nursing (DON), the DON confirmed her expectation of glucose monitor sanitization would include thoroughly wiping the surface, observing the wet time as specified on the container of the sanitizer product, and dry time. She also stated, new wipes should be used to clean and disinfect between residents. The DON confirmed the CMA1 has not had any trainings that included her evaluating her performance of glucose monitoring and sanitizing between residents since she returned working at the facility a little over 90 days ago. The DON confirmed the glucometer was only shared between R13, R40, and R93.

Based on observations, policy review and interview the facility failed to maintain 4 of 4 larger sheet pans, 2 of 6 smaller sheet pans, and 1 utility cart used in food prep area in a manner that was free of food residue. The facility reported a census of 37 residents. Findings included; Observation on 12/01/21 at 10:58 AM revealed 2 smaller sheet pans and 4 larger sheet pans contained baked on food residue. A utility cart with an enclosed bottom had dried food residue on the front of the doors and on the bottom of the cart. The Equipment Sanitation and Safety policy dated 04/2017 directed all food service equipment is to be safely operated and maintained in a sanitary manner following procedures specific to the individual piece of equipment. Procedures: Cleaning of Equipment and Utensils: The Food Code requires that all tableware, such as eating utensils, dishes, glasses, cups, etc. be cleaned and sanitized after each use. This rule also applies to all kitchenware and food contact surfaces used in the preparation, serving, display, or storage of food. An exception to this rule is that the cooling surfaces of grills, griddles and similar cooking devices need not be cleaned after each use but must be cleaned at least once a day. Non-food contact surfaces of all other equipment including tables, counter, mixers, grinders, dishwashing machines, etc. shall be cleaned and sanitized as frequently as necessary in order to prevent accumulation of dust, dirt, food particles and other soil or debris. During an interview 12/02/21 at 8:15 AM with the Administrator acknowledged she had noticed the pans did have residue on them on 12/1/21 while in the kitchen as she cooked and thought they needed to order new ones.

Based on observations, record review, facility investigation review, staff interviews and facility policy review the facility failed to ensure the safety of 2 of 3 Residents (R) (R6 and R7) reviewed with known fall risks by not ensuring care planned interventions in place at all times. The facility also failed to prevent environmental hazards in the bathhouse that resulted in resident sustaining a right femoral fracture from fall for 1 of 3 (R2) residents reviewed. The facility reported a census of 33 residents. Findings include: 1. According to the Quarterly Minimum Data Set (MDS) dated [DATE], R2 had the following diagnoses: non-traumatic [CONDITION(S)], severe intellectual disabilities, [CONDITION(S)], dementia, and depression. The MDS documented a Brief Interview of Mental Status (BIMS) score of 1, indicating severe cognitive impairment. R2 required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Showed always incontinent of urine, frequently incontinent of bowel, noted no falls, and did not utilize alarms. Review of R2's Care Plan with a revision date of 8/4/2020 revealed she was at risk for falls, needed assistance with transfers and other tasks, cognitive impairment, impaired balance, and poor safety awareness. Required assistance of two staff with transfers, used a tilt back wheelchair for locomotion, dependent on staff to push, and unable to transfer independently. Hand written on Care Plan after fall on 8/4/2020 - transferred to hospital for right femoral fracture-will put in place to wheelchair shower chair backwards out of shower area to avoid this. Review of R2's Electronic Health Record (EHR) revealed the following Progress Notes: a. 08/04/2020 3:06 PM - Fall: the writer (Staff F) was sitting at nurse's station charting when heard CMA knocking on shower house window at 1:52 PM. This nurse entered bathhouse and observed resident sitting on floor in front of shower stall still secured in shower chair. Shower chair had slid up onto resident's back, and resident was sitting flat on her buttocks. Her left leg slightly bent to the side and her right leg bent at a 90-degree angle out. This nurse unstrapped bar and removed shower chair off resident and requested staff get the other Registered Nurse (RN) on duty. This nurse moved resident's right leg to assess alignment; shortening and internal rotation noted. When this nurse asked if her leg hurt resident stated I do not want to talk right now, while placing her hand on her right hip. Staff instructed not to move resident or attempt transfer. CMA remained with resident while this nurse placed call to the hospital and received order to transfer to the emergency room for an X-RAY of her right hip/knee. b. 08/04/2020 at 4:04 PM: received a call from the hospital reporting that resident has a severe right femoral facture and is being transferred to another hospital to consult with orthopedics for possible surgery. c. 08/08/2020 2:20 PM: R2 returned to the facility at 11:00 AM following a right femoral fracture repair. Resident was transported via facility van and 2-pivot transfer from wheelchair. Observation on 6/18/2021 at 11:21 AM, revealed R2 in tilt back wheelchair by the nurse's station. Observation on 6/22/21 at 11:51 AM, revealed R2 in tilt back wheelchair by the nurse's station. Observation on 6/29/2021 at 12:23 PM, Staff E Certified Nursing Assistant (CNA) demonstrated how she would assist a resident in the shower chair into the shower stall. She stated she would put the belt on the resident and then push them forward to the stall. After shower completed she would then push the resident backwards with resident facing her out of the shower stall. There is a black threshold over the change in flooring leading to the shower stall. Visual of shower stall did not find any bumps or areas of uneven tiles. Small mounds/hills were present but not appearing to cause chair tires to catch. The shower chair moved through the shower stall with safety belt in place displaying no issues. Review of the facility's Investigative File revealed the facility investigation determined that policy and Care Plan followed. Interventions put in place-included education to CNAs who provide showers to exit the stall by pulling the resident backward to allow more control over the chair. Maintenance Director purchasing new heavy-duty wheels to prevent the same issue from occurring. Review of the hospital x-ray report dated 8/4/2020 revealed frontal view of pelvis, single frontal view of right femur. Impression: femoral diaphyseal fracture with associated rotational displacement. During interview on 6/29/2021 at 12:23 PM, Staff E stated once she has a resident in the shower chair, she would strap them in with the safety belt and back them in and out of the shower stall. She stated the residents would face her as they go in and out of the shower stall. Staff E stated there used to be bumps in the shower stall but not now. She stated they replaced the flooring about 6 months ago. During interview on 6/29/2021 at 1:49 PM, the Administrator stated she was a Social Worker at the time of this incident. She stated after R2's fall, they changed out the shower chair wheels until they got a new chair with a wider base and they replaced the flooring in the bathhouse. She was unsure if the prior flooring had a bump or anything that would have caused the wheels to catch. Stated she believed it was the wheel on the shower chair that was faulty, caught, and turned sideways which caused the resident to fall forward. She stated after the fall staff were educated on pulling residents backwards down the ramp and out of the shower stall. During interview on 6/30/21 at 9:38 AM, Staff J stated when she arrived in the bathhouse; R2 was already on the floor. She does not remember what the CNA told her happened. She remembered the resident was on the floor and could tell by the way she was sitting that she was uncomfortable. She stated R2 was sitting on her bottom with her right foot by her bottom with some internal rotation noted which is indicative of a hip fracture. The CNA sat with R2 the whole time and provided support for the resident until the emergency management staff showed up. During interview on 7/1/21 at 11:38 AM, Staff I stated she was walking backward out of the shower stall. At the end of the ramp, there was a good-sized hump, by the threshold. She stated the resident sat in the shower chair, with the cross bar across her, the resident was facing her and the chair must have hit that spot on the floor. When they hit the bump/hump the resident went down as staff attempted to hold her up but R2 continued to slide down, off the chair, under the cross bar onto the floor. She stated the center of gravity took the resident down to the ground. Staff I stated she had been giving baths in that shower room for over a year and never had an accident like this. Staff I stated when R2 landed, her right leg was outward and hip looked dislocated. She stated she sat with the resident until she left the facility for the emergency room . She stated after incident with the shower chair, the facility got rid of it and got a new one. The new chair has less chance of tipping with a safety belt and larger wheel span. The facility also replaced the bathroom floor so it is all one type of flooring with no difficulties between flooring transitions. She stated she now pushes residents backwards into the shower stall and when exiting the shower stall she walks backwards out of stall with resident facing her. She concluded that the new floor and chair make moving the residents smoother and less worrisome. 2. According to Admission MDS with a reference date of 12/29/2020 R6's had the following diagnoses: fractures, [CONDITION(S)], coronary artery disease, gastro-[CONDITION(S)] reflux disease, left hip fracture, dementia, malnutrition, depression, and chronic obstructive pulmonary disease (COPD). The MDS indicated she had a BIMS score of 2 indicating severe cognitive impairment. The MDS noted that if R6 required extensive assistance of two staff for bed mobility, transfers, dressing, and bathing. The MDS indicated she was occasionally incontinent of urine and bowel. R6 had a fall in the last month prior to her admission/entry or reentry, had a fall in the last 2-6 months prior to her admission/entry or reentry. The MDS indicated she used a bed and chair alarm daily. Review of R6's initial baseline Care Plan with a date of 12/17/20 revealed she required assistance of 1 staff for dressing, positioning, transfers, and toileting. The Care Plan indicated she ambulated with assistance of 1 staff, walker, and a gait belt. She also utilized side rails while in bed: 2 1/4 side rails for positioning and bed control access, bed mobility. The following interventions listed after her falls: a. 12/17/2020 pull-tab alarm applied, due to resident getting up without assistance. b. 12/19/2020 changed alarm to sensor pad that is hooked to the call light due to resident's agitation. c. 1/4/2021 1:1 supervision during waking hours, pull-tab and sensor pad alarm at all times, 30-minute checks while sleeping. Review of Care Plan with a revision date of 1/14/2021 showed R6 at risk for falling related to diagnoses of dementia, impaired cognition, poor balance, poor judgement, and safety awareness. History of bilateral hip fractures, right humerus fractures, and falls. The Care Plan listed the following interventions: 1/4/21 R6 under 1 to 1 supervision during waking hours. She was to have a pull-tab and sensor pad alarm on at all times, and staff instructed to do 30-minute visual checks on her while she was sleeping. Staff instructed to provide her with an environment free of clutter, ensure her call light within reach at all times, and to keep personal items and frequently used items within reach as able. Staff encouraged to give R6 verbal reminders not to ambulate/transfer without assistance. Review of R6's EHR revealed the following progress notes related to falls: a. 12/17/2020 at 2:20 PM: Admission- resident admitted today via facility van. Resident in wheelchair and transferred to bed. Alert and oriented to self only. Hand grips equal and firm, right foot press stronger than left foot, left leg shorter than right, pedal pulses faint bilateral, with 1+ pitting [CONDITION(S)] to left upper thigh with deep purple/pink bruising from surgical repair of L hip fracture, dressings intact to left lower extremity. b. 12/17/2020 at 5:00 PM: Resident has been up and ambulating by herself with her walker on 3 different occasions this afternoon. Appears very confused and difficult to redirect. A pull-tab alarm has been utilized at this time for resident's safety. c. 12/19/2020 10:30 AM: Resident has been getting up on her own and wandering into hall multiple times this shift. She has been wanting to go home, does not know why she is here, or what she should be doing. Redirected multiple times. Alarm sounded all but one time when resident was carrying pull-tab with her. This nurse educated multiple times on the importance of using call light for staff assistance and not getting up on own. Resident reports she understands but would ask again frequently. In her room there is a sheet typed out by her family to remind her of what is going on and reminded to use the call light. Has been toileted multiple times, her television is on westerns per request, snacks and drinks given. Resident was asked what she likes to do and reported cross words. Staff provided large print cross words and word searches. Staff educated to answer alarms ASAP as resident gets up fast and often not using walker. Walker within reach. Alarm on and call light within reach. d. 12/19/2020 at 2:15 PM: Resident continues to be getting up and down, setting off her personal alarm. At times she uses her walker, other times not. Alarm sounds and staff responds immediately but resident is usually already up and to door. Staff changed her alarm to a silent alarm that sounds to the call light and pagers given to staff. Staff educated to watch pager closely for alarm. Resident educated on new alarm and the importance of waiting for assistance. e. 12/19/2020 at 5:10 PM: Call light alarm activated and CNA responded. Staff called the nurse to her room reporting resident was on the floor. Upon entering room resident noted to be lying on floor, face down. Resident rolled self to back and pillow provided for head. Denies hitting head and no abrasions noted. Resident completed of right hip pain, stated she could not move it. Staff noted that her right leg was shorter than left and rotated out. Resident wanted to get up off floor and the nurse educated that because of the fall and her having pain we have to call the doctor prior. CNA stayed with resident at this time. f. 12/19/2020 at 7:07 PM: the facility received report from the hospital that R6 had a right hip fracture. g. 12/22/2020 at 4:33 PM: R6 readmitted to facility. She was to receive skilled services due to her right hip fracture with repair. R6 is to transfer and ambulate with staff assistance of 2, a gait belt and her walker. h. 12/23/2020 at 7:30 AM: Alarm sounding and staff responded. Resident was sitting in recliner with legs thrown over the side moving in a rocking motion as if resident was trying get out of recliner without assist. The nurse assisted her legs back to proper place, and asked resident what was needed. Resident stated well I think I will leave now, and get some [MEDICATION(S)]. This nurse educated resident that breakfast was coming. Resident denies pain to the nurse and denied need for restroom. i. 12/25/2020 at 11:18 AM: Alarm sounding and resident sitting on the edge of bed attempting to stand without staff assist. The nurse entered room and assisted resident with needs. Resident reported she was heading home, and needed to pay the bill. This nurse explained that insurance was covering the stay. Resident currently in chair with alarms on and functioning. j. 12/26/2020 at 1:36 AM: Resident resting quietly with her eyes closed in her recliner. The footrest on her recliner elevated. Sensor pad alarm in place in recliner, on, and working properly. k. 12/26/2020 at 9:39 PM: Resident was very restless this evening and difficult to redirect from attempting to self-transfer. She was found walking by herself with her walker in the hallway after the sensor pad alarm was activated. Her call light was in reach at the side of her chair. She doesn't comprehend when educated not to self-transfer. She has stood up in her room many times by herself. Will monitor closely. l. 12/27/2020 at 8:13 PM: Resident has been very restless this afternoon and evening. She self-transferred frequently and stood up from her wheelchair activating the sensor pad alarm multiple times. Verbal redirection effective for a short time only. Will continue to monitor. m. 12/29/2020 at 10:03 AM: Resident self-transferring frequently this morning, setting off her alarm. Attempted to meet resident's needs, but continued to self-transfer yelling out help what do I do. Resident brought to nurses station in her wheelchair and provided activity and 1:1. n. 12/29/2020 at 8:05 PM: Alarm sounding, CNA entered room observed resident on the floor, summoned nurse. Upon entering room, observed resident sitting upright on the floor with her back resting against the wall. Resident had her right pant leg pulled up above her knee; 2 pinpoint abrasions noted with scant amount of bleeding present. Denies having new onset of pain. o. 1/04/2021 at 1:24 PM: at 12:15 PM R6 was in her room hollering for help. When staff entered her room observed resident lying flat on her back next to her recliner. She complained of right arm pain. During the assessment, it was noted her right shoulder looked abnormal compared to previous assessments. Resident denies hitting her head no lacerations, bleeding or swelling noted. Denies hip pain. Informed resident not to move, a staff member sat with resident while the physician was notified. The nurse received a verbal order to send resident to emergency room for evaluation and treatment if indicated. p. 01/04/2021 at 3:45 PM: R6 returned to facility from the emergency room . Resident has diagnosis of right proximal humerus fracture. Her arm needs to be in sling at all times, someone at her bedside at all times. q. 01/04/2021 at 5:01 PM: discontinued staff at bed side at all times, started 1:1 supervision during waking hours, pull tab and pad alarms in place at all times, and 30 minute checks while resident sleeping. Review of the facility's investigative file revealed an initial report: Investigation: On 1/4/21, fall occurred at approximately 12:15 PM, found resident laying on the floor on her back with no alarms going off complaining of right shoulder pain. Resident was sent to the emergency room and X-ray confirmed a right proximal humerus fracture. New interventions put in place: 1:1 supervision at all times during waking hours, pull-tab and pad alarms to be in place at all times and 30 minute checks while resident is sleeping. Previous Care Planned intervention to have an alarm under her was in question. Alarm was not present under resident at the time of fall but was unplugged and placed in her wheelchair. Review of the radiology report completed on 1/4/21 revealed 2 views of the right shoulder performed. Findings included: comminuted fracture (a break or splinter of the bone into more than two fragments) of the proximal (situated near the center of the body) humerus with the fracture predominantly involving the surgical neck. During interview on 6/22/2021 at 12:22 PM, Staff A stated R6 required a lot of assistance with cares and would try to get up on her own. Resident was on 1:1 supervision for a while because constantly trying to get up on her own. She stated resident's personal alarm would go off and by the time staff would get down there resident would already be on the floor. Stated R6 did not require much assistance when transferring because she would assist by using her walker and depending on the day, compliant with waiting for help. Resident would usually not use call light but had bed and chair alarm. She stated the bed alarm was like a mat on her mattress and the same for her chairs and at one time resident had a pull-tab, they had trialed many different options. She stated R6 had a lot of falls and on the day in question, they were in the middle of lunch; staff had just peeked in on her before going to the dining room about noon and resident was in her recliner, with feet elevated. Did not see her alarm but also was not looking for it. Next thing she knew DON came out and said resident was on the floor. Staff A stated she did not hear alarm go off from the last time she saw her to when she saw the DON come out of resident's room. Stated that resident's room was the first room down the 100 hall, if the alarm had sounded, would not have been able to hear it in the dining room. However, if others were around that area like the nurse's station they would hear it. During meals, they always have one aide or nurse on the halls to answer call lights while the other staff are assisting residents with their meals in the dining room. Stated she did not remember if resident messed with her personal alarms, if she would unplug them, turn them off, or move them from the chair or bed. She believed there might have been one time where she did and thinks that is why they did the pull-tab alarm. During interview on 6/29/2021 at 11:53 AM, Staff F, RN advised that R6 was alert to herself only, had dementia, was non-compliant with call light use and would self-transfer a lot. R6 was an assistance of 1 staff, and was unsure if she had personal alarms when she first admitted to the facility. Staff F indicated they ended up putting a personal alarm on her because of her frequently self-transferring. Stated room was located at the beginning of the 100 hall towards the nurse's station. Staff F indicated that during meal time there is supposed to be a staff member on the hall and if that person was not in a room and her alarm went off they would have heard it. She stated that she never had issues with resident messing with her alarms when she was there. She did recall an event, on her day off, where the resident had taken the pull-tab off. During interview on 6/29/21 at 12:23 PM, Staff E CNA stated R6 admitted to the facility with a hip fracture, fell again, and had to go to the hospital. According to Staff, E R6 required assistance of 1 staff, would self-transfer, and not use her call light. Staff E provided that she had alarms on her bed and chair. She stated R6 would disconnect the alarm cords but the alarm would still sound. She indicated that R6 would not mess with the alarms in a way that would not allow them to function properly. She was not present at the time of the incident; she was off the clock at that time. Staff E stated she did not hear the alarm going off due to the bathhouse being soundproof, she added she could not hear anything outside of the bathhouse. During interview on 6/29/2021 at 1:49 PM, Administrator stated on 1/4/2021, they started to do 1:1 supervision with R6 during the waking hours and completed 15-30 minute checks while she slept. She believed it was Care Planned that way. She was unsure but believed that R6 had personal alarms prior to the fall on 1/4/2021 but would have to look to confirm for sure. She was unsure if the alarm sounded that day because it was a Sunday and she was not in the facility. The Administrator stated she did not personally know if R6 had messed with her personal alarms but did know she was fidgety and anxious. R6 had a hospital bed and was not sure if discussed for her to have a high-low bed; she would need to talk to the clinical staff about that. She stated R6 was non-compliant with the use of her call light and had a short recall of 15 seconds, it seemed. During meal times, not all staff are in the dining room because there are residents that chose not to go to the dining room and they need someone on the floor to monitor lights. During interview on 6/29/2021 at 2:17 PM, DON stated that after R6's first fall they put pull alarms on her and believed they were checking on her more frequently, like every time staff would go down the hall. The alarm that they used was a pad alarm that went under her bed sheets or on top of her chairs. The DON indicated staff usually in her room because she was hollering or her call light was on; she would not sit still. After the fall on 1/4/21, they initiated 1:1 supervision while she was awake and if she were asleep, they would do 30-minute checks. A majority of her falls happened when she was trying to get out of bed; believed one may have been when she was trying to get out of her recliner. R6 had a hospital bed with side rails; she had the half rail at the top of the bed according to the DON. She advised she was not aware if a high-low bed discussed for this resident and believes that they did not think of it because she would still get up all the time. DON stated that R6 loved to watch The Lone Ranger on her television, with her door closed and lights dimmed. She felt she was overstimulated with people going up and down the halls, the call light sounds etc. She said when she was 1:1 supervision they were working on trying to decrease the stimulus for her. She stated on 1/4/21 around lunchtime staff had brought meal trays down the hall and the loudness may have been what triggered R6. She stated she would have assumed the alarm went off but did not do the investigation so not positive. The DON stated during meals, they always have at least one staff left on the floor to answer call lights, alarms, and assist residents' needs while the other staff in the dining room. During interview on 6/30/21 at 11:14 AM, Staff C stated on 1/4/21 about lunchtime she heard R6 yell for help, R6 had transferred herself and lost balance. She did not remember if R6 alarm was going off or not and was not sure if R6 had alarms before this incident. R6 would transfer herself a lot. Staff C stated after she returned from the hospital that day she was 1:1 supervision with alarms. R6 had an alarm in her chair, not sure if it was there after or before the fall where she fractured her shoulder. She had fallen before this time, which was when she broke her other hip or leg. Stated on the day of her fall the last time she saw her was when she gave her morning pills about 8am. R6 was confused at times, did not use call light often, very spontaneous so staff would remind her to use light and ask for help but she would not remember to do so. Staff C indicated once they started doing the 1:1 supervision that seemed to help with her not self-transferring, she would still attempt, but someone would be right there to help. When asked if she felt the facility did everything to prevent this fall, she said she thought so. During staff interview on 7/1/21 at 11:30 AM, Staff D CNA stated on 1/4/21 R6 fell that day and had fallen a lot previously. She stated her personal alarm, which was a pressure pad, was under her the last time she saw her that early morning. Staff F did not think she was around when R6 had fallen later that day. She stated R6 would always move about in her room and would get up on her own. The alarms would go off a lot, if it were in place. R6 was very confused and her steadiness was dependent on her day. She stated that she was normally not on the hall unless a call light was going off. She indicated she believed that fall happened because the staff that was on the hall that day, Staff H was always on her phone, never doing what she was supposed to be doing, which was why others staff members, had to go down that hall to help. During interview on 7/1/21 at 1:24 PM, Staff B stated she did not remember much about the fall that happened on 1/4/21 with R6, just that it was between breakfast and lunch. She stated, she had just delivered lunch, found R6 standing up in room and it looked like she could not get the footrest on her recliner to go down. The resident stated she could not get the chair to go down. She provided there was no alarm going off while she was in R6's room. She added she did not know she required staff assistance while up in her room. Once she sat R6 back down in her recliner, she sat up her lunch and left room. She stated she left R6 in her room in the recliner, with her lunch tray, and her footrest down. While the resident was standing up, she did not remember if she saw an alarm pad in her chair. She added she had heard an alarm going off before while on the hall because she saw staff going in a lot. Staff B stated R6 seemed restless while in her room. During interview on 7/7/2021 at 11:05 AM, Administrator stated R6 liked to mess with the alarms, the facility investigation concluded that the alarm was in her wheelchair not alarming. She stated through their interviews the staff that had been in the room before the fall and stated the alarm was in place. Review of the facility's Safety Alarm Policy dated 8/2015 revealed the purpose of this policy is to maintain resident safety with the least restrictive method possible. Ensure the clip is correctly positioned and attached, check that the alarm is on, and functioning; should be done at a minimum of every shift. This should be documented on the Medication Administration Record (MAR) 3. According to the Quarterly MDS with a reference date of 1/5/21, R7 had the following diagnoses: progressive neurological conditions, [CONDITION(S)] disease, dementia, anxiety, depression, and [CONDITION(S)]. R7's BIMS score and his cognitive skills for daily decision-making not assessed during this review. The MDS indicated he required extensive assistance of 2 staff for bed mobility, transfers, walking in his room, when toileting and utilized a walker. The MDS indicated he had an indwelling catheter and was frequently incontinent of his bowels. The MDS indicated he had a fall since he was admitted to the facility, has had two or more falls with no injuries, he had two or more falls that resulted in an injury (except major injury), and no falls that resulted in a major injury. According to the MDS Resident used a bed, chair, and wander/elopement alarm daily. Review of Care Plan with a revision date of 7/20/2020 showed R7 at risk for falls due to history of falling, self-transfers, walking without assist of walker or staff and his diagnosis of [CONDITION(S)] disease. Interventions of recliner chair changed to regular chair, a sensor pad alarm put in bed and on chair/wheelchair at all times. Staff to offer a lap blanket when in his chair; his bookcase moved next to recliner with DVDs, handgrip lite reacher given to resident and he demonstrated he knew how to use it. Staff to complete fall risk assessments quarterly and as needed. Increase supervision and assistance based on resident needs, assist with walking and encourage nonskid footwear, staff are to anticipate needs as able; 1 assistance with transfers and ambulation with walker; uses wheelchair at times for long distances; and remind him to use call light for assistance. Review of R7's EHR revealed the following progress notes related to falls: A. 02 /02 /2021 at 1:45 PM, the nurse was called to R7's room. Staff had reported resident was on the floor after staff responded to a sounding alarm. b. 02/06/2021 at 11:40 AM, R7's chair alarm sounding. Upon entering room, observed resident on his bottom slightly leaning toward to the left, left arm resting on trash can. Resident was on the floor in front of his recliner; bed alarm on, in place and working properly. c. 02/08/2021 at 3:50 PM the nurse was called to R7's room by staff reporting alarm was sounding and resident was found on the floor. Upon entering room resident noted to be on hands and knees in front of recliner. d. 02/12/2021 at 10:06 PM R7's bed alarm was sounding. Upon entering room observed resident standing up next to the bed. e. 03/06/2021 at 11:19 PM staff responded to a call light in resident's room and found him on floor sitting next to the bed. The bed alarm was not placed on his bed. Review of R7's progress notes revealed they lacked documentation of him messing with his personal alarm. During interview on 7/6/2021 at 2:34 PM, Administrator stated they do fall risk assessments with the MDS reviews. In a follow-up interview on 7/7/21 at 11:05 AM, she stated R7 would take the alarms off. She stated he has had a lot of falls because he likes to self-transfer a lot. Nurses have told her he has had the alarm on a majority of the time but he also messes with it.

Based on clinical record review and staff interviews, the facility failed to provide adequate nursing supervision as planned by the use of personal safety alarms which resulted in further falls, one which resulted in fracture, for 1 of 2 discharged residents reviewed (Resident # 3). The facility identified a census of 44. Findings include: 1. The Medicare 5 day/discharge Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED].#3. The same MDS documented the resident admitted to the facility for Medicare A skilled services on 9/15/17. He required the assistance of 2 for transfers, bed mobility, dressing, hygiene and toilet use. The resident did not walk and depended upon staff for wheelchair mobility. The assessment documented he fell in the last month prior to admission, suffered a fracture prior to admission and fell on ce without injury, once with a non-major injury and a third time with major injury since admission to the facility. The facility did not develop an initial care plan to direct staff on the resident's individualized care needs. The Resident Progress Notes dated 9/15/17 at 12:30 PM documented the resident as alert and oriented to person, place and time and he admitted to the facility for strengthening and care for his [MEDICAL CONDITION]. The resident currently received blood thinning medication, transferred with the assistance of one and a gait belt for transfers, had touch-toe weight bearing on the left leg and could not take tub baths or whirlpools due to the [MEDICAL CONDITION]. The resident's Fall Risk Assessment, dated 9/15/17 and completed by the Director of Nursing (DON), documented a score of 9 (ten or above represents a high risk for falls). The Resident Progress Notes dated 9/16/17 at 2:27 PM documented Resident #3 had six intact staples to an incision on the left hip, five intact staples to a second left hip incision and three intact staples to a third incision on his left hip. An Event Report completed by Staff D, Registered Nurse (RN), on 9/17/17 at 6:01 AM documented Resident #3 got out of bed and was found on his knees on the floor at 5:53 AM. Staff D noted no resident injury and documented she placed a bed alarm on the resident's bed. Review of the Resident Progress Notes revealed no entry regarding this event completed by Staff D. Review of the Resident Progress Notes dated 9/17/17 at 4:50 PM documented the resident found on the floor at 7:30 AM and he denied falling to the left side. Staff E, RN, documented no new injuries upon a check of the resident. Staff E recorded she instructed the resident and his spouse on the use of the call light to alert staff and she informed the resident's son an alarm had been placed to remind Resident #3 to use the call light for assistance with getting up. The Resident Progress Notes entry dated 9/17/17 at 4:53 PM documented the resident's son reported Resident #3 had increased discomfort in the right hip and lower leg. Staff E contacted the on-call physician. The Resident Progress Notes entry dated 9/17/17 at 7:13 PM documented the resident self-transferred to the bathroom and fell in front of his bed. Three staff assisted him off the floor, the resident denied pain or discomfort and moved without difficulty. Staff E contacted the on-call physician regarding this fall. A mobile X-ray arrived at the facility at 11:58 PM and obtained an X-ray of the resident's right hip. An entry dated 9/18/17 at 12:24 AM documented Resident #3 had a impacted [MEDICAL CONDITION] femoral neck (right [MEDICAL CONDITION]). The resident transferred to the hospital by ambulance after physician notification of the x-ray results. During interview on 2/16/18 at 10:05 AM, the DON stated Staff D documented placement of a bed alarm as an intervention for the fall that occurred on 9/17/17 at 5:53 AM. During investigation of the fall, the DON found out the bed alarm had not actually been implemented because the resident was already in bed. Staff D placed the alarm and pad on the resident's bedside table instead. When the DON interviewed Staff E for the subsequent falls she determined the bed alarm had not been implemented by other staff throughout the day and the alarm remained on the resident's bedside table. The DON stated Staff D received disciplinary action for failing to implement the bed alarm at the time she documented it's use.

Based on record review, observations, review of Wanderguard user instructions and staff interviews, the facility failed to provide adequate supervision for 1 of 4 wandering residents wearing an inactive Wanderguard device.(Resident #1) which resulted in the resident eloping from the facility, falling and fractured a femur (thigh) bone. The facility reported a current census of 39 residents. Findings include: Record review of the facility Elopement-Alarm Device guidelines (not dated) identified when a resident is at risk, the resident will be issued an alarm bracelet to prevent elopement. The alarms will be checked daily and the door alarms will be checked weekly. 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS reflected the resident had a BIMS (Brief Interview for Mental Status) score of 4. A score of 4 identified the resident had a severe cognitive impairment. The MDS reflected the resident had [DIAGNOSES REDACTED]. The resident required assistance of one staff person for bed mobility, transfers and ambulation. The resident required extensive assistance of one staff person for toileting. The assessment reflected the resident had a history of [REDACTED]. The Care Plan dated [DATE] identified a problem with the resident being at risk for elopements due to wandering and opening exit doors. The interventions directed the staff to check the Wanderguard (device to keep the resident safe) daily to ensure functioning properly, change per protocol and redirect the resident as needed, the resident is to be accompanied when outside, reflective bathroom stickers are on the resident's bathroom door, motion light in the resident's room and bathroom and moved closer to the nurse ' s station on [DATE]. The Incident Report dated [DATE] at 4:30 AM, reflected staff found Resident #1 outside on the facility grounds, approximately 10 feet from the van shed and lying on his/her right side. The staff person identified the resident ' s skin as warm, alert and confused and showing symptoms of pain to bilateral (both) hips, right shoulder and left knee. The resident stated, had to go to the bathroom. The report identified the air temperature registered about 75 degrees and the ground moist from dew. The nurse notified the physician and received orders to have the resident transported to the hospital. The Nurse's Notes dated [DATE] at 9:02 AM reflected the nurse telephoned the hospital for an update on the resident's condition. The hospital nurse informed the facility the resident had a fractured femur (thigh bone) and was being transferred to another hospital. During an interview on [DATE], the State Climatologist stated, on [DATE] at 7:35 AM, the Shenandoah airport reported a temperature of 73 degrees, wind out of the south at 9 miles per hour (mph), and clear skies. On [DATE] at 2:00 PM, Resident #1 returned to the facility from the hospital. Observation of the resident at 4:15 PM identified the resident as pale, asleep in bed with a sensor activated alarm under the resident. During an observation on [DATE] at 11:15 AM, found the resident up in wheelchair, sitting in the commons area and alert but very confused. The resident ' s legs were elevated on leg lifts, with a sensor alarm noted and activated. Review of the Wanderguard Departure Alert System user instructions that came with each wander guard bracelet identified the following warning: Do not use more than one signaling device on a resident. Two signaling devices, if brought very close together, may not be received by the door monitor and the alarm will not sound. During an interview to the Stanley Healthcare Solutions Technical Service desk on [DATE] at 1:25 PM, the technician stated the wand works with similar signal as the door delivers. The tech stated the staff are not to use the wand close to another device while checking function of a device. On [DATE] at 5:30 PM, Staff F, Certified Nursing Assistant-Certified Medication Aide (CNA-CMA) was interviewed and stated she had switched out the Wanderguard alarms when they (the alarms) had expired. Staff F stated she would use the wand to check activation of them, she did not look at them, and she just went by the response of the wand. Staff F stated she had just learned not to check the function of the alarm, if another resident wearing an alarm is within 4 feet. Resident #1 was friends with another resident, that also had the same Wanderguard alarm and she would check them together at times. Staff F stated she had not read the instructions that accompanied the Wanderguard alarms. On [DATE] at 5:30 PM, Staff A, CNA-CMA stated she had worked at the facility for many years. She stated Resident #1 would be up and down, in the halls, sitting up front or up to a bathroom. She would offer the resident assistance to use the bathroom, offer him/her food or fluids to assist the resident to relax. She stated the resident walked with a limp and usually used the hand rails when walking in the halls but ambulated pretty good. Staff A stated the resident had been up before that night and found in another resident ' s bathroom which was not usual for the resident. Staff A stated she had finished cleaning the wheelchairs around 3:30 AM and then checked the residents living in rooms in the 200 hall. Staff A stated she found Resident #1 asleep in bed. She and Staff C were at the nursing station along with the nurse when Staff C went to check on Resident #1. Staff C found the resident not in bed so they began a search of the building. Then the nurse gave her a flashlight and she went outside using the 200 hall exit door. The door alarmed, the nurse turned it off at the panel as she went on outside. She found the resident not far from the door, lying in the grass. Staff A stated she immediately called for the nurse and an ambulance after an assessment showed signs of injury. She stated the resident had on a pajama top and no bottoms, barefoot and shoes next to his/her feet. The resident laid on his/her right side, confused and not cooperating with the assessment. Staff A stated she did not hear any alarms that night except when staff came back inside from break at around 1:00 AM. She stated it was a quiet night. The resident had a bed sensor alarm that staff found on the headboard. Staff A stated she did not hear that alarm either. On [DATE] at 6:30 PM, Staff B, Licensed Practical Nurse (LPN) was interviewed and stated, when staff realized Resident #1 was missing and they could not find the resident, she gave Staff A, a flashlight to check outside. Staff B stated she went out the 200 hall door since that is the one that the resident would frequently try to exit from. Staff B stated the resident was found immediately and was confused to the point of combativeness and unable to do an assessment. An ambulance and physician was notified and the resident was taken to the hospital. Staff B stated she did not hear any alarms that night. Staff B stated she had last seen the resident at 4:00 AM (asleep in bed) and staff found the resident at 4:25 AM. Staff B stated she knew the resident would take off the alarms. The resident would routinely wander in the hall ways during the night. On [DATE] at 7:00 PM, Staff C, CNA, stated she did not hear alarms at that time of night. Staff C stated she was unsure how the resident got outside, without any staff knowing. She stated she just had a feeling to check on the resident, when she did. During interview on [DATE] at approximately 12:00 PM, Staff E, Registered Nurse (RN) stated they (the staff) are to visually check each Wanderguard to be sure the button is depressed. Staff E stated the staff are not to check the function of the Wanderguards if two residents with a Wanderguard bracelet are close to each other. The staff are to assure the Wanderguards are at least 4 feet apart when checking their function. Staff E stated she had not read the insert that comes with the Wander- guard. Staff E stated she had just learned of the new interventions after the incident. On [DATE] at approximately 12:00 PM, Staff D, LPN was interviewed and stated she learned of the new interventions for preventing elopement after the elopement had occurred. The staff are to visually look at the bracelet and make sure the button is depressed. When the button is depressed, the alarm is activated. Staff D stated she had not read the information in the packet when she opened a new Wander Guard bracelet. The Administrator reported the elopement to the Department of Inspection and Appeals and performed an investigation. The Administrator informed the Department, the resident ' s device had not been activated at placement on [DATE] and when staff checked both the roommate ' s device, the resident ' s device and the door, it homed into the roommate ' s device; Resident #1 did not have an active Wanderguard, because the bracelet button had not been depressed to identify activation. Note: At the time of the complaint investigation, the complaint was coded at a J, immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the G level. The nursing staff are to check the fire doors every day, check the Wander Guards visually and with wand twice a day. Residents with Wander Guard bracelets should be 10 feet apart when checking the bracelets. The facility Administrator provided an inservice to the nursing staff regarding the following: · Review of the elopement policy/wandering residents, · Procedure for when to change and activate the Wanderguard devices . · Procedure to follow when a door has malfunctioned and notification to the proper personnel. · Documentation for checking the doors and the devices. · Procedure for elopement risk assessments. · Procedure for checking a door when an alarm sounds. As of the [DATE] exit conference, the facility needed to continue to inservice the nursing staff of the following: · Continue to monitor the nursing staff to ensure the policy/procedures for checking doors and Wanderguard bracelet devices are being following. · Continue to monitor the nursing staff to ensure the facility policy/procedures are followed when a resident elopes.