Every finding on record at The Blossoms at Oakdale Rehab & Nursing Center

Based on interviews, record review, and facility document review, it was determined that the facility failed to ensure a resident with a pressure ulcer received the necessary treatment to promote healing for one (Resident #110) of one resident. The facility received Resident #110 with a stage III ulcer on 03/13/2025. The first documented applied dressing was on 03/24/2025. The findings include: A review of the admission Nursing Evaluation, completed by Licensed Practical Nurse (LPN) #1, indicated the facility admitted Resident #110 on03/13/2025 from the hospital with diagnoses that include: pneumonia, sepsis. The admission Nursing Evaluation indicated Resident #110 was able to ambulate with the assistance of one person, used a wheelchair, moved in bed with the assistance of one person, was continent of bowel, had episodes of incontinence of bladder, utilized the toilet. Resident #110's skin was dry, fragile, with discoloration and presence of wounds. Description indicated areas of concern such as both arms, and feet, the left knee, the top of head and a wound to coccyx with the dressing clean, dry and intact (C/D/I) upon admission. No measurements of description of coccyx wound indicated. A review of the Medical Diagnosis indicated Resident #110 was admitted with diagnoses that include: sepsis, muscle wasting immunodeficiency due to drugs, and atrophy, muscle weakness, pneumonia, kidney failure, adult failure to thrive, cachexia (wasting syndrome that causes significant unintentional weight loss), malnutrition, and nondisplaced sacrum fracture. The Admissions Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/17/2025, revealed Resident #110 had a score of 6 which indicated the resident had severe cognitive impairment. The MDS indicated Resident #110 had no impairment to arms or legs, used a wheelchair for ambulation, required partial to moderate assistance for lower body dressing, toileting hygiene and all mobility including rolling, sitting and lying. The MDS indicated Resident #110 had a pressure ulcer/injury over a bony prominence, a risk for developing pressure ulcers, an unhealed pressure ulcer and a Stage III ulcer present. A review of Resident #110's Baseline Care Plan, initiated on 03/13/2025, by LPN #1 revealed the resident had current skin integrity issues such as pressures to coccyx, open areas and scabs to bilateral arms and scab to right knee. Interventions were not included. A review of the comprehensive Care Plan Report initiated on 03/14/2025 indicated Resident #110 was at increased risk for alteration in skin integrity related to decreased mobility, falls and malnutrition. The care plan stated Resident #110 was admitted to the facility with Stage III pressure to coccyx. Interventions included weekly measurements and documentation, administer wound care treatments per MD orders. Interventions for the Stage III pressure ulcer included to provide treatment as per MD orders, reposition frequently, monitor for sign and symptoms of infection; to evaluate and change treatment as needed and the treatment nurse or charge nurse would report any new skin integrity issues or concerns to the MD as needed. A review of Medication Administration record, (MAR) revealed on 03/14/2025 Resident #110 was started on a multivitamin, a liquid protein, a water-soluble vitamin, an essential mineral for wound healing regimen. Resident #110 was placed under enhanced barrier precaution on 03/20/2025. A review of Treatment Administration Record (TAR) revealed Resident #110 had an order initiated on 03/13/2025 to monitor coccyx wound for pain, sign and symptoms of infection and dressing intactness until resolved. On 03/21/2025 an as needed order was initiated to clean stage III pressure injury to sacrum with wound cleanser or sterile water, pat dry, apply a layer of [medicated honey ointment], then apply collagen particles and cover with a bordered foam dressing Monday, Wednesday, and Friday as needed. No initials are documented to verify the dressing was placed. On 03/24/2025 an order was given cleanse the Stage III pressure injury to sacrum with wound cleanser or sterile water, pat dry, apply a layer of [medicated honey ointment], then apply collagen particles, cover with bordered foam dressing Monday, Wednesday, and Friday. The first signed date for treatment was 03/24/2025. A review of a Weekly Skin assessment dated [DATE] and 03/25/2025 indicated Resident #110 had an existing wound and an updated weekly wound evaluation should be completed for each existing area of loss and to follow the resident's current skin care interventions. A review of Skilled Documentation for 03/15/2025 and 03/17/2025 indicated Resident #110 had one or more unhealed pressure ulcers at a Stage I or higher and a wound to the sacrum. Skilled documentation for 03/20/2025 indicated Resident #110 had one or more unhealed pressure ulcers at a Stage I or higher with no further descriptions indicated. A review of the Nursing Home Progress Note, completed by the Physician on 03/20/2025 indicated Resident #110's skin had no rash/lesions, skin was warm, dry and of good turgor with no redness or discoloration. No documented indications of a wound. A review of the document titled Progress Notes by the Physician on 03/27/2025 indicated Resident #110 had a Stage III pressure ulcer to the sacrum with orders given for treatment. A review of a submitted document titled Letter from Physician indicated a statement from the physician which revealed, On 03/20/2025, there were no wounds based on initial exam nor was any noted on the body audit noted in the chart. A review of the Hospital Record from 03/10/2025 indicated Resident #110 was admitted to the hospital on [DATE] from home and discharged to the facility on [DATE]. The emergency department assessment indicated there were no rashes, or lesions noted and no wounds. On 03/11/2025 at 10:19 AM, the wound assessment indicated Resident #110 had a stage III pressure injury to the sacrum that measured 3.4cm in length and 2.4 cm in width, margins were well defined, surrounding skin tissue was purple and warm. During an interview on 07/14/2026 at 12:45 PM, the Treatment Nurse indicated if there was a pressure sore identified on a resident, treatment should be initiated immediately or within the first hour. The Treatment Nurse stated, A skin audit consists of a head-to-toe assessment where you would remove all clothing and bandages, document, measure and implement orders. The Treatment Nurse indicated that the facility does have standing orders but a call for a verbal order on a Stage III pressure ulcer should be made. The Treatment Nurse accessed Resident #110 Electronic Health Record (EHR) in [the facility electronic charting system] and indicated there were no weekly wound assessments completed for Resident #110. During an interview on 07/14/2025 at 8:34 PM, LPN #3 indicated she did not recall Resident #110. LPN #3 indicated a body audit was completed on admission, any existing dressing would be removed to obtain measurements and to document the size and shape of any area of concern. LPN #3 indicated that everything would be documented on the assessment nursing evaluation. LPN #3 indicated if a stage III pressure ulcer was present, she would call the doctor for orders. LPN #3 indicated some residents come with orders if they are admitted from a hospital or hospice. LPN #3 indicated the previous treatment nurse was Terminated for not doing her job. A review of the form titled Personnel Change Form indicated LPN #4, the Treatment Nurse that was employed during Resident #110's stay at the facility, was terminated on 06/18/2025 for poor job performance. During an interview on 07/14/2025 at 8:49 PM, LPN #1 indicated that the skin audit was completed upon admission. The head-to-toe assessment would be documented in [the facility electronic charting system], and the dressing would be removed to complete the assessment. If an opened area was present, the findings would be documented, and a treatment order would be placed. LPN #1 was unable to recall Resident #110. During an interview on 07/15/2026 at 10:05 AM, LPN #2 indicated, if a treatment order was received, she would initiate the treatment right then. LPN #2 indicated she would call the doctor for a verbal order if needed, until the doctor made his rounds on Thursdays. During an interview on 07/15/2026 at 11:30 AM, the Physician indicated, he the sees all his residents on Thursdays. The Physician indicated he was available to be called for orders and nurses could send pictures and he would ask for measurements for all wounds. The Physician indicated he went by body audits on his Thursday's rounds. The Physician indicated he saw Resident #110 on 03/20/2025 and there were no wounds present. During an interview on 07/15/2026 at 11:56 AM the Director of Nursing (DON) indicated a body audit was completed by the floor nurse as soon as the resident was admitted . She indicated the body audit was completed from head to toe, and dressings were removed. The skin was assessed for blanching areas, tears, tattoos, bruising, and moles and the Treatment Nurses measures wounds on admission or within 24 hours. She indicated the physician would be called for an order if a Stage III pressure ulcer was present. The DON indicated all documentation of orders, treatments and measurements were entered into [the facility electronic charting system]. She indicated the facility does not document anywhere else. During an interview on 07/15/2026 at 12:07 PM the Assistant Director of Nursing (ADON) indicated she made rounds with the Physician when he saw his residents. She indicated she gets the resident wound list from the Treatment Nurse. The ADON looks at the progress notes and the weekly wound assessments to decide which resident(s) needed to be seen. ADON indicated if a treatment order was placed on the TAR, the treatment should be completed right then, and all treatments and dressing changes were documented on the TAR. During an interview on 07/15/2026 at 2:45 PM the Administrator stated that the professional standard of care would be, If they saw a wound they should address it right then. The Administrator indicated there was a Treatment Nurse in the facility Monday thru Friday and any nurse could call a doctor for orders. The Administrator did not recall the reason for LPN #4's termination. During a second interview and concurrent document review on 07/15/2026 at 1:31 PM the DON stated she did recall Resident #110, and Resident#110 had a deep tissue injury that was being monitored. Review of a document titled Facility Provided Information, dated 03/17/2025 indicated Resident #110 had a suspected Deep Tissue injury (DTI) measuring 4.0 x 5.2, on a handwritten body audit record completed by LPN #2. The document included a written statement by LPN #2, stating a verbal order was received for Resident #110's coccyx from the Physician. The dressing was applied on 03/21/2025 after the wound opened. The document also included an Orders Details page with an order received on 03/21/2025 for a dressing to Resident #110's coccyx for a Stage III pressure ulcer with a start date of 03/24/2025.

Based on observation, record review, and interview, the facility failed to ensure that food was dated properly, food was sealed properly, drip pans under the stove top were cleaned, and that cross contamination did not occur during 2 of 2 observations in the kitchen. The findings are: On [DATE] at 10:22 am, in the dry storage area a large, opened bag of elbow pasta was not sealed, Dietary Manager confirmed this finding and stated that it is approximately eight pounds of pasta. On [DATE] at 10:26 am, a fifteen-pound box of dinner rolls was not sealed, left opened in the walk-in freezer. The Dietary Manager confirmed the findings. On [DATE] at 10:30 am, a gallon pitcher of reconstituted milk was in the double door fridge with no date. The Dietary Manger verified it was not dated. On [DATE] at 10:32 am, in a two-door cooler, a five-pound bag of shredded mozzarella cheese was observed with no receive date or open date. The Dietary Manager confirmed that the dates are missing and roughly a pound left in the bag. On [DATE] at 10:36 am Dietary Manager pulled out drip pan covered in foil from under the stove, the surveyor observed large splotches of brown and black matter. Surveyor observed large chunks of food on the drip pan. On [DATE] at 11:50 AM, the Surveyor observed the dietary cook while getting temperatures on the steam line, the unsanitized body of the thermometer touched the mechanical-soft textured chicken and riblet. On [DATE] at 12:56 PM, the Surveyor observed the Dietary [NAME] had mashed potato on the fingernail of their ungloved right hand. The mashed potatoes fell into the regular mixed vegetables intended to be served to the residents at 1:00 PM. On [DATE] at 2:30 PM, the Dietary Manager stated that food needs to be sealed proper to keep bugs and contaminants out. They then stated that food should be labeled with receive and open dates, so the staff does not use expired food and that staff knows when it was opened. The Dietary Manager then stated that the drip pans under the stove top are to be cleaned nightly and on Monday it was covered in a lot of dried food matter. The Dietary Manager stated that food should not be touched by anything to prevent cross contamination to prevent people from getting sick. On [DATE] at 08:05 AM, the Dietary [NAME] stated that food should not be touched by hands or items to prevent cross contamination and that it ' s an infection control risk. Review of a facility policy titled, Used By Guidelines dated on [DATE] indicates All opened containers of food in the dry storage area should be place in an enclosed container and labeled with content, date opened and use by date. Review of a facility document titled, LC Cleaning List with no date indicated, Clean stove top and drip pan/burners after every meal.

Based on interview and record review the facility failed to ensure a resident's Advance Directive was signed by resident or resident's power of attorney regarding the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 (Resident #49) of 1 resident reviewed for advanced directives/ The findings are: Resident #49 ' s Minimum Data Set with an Assessment Reference Date of [DATE], identified the resident as having a Brief Interview for Mental Status (BIMS) of 12 , a score of ,d+[DATE] indicating the resident has moderate cognitive impairment. Resident #49 ' s Care Plan identified the resident's Brief Interview for Mental Status (BIMS) score was 9 indicting moderate cognitive impairment on [DATE]. Resident #49 medical diagnoses, as identified on the resident's Order Summary Report , included type 2 diabetes mellitus; hypertension; depression; chronic kidney disease; abdominal pain. On [DATE], at 02:16 PM, a review of Resident #49 ' s Physician Order dated [DATE] revealed an order of Do not resuscitate (DNR). On [DATE] at 02:23 PM, a review of Resident #49 ' s Care Plan reflected the resident ' s code status to be Do not resuscitate (DNR), with a date initiated [DATE], with an intervention for DNR status: Check the resident's/responsible party signature on consent form. Verify physician's orders. Check for DNR status indicated on the resident's profile/face sheet. Date Initiated: [DATE]. On [DATE] at 2:00 PM a review of Resident #49 ' s DNR form signed and dated by a friend, indicating Resident #49 does not want Cardiopulmonary Resuscitation (CPR). This form is signed by Friend. Per the record review, this Friend does not have Power of Attorney (POA) for Resident #49. On [DATE] at 2:00 PM, the Administrator said the friend does not have POA for R 49 per record review and Administrator interview. The Physician signed the order on [DATE]. On [DATE] at 2:00 PM, the record review of a document titled, Do Not Resuscitate/Cardiopulmonary Resuscitations DNR/CPR Instruction and Physician Order signed on [DATE] by the same friend, was marked I do not choose to formulate or issue any Advance Directives at this time. A review of the Admission Packet, dated [DATE], reflected the resident signed the forms pertaining to Resident #49 ' s influenza and pneumococcal vaccines, but he did not sign the DNR forms. On [DATE] at 2:57 PM, the Administrator reviewed the DNR for Resident #49 in the electronic record on his computer and said, I do not know if this document is legal or not.

Based on observation, record review, and interview, the facility failed to ensure that the environment was clean and hazard free on the secure unit (200 Hall) affecting 14 residents. A review of the facility policy titled Accidents and Hazards Policy, with a review date of 01/2024, indicated the facility strives to ensure that the resident environment remains as free of accidents and hazards as possible. A review of the facility document titled Housekeeping 200 Hall Cleaning Schedule, undated, indicated that handrails are included in the cleaning check list. On 01/14/2025 at 9:19 AM, the surveyor observed in room [ROOM NUMBER] that the vents were missing on the air conditioning and heating unit for the room, exposing metal edges and electrical components to Resident #60 who resides in the room. On 01/14/2025 at 9:27 AM, the surveyor observed in room [ROOM NUMBER] that the air conditioning and heating unit cover was off on top, exposing metal edges to Resident #73 who resides in the room. On 01/14/2025 at 9:30 AM, the surveyor observed the handrails on 200 halls, the inner part had dust, debris, and food wrappers inside it, throughout the length of the hallway. On 01/14/2025 at 10:05 AM, the surveyor interviewed the Housekeeper, who stated that the inside of the handrails looks like they have not been cleaned in a while. The Housekeeper stated that the handrails were dusty and have debris inside them. The Housekeeper confirmed cleaning the handrails is part of their check list to do. On 01/14/2025 at 10:09 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #9, who stated that the air conditioning and heating units in rooms [ROOM NUMBERS] have sharp edges, and the one in room [ROOM NUMBER] could be a shock hazard due to exposed electrical components. CNA #9 stated that the air conditioning and heating units could be hazardous to the residents as they wander up and down the hallway on the (secure) unit. On 01/15/2024 at 1:30 PM, the surveyor interviewed Maintenance, who stated that the air conditioning and heating units bought by the previous company were too small or the plastic pieces have broken off causing the covers to slip. Maintenance accompanied the surveyor to rooms [ROOM NUMBERS], stated that the sharp edges are hazardous to the residents, and voiced intent to place foam on the edges until they receive new air conditioning and heating units to replace them. Maintenance stated that the sharp edges had not been reported to him. The maintenance logs were reviewed with no related information found.

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for one out of one resident (Resident #69) and ensuring residents face and nails were cleaned before or after meals for one out of one resident (Resident #76). The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2024, revealed Resident #69 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. A review of Resident #69's Care Plan, revised on 11/12/2024, revealed the resident had an ADL self-care performance deficit related to hemiplegia left side, strokes, and contractures of his left hand. Intervention initiated 12/06/2023 included assistance by one staff member with personal hygiene. On 1/14/2025 at 1:12 PM, Resident #69's nails were long with a black substance underneath. On 1/14/2025 at 1:24 PM Certified Nurse Aide (CNA) 11 indicated that nail care is supposed to be completed every day. On 1/14/2025 at 1:27 PM CNA #11 observed Resident #69 nails and indicated they were long with black stuff underneath them. On 1/15/2025 at 1:47 PM Resident #69's nails remained long, with a black substance underneath. On 1/16/2025 at 11:13 AM the Director of Nurse (DON) indicated that nail care is completed on Sundays and is dependent on staffing. The DON indicated that there are no particular days for nail care. She indicated that nail care is completed on shower days also. 2. A facility review of the Dignity Inservice with a date of 10/16/2024 indicates that staff were responsible for, Grooming residents as they wished to be groomed (e.g. hair combed and styled, beards shaved/trimmed, nails clean and clipped.) A review of the Order Summary indicated Resident #76 had diagnoses that included schizoaffective disorder, traumatic brain injury, bipolar II disorder, and unspecified intellectual disabilities. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2024 revealed Resident #76 had scored a 9 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Section GG is coded for a 04 on personal hygiene, which indicated resident is a supervision/touching assistance with tasks. Review of Resident #76's Care Plan initiated on 06/07/2024 indicates had an activity of daily living self-care performance deficit, interventions included personal hygiene supervision. On 01/13/2025 at 10:50 AM, Resident #76 was walking with walker, the surveyor observed that Resident #76's hair is greasy and uncombed, there is dry skin around their nose, brown matter sits in the corners of their mouth and lines the bottom of their lip, and there is matter observed around nail beds on hands. On 01/13/2025 at 11:50 AM, Surveyor observed that Resident #76 had white cream on upper lip, brown and yellow matter is observed in the corner of their mouth, brown matter is observed in a line down their chin, dry skin deposits are noted around Resident #76 ' s nose, matter is observed around nail beds and underneath nails. An unidentified Certified Nursing Assistant (CNA) is washing residents' hands with sanitary towels, handed one to Resident #76 who sat it down on the table. The CNA did not encourage or help the resident with washing hands or face. On 01/13/2025 at 12:00 PM Surveyor observed that Resident #76 is eating meal with unwashed hands and face. Resident #76 is eating cookies for dessert with unwashed fingers, the surveyor observed Resident #76 eat meal and walk away with unwashed hands and face. On 01/14/2025 at 08:30 AM, the surveyor observed Resident #76 finishing coffee from breakfast, brown matter sits in the corner of their lips, three brown lines run down Resident #76's chin, matter is observed around nail beds and underneath nails. On 01/14/2025 at 09:00 AM, the surveyor observed Resident #76 was offered a snack, the resident ' s face and hands were still dirty from breakfast, no attempts made at assisting or encouraging the resident with washing their hands or face before serving. On 01/15/2025 at 08:30 AM, the surveyor observed Resident #76 walking down hallway with walker, brown matter in corners of mouth, a brown line is observed down their chin, matter is observed around nail beds and underneath nails. On 01/15/2025 at 10:09 AM, during an interview CNA #9 stated that when they catch the resident, they attempt to wash hands and face daily or more depending on Resident #76's mood. CNA #9 then stated that it is gross to leave a resident ' s face and hands unwashed, and it could be seen as a dignity issue. CNA #9 stated that more of an effort could be made to clean Resident #76 before and after meals, or in between meals. On 01/15/2025 at 2:30 PM, during an interview the Assistant Director of Nursing (ADON) #5 stated washing hands and faces for the residents should be done in the morning, bedtime, and before and after meals. ADON #5 continued by stating that hands should be washed before and after the bathroom. ADON #5 stated washing hands and faces help reduce infections and bacteria. ADON #5 stated it could be seen as dignity issue for the resident, nobody wants their face or hands dirty.

49596 Based on observation, record review, interview, and facility policy review, the facility failed to ensure 1 of 1 sampled (Resident 47) resident was transferred from the chair to bed appropriately with a lift belt to prevent injury. The facility failed to ensure 1 of 1 sampled (Resident 62) the resident' environment remains as free of accident hazards as is possible. The facility failed to ensure 1 of 1 sampled (Resident 2) received adequate supervision to prevent accidents. Findings include: 1. Review of Resident 47's Care Plan revealed diagnoses of dementia, depressive disorders, and anxiety. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/17/2024 and Staff Assessment for Mental Status (SAMS) suggest long and short-term memory problems. Section GG 0170 shows resident requires moderate assistance transferring from the chair/bed-to-chair. Review of Resident 47's Care Plan revealed Resident 47 has a self-care deficit related to dementia and requires 1 person assistance. On 01/14/2025 at 02:18 PM, the surveyor observed Certified Nursing Assistant (CNA) 3 tell the resident that she was going to lift him up and get him back in the bed. From the privacy curtain CNA 3 was observed picking Resident 47 up at the hips and placing him in the bed, then picking up his legs and lift them up in the bed. A transfer belt was not used. CNA 3 was asked the protocol for assisting residents from the chair to the bed and should a transfer belt be used to transfer a resident back into the bed from their wheelchair. CNA 3 said, No, well . I think so, but I am not sure. We use gait belts but if a resident does not balance well then it does not work well. It probably works better with a gait belt. CNA 4 walked in and CNA 3 asked her if she is supposed to use a gait belt when transferring Resident 47 and CNA 4 confirmed Resident 47 required a gait belt for transfers. CNA 4 revealed that any resident that is capable of standing and pivoting to the bed should be assisted with a gait belt. On 01/14/2025 at 04:29 PM, Administrator provided a blank competency titled Transfers: Bed to Chair and Chair to Bed Skills Competency revealing transfers from chair to bed: wheelchair should be placed against the bed, on the side they are transferring to and encourage resident hands on the arm of the wheelchair and slide the buttocks forward until knees are over the feet. Apply gait belt or transfer belt if being used and stand on the count of 3. Assist resident to pivot by gradually turning with back side to the bed. Have resident reach back to the mattress if they are able and gently assist the resident to sit on the bed and assist in swinging both legs onto the bed, then reposition for comfort and make sure call light is in reach. On 01/15/25 at 09:40 AM, the Director of Nursing (DON) was asked when staff were expected to use a gait belt and revealed that staff are expected to use a gait belt anytime they assist in transferring any resident from the chair to the bed, or bed to chair. When asked if it is appropriate to pick a resident up and place them in bed, the DON stated, No, because someone could get hurt if they are not transferring the resident properly. The DON confirmed that all residents needing transfer assistance should be transferred using a gait belt. 2. Resident #2 ' s Care Plan dated 2/19/2020, identified the resident as having impaired cognitive function related to depressive episodes, anxiety disorder, delusional disorder, hallucinations, psychosis, schizophrenia, bipolar disorder, and dementia, and instructs the staff to monitor/document/report PRN any changes in cognitive function - specifically noting changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Resident #2 ' s Minimum Data Set with an Assessment Reference Date of 11/26/24 revealed the resident to have a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Resident #2 Physician Order, dated 1/15/25, revealed Resident #2 has diagnoses of other schizophrenia, cardiac arrhythmia, dementia. On 01/14/25 at 11:31 PM, Resident #2 is observed ambulating in her wheelchair to the beauty shop. The surveyor overheard the Beautician ask Resident #2 what she wanted done today. Resident #2 told the Beautician they wanted a perm and color. The beautician said, I will need to go see if you have money for a perm and color. The Beautician left beauty shop, leaving the resident in the chair in front of the counter with the shampoo bowl. CNA #10 went to beauty shop to ask Resident #2 if she could get her weight. CNA #10 took the resident to the scales to get her weight and then returned Resident #2 back to the beauty shop. CNA #10 then returned to her job duties, leaving Resident #2 unattended in the beauty shop. The storage closet in the beauty shop was left opened, which contained several bottles of shampoo and conditioner. On the beautician's countertop, directly in front of the chair where Resident #2 was sitting, was a pair of scissors, a hair/beard trimmer, three aerosol cans of hair spray, a box of hair color, soap, a jar of blue liquid with combs inside and the word [brand] disinfectant written on the outside of the jar. Hanging on the wall beside the counter was rack containing a curling iron that was in the on position and hot to the touch. In the unlocked cabinet door of the counter there were several color care products: Items in unsecured cabinet: a. Permanent Creme Color - with a caution of product contains ammonia, 1-naphthol, and ingredients of cetyl alcohol, steareth-21, propylene glycol, steric acid. The MSDS sheet says potential acute health effects - Irritating to eyes, mucosa and skin and may cause burns. b. Demi-permanent cream color - Product contains isopropyl alcohol. c. Pre-bonded permanent color - Note on front of box states may cause allergic reaction. Caution to wear gloves, avoid contact with eyes. This product is intended for professional use only. d. Alkaline Toner - can cause an allergic reaction; contains cetearyl alcohol. e. Semi-Permanent color - lilac - caution may cause allergic reaction. Wear suitable disposable gloves. The Safety data Sheet states Hazards Identification - This product is classified as a hazardous substance . cause serious eye irritation causes mild skin irritation. Keep out of reach of children. f. Permanent color 10-1: Important notice: may cause allergic reaction. Hazards identification - product classified as a hazardous substance. Warning causes serious eye irritation. g. Men ' s Shampoo-n Color warning this product contain ingredients that may cause skin irritation. Avoid contact with eyes. Can cause allergic reaction. Items on countertop: h. Red Aerosol can of hair spray - flammable i. Pump Thermal Spray Curler - hazardous components potassium metabisulfite sodium metabisulfite, hazard information, warning contains chemicals that cause irritation to eyes and skin. May be harmful if swallowed. j. Yellow Aerosol can of hair lift - can states can may explode if heated, k. Black can of Dry wax spray - Flammable aerosol; if in eyes rinse cautiously with water for several minutes; if eye irritation persists, get medical advice/attention. On 1/14/25 at 11:44 AM, the Beautician said this is her first day here and she had not received any training on working with the residents. She said she knew she shouldn't have left the curling iron turned on, but she turned it on when she arrived to work and left it on. The Beautician said she was a contract worker and is not an employee of the nursing home. The beautician said she had worked with the elderly before at a nursing home in Texas as a dietician. On 1/14/25 at 1:00 AM the Administrator said he had not provided any training to the beautician before she began working with the residents. The administrator said the beautician was a contract person and not an employee of the facility. 3. Resident #62 Care Plan identified the resident to be at moderate risk for falls related to cognitive issues, weakness, and balance deficits. He is moderately confused and has poor safety awareness which increases his risks for continued falls. An intervention to remove fall mat from bedside was on initiated 11/14/24. Resident #62 ' s Physician Orders revealed diagnoses of hypertensive, encephalopathy, abnormalities of gait and mobility, muscle weakness, muscle wasting and muscle atrophy, and cognitive communication deficit. Resident #62 ' s Fall Risk assessment dated [DATE] and 11/13/24 identified Resident #62 ' s ability to see in adequate light to be impaired. On 1/13/24 at 10:45 AM, a fall mat was observed at Resident #62's bedside. On 01/14/25 at 9:00 AM, Resident #62 was observed resting in bed with a fall mat at bedside.

50923 Based on observation, record review, interviews, and facility policy review, it was determined that the facility failed to ensure an effective infection control program was implemented to prevent the potential spread of Clostridium Difficile (C. diff). for 1 resident (Resident #66) of 1 resident reviewed for isolation precautions, and the facility failed to ensure a gown was worn for 1 (Resident #39) of 1 resident that was on Enhanced Barrier Precautions. The findings are: Upon review of the Admission Record, Resident #66 was initially admitted to the facility on [DATE], then readmitted on [DATE] with an admitting diagnosis of cellulitis of left lower limb. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/16/2024 revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 suggest cognitively intact). On 01/13/25 at 11:53 AM, the surveyor observed Resident #66 in bed with multiple wounds to their lower extremities. Per review of Resident #66 ' s physician order set, the resident had been taking multiple antibiotics for skin infections and skin grafts to bilateral lower extremities. On the physician ' s order set on 1/9/25, an order was created to place Resident #66 on contact precautions due to a positive stool culture for C. diff. On 1/14/25 at 11:15 AM, the surveyor observed CNA #12 apply personal protective equipment (PPE) to go into Resident #66's room to provide assistance of repositioning. When exiting, CNA #12 removed her PPE, but did not wash her hands with soap and water. When asked about it, she stated, There's not a bathroom I can use in this room so I'm going to this bathroom here to wash them. The survey observed the bathroom CNA #12 used was approximately 30 feet away from Resident #66 ' s room, and this appeared to be the closest bathroom available. On 1/14/25 at 12:20 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) #5 regarding Resident #66 and their isolation. He stated, I see where it isn't best practice to have someone with C. diff in a room without access to soap and water. On 1/14/25 at approximately 2:15 PM, Resident #66 was moved to a room with a bathroom and sink available. On 1/15/25 at 9:40 AM, the surveyor interviewed the Director of Nursing (DON) regarding Resident #66 and their isolation procedure for a resident on contact precaution for C. diff. She confirmed those offering care for a resident should wash their hands with soap and water prior to leaving the room since hand sanitizer is not effective in killing the spores of C. diff bacteria. Upon review of the facility's policy titled Isolation-Categories for Transmission Based Precautions, dated 04/2021, it is noted under Contact Precautions, section 4, subsection m: Remove gloves before leaving the room and perform hand hygiene. 2. A review of Resident #39's Order Summary Report, indicated that Resident #39 had a diagnoses of encounter for attention to cystostomy and colostomy status. A review of Resident #39's Order Summary Report, ordered 8/17/2024 revealed Resident #39 was on Enhanced Barrier Precautions (EBP) related to having a suprapubic catheter, and a colostomy. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #39 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS indicated that Resident #39 had an indwelling catheter, and an ostomy. Review of Resident #39's Care Plan, revised on 9/04/2024 revealed Resident #39 was on Enhanced Barrier Precautions related to having a colostomy. Review of a door sign on Resident #39's door indicated that he was on Enhanced Barrier Precautions. The sign indicated that staff must wear a gown for dressing, bathing, transferring, changing linen, providing hygiene, and wound care. On 1/15/25 at 9:30 AM, the CNA Supervisor and Certified Nurse Aide (CNA) 4 went in Resident #39's room. The CNA Supervisor held Resident #39 over to his right side while care was provided. The CNA supervisor and CNA #4 did not have on a gown. On 1/15/25 at 9:32 AM, the Treatment Nurse entered Resident #39's room. The treatment nurse leaned over Residents # 39 ' s bed to perform a skin assessment, and her shirt touched the bed linen. On 1/15/2025 at 9:40 AM, the Treatment Nurse indicated that she should have worn a gown when doing a skin assessment on Resident #39 because he was on Enhanced barrier precautions. On 1/15/2025 at 9:49 AM the CNA supervisor indicated that she should have worn a gown when holding Resident #39 over because he is on Enhanced Barrier Precautions. Review of a facility policy titled, Enhanced Barrier Precautions dated 09/21/2022, indicated, The Enhanced Barrier Precaution requires gowns and gloves during high-contact resident care activities that provide for transfer of MDRO's (Multidrug-resistant Organisms) to staff hands and clothing. Consider using Enhanced Barrier Precautions when caring for residents indwelling medical devices.

Based on record review and interview, the facility failed to ensure a resident's discharge/transfer information was sent in a timely manner to the Office of the Ombudsman, affecting 1 (Resident 28) of 1 resident sampled for transfers and discharge, and any resident discharged or transferred since the system change. Findings include: A review of the Medical Diagnosis portion of the electronic health record revealed Resident 28 had diagnoses of respiratory failure, heart attack, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 10/15/2024 suggested a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates the resident was cognitively intact). On 01/16/2025 at 09:45 AM, the Administrator was asked for a list of discharge/transfers that were sent to the Ombudsman since October 2024 showing Resident 28's hospitalization on [DATE], and he stated that he will be honest it got behind, and [MDS] is doing them and had to catch them up. On 01/16/2025 at 10:35 AM, the Administrator confirmed he does not have a list of resident discharge/transfers for the last 4 months. Administrator provided a copy of the SNF/NF to Hospital Transfer Form, dated 10/06/2024, and stated this is all he can find from Resident 28 ' s hospitalization . When asked to confirm whether the required information was sent to the Ombudsman regarding Resident 28 ' s hospitalization , he said it got behind, then the MDS nurse said they just found out about it yesterday and was told to get it caught up and done. On 01/16/2025 at 10:42 AM, MDS 2 stated she had been in her role for several years, and that she has never faxed a discharge transfer list to the Ombudsman and does not have a policy or procedure, and stated, I just found out about this yesterday. MDS 2 confirmed she does not know why this information is tracked for the Ombudsman.

Based on record review, interview, and facility policy review, the facility failed to ensure a resident or their representative received a written notice of the bed hold policy in a language they can understand for 1 of 1 sampled (Resident 28) resident. Findings include: A review of Medical Diagnosis revealed Resident 28 had diagnoses of respiratory failure, heart attack, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 10/15/2024 revealed Resident 28 received a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact). On 01/16/2025 08:33 AM, the Administrator was asked for bed holds for Resident 28 for April and October of 2024. The Administrator revealed that they did not have a business office manager during that time, and he would be reaching out to the person that was doing bed holds to see if Resident 28 had one. On 01/16/2025 at 09:00 AM, Resident 28 was asked if she received a bed hold policy, or something explaining how Resident 28 could reserve residents room while hospitalized on [DATE]. Resident 28 did not recall being provided a bed hold policy. On 01/16/2025 at 09:40 AM, the Business Office Manager (BOM) stated that she does not know who was doing bed holds last year prior to the system change, and Resident 28 does not have any bed holds for last year. When asked why it is important to give residents bed holds, the BOM stated it is important so that residents and families know their financial responsibility if they return to the facility, and we hold their bed. She confirmed that residents sent to the hospital should have a bed hold. The BOM was asked to provide a bed hold policy or procedure. On 01/16/2025 at 09:50 AM, the Administrator provided a policy titled Bed Holds and Returns, effective 05/2021, revealing prior to transfers or therapeutic leave, residents or their representative will be informed in writing of the facility bed hold policy. On 01/16/2025 at 10:34 AM, the Administrator provided a copy of the SNF/NF to Hospital Transfer Form, dated 10/06/2024, revealing Resident 28 was sent to the hospital. The Administrator stated that he knows this is not a bed hold but it is the only paperwork he can find showing Resident 28 was sent to the hospital.

Based on interview and record review, the facility failed to ensure the state designated authority was informed when 1 (Resident #39) of 2 (Resident #39 and #41) sampled residents reviewed for Preadmission Screening and Resident Review (PASARR) received a new diagnosis that required evaluation. The findings included: A review of Resident #39's Medical Diagnoses indicated that Resident #39 was diagnosed with bipolar disorder, unspecified on 9/01/2023. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #39 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. On 1/16/2025 at 10:22 AM, the state designated authority indicated the last Level 1 application for PASARR for Resident #39 was on 12/20/2021. When contacted by phone, the state designated authority indicated that they were not informed that Resident #39 was a resident at this facility, and they were not aware of his bipolar diagnosis. On 1/16/2025 at 11:09 AM, the Director of Nursing (DON) indicated that the MDS staff are responsible for notifying the state designated authority if a resident had a new diagnosis that requires a PASARR. On 1/16/2025 at 11:18 AM, MDS #2 indicated that Resident #39 was admitted before she took over the position as MDS Coordinator. MDS #2 indicated that Resident #39 transferred from another facility, and he had a PASARR from the other facility. MDS #2 indicated that Resident #39 was admitted [DATE], and the state designated authority was notified. MDS #2 indicated that she is now responsible for contacting the state designated authority if a resident had a new diagnosis that required a PASARR screening. MDS #2 indicated that Resident #39 was admitted with a PASARR, and a new PASARR was not obtained.

Based on interview and record review, the facility failed to ensure a physician order was followed for a dose reduction for 1 (Resident #43) of 5 residents reviewed for unnecessary medications. The findings are: The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed Resident #43 had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. A review of Resident #43's Care Plan, initiated on 6/07/2024, indicated staff were to administer antidepressant medications as ordered by the physician. A review of an Order Summary Report, revealed Aripiprazole, a medication that is used for depression, was ordered on 4/29/2024 at a dose of 15 milligrams. A review of a form titled Pharmacy MRR (Medication Regimen Review), indicated that the pharmacist made a recommendation to reduce the resident ' s dose of Aripiprazole to 10 milligrams daily on 9/03/2024. The physician agreed with the pharmacist's recommendation on 9/04/2024. The Director of Nursing (DON) or designated nurse did not reduce the Aripiprazole. The DON or designated nurse did not sign or date the form acknowledging the dose reduction. On 1/16/25 at 11:11 AM, the DON indicated that she doesn't know why the dose reduction for Resident #43's Aripiprazole wasn't completed in September of 2024.

Based on observation, record review, and interview, the facility failed to ensure a resident had a functional call light, and that call light was kept in reach to prevent accidents and injuries for 1 (Resident 25) of 1 resident sampled for resident communication availability and functionality. A review of Medical Diagnosis revealed Resident 25 with a diagnoses of dementia, stroke, and heart failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2024 suggest a Brief Interview for Mental Status (BIMS) score of 00 (00-7 indicates severe cognitive impairment). Section GG0120 reveals resident uses a walker, and section GG0170 indicates Resident 25 can walk 50 feet with supervision. Findings include: On 01/13/2025 at 11:21 AM, Resident 25 was observed resting in A bed without a call light in reach. There is only one call light, and it is on the unoccupied B bed. The surveyor pulled the bathroom emergency cord and the light did not come on above the outside door. Resident 25 asked what would you do if you needed to call for help, and Resident 25 responded, I do not know. On 01/13/2025 at 11:33 AM, Certified Nursing Assistant (CNA) 3 pressed the call light button on the unoccupied B bed and said it did not work. CNA 3 stated the resident could fall and get stuck and need us and not be able to call. CNA 3 tested the call lights and revealed the only working call light is the bathroom call light and explained that the light does not come on above the door. The call light on the unoccupied B bed was observed not to be attached to the wall. On 01/14/2025 at 08:45 AM, CNA 4 was observed in Resident 25's room and was asked if the call lights were working. CNA 4 pressed the call light button now resting on A bed and confirmed It is not lighting up on the wall and stated it does not work. On 01/15/2025 at 08:10 AM, Resident 25 was observed sitting on the toilet, and she stood up and is hanging on to the wall trying to get to the bed. Resident 25 appeared shaky and unsteady. On 01/15/2025 at 08:14 AM, Licensed Practical Nurse (LPN) 7 presented to Resident 25's room, and handed Resident 25 a rolling walker and Resident 25 rolled to the sink to wash her hands. LPN 7 was asked if the resident is capable of using her call light, and LPN 7 confirmed that she does know how to use the call light and should call for assistance. CNA 8 was asked if the call light had been fixed. Yes, I believe so. They said they did. The surveyor pressed the call light button, and it did not light up at the control on the wall by Resident 25 ' s bed. On 01/15/2025 at 09:02 AM, LPN 7 confirmed they have a 500-hall maintenance log (the unit on which Resident 25 resided), and did not find a report that Resident 25 did not have a call light in her room. On 01/15/2025 at 09:10 AM, the surveyor observed Resident 25 sitting up in a wheelchair watching TV, and the call light was out of reach wrapped around the rail of A bed and resting in the floor behind Resident 25's wheelchair. On 01/15/25 at 09:40 AM, the Administrator confirmed that all residents should have a working call light for safety reasons. He stated that the battery might be dead and need changed. Administrator revealed that he is aware they have some call light issues. During an interview on 01/15/25 at 01:00 PM, the Director of Nursing (DON) was asked for the process staff were expected to follow when leaving a resident room and ensuring they can call for assistance. The DON reported that the call light should be placed in residents reach. The DON stated that a resident not having a call light would not be appropriate, and residents would not be able to call staff if they had a concern, it is a safety issue. On 01/15/2025 at 01:17 PM, the DON provided documentation of an in-service titled November-CNA In-Service, dated 11/07/2024, revealing topic included rounds, falls, call-ins, documentation, meal service, showers, nails, and call lights/pagers. No other information applies to Resident 25 not having a call light.

Based on observations, interview and record review, the facility failed to provide pharmaceuticals to meet the needs for 1 (Resident #27) of 1 sampled resident. The findings are: Resident #27 had diagnoses of chronic pain, hypomagnesemia, and nausea. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/2023 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitively intact) and had received scheduled pain medication with frequent pain rated 5 on a scale of 10 over the past 5 days. On 01/24/24 at 11:17 AM, while conducting a review of the 600 Hall medication cart it was noted that Resident #27's supply of Oxycodone 10 milligrams (an opioid pain medication) had been depleted to zero. Upon further investigation the Emergency Box's supply had been depleted to zero. Resident #27's Physicians Orders dated 01/20/2024 documented Oxycodone 10 milligrams 1 tablet by mouth every 12 hours for Pain; Magnesium Gluconate Oral Tablet 500 milligrams 1 tablet by mouth two times a day related to Hypomagnesemia; and Ondansetron HCl (Hydrochloride) (Zofran) Injection 4 milligrams intramuscularly every 6 hours as needed for nausea/vomiting. Resident #27's Progress Notes dated 01/22/2024, 01/23/2024, 01/24/2024 and 01/25/2024 documented Oxycodone 10 milligrams and Magnesium Gluconate not given due to awaiting delivery from pharmacy. Resident #27's Medication Administration Record (MAR) documented Oxycodone 10 milligrams and Magnesium Gluconate 500 milligrams not given due to unavailability. Resident #27's Care Plan with a revision date of 12/11/2023 documented, [Resident #27] is being treated for chronic pain. He has potential for breakthrough pain . Notify physician if interventions are unsuccessful . On 01/24/2024 at 11:20 AM, Licensed Practical Nurse (LPN) #1 was asked, What is the procedure when a resident is out of a controlled medication? LPN #1 replied that the medication is given and signed out from the emergency [ER] box. LPN #1 was then asked, What is done if the emergency box is out of the medication? LPN #1 stated, [Resident #27's] medication has been ordered from the pharmacy several times it just has not been delivered from the pharmacy yet. LPN #1 was asked if she had faxed confirmation that the medication had been requested and she said no she did not. On 01/24/24 at 11:46 AM, Registered Nurse (RN) #2, the Assistant Director of Nursing (ADON), was asked, What do you do if a narcotic pain medication is out? RN #2/ADON responded, We call the pharmacy and reorder and use from the Emergency Box until the medication is received. RN #2/ADON was then asked, What do you do if the ER Box is out of the medication? RN #2/ADON responded, Then we have a problem, the nurse should notify the Director of Nursing (DON) or myself. We would then call the physician and the pharmacy to resolve the situation. On 01/24/24 at 03:00 PM, Resident #27 said the worst the pain had been in the past 2 days was a 5 out of 10 (with 10 being the worst pain) and that his pain usually was around a 4. He has been asking for a nausea shot but was told they are waiting for it to come from the pharmacy. The last time it was documented that Resident #31 received a Zofran (for nausea) injection was 01/23/2024 at 5:00 AM. On 01/25/2024 at 10:20 AM, LPN #2 (Physician's Nurse) clarified that she had faxed an order to the pharmacy for Resident #27's controlled medication. When asked if she had faxed confirmation of the prescription being sent, she confirmed she did not. When asked if she or the physician had been contacted by the facility concerning the medication not being available and a request for an alternative, she confirmed that they had not until 01/24/2024. The facility ' s Medication Controlled Substances Policy and Procedure received from the Nursing Consultant on 01/24/2024 at 3:13 PM documented, .7. All controlled medications are reordered when needed to allow time for acquisition and transmittal of required original written prescription to the provider pharmacy, if necessary .

Based on observation and interview, the facility failed to ensure pureed foods were processed to the correct consistency to meet the needs of 4 residents who had physician's order for a pureed diet according to a list provided by the Dietary Manager on 01/22/24 at 12:05 PM. The findings are: a. On 01/24/24 at 11:00 AM, Dietary Aide #1 began prepping chili mac for the four puree diets in the facility. Dietary Aide #1 used an 8 ounce scoop to put four servings of chili mac in the food processor bowl and turned it on. Dietary Aide #1 added two 5.5 ounce cans of tomato juice to the pureed chili mac and continued to run it. At 11:15 AM, Dietary Aide #1 washed her hands and then checked on the puree and poured thickener in it without measuring. The Surveyor asked how much thickener did you use? Dietary Aide #1 said approximately 2 teaspoons of thickener. Dietary Aide #1 turned on the food processor and blended it without measuring. At 11:18 AM, the the puree chili mac had a runny texture. Dietary Aide #1 continued to prep for lunch, and then came back to check on the puree for a second time. At 11:20 AM, Dietary Aide #1 poured thickener in the chili mac without measuring and then began to blend the puree again. When Dietary Aide #1 was asked the amount thickener added, she said approximately 1 tablespoon. Dietary Aide #1 checked the chili mac puree, and it had a runny texture as it dripped rapidly off the tablespoon. Dietary Aide #1 checked the puree again with the tablespoon and it was still runny. Dietary Aide poured thickener in it again without measuring. When Dietary Aide #1 was asked the amount of the thickener she added, she said approximately another tablespoon of thickener and started to blend it again. Dietary Aide #1 checked the chili mac puree again and as it was still runny and dripping off the tablespoon and proceeded to pour thickener in it again without measuring. Dietary Aide #1 was asked how much thickener was added, and Dietary Aide #1 said approximately 1 tablespoon. Dietary Aide #1 checked the chili mac for the last time, and it still had a runny texture. Dietary Aide #1 picked up the food processing bowl and proceeded to pour it into a stainless steel bin and placed the stainless-steel bin on the serving line at 11:25 AM. b. On 1/24/24 at 11:28 AM, observed Dietary Aide #1 prepping to puree garlic bread. Dietary Aide #1 added half a cup of melted butter to the food processor. Dietary Aide #1 left to get a loaf of white bread and proceeded to get five bread slices. She took the crust off one slice and added it to the food processing bowl. Dietary Aide #1 use a bread knife to cut the crust off of the other four slices. Dietary Aide #1 then added the rest of the white bread slices in the food processor bowl tearing them into chunks, and then turned it on. Dietary Aide #1 washed her hands and got milk out of the cooler. Dietary Aide #1 then poured half of a pint of the milk into the garlic bread puree without checking the puree texture. At 11:35 AM, Dietary Aide #1 checked the pureed garlic bread using a tablespoon. The puree was grainy with a gritty sand like texture and runny. Dietary Aide #1 then added 3 tablespoons of thickener to the puree and continued to run the food processor. At 11:38 AM, Dietary Aide #1 checked the pureed garlic bread with a tablespoon and proceeded to put it in a stainless steel bin to add to the serving line. The pureed garlic bread was runny with a grainy appearance and gritty sand like texture. c. On 1/24/24 11:45 AM, the Surveyor test tasted the chili mac puree, the consistency was runny, and the flavor was bland. The Surveyor taste tested the garlic bread, which was grainy in consistency, the garlic butter was overwhelming in flavor, and it was runny. d. On 1/24/24 at 12:00 PM, the Surveyor observed lunch service. Dietary Aide #1 served two 8 ounce scoops of chili mac and 1 dip scoop of pureed garlic bread onto a plate. The chili mac puree spread out on the plate and did not stay formed. The pureed garlic bread spread out onto the plate and did not stay formed. At 12:05 PM, Dietary Aide #1 served the next pureed diet, the chili mac puree spread out onto the plate and did not stay formed. When Dietary Aide #1 used the dip scoop for the pureed garlic bread, a small chunk 3 centimeter (cm) wide and 2 cm long fell out of the scoop back into the stainless steel bin. The scoop of pureed garlic bread spread out on the plate and did not stay formed. e. On 1/26/24 at 10:45 AM, the Surveyor asked the Dietary Manager what could happen if the puree is a thin consistency. The Dietary Manager said that they could choke. f. On 1/24/24 at 12:00 PM, the Dietary Manager provided recipes for the lunch puree items, which stated for the chili mac that for 5 servings 3 3/4 cups of chili mac with 1 1/2 cups of water, and 1 tsp [teaspoon] of hot beef base. The pureed garlic bread recipe stated, Four servings to use 4 slices of garlic bread, 1 tbs [tablespoon] and 2 tsp of margarine, solids, melted, and 2/3 cup of whole milk.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for, (677) providing nail care for resident dependent on staff. The failed practice had the potential to affect 89 residents as identified on the Census by Hall provided by the Administrator on 01/22/24 at 12:00 pm. The findings are: 1. A Recertification survey was conducted on 01/26/24 at the facility. During this survey, F677 was cited for the facility's failure to ensure residents who required assistance with activities of daily living (ADL) were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for 1 (Resident # 31) of 31 sampled residents who required assistance with personal hygiene and grooming. A review of the facility' s Plan of Correction, with a correction date of 12/04/22 indicated: a. 11/03/2022, upon identification, the DON/designee assessed Residents #24, #45, #84 and #347 and provided nail care. DON/designee also assessed Resident #24 and provided facial hair removal at the resident's request. 11/03/2022 the facility identified 96 residents who required assistance with nail care. Those residents were assessed by the DON (Director of Nursing)/designee without negative findings. On 11/03/2022 the facility identified 52 residents who required assistance with shaving. The DON/designee assessed those residents with no negative findings.11/03/2022 the DON/designee educated/re-educated nursing staff on providing ADL care, including nail care, and shaving for residents who require assistance. The DON/designee will monitor residents who require assistance with ADL care to include nail care and shaving to ensure assistance has been provided according to the resident's preferences 3x/week for 2 weeks then weekly for 6 weeks or until compliance is achieved. DON/designee will immediately correct any negative finding. The DON/designee will report negative findings to the QA [Quality Assurance] committee monthly for review and recommendation for change as indicated. 2. A policy titled, QAPI PLAN, provided by the Administrator on 01/22/24 at 11:00 AM documented, .1. Measurement of performance using objective quality indicators. 2. Implementation of system interventions to achieve improvement in quality. 3. Evaluation of the effectiveness of the interventions. 4. Plan and initiation of activities for increasing or sustaining improvement . 3. On 01/25/23 at 11:37 AM, the Surveyor asked the Administrator how the Quality Assessment and Assurance (QAA) Committee knows when an issue arises in any department. The Administrator said we talk about it in our stand-up meetings and inform staff by in-servicing them. And meet monthly to ensure there are no issues or concerns. The Surveyor asked how the QAA Committee knows when a deviation from performance or a negative trend is occurring. The Administrator said we would identify and review the process and see that we still have the same issue, basically monitor the issue. The Surveyor asked how the QAA Committee decides which issues to work on. The Administrator said the number one is the one that affects the residents. The Surveyor asked how long the QAA Committee will monitor an issue that has been corrected. The Administrator said when we meet for our monthly, we will discuss if issues are getting better and if not then we will change it. The Surveyor asked is the QAA Committee aware of repeated survey deficiencies. The Administrator said no.

Based on observation, record review, and interview, the facility failed to ensure staff followed contact precautions including the appropriate use of Personal Protective Equipment (PPE) and Hand Hygiene during resident care and after exiting Contact Isolation rooms, to prevent the potential spread of infection to other residents for 1 (Resident #27) of 1 sampled resident who was in contact isolation due to positive Clostridium Difficile Colitis (C-Diff). This failed practice had the potential to affect 15 residents who required the use of the mechanical lift, as documented by a list of residents provided by the Nurse Consultant on 01/26/24 at 10:30 am. The findings are: 1. On 01/23/24 at 10:22 am, Certified Nursing Assistant (CNA) #2 donning (put on) PPE before entering Resident #27's room. Resident #27 was on contact isolation due to C-Diff. CNA #2 took a mechanical lift to the room after donning PPE. CNA #1 and Licensed Practical Nurse (LPN) #1 donned PPE and went into Resident #27's room. The Surveyor donned PPE and followed the staff into the room. Resident #27's door was shut, and the privacy curtain pulled while staff changed the resident's brief. The Surveyor overheard LPN #1 tell Resident #27 that she was putting cream on his bottom. Resident #27 was asked permission for the Surveyor to observe staff using the lift, permission granted. The privacy curtain was pulled open, Resident #27 was rolled, and the lift pad placed under him by LPN #1 and CNA #1, then the resident's clothes were put on. The Surveyor observed both CNAs and LPN #1 wearing gloves. There were no other gloves in the room for staff to change into. CNA #1 proceeded to make the resident's bed, while CNA #2 and LPN #1 applied the lift pad sling to hooks on the lift and lifted the resident to a bedside recliner. LPN #1 was holding Resident #27's catheter bag in gloved hands and placed it on the side of the recliner. LPN #1 then touched Resident #27's bedside table moving it up closer to the resident then handed the resident the phone off the bedside table. Resident #27 asked LPN #1 to take his water pitcher and put more water in it. LPN #1 stated, I will but I need to change my gloves before I touch your drink. Both CNAs and LPN #1 walked past Resident #27's bathroom and doffed (took off) their PPE, then went outside in the hall. They used wall mounted alcohol based hand rub (ABHR) then walked down the hall to a bathroom where they washed their hands with soap and water. 2. On 01/23/24 at 10:45 am, CNA #1 doffed the PPE and left Resident #27's room. CNA #1 used wall mounted ABHR then walked to a bathroom where hand hygiene was performed. CNA #1 was asked did you change your gloves in the resident's room after personal care and before making the resident's bed. CNA #1 stated, No. The Surveyor asked should you have performed hand hygiene and donned clean gloves before making Resident #27's bed? CNA #1 stated, Yes. The Surveyor asked should hand hygiene be performed after doffing PPE? CNA #1 stated, Yes, I came outside and used ABHR, then went to the bathroom down the hall to wash my hands. The Surveyor asked could you have used the bathroom in the resident's room to wash your hands? CNA #1 stated, I guess I could have. 3. On 01/23/24 at 10:47 am, CNA #2 left the room. The Surveyor asked CNA #2 did you change gloves in the room after personal care? CNA #2 stated, No. The Surveyor asked should you have performed hand hygiene and donned clean gloves before touching Resident #27's bedside table and after touching the lift? CNA #2 stated, Yes. The Surveyor asked should you have performed hand hygiene after doffing PPE and before leaving Resident #27's room? CNA #2 stated, I was going down the hall to the bathroom. The Surveyor asked could you have used the bathroom in the resident's room to wash your hands? CNA #2 stated, Yes. 5. On 01/23/24 at 10:55 am, LPN #1 was asked did you change your gloves in the room after applying cream to Resident #27's bottom? LPN #1 stated, No. The Surveyor asked should you have performed hand hygiene and donned clean gloves before you touched the catheter, the bedside table and Resident #27's phone? LPN #1 stated, Yes. The Surveyor asked after doffing PPE did you perform hand hygiene before exiting the resident's room? LPN #1 stated No, I was going to use the bathroom down the hall. The Surveyor asked could you have used the bathroom in the resident's room to wash your hands? She stated, I didn't think about that. 6. On 01/26/24 at 09:44 am, observed CNA #5 exit Resident #27's room. CNA #5 had already doffed PPE before exiting the room and taking ABHR from her pocket and applying. The Surveyor asked if hand hygiene was performed before leaving Resident #27's room. CNA #5 stated, Yes, I used ABHR right after I left the room. The Surveyor asked did you wash your hands with soap and water? CNA #5 stated, No. The Surveyor asked do you know why Resident #27 is on contact precautions. CNA #5 stated, No. I just know that they are on isolation. I don't know why. 7. On 01/26/24 at 09:50 am, the Director of Nursing (DON) was asked when a resident has C-Diff, what type of hand hygiene should be performed. The DON stated, Wash your hands with soap and water. The Surveyor asked when a resident that requires a lift, is in isolation, what is the protocol? The DON stated, We usually leave the lift in the room with the resident or clean it with anti-bacterial disinfectant if we need to use it on other residents. 8. A facility policy titled, Isolation Policy and Procedure, provided by the DON on 01/25/24 at 11:04 am documented, .4. Remove protective equipment apparel according to instructions and dispose of it in the room. 5. Wash hands thoroughly . 9. A facility policy titled, Hand Hygiene Policy and Procedure, provided by the DON on 01/25/24 at 11:04 am documented, .Hand hygiene will be performed by all staff consistent with accepted standards of practice, to reduce the spread of infections and prevent cross contamination .

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for 1 (Resident #31) of 31 (Residents #4, #8, #9, #17, #19, #20, #23, #25, #27, #30, #31, #32, #35, #40, #41, #45, #46, #49, #57, #58, #59, #73, #75, #83, #84, #85, #87, #243, #246, and #247) sampled residents who required assistance with personal hygiene and grooming. The findings are: a. Resident #31 had diagnoses of down syndrome, intellectual disability, and a cognitive communication deficit. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/23 documented the resident received a score of 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). b. On 01/22/24 at 01:00 PM, Resident # 31 was eating lunch with his right hand. Observed the resident sucking food off his first and second fingers while eating lunch. The fingernails on the right hand were 3 inches long past the tips of the fingers with a dark substance under all five and both eyes were covered in a thick yellow gummy substance on the top and bottom part of the eye lid. c. On 01/23/24 at 09:25 AM, Resident #31 was up in a wheelchair for the dentist. Certified Nursing Assistant (CNA) #4 wheeled the resident past the surveyor. Both of Resident #31's eyes were matted up with a thick yellow gummy substance on the top eyelids. The left hand was in Resident #31's lap and the fingernails were 3 inches long past the tips of the fingers. Resident #31's right hand had a dark substance under all five nails and the length had not been trimmed. d. On 01/25/24 at 2:30 PM, the Surveyor accompanied the Certified Nursing Assistant (CNA) Supervisor to Resident #31's room. The Surveyor asked the CNA Supervisor to describe the nails on Resident #31's right hand. The CNA Supervisor said that they were long, and that the resident refuses nail care. The Surveyor asked if the resident eats with his hands. The CNA Supervisor said yes, the resident does. The Surveyor explained that on Monday while the resident was eating lunch, Resident #31 was observed eating with his right hand and sucking food off of his fingers, and asked what are your thoughts about that? The CNA Supervisor said that the nails are long and dirty with a dark substance under them. The CNA Supervisor asked the resident if they could perform nail care. The resident smiled and nodded. The Surveyor asked to observe, and the resident smiled again. The Surveyor observed nail care performed by the CNA Supervisor and CNA #4 with no issues from the resident. Resident #31 was looking at his hands when the Surveyor left the room. e. On 1/25/24 at 10:50 AM, the Surveyor asked the Director of Nursing (DON) when should nail care be performed. The DON said that it should be performed on bath days and at least weekly. f. Resident #31's Care Plan with a revision date of 06/22/23 stated, .has an ADL [activities of daily living] self-care performance deficit r/t [related to] weakness. He needs assist with all his daily functions . often eats with his fingers . prefers to wear his nails longer . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . g. On 01/26/24 at 10:30 AM, the Nurse Consultant provided a policy titled, ADL Care of a Resident Policy and Procedure that stated, .Procedure: .3. Provide the following services if applicable and refer to the individual policies for reference . C. Hand Care .

Based on observation, interview and record review, the facility failed to ensure oxygen cylinders were secured to prevent possible injury or explosion as evidenced by two oxygen cylinders observed in 1 (Resident #3) of 1 Resident ' s room. The findings included: On 08/17/2023 at 2:43 PM, observed Resident #3 was transferring self from the wheelchair to the side of the bed. A portable oxygen cylinder tank was standing next to the end of the bed unsecured. There was a second oxygen cylinder tank in a plastic bag sitting next to the two-drawer nightstand. The Surveyor asked Resident #3, Do you use this oxygen cylinder tank next to your nightstand? Resident #3 stated, That one is mine from home. My family brought it up here in case I go out with them for a while, I would have a smaller one here. On 08/17/2023 at 2:46 PM, the Surveyor asked the Advanced Practice Registered Nurse (APRN) should the two oxygen cylinder tanks be sitting on the floor unsecure? The APRN said no, they shouldn't it could create an explosion. On 08/17/2023 at 2:49 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Should these two oxygen cylinder tanks be sitting in the floor unsecured? LPN #1 stated, No, they should not. The Surveyor asked LPN #1, what can happen with the tanks being unsecured? LPN #1 stated, They can fall over and explode. On 08/18/2023 at 3:30 PM during interview the Director of Nursing (DON), confirmed oxygen cylinder tanks should not be left unsecured standing next to a resident ' s bed. Review of the facility ' s policy titled Oxygen Tank Storage and Handling undated provided by the Administrator on 08/18/2023 showed, oxygen tanks must be secured to provide safe storage and handling.

Based on observation, interview and record review, the facility failed to ensure oxygen orders were obtained prior to administering oxygen therapy to 1 (Resident #3) of 3 case mix residents. The findings included: During observation on 08/17/2023 at 2:43 PM, Resident #3 was wearing oxygen via nasal cannula at 2 Liters connected to an oxygen concentrator in the room. During record review, it was found Resident #3 did not have orders for oxygen therapy. On 08/18/2023 at 3:25 PM the Surveyor asked ADON (Assistant Director of Nursing) #1, Should Resident #3 have an order for oxygen? ADON #1 stated, Yes, it was documented on her admission assessment that she uses oxygen. I don't know why an order was not put in. On 08/18/2023 at 3:27 PM ADON #2 confirmed there were no physician's order for oxygen. Review of facility's policy titled Oxygen Administration undated provided by the Administrator on 08/18/2023 at 3:43 PM showed, Check the physician's order for liter flow and method of administration.

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, the refrigerator and the dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed and/or discarded on or before the expiration or use by date to prevent the growth of bacteria; failed to ensure 1 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; leftover food items were used properly to maintain food quality for residents who received meal trays from 1 of 1 kitchen; and dietary staff washed their hands before handling clean equipment. These failed practices had the potential to affect 98 residents who receive meals from the kitchen (total census:98) as documented on a list provided by the Dietary Supervisor on [DATE] at 2:00 PM. The findings are: 1. On [DATE] at 10:40 AM, there was a pan of left-over scrambled eggs on a shelf in the refrigerator. Dietary Employee (DE) #1 was asked, What was in the zip lock bag? She stated, That was leftover scrambled eggs from breakfast. They will use it for the pureed egg in the morning. 2. On [DATE] at 10:42 AM, the corners of the ice machine panel had a wet black and grayish residue on them. DE #1 was asked to wipe the black/gray residue at the corners of the panel. She did so, and the black/gray substance easily transferred to the paper towel. The Surveyor asked DE #1 to describe what was at the corners of the panels. She stated, They were black [NAME] [thick black matter]. The Surveyor asked, Who uses the ice from the ice machine? She stated, We use it to fill beverages served to the residents at the mealtimes. 3. On [DATE] at 10:45 AM, one opened box of bacon was on a shelf in the walk-in refrigerator. The box was not covered or sealed. 4. On [DATE] at 10:48 AM, the following observations were made in the Dry Storage Room: a. A container with 30 boxes of cocktail sauce with no dates when the packages were delivered. b. A container with 107 packages of tartar sauce with no dates when the packages were received. c. A container with 70 individual packages of lemon juice was with no dates when the products were received. 5. One 3 pound (lb.) box of lemon bar crust mix was on a shelf with an expiration date of [DATE]. 6. One 3 lb. box of lemon bar crust mix with an expiration date of [DATE]. 7. A container with 79 packages of mayo with no dates when the packages of mayo were received. 8. On [DATE] at 11:14 AM, the following observations were made in the walk-in freezer: a. An opened box of dinner rolls was stored on a shelf in the walk-in freezer. The box was not completely covered or seal. b. An opened box of cinnamon dough was stored on a shelf in the walk-in freezer. The box was not covered or sealed. 9. On [DATE] at 11:16 AM, one opened box of plain salt was in a metal cabinet, not covered. 10. On [DATE] at 11:30 AM, DE #2 turned on the hand washing sink and washed her hands. After washing her hands, she turned off the faucet with her bare hand. At 11:36 AM, she walked out of the kitchen and came back with tray cards. She placed the cards on the counter. She picked up condiments and placed them on the trays. Without washing her hands, she picked up glasses that contained beverages by their rims and placed them on the trays. 11. On [DATE] at 11:45 AM, the following observations were made in the freezer in the Nourishment Room on the 400 Hall: a. A box of ice cream was stored in the freezer. The ice cream had pinpoint crates on it and there was no opened or received date on the container. The Surveyor asked DE #1 to describe the appearance of the ice cream. She stated, It looks like it has been melted. b. A box of Neapolitan ice cream was in the freezer, there was no opened or received date on the container. The ice cream was discolored. The Surveyor asked DE #2 to describe the appearance of the ice cream. She stated, It looked a little melted around the edges. c. A box of strawberry ice cream was in the freezer, there was no opened or received date on the container. The ice had ice cycles on it. DE #2 stated, It has ice cycles on it. d. A box of cookie dough ice cream was stored in the freezer, there was no opened or received date on it. The ice cream was discolored, had ice cycles on it. DE #2 was asked to describe the appearance of the ice cream. She stated, It looks nasty. It has freezer burn on it. 12. On [DATE] at 3:25 DE #3 was wearing oven mittens over his gloves. He removed a pan of macaroni and cheese from the oven and placed it on the counter. He removed the oven mittens and placed them on the counter. Without changing gloves and washing his hands he used his contaminated gloved hand to attach the blade at the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 13. On [DATE] at 3:33 PM DE #4 opened the refrigerator, took out a gallon of whole milk and a carton of nectar juice. Without washing her hands, she picked up glasses that contained beverages by their rims to be served to the residents for supper and placed them in the refrigerator. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 14. On [DATE] at 3:56 PM, The Surveyor asked DE #3, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have removed gloves and washed my hands. 15. The facility's policy titled, Hand Washing, provided by the Dietary Supervisor on [DATE] at 2:00 PM documented, .Food service personnel shall wash hands. Before preparing or handling food . 16. The facility policy titled, Pureed Egg of Choice, provided by the Dietary Supervisor on [DATE] at 2:00 PM documented, .Place prepared egg and milk as needed in a washed and sanitized food processor, blend until smooth . Reheat to > [greater than] 165 degrees F. [Fahrenheit] for at least 15 seconds . Discard leftovers .

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure planned interventions to prevent accidents were implemented for 1 (Resident #3) of 5 (Residents #1 through #5) case mix residents who were at risk for falls and failed to ensure a system was in place to ensure safety alarms were functioning correctly for 2 (Residents #1 and #5) of 5 (Residents #1 through #5) case mix residents who used alarm pads. This failed practice resulted in actual harm to Resident #3, who had a fall without the care planned alarm in place, resulting in a fractured right femoral neck requiring surgical repair, and had the potential to affect 62 residents who were at risk for falls, 14 residents who used sensory pad alarms and 5 residents who used string/clip alarms, as documented on lists provided by the Administrator on 12/29/11 at 1:42 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Medicare 30-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/15/11 documented the resident scored 6 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance of two persons for bed mobility and transfers, was not steady and required human help to stabilize between surfaces, had no limitations in range of motion of extremities and had no falls since admission or previous assessment. a. A Fall Risk assessment dated [DATE] documented the resident scored 16 (a total score of 10 or above represented high risk). b. The Plan of Care dated 6/13/11 and reviewed on 8/19/11 and 10/6/11, documented a problem of risk of falls with an approach of, "I have a bed/chair alarm to alert staff when I make attempts to get up without assist." The Nursing Assistant Kardex (Certified Nursing Assistant-CNA Care Plan) that was not dated, documented in the section for "Instructions," "bed/chair alarm." The Plan of Care and CNA Care Plan were not specific as to what type of alarm device should be used for this resident. c. An Event Reporting sheet dated 11/22/11 at 10:35 a.m., documented the resident was observed on the floor with "personal body alarm going off." The report documented the resident had a small, reddened area to the middle left side of the back. A new approach was documented on the Event Report and on the Plan of Care "change pull (clip) alarm to pressure alarm," and the Event Report's documentation of the new planned intervention was signed by the Assistant Director of Nursing (ADON). d. An Event Reporting sheet dated 11/22/11 at 2:20 p.m., documented the resident was "observed on floor again, alarm going off," and no injuries noted. The report did not document what type of alarm was in use for the resident at that time. e. Nurses Notes dated 11/22/11 and untimed, documented, "Resident observed on floor (times) 2 today. No injuries noted. Both times resident was attempting to transfer (without) assistance. Personal alarm was on (and) working (at) time resident made his attempts." There was no documentation in that note of a new, sensory pad alarm used as planned after the first fall on 11/22/11. f. The next Nurses Note dated 11/25/11 did not document information about the resident's alarm use. g. An Event Reporting sheet dated 12/3/11 at 4:00 a.m. documented the resident was observed on the floor at the foot of the bed and, "alarm observed on bed and in the ON position. Asked (resident) about alarm and (resident) replies, 'I took it off'. No obvious (sign/symptom) of injury noted at this time." The report documented, "Explained to (resident) the importance of alarm and to leave it attached to clothing. Instructed CNA's to hide the alarm clip to center of back." The same report documented another entry , "Day Shift" nurse observed the resident with pain and he was sent to a local hospital for "treatment of [REDACTED]. h. A hospital Operative Report dated 12/6/11 documented the resident had surgical repair of a right femoral neck fracture. i. Medicare Nurses Notes dated 12/9/11 documented the resident's readmission to the facility. Medicare Nurse's Notes dated 12/9/11 through 12/17/11 did not document what type of alarm the resident had in use during that period of time. j. An Event Reporting sheet dated 12/17/11 at 10:00 a.m. documented the resident was found lying on his back between beds in his room, "alarm still on (wheelchair)... When asked about alarm, (resident) said, 'I took it off,'... Re-educated resident to leave alarm on, change to pressure alarm." k. On 12/29/11 at 10:05 a.m., the DON was asked who was responsible for verifying that new interventions were put in place as planned and she stated the ADON had that responsibility. l. On 12/29/11 at 11:10 a.m., the ADON was asked why the pressure alarm was not put in place as planned for the resident and she stated, "I think I did put a pressure alarm in place." The ADON was asked for documentation of when she did that and as of 12/29/11 at 3:15 p.m., the facility had not provided that information. 2. Resident # 5 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 8/17/11 documented the resident scored 4 on a BIMS (0-7 indicates severely impaired), was independent in bed mobility, transfers, walking in room, in corridor, locomotion on unit, required supervision with set up for locomotion off unit and had one fall since admission or prior assessment. a. A Fall Risk assessment dated [DATE] documented a score of 13 with a total score of 10 or above indicating a high risk of falls. b. The Event Reporting form dated 12/6/11 documented, "Time of Occurrence: 11:20 a.m... Res (Resident) out to MD (medical doctor) this a.m., Ativan given at MD's office. (At) 11:15 a.m. Res was sleeping, then at 11:20 a.m. Res was observed sitting in floor between sink and bed... L (left) leg noted to be shortened with outward rotation-Res c/o (complaining) left hip pain. Staff with resident until EMT's (emergency medical technicians) arrived, sent to ER (emergency room ) for eval (evaluation)." c. A hospital form documented the resident was admitted on [DATE]. The Consultation from the local hospital dated 12/7/11 documented, "Chief Complaint: Left hip pain. History of present illness:.. (Resident #5) ...resident of a nursing home secondary to dementia who had an inadvertent fall with acute left hip pain. He ambulates either with a quad cane or walker at the nursing home... evaluated in emergency room where X-rays demonstrated a left intertrochanteric hip fracture and orthopedic consultation is requested... X-ray, Left Hip: Comminuted displaced left intertrochanteric hip fracture, Impression: 1. Comminuted left intertrochanteric hip fracture, 2. Dementia, 3. Type 2 diabetes mellitus... recommend reduction and internal fixation by trochanteric femoral nailing." Surgical repair of fractured left hip was done on 12/7/11. d. Nursing Home admission orders [REDACTED]. e. The Resident Plan of Care dated 12/6/11 documented, "Low bed with mat, sensory pad bed/chair alarm." f. On 12/29/11 at 9:20 a.m., the resident was in therapy sitting in a wheelchair with a pressure alarm pad in place. PT #1 and OT #1 were asked to assist the resident into a standing position to check the functioning of the pressure alarm. When the resident stood up, the alarm failed to sound. The physical therapist stated, "I would assume that the batteries were dead." The OT re-inserted the connection to the alarm unit and it sounded briefly. At 9:25 a.m., a second attempt was made at standing the resident up and again the alarm failed to sound. g. On 12/29/11 at 9:30 a.m., the PT stated, "Pad was bad; the OT replaced it." The Surveyor had the resident to stand and the alarm sounded. 3. Resident #1 had [DIAGNOSES REDACTED]. The 14 Day Medicare MDS with an ARD of 12/3/11 documented the resident scored 7 on a BIMS (0-7 indicates severe impairment), required extensive assistance with bed mobility and transfer, and had 2 or more falls since admission or last assessment. a. The Resident Care Plan documented a problem dated 7/18/11 of I need help with my care daily... I get in the floor a lot sometimes sit, crawl or scoot around. I have trouble seeing at times..." A handwritten note dated 11/9/11 documented, "I&A, (no) injury. low bed (with) mat (mattress), alarm on & (and) working." b. The Event Reporting form dated 11/28/11 at 10:55 p.m. documented, "Resident found sitting on fall mat, alarm not working..." c. The Event Reporting form dated 12/1/11 at 1:00 p.m. documented, "Resident removed self release belt and then tried to transfer self from wheelchair to bed and fell on to floor. The alarm was not alarming, the belt when checked alarms for a few sec (seconds) then stops, maintenance informed verbally and in writing on maintenance log book. Maintenance repaired..." d. On 12/29/11 at 9:32 a.m., the resident was in Physical Therapy in a wheelchair with a pressure alarm in place. The alarm sounded when the resident was assisted to stand. 4. On 12/29/11 at 9:40 a.m., the Director of Nurses (DON) was asked, "Do you have a system in place to check if alarms are working?" The DON stated, "Anytime they (CNAs) are with the residents, they check the alarms, not necessarily to document it (the check of the alarms)." At 9:55 a.m., the DON stated, "The CNAs are to check the alarms on the floor... The nurses put interventions immediately in place. I go back and go through the interventions. The ADON is responsible for verifying that the interventions are put in place." 5. On 12/29/11 at 10:25 a.m. the Administrator stated, "The Incident Reports are reviewed at stand up meeting, we review the I/A's and tracking and trending at meeting... the (ADON) is the person that implements the interventions and the MDS coordinators will update the care plan." 6. On 12/29/11 at 11:20 a.m., the ADON was asked who was responsible for checking that planned interventions to prevent accidents were in place every day. The ADON stated, "The CNAs check it everyday. It is not documented."