Every finding on record at The Terraces of Phoenix

Based on clinical record review, staff interviews, observations, and facility documentation, staff interviews and policy review, the facility failed to ensure that one staff member had the required qualified food handlers card. The deficient practice could result in deficient practices related to the competency of food service staff. Findings: In an interview on June 12, 2025 at 2:05 p.m with Assistant Human Resource (staff #301) confirmed that the food handlers card for dishwasher-Busperson staff #112 is no longer valid and has not been renewed. The food handler certification of completion was issued on September 17, 2021, and was valid through September 17, 2024. Staff #301 confirmed had sent food handler certification token email to pre-register for renewal on November 13, 2024, however did not follow-up after that. Review of the facility [NAME] job description indicated a ServSafe certification and/or Food Handlers Certification or enrollment in the certification course preferred.

Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure showers were provided for one resident (#89). The deficient practice can result in residents not receiving care of activities of daily living to maintain highest practicable welbeing. Findings include: Resident was admitted on [DATE] and discharged [DATE] with diagnoses of occlusion and stenosis of right posterior cerebral artery, local infection of the skin and subcutaneous tissue, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance Review of the resident's care plan revealed a focus for activities of daily living (ADL) self-care performance deficit, incontinence of bowel and bladder related to dementia, impaired balance and limited mobility. Interventions included documentation of refusal of care and cleaning of peri-area with each incontinence episode. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident a Brief Interview for Mental Status (BIMS) evaluation with a BIMS score of 13, indicating cognition intact. The MDS assessment revealed that the resident did not exhibit rejection of care behavior during the assessment period. The assessment also revealed that the resident required partial/moderate assistance with shower or bathing. Review of the progress notes revealed no documentation for refusal of showers or baths. Review of the facility ADL Verification Worksheet for July 23, 2024 thru July 28, 2024 revealed one shower provided on July 28, 2024. No documentation of shower or bath evident from July 29, 2024 thru July 31, 2024. Review of ADL documentation for bathing revealed no documentation July 25, 2024 thru July 31, 2024. Review of the facility Follow-Up Question Report dated July 26, 2024 thru August 9, 2024 for ADL-Bathing revealed one shower provided on August 6, 2024 and one refusal on August 9, 2024. Further review of the Bathing task log revealed that the scheduled showers/bathing did not occur on the following dates: - August 1, 2024, August 2, 2024 and August 7, 2024 - coded as NA indicating that resident not assigned bathing during shift. The review also revealed no documentation on August 4, August 5, and August 8 2024. An interview was conducted on June 12, 2025 at 9:52 a.m. with Certified Nursing Assistant/ Restorative Nursing Assistant (CNA/RNA/Staff #21). Staff #21 stated residents are provided showers twice per week and are scheduled, further stating if they need an additional one or request one then staff are able to provide them one as needed. Staff #21 stated all showers are documented on shower sheets for skin assessments and are given to the nurse who signs off on them. Staff #21 stated if residents refuse their shower, staff will ask the RNA to offer the resident their shower, if the resident continues to refuse the RNA will notify the nurse and the nurse will speak with the resident to determine the reason for the refusal which could be due to prefer to have/not have a male, pain, or preference for a later time. An interview was conducted on June 12, 2025 at 10:19 a.m. a.m. with Licensed Practical Nurse (LPN/Staff #57). Staff #57 stated residents are offered two- three showers weekly and are scheduled according to their room number. She stated baths/showers are assigned to the CNA assigned to that room for the day. Staff #57 stated if a resident refuses their shower/bath, it is reported to the nurse who will have a conversation with the resident to determine the cause and offer a solution with a different time or day. If the resident continues to refuse, the refusal is documented on the shower sheets and in the nursing progress notes. An interview was conducted with Director of Nursing (DON/ Staff #109). The DON stated she started her position nine months prior and that it is her expectation that all residents are scheduled for a shower twice per week and will try to accommodate for an additional shower if a resident should request one. The DON reviewed the shower documents and stated; based on the documentation there is a nine-day lapse where the resident was not documented as having a shower between July 28, 2024 and August 6, 2024 and no documentation that resident #89 refused. The DON stated the lapse would prompt her to look further as to why the resident did not have a shower. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting states resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care)

Based on clinical record review, interviews, and policy, the facility failed to provide one resident (#21) and/or the resident's representative with bed-hold policy information before a transfer to the hospital. The deficient practice could result in residents being unaware of their bed-hold rights. Findings include: Resident # 21 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that includes metabolic encephalopathy, pulmonary coccidioidomycosis type 2 diabetes mellitus without complications, coccidioidomycosis meningitis, and chronic obstructive pulmonary disease. A progress note regarding resident's admission dated May 8, 2025 indicated that the resident was alert and oriented to person, place, and time. The note also indicated that resident can make himself understood and usually understands others. Review of a progress note dated May 10, 2025 revealed that the resident had a change of condition (COC). The COC was noted as the resident declining to the point where he was non-ambulatory and unable to make needs known. The note documented that provider and spouse were notified of resident's condition. The resident's spouse requested to send resident to the hospital. The progress note indicated that the resident was transported to the hospital by Emergency Medical Services (EMS). Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had an unplanned discharge from the facility on May 10, 2025. The assessment indicated that the resident was discharged to a hospital. A progress note dated May 11, 2025 indicated that the resident was admitted to the hospital with a diagnoses AMS (altered mental status) and hypoxia. Further review of resident #21's clinical record did not reveal documentation that the facility provided the resident and/or his representative a written notice of the facility's bed-hold policy when the resident was transferred to the hospital on May 11, 2025. Review of the Progress Notes dated May 23, 2023 indicated that the resident was re-admitted to the facility that day. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. An Ombudsman Notice of Resident Discharge letter dated June 6, 2025 revealed that the ombudsman was notified that resident #21 was discharged to an acute care hospital on May 10, 2025. An interview with resident # 21 and his spouse was conducted on June 11, 2025 at 12:56 pm. Resident #21 stated that the facility did not provide him any information regarding their bed hold policy or provide him with a bed hold agreement prior to his discharge to the hospital. The resident's spouse also indicated that she was not provided any bed hold information. Resident #21 noted that he was not in the same room he was assigned to prior to his hospitalization. An interview with the Director of Nursing (DON/staff #109) was conducted on June 12, 2025 at 2:55 pm. Staff #109 stated that bed holds are signed by the resident during hospital transfer under non-emergent situations. The signature would be obtained by social services or the floor nurse. If the resident was sent out via 9-1-1 (emergency), it is common for the bed hold agreement not to be signed immediately, however, there is a 24-hour timeframe to complete and get the bed hold agreement signed. The DON stated that the resident could have signed the bed hold agreement prior to transfer to the hospital since it was a non-emergent situation. A CMS-807 form dated June 12, 2025 was submitted at 1:48 pm requesting a signed bed hold agreement for Resident # 21. The form was returned at 2:40 p.m. without the requested agreement and was annotated, No bedhold signed agreement with the DON's initials. Review of the facility policy titled Bed-Holds and Returns revised October 20, 2023 indicated that all residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice, well in advance of any transfer and at the time of transfer, with the exception of emergency which is 24 hours.

Based on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to protect the rights of two residents (#12 and #23) to be free from sexual abuse by another resident (#45). The deficient practice could result in the potential for harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. The census was 43. Findings include: -Resident #23 admitted on [DATE] with diagnoses of dementia and depression. The care plan dated May 16, 2023 revealed the resident had impaired cognitive function. The goal was that the quality of life will be nurtured and the resident will be exposed to pleasurable events each day. Intervention included to engage the resident's senses with pleasant smells. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that staff assessment that the resident had severe cognitive impairment. A health status note dated August 7, 2024 included that the resident's Power of Attorney (POA) was informed of an inappropriate behavior displayed by a male resident to the resident #23; and that, the male resident was witnessed to touch the resident's arm/back. An interview was conducted with the social service director (SSD) on August 9, 2024 at 1:30 p.m. The SSD that he was aware of the incident regarding resident #45 touching resident #23; and that, he was not part of the investigation. The SSD said that resident #23 was non-verbal and her eyes would track you when you are talking to her but cannot indicate a yes or no response. -Resident #12 admitted on [DATE] with diagnoses of hemiplegia and hemiparesis, major depressive disorder and anxiety. The quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15 which indicated the resident had intact cognition. The undated active care plan revealed that the resident was at risk for problematic behavior i.e. history of fabricating false accusations against staff that attempt to give directions on ADLs (activities of daily living), medications, diabetes control and management. The goal was that the resident will accept re-direction when making false accusations. Interventions included to identify stressful times of the day, schedule activities and tasks for other times, help the resident to cope using past successful coping mechanisms and praise/reward resident for demonstrating appropriate interactions with staff and others. The undated active care plan also included that the resident had actual or suspected history of personal trauma, was abused by a babysitter at the age of 3 and had associated behaviors of mis-trust for other caregivers. The goal was that the resident will maintain psychosocial well-being. Interventions included to offer reassurance of safety and trust and restore a sense of control by honoring the resident's choices. The nursing progress note dated July 26, 2024 included that the resident reported to the certified nursing assistant (CNA) that she had a bad day because something happened to her today that brought back past memories. Per the documentation, the resident had no unusual events reported other than officers here to visit for statement due to accusation regarding a staff member on another date and time. A late entry alert note dated August 1, 2024 included that the resident was seen by investigators before lunch; and that, the investigators went to speak to the Administrator. In an interview with resident #12 conducted on August 9, 2024 at 4:45 p.m., the resident stated that resident #45 would come up to her often up to twice daily and rub her knee and thigh; and that, the touch was very unwanted. The resident also stated that she had reported this to several nurses and certified nursing assistants (CNAs) who were often were present in the area when resident #45 touches her. The resident said that when this happens, the nurses and CNA who were present would laugh and think that it was funny, and would tell Resident #45 not to touch her. The resident stated that she can escape into her room which is her safe place because resident #45 does not enter her room. However, the resident stated that resident #45 would sit right outside her door and stare at her specifically when she changes clothing. An interview was conducted with the social service director (SSD) on August 9, 2024 at 1:30 p.m. The SSD that the administrator was the one investigating the incident on resident #45 patting another female resident on the shoulder. In an interview with a CNA (staff #6) conducted on August 9, 2024 at approximately 5:00 p.m., the CNA state that on Monday, August 5, 2024, she witnessed resident #45 rubbing the arm and back of resident #12 who had not in any way invited the touch. The CNA stated that she told resident #45 that he could not do that and then she went to report the incident to the RN (staff #5) -Resident #45 was admitted on [DATE] with diagnosis of dementia. The MDS assessment dated [DATE] included a BIMS score of 7 indicating the resident had severe cognitive impairment. The undated care plan revealed the resident had a behavior problem of inappropriate touching of a female resident related to dementia. The goal included that the resident will have no evidence of behavior problem of inappropriately touching. Interventions included 1:1 monitoring x 2 weeks, document his behavior every shift, report any sexual behavior to nurse and redirect as needed. A progress note dated July 24, 2024 and written by a registered nurse (RN/staff #5) revealed that the resident touched a female resident on the leg; and that, it was unwanted. Per the documentation, the resident was redirected. There was also no evidence found in the clinical record that interventions were put in place to prevent the reoccurrence of resident #45 inappropriately touching or sexual advances to other female residents . A health status note dated August 1, 2024 included that the resident was sexually explicit, was masturbating in his bed and was asking where's that girl? referring to the CNA. A health status note written by a registered nurse (RN/staff #5) dated August 7, 2024 revealed that the resident was observed multiple times groping the breasts of a female resident. Per the documentation, staff explained to the resident the wrongful behavior, was redirected and the resident showed no signs of understanding. Another health status note dated August 7, 2024 included that the resident was on alert charting related to inappropriate activities of wanting to touch other residents; and that, the resident was monitored hourly regarding his whereabouts. A behavior note dated August 7, 2024 included that the physician was notified regarding the resident's inappropriate behavior. Despite the documentation that a resident was observed multiple times groping the breasts of a female resident, the facility self-report received on August 7, 2024 revealed that the resident was seen touching another resident; and that, the facility was investigating specifically the location of resident touching. A written statement from the RN (staff #5) dated August 7, 2024 included that the RN was at his medication cart on August 6, 2024 at approximately 5:30 p.m., he saw resident #45 was trying to touch resident #23; and that, the RN was able to intervene and redirect resident #45 before resident #45 could touch resident #23. Per the documentation, the RN assumed that resident #45 was going to grope the breasts of resident #23 because the RN had seen resident #45 was reaching towards the breasts of resident #23. Further, the documentation included that resident #45 attempted 3 times and was seen approaching resident #23 with arms stretched towards the mid-section of the body of resident #23. The behavior note dated August 8, 2024 included that the resident was alert and oriented with some confusion; and, was self-propelling around the unit. Another behavior note dated August 8, 2024 revealed that the resident continued to be monitored for inappropriate behavior of wanting to touch/feel other residents. Per the documentation, the resident was able to respond [NAME] or no and was routinely self-propelling his wheelchair in the unit between hallways. A physician order dated August 8, 2024 included an order to monitor behavior of inappropriate touching to others every shift for a diagnosis of dementia. In a phone interview with the RN (staff #5) conducted on August 9, 2024 at 2:01 p.m., the RN stated that he had worked at the facility for 8 months; and, he does not think that staff could evaluate a resident with dementia regarding consensual sexual relationship with another resident. The RN stated that resident #45 had inappropriately touched residents #23 and #12; and that, he documented these incidents in the progress notes but did not report the incidents to anyone. In a later interview with the RN (staff #5) conducted on August 9, 2024 at 3:40 p.m., the RN stated that he did not witness the incident between resident #45 and resident #12. He stated that resident reported the allegation of abuse; and that, resident #45 touched resident #12 who reported that it was an unwanted touch. The RN said that he does not know if unwanted touching between residents was considered abuse; and, he did not report it to a supervisor because he was not sure what to do in the situation. An interview was conducted on August 9, 2024 at 4:45 p.m. with the Administrator who stated that her expectations was for staff to report abuse allegations immediately. She stated that an allegation of abuse was received, staff will ensure safety of the resident, separate the residents for the alleged perpetrator (staff or resident), monitor the affected residents for psychosocial effects or concerns, and document the incident. She stated that staff received in-service and computer training on how to identify abuse; and in these trainings, staff were provided specific examples of what abuse could look like, and when in doubt to report it to her. Regarding resident #45, the administrator stated that resident #45 had not been moved from the unit when the incident between resident #45 and resident #12 because resident #12 usually spend time close to the nurse's station; and, resident #45 was not trying to seek resident #12. A policy on Elder Abuse Prevention, Identification, Response, Reporting with revision date of October 10, 2023 included that team members are expected to prevent, identify, respond to, and report allegations of elder abuse according to the steps of this procedure. Identification of abuse from witnessed events, verbal resident report of abuse, and audit of resident records, among others methods of identification. In response to allegations or witness events, general steps include, take steps to protect the resident and prevent further potential abuse immediately, report the allege violation within required time frames, take appropriate corrective action, and revise the residents care or service plan. All allegations received by a team member are to be reported as soon as practicably to the appropriate leadership team member or designee. If an altercation occurs between resident, they should be separated by staff and placed in two different areas.

Based on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to ensure allegations of sexual abuse for two residents (#23 and #12) by another resident (#45) was reported immediately to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement. The deficient practice could result in the potential harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The census was 43. Findings include: On August 9, 2024 at 5:34 p.m., a condition of IJ was identified. The administrator was informed of the facility's failure to ensure residents were free from sexual abuse by a resident was found. The administrator presented the removal plan on August 9, 2024 at 8:23 p.m. The administrator was informed that the removal plan was not acceptable and failed to include any assessment completed for resident #12 and #23; until when will resident #45 be placed on 1:1 supervision; other interventions put in place to prevent inappropriate behaviors for resident #45; when the in-service training was started and expected to be completed for all staff; identify the staff that would complete the in-service training; and, actions the facility will take if a staff did not complete the required in-service/training. A revised removal plan was received on August 9, 2024 at 9:25 p.m. and was not accepted because it failed to include when the in-service training was started for all staff including staff that were on leave; how the facility will monitor resident #45 for inappropriate behaviors; until when will resident #45 be placed on 1:1 supervision; other interventions put in place to prevent inappropriate behaviors for resident #45; what actions will be taken for staff who documented the incident but did not report the allegation of abuse; and, how often and what kind of audits or monitoring will be done to identify any potential abuse. Another revised removal plan was presented by the administrator on August 9, 2024 at 10:31 p.m. the administrator was informed that the removal plan was not accepted and failed to include: what actions will be taken for staff who documented the incident but did not report the allegation of abuse; how the facility will monitor resident #45 for inappropriate behaviors; and, how often and what kind of audits or monitoring will be done to identify any potential abuse. On August 10, 2024 at 8:33 a.m., the administrator presented a revised removal plan that was accepted at 8:47 a.m. The accepted removal plan included: -Medical and Psychiatric Assessment completed for resident #12 and #23; -In-service training on abuse was started and expected to be completed for all staff including staff that were on leave; -Actions the facility will take if a staff did not complete the required in-service/training; -Actions taken for staff who documented the incident but did not report the allegation of abuse; -How the facility will monitor resident #45 for inappropriate behaviors, until when will resident #45 be placed on 1:1 supervision and other interventions put in place to prevent inappropriate behaviors for resident #45; and, -How often and what kind of audits or monitoring will be done to identify any potential abuse. On August 10, 2024 at 12:28 p.m., the condition of IJ was removed after multiple observations were conducted of the facility implementing their removal plan which included resident and staff interviews, personnel record review, in-service training of staff and review of documentation provided by the facility. -Resident #12 admitted on [DATE] with diagnoses of hemiplegia and hemiparesis, major depressive disorder and anxiety. The quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15 which indicated the resident had intact cognition. The undated active care plan revealed that the resident was at risk for problematic behavior i.e. history of fabricating false accusations against staff that attempt to give directions on ADLs (activities of daily living), medications, diabetes control and management. The goal was that the resident will accept re-direction when making false accusations. Interventions included to identify stressful times of the day, schedule activities and tasks for other times, help the resident to cope using past successful coping mechanisms and praise/reward resident for demonstrating appropriate interactions with staff and others. The undated active care plan also included that the resident had actual or suspected history of personal trauma, was abused by a babysitter at the age of 3 and had associated behaviors of mis-trust for other caregivers. The goal was that the resident will maintain psychosocial well-being. Interventions included to offer reassurance of safety and trust and restore a sense of control by honoring the resident's choices. The nursing progress note dated July 26, 2024 included that the resident reported to the certified nursing assistant (CNA) that she had a bad day because something happened to her today that brought back past memories. Per the documentation, the resident had no unusual events reported other than officers here to visit for statement due to accusation regarding a staff member on another date and time. The documentation did not include whether the allegation was reported to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement. A late entry alert note dated August 1, 2024 included that the resident was seen by investigators before lunch; and that, the investigators went to speak to the Administrator. There was no evidence found in the clinical record that this incident was reported to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement until August 9, 2024. Review of the SA complaint tracking system included a facility self-report dated August 9, 2024. The self-report revealed that during their investigation of another incident, the facility found in the clinical record that on July 24, 2024 resident #45 touched the leg of resident #12. In an interview with resident #12 conducted on August 9, 2024 at 4:45 p.m., the resident stated that resident #45 would come up to her often up to twice daily and rub her knee and thigh; and that, the touch was very unwanted. The resident also stated that she had reported this to several nurses and certified nursing assistants (CNAs) who were often were present in the area when resident #45 touches her. The resident said that when this happens, the nurses and CNA who were present would laugh and think that it was funny, and would tell Resident #45 not to touch her. The resident stated that she can escape into her room which is her safe place because resident #45 does not enter her room. However, the resident stated that resident #45 would sit right outside her door and stare at her specifically when she changes clothing. In an interview with a CNA (staff #6) conducted on August 9, 2024 at approximately 5:00 p.m., the CNA state that on Monday, August 5, 2024, she witnessed resident #45 rubbing the arm and back of resident #12 who had not in any way invited the touch. The CNA stated that she told resident #45 that he could not do that and then she went to report the incident to the RN (staff #5) -Resident #23 admitted on [DATE] with diagnoses of dementia and depression. The care plan dated May 16, 2023 revealed the resident had impaired cognitive function. The goal was that the quality of life will be nurtured and the resident will be exposed to pleasurable events each day. Intervention included to engage the resident's senses with pleasant smells. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that staff assessment that the resident had severe cognitive impairment. A health status note dated August 7, 2024 included that the resident's Power of Attorney (POA) was informed of an inappropriate behavior displayed by a male resident to the resident #23; and that, the male resident was witnessed to touch the resident's arm/back. An interview was conducted with the social service director (SSD) on August 9, 2024 at 1:30 p.m. The SSD that he was aware of the incident regarding resident #45 touching resident #23; and that, he was not part of the investigation. The SSD said that resident #23 was non-verbal and her eyes would track you when you are talking to her but cannot indicate a yes or no response. -Resident #45 was admitted on [DATE] with diagnosis of dementia. The MDS assessment dated [DATE] included a BIMS score of 7 indicating the resident had severe cognitive impairment. The undated care plan revealed the resident had a behavior problem of inappropriate touching of a female resident related to dementia. The goal included that the resident will have no evidence of behavior problem of inappropriately touching. Interventions included 1:1 monitoring x 2 weeks, document his behavior every shift, report any sexual behavior to nurse and redirect as needed. A progress note dated July 24, 2024 and written by a registered nurse (RN/staff #5) revealed that the resident touched a female resident on the leg; and that, it was unwanted. Per the documentation, the resident was redirected. The documentation did no include whether the incident was reported to the the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement. There was no evidence found in the clinical record that this incident was reported to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement. There was also no evidence found in the clinical record that interventions were put in place to prevent the reoccurrence of resident #45 inappropriately touching or sexual advances to other female residents. A health status note written by a registered nurse (RN/staff #5) dated August 7, 2024 revealed that the resident was observed multiple times groping the breasts of a female resident. Per the documentation, staff explained to the resident the wrongful behavior, was redirected and the resident showed no signs of understanding. Another health status note dated August 7, 2024 included that the resident was on alert charting related to inappropriate activities of wanting to touch other residents; and that, the resident was monitored hourly regarding his whereabouts. A behavior note dated August 7, 2024 included that the physician was notified regarding the resident's inappropriate behavior. Despite the documentation that a resident was observed multiple times groping the breasts of a female resident, the facility self-report received on August 7, 2024 revealed that the resident was seen touching another resident; and that, the facility was investigating specifically the location of resident touching. A written statement from the RN (staff #5) dated August 7, 2024 included that the RN was at his medication cart on August 6, 2024 at approximately 5:30 p.m., he saw resident #45 was trying to touch resident #23; and that, the RN was able to intervene and redirect resident #45 before resident #45 could touch resident #23. Per the documentation, the RN assumed that resident #45 was going to grope the breasts of resident #23 because the RN had seen resident #45 was reaching towards the breasts of resident #23. Further, the documentation included that resident #45 attempted 3 times and was seen approaching resident #23 with arms stretched towards the mid-section of the body of resident #23. The undated facility report revealed that interviews with staff working on the PM shift on August 6, 2024 revealed no findings related to resident #45 touching other residents on the breast or private area. The report also included an interview with resident #12 who reported that she saw resident #45 touched resident #23 on the leg, arm and then rubbed her boob; and that a CNA was around when it happened. The report included an interview with a CNA named by resident #12. Per the documentation, the CNA reported that she saw resident #45 rubbing the arm and back of resident #23 liked resident #45 was comforting resident #23; and that, she told resident #45 that he can't do that. Further, the CNA denied seeing resident #45 touched the breast of resident #23. Continued review of the facility report revealed that the RN (staff #5) who documented the inappropriate behavior of resident #45 was interviewed; and that, the RN was not able to provide specific details about location, times and/or specific events related to the incident with resident #23. In a later interview with the RN (staff #5) conducted by the facility, the RN was at his medication cart on August 6, 2024 at approximately 5:30 p.m. and saw resident #45 was trying to touch resident #23. The documentation included that the RN was able to intervene and redirect resident #45 before resident #45 could touch resident #23. Per the documentation, the RN assumed that resident #45 was going to grope the breasts of resident #23 because the RN in other instances had seen resident #45 inch close, leaned over with arms stretched out in the direction of resident #23 but never made physical contact. Further, the documentation included that resident #45 attempted 3 times and was seen approaching resident #23 with arms stretched towards the mid-section of the body of resident #23. Further review of the facility report revealed that the facility was unable to substantiate that abuse occurred and the RN (staff #5) made an addendum to his progress notes clarifying what he witnessed, the nurse's statement from the following shift corroborated that resident #45 did not touch resident #23 and the CNAs statement did not validate that she witnessed the allegation like resident #12 had reported. It also included that the police did not take the case as sexual abuse and were not pressing charges on resident #45. A physician order dated August 8, 2024 included an order to monitor behavior of inappropriate touching to others every shift for a diagnosis of dementia. In a phone interview with the RN (staff #5) conducted on August 9, 2024 at 2:01 p.m., the RN stated that he had worked at the facility for 8 months; and, he does not think that staff could evaluate a resident with dementia regarding consensual sexual relationship with another resident. The RN stated that resident #45 had inappropriately touched residents #23 and #12; and that, he documented these incidents in the progress notes but did not report the incidents to anyone. In a later interview with the RN (staff #5) conducted on August 9, 2024 at 3:40 p.m., the RN stated that he did not witness the incident between resident #45 and resident #12. He stated that resident #12 reported the allegation of abuse; and that, resident #45 touched resident #12 who reported that it was an unwanted touch. The RN said that he does not know if unwanted touching between residents was considered abuse; and, he did not report it to a supervisor because he was not sure what to do in the situation. An interview was conducted on August 9, 2024 at 4:45 p.m. with the Administrator who stated that her expectations was for staff to report abuse allegations immediately. She stated that an allegation of abuse was received, staff will ensure safety of the resident, separate the residents for the alleged perpetrator (staff or resident), monitor the affected residents for psychosocial effects or concerns, and document the incident. She stated that staff received in-service and computer training on how to identify abuse; and in these trainings, staff were provided specific examples of what abuse could look like, and when in doubt to report it to her. Regarding resident #45, the administrator stated that resident #45 had not been moved from the unit when the incident between resident #45 and resident #12 because resident #12 usually spend time close to the nurse's station; and, resident #45 was not trying to seek resident #12. A policy on Elder Abuse Prevention, Identification, Response, Reporting with revision date of October 10, 2023 included that team members are expected to prevent, identify, respond to, and report allegations of elder abuse according to the steps of this procedure. Identification of abuse from witnessed events, verbal resident report of abuse, and audit of resident records, among others methods of identification. In response to allegations or witness events, general steps include, take steps to protect the resident and prevent further potential abuse immediately, report the allege violation within required time frames, take appropriate corrective action, and revise the residents care or service plan. All allegations received by a team member are to be reported as soon as practicably to the appropriate leadership team member or designee. If an altercation occurs between resident, they should be separated by staff and placed in two different areas.

Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#150 and #56) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in inadequate care of residents. Findings include: Review of the personnel file of a registered nurse (RN/staff 150) revealed a hire date of April 26, 2021. The file revealed no evidence of infection control and Abuse/neglect/exploitation training since January and July, 2022. Review of the personnel file of a activity coordinator (staff 56) revealed a hire date of January 21, 2014. The file revealed no evidence of Abuse/neglect/exploitation training since May, 2016, no evidence of Resident rights training since June, 2017 and no evidence of Infection control and prevention training since December, 2018. An Interview was conducted on May 29, 2024 at 2:12 p.m. with the Human Resource Director (staff # 125), she stated that she is not sure about orientation and in-service education policy. She further stated that Relias send a reminder when staff training class is due, it's also self-monitoring thing and she also sent reminder to staff and supervisor if they are way behind. An Interview was conducted on May 30, 2024 at 9:15 a.m. with the Interim Director of Nursing (staff # 5), she stated that there are certain in-service training done through relias. She further stated that she has been here for 2 months so she was not sure about in-service training but she will do competency and also access staff before the year. She also stated risk for staff not getting training that they won't be updated to process and procedure and it would cause problem to residents. Review of facility policy regarding Elder Abuse Prevention Identification, response, and reporting, revised on 10/20/2023 stated that onboarding and annual education is necessary for all team members to understand their role in abuse prevention, management, and reporting.

Based on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP). The deficient practice could result in improper infection prevention practices in the facility. Findings include: An interview was conducted May 29, 2024 at 10:34 AM with Licensed Practical Nurse and designated Infection Preventionist (LPN/IP/Staff # 100) who stated although had coursework in Infection Prevention, did not have an infection prevention program certificate of completion at this time. Staff # 100 stated she had not taken the final cumulative assessment in order to receive her certificate of completion. Staff # 100 stated initially it was a collaborative task for whoever was present, but was handed-off the IP position by fire around March 15, 2024, after previous qualified Infection Preventionist/Director of Nursing left the facility. An interview was conducted on May 29, 2024 at 01:07 PM with Interim Director of Nursing (IDON/Staff # 5) who confirmed that Staff # 100 was the designated Infection Preventionist at this time. Staff # 100 stated the facility is going to remove staff #100 out of her floor service duties, and whatever the requirement is, the facility will make sure staff #100 meet the requirement. Review of State Operations Manual, Appendix PP-2022 update (revised June 2022), regulations revealed the facility must: designate one or more individuals as the Infection Preventionist (IP) who is responsible for the facility's Infection Prevention Control Program. The IP must S483.80(b)(4) Have completed specialized training in infection prevention and control. The IP must be qualified by education, training, experience or certification. Training can occur through more than one course, but the IP must provide evidence of training through a certificate of completion or equivalent documentation.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions (EBP), signage and personal protective equipment were in-place to help prevent development or transmission of infections. The deficient practice could result in development or transmission of infections within the facility. Findings Include: Resident #352 was admitted on [DATE] with diagnosis including sepsis, unspecified organism, onset date May 22 2024, Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere onset May 22, 2024, Urinary tract infection, site not specified New UTI 3.19.24, Pressure ulcer of left heel, unstageable May 22, 2024, Benign prostatic hyperplasia with lower urinary tract symptom. A review of the physician orders revealed an order dated February 7, 2024 for an indwelling catheter size 16 French with a 15cc bulb. A review of the quarterly MDS (minimum data set) dated May 17, 2024 revealed that the resident BIMS (brief interview of mental status) was unable to be completed. The MDS further revealed that resident #352 had an in-dwelling catheter in place and a diagnosis of obstructive uropathy. A review of the care plan revealed that an indwelling catheter was in place for an obstructive uropathy. The care plan further notes interventions of monitoring for pain or discomfort, monitoring for UTI's (urinary tract infections), catheter care per shift and reporting any unusual observations to the nurse. An observation was conducted on May 28, 2024 at 10:46 AM. It was observed that there was no signage outside of the room of resident #352 alerting to enhanced barrier precautions, nor was PPE (personal protective equipment) visible outside of the resident's room. A box of gloves were observed in the resident's room, but no other PPE was present either within or directly outside of the resident's room. A secondary observation was conducted on May 28, 2024 at 2:37 PM. No signage for enhanced barrier precautions or PPE outside of the resident # 352's room were observed. An interview was conducted on May 29, 2024 at 11:25 PM with staff #100 Infection Preventionist /Licensed Practical Nurse (LPN/IP). Staff #100 Stated that she was recently placed as the IP person after assisting the facility during a Covid outbreak and was thrown in by fire as the Infection Preventionist. Staff #100 EBP was placed for all residents with catheters and wounds the morning of May 20, 2024. Staff #100 stated she was aware of the recent changes with CMS guidelines regarding EBP, but does not know why the EBP precautions were not previously placed. An interview was conducted on May 30, 2024 at 1:49 PM with staff #80 CNA (Certified Nursing Assistant). Staff #8 stated that resident # 352 has an indwelling catheter and has had one for a while. She stated that she had been informed on May 30, 2024 that she was to use precautions when caring for resident #352 catheter, using gown and gloves. She stated there were no Enhanced Barrier Precaution prior to May 30, 2024 for resident #352. Staff #8 stated she could not recall receiving training on transmission based or enhanced barrier precautions, she may have had training through Relias, but did not know the difference between the two precautions. An interview was conducted on May 29, 2024 at 01:07 PM with staff #5 Interim DON (Director of Nursing). Staff #5 stated that not having anyone available in the role as IP and her short-term role as the DON has been part of the conversation and in hindsight it was not something they have been practicing. 49325 Findings include: On May 29, 2024 at 11:08 AM a list of resident names with indwelling devices, wounds, and multi-drug-resistant organisms (MDRO) was requested. The list was reviewed and revealed the following number of residents in the facility within each category: indwelling devices: 4 residents; MDRO: 2 residents. Moreover, the list of residents with wounds that was provided included 21 residents. On May 29, 2024 at 8:50-8:55 AM, an observation of the facility rooms, consisting of hallway rooms 8100-8124 revealed no PPE or enhanced barrier signage present at any resident room. An interview was conducted on May 29, 2024 at 09:56 AM with Certified Nursing Assistant (CNA/Staff # 80) who stated that communication regarding the personal protective equipment (PPE) that needs to be worn is through the signage posted outside a resident' room. Staff # 80 stated she was not completely familiar with transmission-based precautions, however if there is any instructional signage on the wall staff are expected to follow instructions on the signage. An interview was conducted on May 29, 2024 at 10:01 AM with Registered Nurse (RN/Staff # 50) who stated that the risks of not having a signage are risks of spreading infection and chances that staff may also be infected. Staff # 50 stated if there were sign of enhanced barrier precaution (EBP) staff should wear gloves and gown. Staff # 50 confirmed that there were no EBP signage present. An interview was conducted May 29, 2024 at 10:34 AM with designated Infection Preventionist (LPN/IP/Staff # 100) and Interim Director of Nursing (IDON/Staff # 5). Staff # 100 stated if residents have Foley catheters or wounds enhanced barrier precaution (EBP) should be in place. Staff # 100 confirmed that the EBP signage had not been present and was placed today for all residents. Staff # 100 stated she had provided EBP training this morning regarding when it would be appropriate to wear PPE; and that, she gave examples. Staff # 100 stated that she was handed-off the position by fire around March 15, 2024, after previous qualified Infection Preventionist/Director of Nursing left the facility. Interim Director of Nursing confirmed no EBP signage was present in the facility since the last infection preventionist up to this point. Review of the facility's policy titled, Enhanced Barrier Precautions dated August 2022 revealed, enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDRO's) to residents; and that, EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; and that, EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; and that, signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required; and that, PPE is available outside of the resident rooms. The CDC website on healthcare acquired infections revealed that the enhanced barrier precautions are an infection control intervention designed to reduce the transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. The CDC further stated that nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's (multi-drug resistant organisms). The CDC website further stated that the use of gown and glove for high-contact resident care activities is indicated when contact precautions do not otherwise apply. Updated July 12, 2022. https://cdc.gov/hai/containment/PPE-Nursing-Homes.html.

Based on clinical record reviews, staff and resident interviews, and policies and procedures, the facility failed to ensure that advance directives were accurate for one resident (#9). The deficient practice could result in residents' wishes not being honored. Findings include: -Resident #9 was admitted to the facility on [DATE], with a diagnosis of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing. Review of the clinical record revealed a prehospital medical care directive which included the resident was a Do Not Resuscitate (DNR) status. The medical care directive was signed by the resident on May 2, 2024. However, review of the physician orders signed and dated May 8, 2024 revealed an order for a Full Code status. An interview was conducted with resident #9 on May 30, 2024 at 01:00 PM who stated she had signed paperwork indicating her preferences for DNR. She stated I have had a good life, I don't want any heroic measures done on me. An interview was conducted with a Registered Nurse (staff #38) on May 30, 2024 at 1:16 p.m. She reviewed the resident's chart stating the residents current code status is a full code. She also reviewed the state forms noting the resident's actual status is a DNR. Registered Nurse (staff # 38) stated the orders needed to be corrected because they were not correct. Registered Nurse (staff #38) stated the risks associated with a resident's advance directives being incorrect and not reflecting the resident's decision could cause the resident to receive life saving measures when the directives were not to. An interview was conducted with the Interim Director of Nursing (DON/staff #5) on May 30, 2024 at 1:31 p.m. She stated she has focused on the advance directives due to recent audits. When she reviewed the resident's clinical chart the code status had been changed to DNR. Registered Nurse (staff #38) informed the DON that the residents code status was Full Code and she had changed it to reflect the correct status of DNR. (DON/staff #5) stated that it is her expectations that advance directives be completed and be accurate. Review of the facility policy titled Advance Directives (Revised September 2022) the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure care plan was revised for one resident (#53). Findings include: Resident # 53 was admitted to the facility on [DATE] and discharged [DATE], with diagnoses that included Nondisplaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with routine healing, Pain in left ankle and joints of left foot, Unspecified open wound, right foot, subsequent encounter, Unspecified open wound, left foot, subsequent encounter, Unspecified open wound, right lower leg, subsequent encounter, Unspecified open wound, left lower leg, subsequent encounter, Unspecified osteoarthritis, unspecified site, Nondisplaced fracture of medial malleolus of right tibia, initial encounter for closed fracture. An annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was conducted revealing a BIMS score of 15 indicating resident cognition is intact. Review of Section G revealed resident required extensive assist with toileting, transfers, dressing, personal hygiene and required two plus persons for physical assist with transfer, balance during transitions and walking. Functional limitation in range of motion revealed impairment on one side with lower extremity, used wheelchair and walker for mobility. Review of the comprehensive care plan effective dated 7/12/2023 and created on 7/12/2023 revealed the resident was at risk for falls related to weakness, impaired mobility, foot wounds, medications. Review of Progress note dated 7/18/2023 at 12:56 pm stated that the resident reported she had fall in restroom on 7/16/2023. The note further stated that on 7/16/2024, she was assisted by a Certified Nursing Assistant (CNA) in the restroom and her legs became weak and she was lowered to the floor with assistance from the CNA. The note stated the resident did not hit her feet or leg but stated her ankle might have turned when she was sitting down. Further review of the care plan revealed that it had not been revised to reflect the level of assistance required for resident #53 with toileting, transfers, dressing, personal hygiene. A phone interview was conducted with a Certified Nursing Assistant (CNA/staff #105) on May 30. 2024 at 12:19 p.m. She stated she had previously worked for the facility 2022-2023 and could recall the incident involving resident #53. She stated she had assisted the resident with toileting when the resident wanted to sit down due to anxiety and feeling weak. CNA/staff #105 stated using the gait belt, she sat the resident on the floor, because she couldn't place her back on the toilet due to feces on the toilet seat. CNA/staff #105 stated she had requested assistance from Registered Nurse (RN/Staff #39) prior to assisting the resident to the bathroom. She stated she waited 10-15 minutes for assistance, but (RN/Staff #39) never came to assist her. She stated the reason she asked for help was due to the resident complaining of feeling weak the day prior. She stated she was asked by the former DON to change her statement regarding asking for assistance from the nurse prior and that the she was aware the resident was a two-person assist with toileting. (CNA/staff #105) stated she refused to change her statement because she had looked at the resident's care plan and there nothing care planned indicating a non-weight bearing status or the need for a two-person transfer. An interview was conducted with a Registered Nurse (RN/staff #39) on May 30, 2024 at approximately 2:00 p.m. She stated she could not recall any of the incident, but believed the resident was a two- person transfer and that (CNA/staff #105) did not request her assistance with transfer of the resident. She stated the resident had an x-ray completed at the facility and was transferred to the hospital. An interview was conducted with the Interim Director of Nursing (DON/staff #5) on May 31, 2024 at 8:36 a.m. She stated that when a CNA needs information regarding a resident's level of assistance they would find this information in the resident's care plan and that they do not have access to the MDS. She further stated her expectations are that a resident's level for assistance would be in the care plan, shared in report and in the nurses charting. (DON/staff #5) reviewed the MDS for resident #53 confirming the resident is a three indicating the resident is an extensive assist with two plus people. (DON/staff #5) also reviewed the current plan stating the care plan did not reflect the level of assistance required for resident transfers and that the care plan should reflect the MDS. A facility policy regarding Care Plans Baseline included the following: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission

Based on staff interviews, review of the clinical record, facility documentation, and policy and procedure, the facility failed to notify one resident's (#1) representative timely when there was a significant change in the resident's condition related to pressure ulcers. The deficient practice could result in resident representatives not being notified when residents experience a change in condition. Findings include: Resident # 1 was admitted on [DATE] with diagnoses of anxiety, femur fracture, need for assistance with personal care, fall, femur fracture, dementia, hemiplegia affecting left non-dominant side, and unspecified hearing loss bilateral. The admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated resident had intact cognition. The assessment also revealed no evidence of pressure ulcers at admission. The admission progress note dated February 25, 2023 revealed no evidence of break in skin integrity to bilateral heel ulcers. The assessment included bruising to the right arm and discoloration to bilateral lower extremities, and surgical incision to right hip. Review of wound assessments dated March 8, 2023 revealed deep tissue ulcers to the right and left heel ulcers. The nursing progress notes dated March 12, 2023 revealed purplish red discoloration to bilateral heels; and that, an order for betadine was received. A physician orders dated February through March 2023 revealed no orders for care/treatment of the right and left heel ulcers from March 12 through 21, 2023. The physician order dated May 22, 2023 revealed a treatment order to apply Santyl to the right and left heel pressure injury; and, to monitor for signs/symptoms of infection. Despite identification of pressure ulcers to the right and left heels, the clinical record revealed no evidence that the resident's representative was notified of the pressure ulcers from March 12 through 25, 2023. The nursing progress notes dated March 26, 2023 revealed the resident's representative was notified of the presence of the bilateral heel ulcers at the time of discharge. The discharge summary dated March 25, 2023 revealed evidence of right and left heel pressure ulcers present upon discharge. An interview was conducted on June 6, 2023 at 2:55 p.m. with a registered nurse (RN/staff #20), who stated that when a pressure ulcer is identified the expectation was to notify the provider and family. She further stated that notification should be documented in the progress notes; and that, notification to the family should be done on the shift that it occurred or the wound was identified and prior to the end of the shift. She stated that the sooner the family was notified, the better. Regarding resident #1, the RN stated that the expectation was that the resident had been notified of the heel ulcers; and that, the notification should have been documented in the clinical record. An interview with the Director of Nursing (DON/staff #21) was conducted on June 6, 2023 at 1:24 p.m. The DON stated that a facility acquired pressure ulcer would be considered a change of condition; and when this occurs, the provider and family should be notified. She also stated that the notification should occur during the shift that it was identified, and be documented in the progress notes. A review of the clinical record was conducted with the DON who stated that there was no evidence that the resident's representative had been notified regarding the change of condition of pressure ulcers for resident #1; and that, this did not meet her expectations. Review of the facility policy on Change in a Resident's Condition or Status, revealed that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical condition or status. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff. A nurse will notify the resident's representative when the resident is involved in any accident/incident that results in injury and when there is a significant change in the resident's physical status.

Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that a care plan was implemented for one resident (#1) regarding pressure ulcer/skin impairment interventions. The deficient practice could result in a plan of care that did not meet the resident's needs. Findings include: Resident # 1 was admitted on [DATE] with diagnoses of anxiety, femur fracture, need for assistance with personal care, fall, femur fracture, dementia, hemiplegia affecting left non-dominant side, and unspecified hearing loss bilateral. A nursing admission evaluation dated February 25, 2023 revealed no evidence that the resident had deep tissue injury of bilateral heels. The care plan dated February 25, 2023 revealed the resident had pressure ulcers and skin integrity as focus of care. Intervention included to use pillows, pads, or wedges to reduce pressure on heels and pressure points, turn/reposition, and, if skin impairment occurs monitor/document location, size and treatment of skin injury and report any signs of skin breakdown, abnormalities, failure to heal, signs/symptoms of infection, maceration to provider. Review of the February 2023 Treatment Administration Report (TAR) revealed no evidence of use pressure relief to the bilateral heels. There was no evidence found in the clinical record that pressure relief to bilateral heels was implemented as care planned. The care plan dated March 3, 2023 revealed the resident had an unstageable pressure injury, deep tissue injury (DTI). Interventions included to float heels while in bed or chair, wear heel protectors, secure assistance for turning, positioning and transfer, reposition every one to two hours or more often and use low air loss mattress to bed and pads when sitting. The care plan included that the resident would not keep heel protectors on. The wound assessments for right and left heel ulcers dated March 8, 2023 revealed deep tissue ulcers to the right and left heel ulcers; and that, foam heel protector was applied. The physician order dated March 8, 2023 revealed an order for sureprep to bilateral heel pressure injury every shift, apply foam heel protectors at all times, offload both heels when in bed. There was no evidence found in the clinical record that turning/repositioning, or heel elevation was implemented as care planned after March 8, 2023. The nursing progress notes dated March 12, 2023 revealed purplish red discoloration to bilateral heels; and that, an order for betadine was received. The TAR for March 2023 revealed no evidence of that pressure relief was provided or implemented as care planned from March 1 through March 12, 2023 Succeeding wound assessments dated March 17 and 22, 2023 revealed no evidence that the foam heel protector was applied to bilateral heels. Continued review of the clinical record revealed that wound measurements increased between March 8, 2023 through March 22, 2023. The physician order dated May 22, 2023 revealed a treatment order to apply Santyl to the right and left heel pressure injury; and, to monitor for signs/symptoms of infection. An interview was conducted on June 6, 2023 at 2:58 p.m. with a certified nursing assistant (CNA/staff #22) who stated that residents were repositioned every 30 minutes; and that, pillows are used to offload the heels. However, the CNA stated that this was not documented in the clinical record. An interview with a registered nurse (RN/staff #20) was conducted on June 6, 2023 at 2:25 p.m. The RN stated that the facility uses pillows or foam boots for pressure relief to resident's heels; and that, there should be an order for the pressure relieving devices and for turning and repositioning. She stated that pressure relief to the heels should be documented in the progress notes, and in the TAR. Regarding resident #1, the RN stated that the resident developed deep tissue injuries on bilateral heels; and that they were offloading her heels and the resident was on a low air loss mattress. In an interview with the Director of Nursing (DON/staff #21) conducted on June 6, 2023 at 1:24 p.m., the DON stated that if there was not a physician order for heel protectors, nursing should document off-loading/pressure relief in the daily nursing notes. She also said that any orders for pressure relief would be documented on the TAR. During the interview, a review of the clinical record was conducted with the DON who stated that there was no evidence of orders for pressure relief to the bilateral heels of resident #1; and, there was no evidence found that the resident was turned/repositioned, and had heels offloaded. She stated that these interventions should be documented in the progress notes, or in the TAR. Further, the DON stated that there was no evidence that the bilateral heel ulcers were offloaded per the care plan from March 17, 2023 through March 26, 2023. The DON stated that the expectation was to follow the interventions as care planned. She stated that she could not say if pressure relief occurred because there was no documentation found in the clinical record. The DON stated that the risk of not following the interventions as care planned for pressure relief could result in the wound getting larger, or the pressure not being relieved. Review of the facility policy on Pressure Ulcers/Skin Breakdown - Clinical Protocol revealed the nurse shall describe and document/report current treatments including support surfaces. The physician will order pertinent wound treatments, including pressure reduction surfaces, dressings and application of topical agents. The physician will guide the care plan as appropriate, especially when wounds are not healing, or new wounds develop despite existing interventions. Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions. The facility policy on Care Planning, revealed resident care plans are based on resident assessments and developed by an interdisciplinary team (IDT). The IDT team is responsible for the development of resident care plans.

Based on observations, staff interviews, and policy, the facility failed to ensure food items were food product were discarded on or before the expiration date in accordance with professional standards. Findings include: During a walkthrough of the kitchen conducted on [DATE] at 9:35 am, with Director of Dining (staff #11) and Registerd Dietician (staff #117), multiple observations were made in the large refrigerator, freezer, and dry storage: -a one-gallon container of onion and bell peppers mixture were observed in the walk-in refrigerator with approximately one half of the onion-peppers mixture remaining with a use by date of [DATE]. During a walk-through in the kitchen conducted with the Director of Dining (staff #11) and Registerd Dietician (staff #117), were unable to state the last time the onions and pepper mixture used. Staff #11 stated the porter puts away orders, and takes out anything that is outdated. Director of Dining (staff #11) stated the porter did not follow the facility process for discarding outdated food and there is a possible risk of food borne illness if served to residents. The An interview was conducted on February 2, 2023 at 09:24 AM with dietary porter # 52, who stated his role as porter for the warehouse is to make sure all produce is put away, rotated, label dry goods and produce, and for checking foods in fridge for their use by dates. He reported one of the first tasks he completes is checking dates and labels on refrigerated and storage items for expiration dates. He reported storage dates are three to five days. He also reported that he does not believe the onion pepper mixture had been used based on the menu, but stated if someone had eaten the expired food it could have resulted in illness. Staff #52 stated the Chefs are also responsible in checking dates on food items when he is not working in the facility. An interview was conducted with Sous Chef (staff #101) on February 2, 2023 at 09:32 AM, who stated that he is in charge of the kitchen in the mornings. He stated everyone is responsible for ensuring foods are rotated and discarded when expired, and also making sure labels are dated. He stated julienned peppers would have been used during the weekend of [DATE] or 29th for fajitas and could have been used for additional recipes. He reported the outcome of using the outdated peppers and onions could have definitely made someone sick if they were used after that date. Further inverview was conducted on February 2, 2023 at 09:44 AM with the Chef (staff #19), who provided a menu for the week of [DATE]- [DATE] and reported the pepper-onion mixture was not used in any of the recipes after the use by date. He also stated that if they were used after the use by date it could have resulted in foodborne illness through spoilage of product for anyone who would have eaten the peppers and onions. Review of the facility policy titled, Food and Supply Storage, revealed that unused portions or open packages should be covered, labeled and dated. Discard food past the use-by or expiration date.

Based on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during wound treatment for one resident (#32) per professional standards of practice. Resident #32 admitted on [DATE] with diagnoses that included dementia, psychotic disturbance, alzheimer's disease, and pressure ulcer of sacral region, stage 4. Review of a care plan dated September 24, 2021 revealed the resident had a stage 4 pressure injury to sacrum. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed a Staff Assessment for Mental Status score of 3, which indicated severe impairment. Further review revealed the resident had one unhealed stage 4 pressure ulcer. Review of a physician orders revealed: -Dated January 26, 2023 treatment to sacral wound apply collagen sheet and cover with sacral foam dressing. Change daily and PRN (as needed) for soilage. An observation of wound care and treatment was conducted on February 1, 2023 at 10:27 AM, with an Licensed practical nurse (LPN/staff #118). The LPN washed her hands in the sink and entered the room, placing gloves on both hands. The LPN positioned the resident on her left side and removed the resident's brief. She proceed to remove the previous/old wound dressing, cleansed the ulcer with wound cleanser saturated 4x 4 gauze, opened the collagen dressing packet, and secondary foam dressing. The LPN then placed her gloved hand into her scrub and removed a felt tip pen from her scrub pocket. She wrote the date on the outside of the foam dressing, and replaced the pen into her pocket. The LPN applied the collagen dressing to the base of the wound, and covered with the secondary foam dressing. She removed the gloves, sanitized her hands, repositioned the resident and then entered the resident's bathroom and washed her hands. The LPN was not observed to remove her gloves and sanitize her hands after removal of the old dressing, and donn a clean pair of gloves prior to application of the new (clean) ulcer dressing. An interview was conducted with the wound care nurse (LPN/staff #118) on February 1, 2023 at 1:58 PM. She stated that she uses one pair of gloves to remove and clean the wound, and then another clean pair of gloves to apply the new dressing. She stated that she did not do that during the wound care observation, and that this did not follow the facility process. The LPN stated that the risk could result in spread of infection. An interview was conducted on February 2, 2023 at 2:26 PM with the Director of Nursing (DON/staff #133), who stated that she expected nurses to remove gloves and sanitize their hands after removing the old dressing, and to donn new/clean gloves prior to applying the new/clean dressing. An interview was conducted on February 1, 2023 at 2:37 pm via the telephone with a Registered Nurse (RN, Wound Nurse/staff #115), who stated that the facility expectation for wound care treatments, includes donning a clean pair of gloves and removing the old/dirty dressing, removing the gloves, sanitizing hands and donning a clean pair of gloves prior to applying the new/clean dressing. She stated that nurses need to remove the gloves after removing to prior/old dressing because the dressing that is being removed is considered dirty. She further stated that that the nurse should not reach into her pocket for a pen without removing the gloves first, especially if she had used the same pair of gloves to remove an old dressing. She stated that the risk would be infection or exposing the wound to other organisms. Review of the facility policy titled, Wound Care, revealed to put on exam glove and loosen tape and remove dressing, pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves, wash the wound, apply treatments as indicated.

Based on review of records, staff interviews and review of policies and procedures, the facility failed to ensure that two residents (#24, #14) were provided care and services that met professional standards of quality resulting in the residents receiving medications/supplements that were not ordered by the physician. The facility census was 52 residents, and the sample was 18. The deficient practice has the potential for the resident not receiving the appropriate treatment. Findings include: -Regarding Resident #24 Resident #24 was admitted on [DATE], with diagnoses that included chronic embolism and thrombosis of left femoral vein, peripheral vascular disease, and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status of 14, which indicated intact cognition. Review of physician order's revealed an order dated July 14, 2022 for Herbal supplement Ocuprime supplement. Review of physician orders revealed no evidence of orders for administration of Visifree supplement. A medication observation was conducted on February 1, 2023 at 8:32 AM with a Licensed Practical Nurse (LPN/staff #112), who administered two Visifree capsules to resident #24. -Regarding Resident #14: Resident #14 was admitted on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, and chronic kidney disease, stage 3. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview of Mental Status of 15, which indicated intact cognition. Review of physician orders revealed no evidence of orders for administration of Centrum Minis supplements or Florastar a probiotic supplement. Further review of the physician orders revealed an order for Centrum Complete 18mg (milligram) - 400 mcg (microgram) dated October 1, 2021. A medication observation was conducted on February 1, 2023 a registry LPN (staff #170), who administered one Centrum Mini and one Florastar capsule to resident #14. An interview was conducted on February 1, 2023 at 1:19 PM with the Director of Nursing (DON/staff #113), who stated that the facility policy is to obtain a physician order for all medications prior to being administered. She stated that the provider will review medications that resident's order from the internet prior to administration. She reviewed resident #24's clinical record and stated that the resident orders supplements from the internet. She also stated that they do not have an order for the Visifree supplement. The DON also stated that regarding resident #14, that she was not sure that nursing had informed the provider that the resident provided his own medications, Centrum Minis and Floraster. Further interview was conducted with the DON on February 1, 2020 at 2:19PM, who stated that after further clincial review, the Centrum Mini and Floraster did not have a physician order prior to administration for resident #14. She further stated that she reviewed the clinical record and that Centrum Complete and Centrum Minis are not the same formulary. There should have been a physician order for the administration of the Centrum Minis. She also stated that the Centrum Minis bottle had been opened in December of 2022, so had been administered since that time without a physician order. The DON stated that there was no order to administer Floraster. She stated that after review of resident #24's clinical record, that there was an order for a herbal supplement Ocuprime, but the formulary was not the same as Visifree. She further stated that there was no evidence of a physician order for Visifree and the medication should not have been administered. She also stated that this did not follow the facility policy, that all medications need a physician order prior to administration. She stated that risk would be that the physician would not be aware of the multivitamins the resident was taking. An interview was conducted on February 2, 2023 at 9:06 AM with a Registered Nurse (RN/staff #119), who stated that it is the facility policy to follow physician orders as written, and to obtain physician orders, for all medications administered including nutritional and dietary supplements, vitamins, and minerals. She further stated that all medications need to be verified with physician review, including supplements, vitamins. Review of the facility policy titled, Mediation and Treatment Orders, revealed that Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to ensure services provided met professional standards of quality by failing to follow physician orders [REDACTED].#19). The deficient practice could result in adverse clinical outcomes. Findings include: Resident #19 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the current care plan revised 9/4/18 revealed the resident had a potential nutritional problem related to decreased cognition as evidenced by variable meal intake around 50% and the need for assistance/coaching. The goal was for the resident to maintain adequate nutritional status. Interventions included providing set-up and assistance with meals in the dining room as needed/accepted and monitoring, documenting, and notifying the physician as needed for refusals to eat and concerns during meals. Review of the percentage of meals eaten revealed the following for (MONTH) and (MONTH) 2019: For July, 36 meals the resident consumed was 50% or less. For August, 39 meals the resident consumed was 50% or less. The quarterly admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident cognitive skills were moderately impaired for daily decision making and the resident required supervision for eating. A quarterly nutrition review dated 8/30/2019 revealed the resident had decreased her consumption of solid food to 26-50% but was not a risk for unintended weight loss. Review of the summary of physician orders [REDACTED]. The percentage of meals eaten for (MONTH) and (MONTH) 2019 revealed the following: For September, 32 meals the resident consumed was 50% or less. For (MONTH) 1-16, 20 meals the resident consumed was 50% or less. Further review of the clinical record revealed no documentation that 1:1 assistance was provided to the resident as ordered or that the care plan included this order. An observation was conducted of the resident on 10/15/19 at 09:38 AM. The resident's breakfast was sitting in front of her on a bedside table. The breakfast was a full size waffle, fries and bacon. The resident was not observed to attempt to eat the food in front of her and no staff were observed in the resident's room. During a lunch observation conducted on 10/15/19 at 12:53 PM, a Certified Nursing Assistant (CNA) was observed to deliver the resident's tray, raise the head of the bed, set up the tray, and leave the room. An observation was conducted of the resident in the north dining room on 10/16/19 at 12:10 PM. She was sitting at a table with three other residents and a CNA was sitting across from the resident assisting two other residents. The resident was observed drinking out of a cup without assistance. The resident was observed unable to grasp the spoon on the table to eat the bowl of food in front of her. The resident was unable to eat until staff assisted her. An attempt was made to interview the resident however; the resident was unable to answer questions. The resident would say one word and make facial expressions. In interview conducted with a CNA (staff #20) on 10/16/19 at 10:39 AM., she stated the resident makes up her own mind about where and when she eats. The CNA stated that when the resident eats her meals in her room sometimes she eats by herself because if staff stays in the room, the resident will not eat. She stated that they will leave the resident alone to eat and will check back on her. The CNA stated that if they notice the resident needs help, they will help her. An interview was conducted with a Licensed Practical Nurse (LPN/staff #61) on 10/16/19 at 12:44 PM. She stated that if the staff is concerned with the resident's meal intake, they can obtain an order for [REDACTED].#61 stated staff will leave the resident alone when she eat her meals in her room but will pop in to check on her every 15-20 minutes. She stated they follow the care plan for the resident's nutritional needs. She also stated the resident is weighed monthly now because she is not a high risk for weight loss. During an interview conducted with the Director of Nursing (DON/staff #4) on 10/16/19 at 12:54 PM., she stated that if a resident is not eating more than 50% of their meals, she expects the CNA to report it to the nurse so the Interdisciplinary Team (IDT) team can address it in the morning meeting. She stated the staff should also address the lack of intake with the resident and offer other options. The DON stated that when a resident is a high risk for weight loss they are weighed weekly. She stated this resident is not at high risk and is weighed monthly. She stated she was not aware there was an order for [REDACTED]. In an interview conducted with the Dietary Manager (staff #125) on 10/16/19 at 01:18 PM., she stated this resident is not at risk for weight loss based on the resident's intake per meal, Body Mass Index (BMI), lab work, and the quarterly/annual reviews. She stated she was not aware the resident had an order for [REDACTED].>The facility's policy titled Clinical Nutrition Services: Nutrition Assessment and Monitoring revised 8/2019 revealed the individualize plan of care will be written and reviewed regularly when changes are noted. The plan of care will be shared with and agreed upon by the resident and/or representative. The nutrition assessment will include data from staff members including meal intake and appetite. Interval assessments will be completed for nutritional concerns such as poor intake of food/fluid and refusal to eat.

Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure oxygen tubing for one sampled resident (#8) was changed as ordered and stored consistent with professional standards of practice. The deficient practice could result in respiratory complications and infection. Findings include: Resident #8 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) 2019 revealed the oxygen tubing was changed on (MONTH) 6 and again on (MONTH) 13. During an observation conducted of the resident's room on (MONTH) 15, 2019 at 9:56 a.m., the resident was not observed using oxygen. The oxygen concentrator was on and in the bathroom shower. The tubing was connected to the concentrator and part of the tubing was lying on the floor of the shower. Another part of the tubing was looped around the grab bars next to the toilet. The tubing extended out of the bathroom, into the resident's room and was wrapped around the table next to the resident who was sitting in a chair. The tubing on the concentrator had a label with the date (MONTH) 12 on it. The nasal cannula had a separate label that had the date (MONTH) 5 on it. An interview was conducted with the resident immediately following this observation. The resident stated the oxygen concentrator was moved into the shower that morning to make room for staff to clean up an accident and that no one noticed the concentrator needed to be moved back into her room. Resident #8 stated that she does not know when the staff changes the oxygen tubing. Another observation was conducted of the resident's room was on (MONTH) 16, 2019 at 1:25 p.m. The oxygen concentrator was observed in the bathroom, but was no longer in the shower. Part of the tubing from the concentrator was wrapped around the grab bars next to the resident's toilet, and part of it was coming out of the bathroom and lying on the floor next to the resident's bed. The label on the tubing was dated (MONTH) 12. The tubing for the nasal cannula was on the table next to the resident's bed, and the label was dated (MONTH) 5. An observation was conducted of resident #8's room on (MONTH) 17 at 10:20 a.m. The oxygen concentrator was observed in the resident's bathroom. The tubing was wrapped around the grab bars behind and next to the toilet, coming out of the bathroom and lying on the table next to the resident's bed. The label on the concentrator tubing contained the date 12. The label on the nasal cannula tubing contained the date (MONTH) 19. An interview was conducted with a Registered Nurse supervisor (RN/staff #102) on (MONTH) 16, 2019 at 2:59 p.m. The RN stated the night shift staff changes the oxygen tubing for all residents who have that order. Staff #102 stated the tubing should be changed at least weekly, and should be done on schedule. She stated once the tubing has been changed and labeled it will documented on the TAR. The RN stated that the night nurse may have missed changing resident #8's oxygen tubing. She also stated that it should not have been documented as done on the TAR if it was not done. The RN stated that the date on the labels is the date the tubing is supposed to be changed. The supervisor stated that she did not want to observe the tubing at this time, and that she would ask the night nurse what happened when she reported for work. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 17, 2019 at 10:38 a.m. The DON stated all oxygen tubing should be changed weekly and as ordered. She also stated the labels on the tubing should be updated when the tubing is changed, and documentation on the TAR should reflect the task was done. She stated it was brought to her attention yesterday that resident #8's oxygen tubing had not been changed as ordered. She stated the tubing was changed last night (October 16, 2019). The DON stated she did not know why it was documented on the TAR that the oxygen tubing was changed when the labels on the tubing did not reflect it was changed. She stated that the date on the tubing should be the date the tubing was last changed. During an interview conducted with a Certified Nursing Assistant (CNA/staff #68) on (MONTH) 17, 2019 at 12:58 p.m., the CNA stated the oxygen tubing should be kept in a bag in the resident's room when not in use. Another interview was conducted with the DON on (MONTH) 17, 2019 at 1:05 p.m. She stated that all oxygen tubing should be kept in a black antimicrobial bag when not in use. She stated this bag should be stored somewhere near the concentrator. She also said they change the bags every 30 days to prevent infections. The DON stated the tubing should never be stored on the floor. The DON also indicated that she was not aware of how resident #8's oxygen tubing was being stored. The facility's policy and procedure regarding Respiratory Therapy Prevention of Infection revised (MONTH) 2011 revealed the purpose of the procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. The policy instructs to change the oxygen cannula and tubing every seven days or as needed, and to keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.

Based on observations, clinical record review, resident and staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment for one resident (#13) was accurate regarding restraints. The deficient practice could result in inaccuracies within the resident's clinical record. The census was 53 residents. Findings include: Resident #13 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A side rail usage assessment dated (MONTH) 15, 2019 revealed the resident required the assistance of one person to enter or exit the bed and was able to move and change positions in bed without assistance. The assessment included the resident preferred to have the rails in place and was able to enter and exit the bed on her own with the rails in use. A physician's orders [REDACTED]. Review of the care plan initiated (MONTH) 7, 2019 for quarter side rails as a therapeutic device to support mobility and independence revealed the goal was to enhance functional independence and promote skin integrity through the use of the right quarter rail for positioning and turning while in bed. Interventions included the resident uses the right side rail to assist with transfers. However, the quarterly MDS assessment dated (MONTH) 9, 2019 revealed resident #13 was coded as having bed rails used daily as a physical restraint. During an observation conducted of resident #13's room on (MONTH) 15, 2019 at 8:51 a.m., quarter rails was observed attached to each side of the resident's bed. An interview was conducted with resident #13 on (MONTH) 15 at 1:40 p.m. The resident stated she likes having the bed rails and that she uses them to help her get in and out of bed. She stated she does not use them all of the time, and the rails do not prevent her from getting out of bed. Resident #13 stated she is able to transfer from her wheelchair to the bed without assistance, and she is able to walk around her room without assistance. An interview was conducted with the MDS coordinator (staff #92) on (MONTH) 17, 2019 at 9:15 a.m. Staff #92 stated resident #13 uses the bed rails to assist her with getting in and out of bed. Staff #92 stated the resident has had the bed rails for a long time, and the resident feels safer with the bed rails up. Staff #92 stated she has checked the RAI manual guidelines and believes any use of bed rails qualifies as a restraint and must be coded as such on the MDS assessment. Staff #92 stated anyone in the facility with bed rails will have a restraint coded on their MDS assessment since the resident is not able to remove the bed rail in case of an emergency. She also stated the bed rail is not used as a restraint, but for mobility assistance. Another interview was conducted with the MDS coordinator (staff #92) on (MONTH) 17, 2019 at 10:45 a.m. Staff #92 stated that after checking with other staff, she has modified the resident's MDS assessment to remove the restraint. Staff #92 stated she was informed that since the bed rails do not restrict the resident's movement or ability to get in and out of bed, they are not classified as a restraint. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 17 at 10:57 a.m. The DON stated the facility is restraint free and no resident should have a restraint coded on their MDS assessment. The DON stated that the bed rail does not restrict the resident's movement, and the resident is still able to get in and out of bed without assistance with the bed rails in place. Review of the RAI manual revealed physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The manual also revealed the assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definition; remember the decision about coding a restraint depends on the effect it has on the resident. The RAI manual included that it is required that the assessment accurately reflects the resident's status and that the importance of accuracy completing and submitting the MDS assessment cannot be overemphasized.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure 1 of 15 sampled residents (#35) code status was consistent in the clinical record. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #35 was admitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Review of a nursing health status note dated (MONTH) 28, 2019 revealed the power of attorney (POA) for the resident would be signing the admission paperwork the next day. The note included the resident was willing to sign the paperwork but was unable to. A physician's orders [REDACTED]. Review of the care plan regarding advance directive initiated (MONTH) 28, 2019 revealed the resident and the resident family stated preference is that in the event cardiac function stops initiate CPR. The goal was that the resident preference will be honored in the event of a cardiac emergency. An intervention included that in the absence of breathing and pulse to call 911 and begin CPR. The admission Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. However, a Statement of Treatment Preferences signed (MONTH) 8, 2019 by the POA and the facility representative revealed a request that while a resident at the facility the resident will be designated a do not resuscitate (DNR). Per the form, it is understood this means no cardiopulmonary resuscitation will be employed in the plan of treatment, if necessary. A Pre-Hospital Medical Care Directive dated and signed (MONTH) 8, 2019 by the POA, Licensed Health Care Provider, and a witness revealed that in the event of cardiac or respiratory arrest, the resident refuses any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration or advanced cardiac life support drugs and related emergency medical procedures. Further review of the clinical record revealed no evidence the physician order [REDACTED]. During an interview conducted with the resident on (MONTH) 15, 2019 at 8:49 a.m., the resident stated that he did not want CPR. In an interview conducted on (MONTH) 16, 2019 at 12:13 p.m. with a registered nurse (RN/staff #49), she stated advance directives are completed upon admission. She stated that if the resident is a full code, the nurses will fill out the advance directive form with the resident and make sure that the electronic clinical record reflects the goals stated on the form. She further stated that if the resident's code status is DNR, the nurse will explain the DNR status before the resident, nurse and a witness signs the form. The RN stated that the physician will be notified that the resident is a DNR and will complete the pre-hospital medical care directive form with the resident. She stated the nurse that completes the form is expected to update the advance directives in the electronic clinical record. The RN stated that the day shift will usually tell the supervisor who will update the care plan, but the other shifts will update the care plan themselves. She states that this resident's code status was a mistake because the paper clinical record should be the same as the electronic clinical record, and that this could be a problem as most nurses would check the electronic clinical record and not the paper clinical record. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 16, 2019 at 12:38 p.m. The DON stated that whoever put the DNR status in the paper clinical chart would be expected to change the status in the electronic clinical record as well. The DON stated that she remembers the resident's POA made this change and that it should have been updated in the electronic clinical record. Review of the facility's policy for Advance Directives revised (MONTH) (YEAR), revealed advance directives will be respected in accordance with state law and facility policy. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The Care Plan Team should be informed of changes or revocations of a directive so appropriate changes can be made in the care plan. The DON or designee will notify the physician so that appropriate orders can be documented in the clinical record. The policy also revealed that if the resident or the resident representative refuses treatment, the facility and care providers will modify the care plan as appropriate.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the nutrition care plan was revised for one resident (#19). The deficient practice could result in inaccuracies regarding resident care. Findings include: Resident #19 was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the nutrition care plan initiated 12/12/2016 revealed a goal that the resident will maintain adequate nutritional status. Interventions included providing and serving diet as ordered, providing set-up and assistance with meals in the dining room as needed/accepted. Review of the summary of physician orders [REDACTED]. However, further review of the care plan did not reveal the care plan was revised to include the order for the resident to receive 1:1 assistance with her meals. An interview was conducted with a Certified Nursing Assistant (CNA/staff #20) on 10/16/19 at 10:39 AM. She stated the resident makes up her own mind on where and how she wants to eat her meals. She stated the resident will either eat in the dining room or in her room. The CNA stated the resident will not eat sometimes unless staff leaves the room. During an interview conducted with a Licensed Practical Nurse (LPN/staff #61) on 10/16/19 at 12:44 PM., she stated staff follows the care plan for the residents' nutritional needs. The LPN stated that staff will pop in to see the resident every 15-20 minutes to ensure she is eating. During an interview conducted with the Director of Nursing (DON/staff #4) on 10/16/19 at 12:54 PM., the DON stated that the care plan should include the physician order [REDACTED]. She stated the care plans are updated by the nursing supervisor and nursing staff as new orders are written. The DON stated care plans are reviewed weekly and corrected as needed for a change in the resident's condition or if new orders are obtained. She stated she was not aware there was an order for [REDACTED]. An interview was conducted with the Dietary Manager (staff #125) on 10/16/19 at 01:18 PM. She stated she was not aware the resident had an order for [REDACTED].>The facility policy titled Care Planning with an effective date of 11/28/2016 revealed care plan for residents is a critical job function for licensed nurses when new orders are received. The policy also revealed physician orders [REDACTED].

Based on observations, clinical record reviews, resident and staff interviews, documentation from the Centers for Disease Control (CDC) and policy review, the facility failed to ensure that contact precautions were in place for two residents (#113 and #377) with symptomatic Clostridium Difficile (C-diff). As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On May 5, 2015 at 2:20 p.m., the Condition of Immediate Jeopardy was identified. The Administrator and Director of Nursing (DON) were informed of the facility's failure to implement contact precautions for two residents with known symptomatic[DIAGNOSES REDACTED] infections. Staff were observed entering both residents' rooms, without applying gloves and gowns. Observations revealed that there was no PPE (personal protective equipment) available for staff outside of the residents rooms or in the hallway, and the Administrator stated that gowns would need to be ordered. Also, there were no signs outside of the resident's room to alert visitors and residents to check with the nurse before entering. In addition, resident #113 and #377 were also observed in the facility's dining room on May 4 and 5, 2015, without gloves and gowns in place. The Administrator and DON presented a plan of correction on May 5, 2015 at 4:30 p.m. The plan presented was returned for additional corrective measures that were to be included. The final plan of correction was accepted at 4:55 p.m. Multiple observations were conducted on May 6, 2015 of the facility implementing their plan of correction, which included in-services regarding infection control and implementing contact precautions for[DIAGNOSES REDACTED] for the two residents. Observations revealed that PPE was stationed outside of the two residents rooms and staff were donning gloves and gowns, prior to entering those rooms. The Condition of Immediate Jeopardy was abated on May 6, 2015 at 12:00 p.m. -Resident #113 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had chronic[DIAGNOSES REDACTED] since January 2015. A physician's orders [REDACTED]. A care plan dated March 25, 2015 for antibiotic therapy related to[DIAGNOSES REDACTED] included an intervention that the resident was to be on isolation precautions until diarrhea free, with 72 hours of antibiotic therapy. According to the April 2015 nurse's notes, the resident was being monitored for loose stools. A nurse's note dated April 18, documented the resident had loose stools. Nurse's notes from April 24 through 29, included the resident had approximately 26 episodes of loose stools. A nurse's note dated May 3, 2015, documented the resident had a small liquid bowel movement. An observation was conducted on May 4, 2015 at 12:10 p.m., of resident #113 in the dining room. The resident was observed to be seated at the dining room table with three other residents. The resident was not wearing a gown or gloves. An observation outside of the resident's room was conducted on March 4, 2015 at 3:00 p.m. There was a small orange colored dot on the resident's name plate outside the door of the room, however; there was no sign posted at the entrance of the room informing residents and visitors to check with the nurse before entering. There was also no PPE available to staff outside of this resident's room or anywhere in the hallway area. During an interview with resident #113 on May 4, 2015 at 3:15 p.m., she stated that she has had[DIAGNOSES REDACTED] since January 2015 and was told by the doctor it was under control, but was having difficulty again with her bowels and was put back on antibiotics. During an observation conducted on May 4, 2015 at 3:20 p.m., a CNA entered the resident's room, without donning a gown and gloves. During an observation of the dining room on May 5, 2015 at 8:20 a.m., the resident was observed to be seated at a dining room table with three other residents, without wearing a gown or gloves. An interview with the resident's Licensed Practical Nurse (LPN) was conducted on May 5, 2015 at 1:25 p.m. He stated the orange circle is our coding system for residents that have[DIAGNOSES REDACTED]. He said they have to be on medication and be free of active diarrhea for 72 hours per facility policy, and then they are allowed to go out of their rooms and be with other residents. During an interview on May 5, 2015 at 3:33 p.m., the resident's CNA stated that she uses gloves to assist the resident, but does not use gowns. The CNA stated that she believes they are out of them. -Resident #377 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Review of a nurse's note dated May 3, 2015 at 6:46 a.m., revealed the resident was assisted to the bathroom and had a large liquid stool. A nurse's note dated May 4, 2015 at 2:50 a.m., included the resident was assisted to the bathroom and had a large liquid stool. Further review of the clinical record revealed there was no care plan in place related to[DIAGNOSES REDACTED]. On May 4, 2015 at 11:55 a.m., it was observed that there was an orange dot on the name plate outside of this resident's room. At approximately 12 p.m., a therapist was observed entering the resident's room and completed some exercises with the resident. The therapist did not don any gloves or gown. The therapist then wheeled the resident to the dining room for lunch. The resident did not have a gown or gloves on. There was also no sign outside of the resident's room, alerting residents and visitors to check with the nurse before entering. On May 5, 2015 at the noon meal, the resident was again observed in the dining room. The resident was seated at a table with other residents and did not have a gown or gloves on. An interview was conducted on May 5, 2015 at 12:30 p.m., with a certified nursing assistant (CNA) working on the unit where the resident resided. The CNA stated that he did not know what the round orange dots outside of some rooms meant, but would find out. The CNA then located a sheet regarding infection control procedures. Per the documentation, the facility used a colored dot system for various types of infections. The information included that the orange dot was used for residents with[DIAGNOSES REDACTED] and noted the following: Precautions use gloves, hand washing with soap and water (alcohol based sanitizers do not kill the CDIFF germs). Gown if soiling of your clothes is likely. An interview was conducted on May 5, 2015 at 12:45 p.m., with the CNA providing direct care to the resident. The CNA knew that the orange dot indicated the resident had[DIAGNOSES REDACTED]. She stated that she always uses gloves when caring for this resident, but did not wear a gown and as far as she knew they did not have any gowns to wear. She added that the resident is dependent on the staff for toileting and hygiene. On May 5, 2015 at 2:20 p.m., the Administrator stated that if both residents are going to be on contact precautions, he would have to order gowns, as he did not think they had any in central supply. He also stated he was surprised that a CNA did not know what the orange dot meant, as staff had been inserviced on the various colored dots. The Administrator also stated that they no longer post signs outside of resident rooms and went to a colored dot system. An interview was conducted on May 5, 2015, with the DON. The DON stated that they did not think they needed to wear gowns and that gloves would be sufficient. She stated that both residents should have been on contact precautions. Interview was conducted on May 6, 2015 at 8:30 a.m., with a CNA who stated that resident (#377) was reported to have had another liquid stool early in the morning. Review of the facility's policy regarding[DIAGNOSES REDACTED] revealed preventative measures will be taken to prevent the occurrence of[DIAGNOSES REDACTED] infections among residents and precautions will be taken while caring for residents with[DIAGNOSES REDACTED] to prevent transmission to others. The policy included that[DIAGNOSES REDACTED] spores can persist on resident-care items and surfaces for several months and are resistant to common cleaning and disinfection methods. Residents with diarrhea associated with[DIAGNOSES REDACTED] (i.e. residents who are colonized and symptomatic) will be placed on Contact Precautions. Healthcare workers will wear gloves and gowns upon entering the room of a resident with[DIAGNOSES REDACTED] infection, and will remove gowns and gloves prior to exiting the room. Review of the Centers for Disease Control and Prevention guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands who have touched a contaminate surface or item. For the prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines also stated to use gloves and gowns when entering patients' room and during care and for all interactions that involve contact with the patient even during short visits or potentially contaminated areas in the residents environment. In addition, the CDC guidelines included that[DIAGNOSES REDACTED] infected residents continue to shed organisms for a number of days following the cessation of diarrhea.

Based on closed and current clinical record reviews, observations, facility documentation, staff interviews, and review of facility policies and procedures, the facility failed to ensure that two residents (#60 and #108) were provided care and services to prevent falls with injuries and failed to ensure that two residents (#26 and #55) were assessed for the safe use of quarter bed rails. Findings include: -Resident #60 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed an initial nursing assessment dated [DATE], which identified the resident to be a high risk for falls, with a score of 19. Narrative nursing documentation dated December 30, 2013, included the resident was alert but confused and that safety awareness was an issue. A care plan for fall risk related to a history of falls and impaired balance, included interventions to report and document all falls, teach/encourage the resident to use handrails/assistive devices properly, and to wear proper non-slip footwear when out of bed. A care plan related to the hip fracture due to a fall, included as an intervention to place the resident's bed in the lowest position, with wheels locked. An admission Minimum Data Set (MDS) assessment dated [DATE], reflected the resident required extensive assistance of two plus person physical assistance during transfers. In addition, the resident was assessed to be unsteady during surface-to-surface transfers and only able to stabilize with human assistance. Review of the interdisciplinary progress notes from January 6 through 24, 2014, revealed the resident had orthostatic hypotension, with episodes of tremors during therapy related to Parkinson's disease. The resident was also documented to demonstrate mild to moderate confusion at times. An occupational therapy (OT) note dated January 24 at 3:51 p.m. revealed that "...during episodes of postural hypotension, patient's level of awareness is reduced as well as, delayed response to simple one step directions." Interdisciplinary progress notes for January 27, 2014, revealed the resident demonstrated increased confusion. An OT note dated January 27 at 9:15 p.m., documented that the resident had increased confusion and had difficulty following familiar one step directions. The resident was also noted to have increased tremors in bilateral upper extremities, with decreased focus. Review of a nursing progress note also dated January 27 at 10:40 p.m., revealed that at 5:30 p.m. a certified nursing assistant (CNA) was "getting resident up for supper. She put him in the wheelchair. She turned around to get his foot pedals and he stood up and fell on the floor...Assessed for ROM (range of motion). Two abrasions noted on forehead." Another Fall Risk Assessment was completed on January 27, 2014. The documentation included the resident's fall risk score had increased to 23. Checked under this assessment were that new interventions were identified and the care plan was updated. However, the assessment lacked documentation regarding what the new interventions included. Further review of the closed clinical record revealed there was no further documentation of any interventions implemented at this time. Nursing progress notes dated January 31 at 9:53 p.m., included the resident was "very confused this evening" and that the resident made numerous attempts to climb out of bed on his own after supper and that staff "quickly responds to alarm to prevent injury." A nursing progress note dated February 1 at 1:54 p.m., documented the resident was alert but incoherent for most of the time, with visual hallucinations observed. The resident was also documented to have attempted to get out of bed twice and that the bed alarm was on and bed was in the low position. The fall risk care plan was eventually updated on February 3, seven days after the fall (from January 27). Included as a new intervention was that an alarm would be used to alert staff that the resident was getting out of bed. The documentation did not address that an alarm would be utilized in the wheelchair, even though the fall on January 27, was from the wheelchair. Nursing progress note dated February 3, 2014 at 11:10 p.m., documented that after supper the resident was very confused and attempted to climb out of bed. Staff was noted to have reminded the resident numerous times to use the call light, despite the documentation that the resident was very confused. There was no documentation that the bed alarm was in place and sounded during this attempt, nor if the bed was in the lowest position. Review of the nursing progress notes dated February 8, 2014 documented that at 2:00 p.m., the resident transferred himself from the chair to the bed and that the chair alarm was on, with no fall incident and staff placed the resident in bed. The nursing progress note for February 8, further documented that at 5:00 p.m., the resident was observed on the floor by his wheelchair, with the wheelchair pushed back to the wall by the resident's television. The resident was unable to explain how he had fallen. The resident was noted to complain of pain to his right thigh and was assisted back in bed. An order was obtained for a right hip x-ray. Review of the x-ray results dated February 8, 2014, reflected an acute periprosthetic femur fracture. A physician's orders [REDACTED]. An interview was conducted on March 26, 2014 at 4:19 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Nursing administration stated that a Falls Meeting was held every week and that Fall Intervention Sheets were created from these meetings and were kept in the CNA's book. However, nursing administration could not provide the sheets for resident #60, explaining that they were discarded after the resident's discharge from the facility. With regards to updating the care plans with new interventions after the resident fell (on January 27), staff stated that an incident report would be generated with any interventions listed and should be included in the resident's care plan. The DON stated that nursing administration or the nurse supervisor should update the care plan, within 24 to 72 hours. Another interview was conducted on March 27, 2014 at 1:48 p.m., with the DON. The DON reviewed the resident's clinical record and acknowledged that the alarm for the wheelchair was not specified in the care plan. Regarding the fall on February 8, the DON stated that the resident was in his room in the wheelchair with the alarm applied, but a visitor had turned off the alarm. However, the facility was unable to provide any documentation regarding the specifics surrounding the fall and the DON further stated that the information regarding this fall was on their incident report, which was used as an internal tool for facility use only and they could not provide the information. An interview with the MDS coordinator was conducted on March 27, 2014 at 2:29 p.m. After reviewing the resident's care plans, the MDS coordinator stated that she could not find evidence that any interventions were implemented sooner than the care plan update of February 3, for the fall that occurred on January 27. Review of a policy regarding Falls and Fall Risk included that based on evaluation and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. The policy further documented that if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of the fall. The policy also included that staff will identify and implement relevant interventions to try to minimize serious consequences of falling. -Resident #26 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed a nursing progress note dated February 17, 2014 which documented that at 4:00 p.m., the resident was found by a CNA with "buttocks on bed and upper body (chest) on the bed leaning against bed rail. Resident assessed for injury and redness noted to chest wall. Resident was attempting to reach for phone when he slid out of bed." Review of a quarterly MDS assessment dated [DATE], revealed that the resident was coded as extensive assistance with one person physical assist for bed mobility and transfers. The resident was also not assessed to use bed rails. A Fall Risk assessment dated [DATE], reflected the resident was a high fall risk. Review of a care plan for falls included for the use of handrails on walls as part of the resident's safe environment. The care plan did not include the use of any bed rails. Multiple observations were conducted during the survey of the resident in bed, with quarter side rails in the up position on both sides of the bed. Each bed rail was noted to have four gaps large enough for the resident to fit an extremity through. Further review of the clinical record revealed there was no assessment that was completed prior to the implementation of the bed rails, in order to determine if the use of the bed rails posed any safety concerns, or if the bed rails would be a possible restraint. During an interview with a registered nurse (RN) on March 27, 2014 at 2:50 p.m., the RN stated the quarter rails were used as an enabler to assist in transfers and bed mobility. The RN also stated that there was no system to evaluate if the use of the quarter rails were a restraint. On March 27, 2014 at 3:30 p.m., the DON stated that the bed rails on the resident's bed were referred to as enablers and were not considered as restraints, so there were no assessments for their use and were not care planned. -Resident #108 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan related to the hip fracture due to a previous fall included to modify the environment as needed to meet current needs and for the bed to be in the lowest position, with wheels locked. A falls care plan included the following interventions; bed in lowest position when resident is in bed and use bed alarm to alert staff that the resident is getting out of bed. Review of the progress notes revealed the resident sustained [REDACTED]. The resident had tried to transfer herself from the bed to the wheelchair and was found sitting on the floor next to her bed. The note included the "bed alarm placed on her bed and in low position." As a result of the fall, x-rays were ordered on October 18, 2013. The results showed there was no acute fracture or dislocation of the resident's right hip. A falls note dated October 19, 2013, revealed that the resident's care plan was updated, although there were no new interventions identified. Review of the fall care plan revealed that it was not updated to reflect any additional measures that were implemented after this fall. A progress note dated October 24, 2013, documented that the bed alarm was going off, and a CNA found the resident laying on the floor next to the bed. The resident had landed on her right hip. The resident complained of pain and was unable to move her right leg. The documentation did not include if the resident's bed was in the low position, at the time of the fall. A physician's orders [REDACTED]. According to the Diagnostic Imaging report dated October 24, 2013, the resident had a "suspected periprosthetic fracture through the intertrochanteric region." An interview was conducted with the MDS nurse on March 26, 2014, who stated that care plans should be updated when a resident sustains a fall. The DON was interviewed on March 26, 2014 at 3:10 p.m. When asked if she could provide any documentation that the resident's bed was in a low position at the time of the fall, she stated that she had no further documentation beyond what was listed in the progress notes. -Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE], revealed the resident had moderate cognitive impairment. A fall risk assessment dated [DATE], assessed the resident to be at high risk for falls. According to a falls care plan, the resident had impaired balance and mobility, and impaired safety awareness. Interventions included to encourage the use of hand rails and grab bars when attempting to stand. During the survey, observations were conducted on March 25 and 26, 2014, of the resident lying in bed, with two quarter side rails in the up position. Further review of the clinical record revealed there was no assessment that was completed prior to the implementation of the bed rails, in order to determine if the use of the bed rails posed any safety concerns, or if the bed rails would be a possible restraint. During an interview with the physical therapy manager on March 28, 2014 at 9:30 a.m., he stated that they do not have a specific assessment for the safe use of bed rails. During an interview with a licensed practical nurse (LPN) on March 28, 2014 at 10:15 a.m., she stated that the assessment documentation for weather or not bed rails are safe would be on the fall risk assessment. However, review of the fall risk assessment from February 19, revealed there was no assessment information that referenced to whether or not the bed rails were safe for this resident. Review of the manufacturer's service manual for the supplier of the beds included the following regarding bed rails: "...assist devices or side rails are designed to be used with specific...bed frames. Once mounted on the appropriate bed frame, assist devices or side rails become an integral part of the...bed system. When assessing the risk for entrapment, you need to consider your bed, mattress, head/foot panels, assist devices and other accessories, as a system. It is also extremely important to review the resident/patient's physical and mental condition and initiate an appropriate individual care plan to address entrapment risk." A policy was requested regarding bed rail/restraint use, however, administrative staff stated that they did not have a policy for bed rail assessments.