Every finding on record at The Wheatlands Health Care Center

The facility reported a census of 45 residents and identified one centralized medication storage room, four medication carts, and one nurse treatment cart. Based on observations and interviews, the facility failed to provide a safe environment for seven residents, identified as cognitively impaired and independently mobile by the failure to ensure the medication storage room door remained closed and secured when not in use. This deficient practice had the potential to lead to accidental ingestion of prescription and non-prescription medications that could be harmful to the residents. Findings included: - On 12/04/24 at 06:15 AM, the door to the medication room located off of the main lobby was observed to be propped open by a trash can attached to the nurse's treatment cart with no staff present and remained open until 12/04/24 at 06:24 AM when Licensed Nurse (LN) K moved the nurse treatment cart and closed the door. On 12/04/24 at 06:24 AM, LN K stated the medication storage room door should never be propped open and identified the medication storage room contained prescription and non-prescription medications and medical supplies (bandages, dressings, etc.). On 12/04/24 at 12:16 PM, Administrative Nurse B stated she expected staff to ensure the medication storage room door was closed and locked at all times and the medication carts were locked at all times when not in use. Administrative Nurse B confirmed the medication storage room contained surplus prescription and non-prescription medications and assorted medical supplies. Administrative Nurse B stated the door to the medication storage room being propped open was an ongoing and known concern. Administrative Nurse B identified the facility had seven cognitively impaired and independently mobile residents. The facility's Medication Labeling and Storage policy, dated 10/2024, documented the facility would store all medications in locked compartments and only authorized personnel would have access to the keys. The policy documented that compartments containing medications would be locked when not in use and not left unattended if open. The facility failed to provide a safe environment for seven residents by the failure to ensure that the medication storage room door remained closed and secured when not in use. This deficient practice had the potential to lead to accidental ingestion of prescription and non-prescription medications that could be harmful to the residents.

The facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - On 12/02/24 at 09:44 AM during an initial tour of the main kitchen, refrigerator and dry food storage areas with Dietary Manager C, the following areas of concern were observed: One container of dry drink mix observed sitting on the floor, unopened. One container of dry potatoes mix observed sitting on the floor, unopened. One bottle of sweet and sour sauce with an expiration date of 09/27/24 found on a shelf. One sealed package of pork loins dated 07/20 and located in the freezer. One sealed package of beef pot roast with a package date of 01/17/23, with ice growing off of it. One unsealed/open bag of chicken wings spread out throughout the freezer, without a date or label. Three sealed bags of unknown meat, without a date or label and located in the freezer. 16 boxes of frozen food items observed sitting on the floor of the walk-in in freezer. On 12/02/24 at 10:31 AM, an interview with Dietary Manager C revealed she expected staff to label, and date opened food items. Dietary Manager C stated that the above concerns identified with dry storage and freezer storage, which included undated and unsealed items were unacceptable. Dietary Manager C confirmed the most recent truck delivery was on 11/29/24. The facility's policy Dating Food and Nourishment dated 06/2024 revealed that any items placed in the refrigerator, perishable items removed from original containers, frozen nourishment and opened pre-dated food items all will be labeled and dated dates on food will be checked daily all foods are to be covered, labeled, and dated. The facility policy Dating Food and Nourishment dated 06/2024 lacked any information about storing boxes on the floor or requiring staff ensure food consumed by ready-to-eat date. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility reported a census of 45 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed transport clean and distribute clean laundry to the residents of the facility when staff failed to perform hand hygiene between resident room contacts. The facility further failed to maintain an effective infection control program related to enhanced barrier precautions (EBP - a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care for Resident (R) 1, wound care on R9, and peri-care (cleaning of the area between the genitals and anus) for R198. Additionally, the facility failed to provide respiratory care consistent with professional standards of care for R4 regarding the use and storage of oxygen supplies that were not stored in a clean manner or changed when appropriate. These deficient practices had the potential to spread possible infections to the residents in the facility. Findings included: - On 12/03/24 at 08:19 AM, observation of R4's room revealed oxygen tubing that was not in use, was wound in a ball and sat on the top of the oxygen concentrator. The tubing was marked with a date of 11/01/24. Observation on 12/03/24 at 08:53 AM, Licensed Nurse (LN) R performed a dressing change on R9's wound and failed to change gloves or perform hand hygiene between the dirty and clean phases of wound care. Observation on 12/03/24 at 09:31 AM Laundry Aide J was observed going between three resident rooms delivering clean laundry and failed to perform hand hygiene between resident room contacts. Observation on 12/03/24 at 02:03 PM, LN N and Certified Nurse Aide (CNA) I performed a skin check and peri-care for R198. LN N and CNA I failed to perform hand hygiene or change gloves between the dirty and clean phases of peri-care. Additionally, staff failed to place a new and clean brief on R198 after performing peri-care. Observation on 12/04/24 at 07:25 AM, CNA M and Certified Medication Aide (CMA) L performed peri-care and catheter care for R1. CNA M failed to perform hand hygiene or change gloves between the dirty and clean phases of peri-care and catheter care. CMA L failed to perform hand hygiene with the glove change between the dirty and clean phases of catheter care. Additionally, when the catheter bag (a large drainage bag attached to the catheter and hung from the bedrail or wheelchair frame) was changed to a leg-bag (a small drainage bag attached to the catheter and worn on the resident's leg underneath clothing), CMA L failed to place a protective cap on the tip of the tubing and dropped the tip of the catheter bag drainage bag tubing onto the floor. CMA L then placed the catheter bag into a clean trash bag attached to the grab bar in the bathroom without cleaning or replacing the contaminated tubing. Further, CNA M performed peri-care for R1 with multiple swipes and utilized the same wipe. During an interview on 12/03/24 at 09:05 AM, LN R confirmed she did not perform hand hygiene or changed her gloves when she transitioned from the dirty phase to the clean phase of wound care. During an interview on 12/03/24 at 09:34 AM, Laundry Aide J confirmed she did not perform hand hygiene between resident room contacts and stated that she was not trained to perform hand hygiene when only delivering clean laundry. During an interview on 12/03/24 at 09:42 AM Housekeeping Supervisor E stated the expectation was for laundry/housekeeping staff to perform hand hygiene whenever the entered or exited a resident's room. During an interview on 12/04/24 at 07:40 AM, CMA L confirmed she changed her gloves but did not perform hand hygiene when they transitioned from the dirty phase of catheter care and peri-care to the clean phase of catheter and peri-care. Additionally, CNA M confirmed that she did not change her gloves or perform hand hygiene when they transitioned from the dirty phase of catheter care and peri-care to the clean phase of catheter care and peri-care. CMA L confirmed that the catheter tubing fell to the floor but did not believe that the catheter tip had actually came in contact with the ground and continued to place the catheter drainage bag and tubing inside the clean bag attached to the grab bar in the bathroom. CNA M confirmed that she performed peri-care with multiple wipes and utilized the same wipe and stated that she should have used one wipe per swipe. During an interview on 12/04/24 at 08:35 AM, Administrative Nurse G stated the expectation was for staff to place a clean a protective cap on the tip of the catheter drainage bag before it was stored in the bag that was attached to the grab bar in the bathroom. Additionally, Administrative Nurse G stated if the cleanliness integrity of the tip of the catheter drainage bag tubing was in question, staff should discard the drainage system and obtain a new drainage system. She further stated that peri-care should be performed utilizing one wipe per swipe and staff should not fold and re-use disposable wipes and staff should change their gloves and perform hand hygiene between the dirty and clean phases of all cares. During an interview on 12/04/24 at 08:43 AM, CMA Y stated oxygen tubing should be changed every month. During an interview on 12/04/24 at 08:57 AM, Administrative Nurse G stated all laundry/housekeeping staff should perform hand hygiene before and after entering or exiting a resident's room. During an interview on 12/04/24 at 11:19 AM, LN R stated CMA staff should change out the oxygen tubing then date and initial the tubing once a month. During an interview on 12/04/24 at 02:47, Administrative Nurse G stated she was unsure how often oxygen tubing should be changed, but that there was an order in each resident's Electronic Health Record (EHR), which would populate the task on the Medication Administration Record (MAR) The facility's Infection Control policy, dated 12/2023 documented staff would perform hand hygiene before and after contact with a resident, immediately after removing gloves, when moving from contaminated body sites to clean body sites during resident care. The facility failed transport clean and distribute clean laundry to the residents of the facility. Additionally, the facility failed to maintain an effective infection control program related to EBP when providing catheter care for Resident (R) 1 and wound care on R9 and peri-care for R198. Further, the facility failed to provide respiratory care consistent with professional standards of care for R4 regarding the use and storage of oxygen supplies that were not stored in a clean manner or changed when appropriate. These deficient practices had the potential to spread possible infections to the residents in the facility.

The facility reported a census of 45 residents with 12 residents sampled. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident (R) 24, who stood in her room partially dressed in pants and an undergarment, when a staff member walked by R24's room, looked into R24's room and continued to walk down the hallway without intervening. This practice had the potential to lead to negative psychosocial effects related to dignity. Findings included: - The Electronic Health Record (EHR) included the diagnoses of major depressive disorder (MDD - a major mood disorder which causes persistent feelings pf sadness) and dementia (a progressive mental disorder characterized by failing memory, confusion). The 05/13/24 Significant Change Minimum Data Set (MDS) documented R24 had a Brief Interview of Mental Status score of 12, which indicated moderately impaired cognition. The assessment documented R24 required supervision/setup assistance with bathing, eating, and oral hygiene and was otherwise independent with cares. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/13/24 documented R24 was alert and oriented to person/place/time with moments of confusion and disorientation. The Quarterly MDS dated [DATE] documented a BIMS score of nine which indicated moderately impaired cognition. The MDS documented R24 required partial/moderate assistance with bathing and toileting; supervision/touching assistance with dressing, footwear application, and personal hygiene; and setup assistance with oral hygiene and eating. The Care Plan, reviewed 12/03/24, documented an intervention dated 12/18/23 that staff should pull the curtain for privacy and dignity in the shower room but lacked additional interventions specifically related to privacy or dignity. On 12/03/24 at 12:10 PM, R24 observed standing in her room wearing pants and an undergarment, and visible from the hallway with the door to her room open. On 12/03/24 at 03:36 PM, R24 stated that staff sometimes left the door open when providing her cares or when she was getting dressed, and this bothered her. On 12/03/24 at 12:10 PM, Housekeeping Staff P walked by R24's room, looked into R24's room and continued to walk down the hallway, without closing her door. On 12/03/24 at 12:16 PM, Housekeeping Staff P confirmed R24 was standing in her room and was only wearing an undergarment above the waist with the door to her room open, and confirmed she should have closed the door and alerted nursing staff, that the resident might require assistance. On 12/03/24 at 12:22 PM Certified Medication Aide (CMA) W stated if a resident was observed from the hallway wearing only undergarments, the first step would be to close the door to protect the resident's privacy and dignity and then assist if needed. On 12/03/24 at 03:00 PM Certified Nurse Aide (CNA) O stated if a resident was observed from the hallway only wearing undergarments, staff should close the door to protect the resident's privacy and dignity and assist as needed. On 12/03/24 at 03:43 PM, LN N revealed that if a resident was observed in their room wearing only undergarments the first thing staff should do is to close the door, then provide whatever assistance that may be required. On 12/03/24 at 03:53 PM, Administrative Nurse B stated the facility expected all staff to provide dignity by closing the door if a resident was discovered partially dressed in their room. Administrative Nurse B confirmed that staff walking by R24's room and seeing the resident partially dressed and failed to close the door, was a dignity concern. The facility's Right to Dignity policy, dated 10/2024 documented the facility would promote care in a manner and environment that maintains and enhances dignity and respect. The facility failed to protect the privacy and dignity R24 who stood in her room wearing pants and her undergarment, and a staff member walked by R24's room, looked into R24's room, and continued to walk down the hallway without intervening. This practice had the potential to lead to negative psychosocial effects related to dignity.

The facility identified a census of 45 residents, with 12 residents sampled, and one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to provide a pressure reducing device on the bed to prevent a pressure injury for Resident (R) 9. Additionally, the facility utilized the incorrect size full body sling when transferring R9 in and out of bed with the mechanical lift. Findings included: - Resident (R)9 's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 11, which indicated moderately impaired cognition. R9 required total assistance with activities of daily living (ADL), which included toileting, transfers, bathing, and wheelchair mobility. R9 required maximal assistance with bed mobility, hygiene, dressing, footwear, and oral care. R9 was always incontinent of bladder. The Pressure Ulcer Care Area Assessment (CAA) dated 11/01/24, documented R9 had an open area to her back. R9 had an air mattress and cushion to her recliner and wheelchair. The CAA included the wound would be assessed weekly by administrative wound care nurse and noted she was currently on a repositioning schedule. The Urinary Incontinence and Indwelling Catheter CAA dated 11/01/24, documented R9 was incontinent of bowel and bladder, wore adult briefs, and was dependent on staff for toileting hygiene and toileting needs. R9 refused to toilet in the bathroom and requested staff change her brief when it was soiled. The Admission MDS dated [DATE], documented the resident had a BIMS of 14, which indicated intact cognition. The MDS noted required maximum assistance with upper body dressing and required total assistance with bed mobility, transfers, and toileting. R9 was always incontinent of bladder. The MDS indicated R9 had a stage two pressure (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) ulcer on admission, and no pressure reducing device on bed or chair. The Pressure Ulcer CAA dated 08/22/24, documented R9 admitted with a healing stage two pressure ulcer. The resident's Care Plan included the following interventions: 08/14/24 - Staff instructed to turn and reposition totally dependent R9 every two hours and as necessary. R9 required a full body lift sling and mechanical lift for all transfers with assistance of two staff members. The staff were to avoid positioning the resident on her bottom for long periods of time and try to limit time up in her wheelchair to less than two hours. The staff were to monitor, document, and report any changes in skin status appearance, color, and wound healing. 08/14/24, revised 11/25/24 - Staff instructed that R9 required a pressure reducing cushion in her wheelchair and recliner. The staff were to offload her back with a blanket or pillow when in her wheelchair or recliner, and to leave her bed as flat as possible, to reduce shear. 10/23/24 - Staff instructed to provide protein shakes twice a day for wound healing. 12/02/24 - Staff instructed to provide Juven (a therapeutic nutrition drink mix powder designed to support tissue building and collagen formation in the dietary management of wounds) as per ordered. Review of the Physician Orders documented the following orders: 08/14/24 order for the history of stage two pressure injury to right buttock: keep skin clean and dry after each incontinence episode apply moisture barrier or calmoseptine cream (is used to protect skin from wetness, urine, or stools); Notify the nurse of worsening or changes in healed area. 08/14/24 order for the resolved pressure ulcer to right buttock, staff were to monitor every morning and at bedtime, apply moisture barrier after each incontinent episode, and ensure the pressure reducing cushion was utilized in her wheelchair and recliner and reposition every two hours. 10/15/24 order to offload the wound to the residents left lower back when in bed. Educate and remind staff on every shift to use caution when placing or removing full sling lift. Pad full sling with soft blanket between resident and sling. 10/21/24 order for staff to monitor dressing to left lower back to ensure dressing is intact. If overly soiled or no longer intact change dressing as ordered. 11/25/24 order for staff to cleanse the wound to left back with wound cleanser, pat dry and apply skin prep (liquid skin protectant) around the wound. Apply collagen (a protein that plays a key role in the body's wound healing process) to wound bed, cut calcium alginate (a non-adhesive, absorbent wound dressing) to fit over wound bed. Apply a foam pad with approximate 2 centimeter circle cut out (goal is to offload pressure to area) then cover with large Opti foam (a medical-grade foam dressing used for wound care) dressing. Change every other day and as necessary. 11/25/24 order to offload wound to the left lower back, use pillows while in bed and soft blankets while up in wheelchair. The Skin assessment dated [DATE] at 03:52 PM documented, R9 had a healing stage two pressure ulcer to her right buttock, which measured approximately 2 centimeters (cm) by 2 cm, with pink new dermal (the thick layer of living tissue below the outer layer of skin) tissue. Review of the Skin Assessments dated 08/16/24 through 12/03/24 lacked further documentation of the right buttock healing stage two pressure ulcer and the wound on resident's left lower back. Review of EHR from 08/14/24 through 10/13/24 lacked any Skin-Wound Notes (a template used by Administrative Nurse G/Wound Nurse template to monitor skin concerns). The Skin-Wound Note dated 10/14/24 at 03:09 PM documented staff reported an abrasion on R9's left lower back. The note included the area looked like it could be from the full body sling. The wound measured 1.5 cm by 1 cm, with 0.1 cm in depth. The wound bed was 80 percent slough (dead tissue, usually cream or yellow in color) and 20 percent pink tissue, and noted the staff updated the provider and received new orders. The Skin-Wound Note dated 10/21/24 at 09:25 AM documented wound measured 1.3 cm by 1 cm, with 0.2 cm in depth. The wound bed is 90 percent slough and 10 percent pink tissue. The note included a discussion with R9 to try a different wheelchair and a pressure reducing air mattress, and staff were educated to provide a soft blanket between the resident and the full body sling. The Skin-Wound Note dated 10/29/24 at 08:14 AM documented hospice notification and will provide a high back wheelchair for wound healing and positioning. The Skin-Wound Note dated 11/04/24 at 07:14 AM documented wound measured 1 cm by 1 cm, with 0.2 cm depth, wound bed was 20 percent slough and 80 percent pink tissue. R9 reported she did not like the high back wheelchair and air mattress and requested to have a different mattress and wheelchair provided by hospice. The Skin-Wound Note dated 11/18/24 at 12:41 PM documented the wound on the left lower back measured 1cm by 0.8 cm, by 0.2 cm in length, and the wound bed was 70 percent slough and 30 percent pink tissue. The Skin-Wound Note dated 11/25/24 at 10:03 AM documented the wound to the left lower back was obviously over a bony prominence. The wound had worsened and measured 1.5 cm by 1 cm, with 0.2 cm depth. The wound bed was 80 percent slough and 20 percent red tissue, with serosanguinous (semi-thick blood-tinged) drainage noted on the removed dressing. R9 declined an air mattress and continued on a turn and reposition program, every two hours and as needed. The staff updated the provider and received new orders. The Skin-Wound Note dated 12/02/24 at 11:08 AM documented the wound on the left lower back measured 1.5 cm by 2.5 cm, with 0.1 cm depth. The wound bed was 90 percent slough and 10 percent eschar (dead tissue), and the wound had an odor and moderate amount of purulent (producing or containing pus) drainage, with a wound culture obtained. R9 was started on Doxycycline (an antibiotic used to treat infections) 100 milligram capsule, one capsule by mouth for seven days. During an observation on 12/03/24 at 08:44 PM, Certified Nurse Aide (CNA) S and Certified Medication Aide (CMA) CC assisted R9 to bed from her wheelchair. CNA S and CMA CC utilized the mechanical lift, R9 had a full body mesh sling with a light blue binding around the edge of lift. The sling was observed to be an extra-large Invacare sling. R9 held onto the bar of the lift, the sling was noted to be quite large, the top of the sling was hanging over R9's head on her face near her eyes and the bottom of the sling was near R9's knees. During an observation on 12/03/24 at 08:53 PM, Licensed Nurse (LN) R administered treatment to R9's wound on the left lower back. LN R reported the area on R9's left lower back was approximately 2.5 cm by 3 cm. Observed a moderate amount of purulent drainage on the removed wound dressing. There was approximately 90 percent slough and 10 percent eschar noted on the wound bed. The wound was over a bony prominence and surrounding the wound was redness that was blanchable (to press on a person's skin to push blood away and wait for return to determine blood circulation). During an interview on 12/03/24 at 09:00 AM, CMA CC reported that care plans do not include what size or type of sling to use when transferring a resident with a mechanical lift. During an interview on 12/03/24 at 09:00 AM CNA S reported the staff just grab a sling from linen closet to use if resident did not have one in their room. CNA S reported she thought the sling that was used with R9 was the correct size. CNA S reported that she was not trained to use a sling by size and did confirm the sling covered R9's head to her eyes. During an interview on 12/03/24 at 09:40 AM, Administrative Nurse H reported that she would not care plan the size or what type of sling to use for transfers with a mechanical lift. She reported that the facility did not use weight or height of a resident to determine what sling to use. Administrative Nurse H reported that R9 had lost weight since admission and that the same sling is being used. She also reported that if the staff used a bigger sling, the resident would be safer than using a smaller sling. During an interview on 12/03/24 at 11:30 AM, Administrative Nurse G reported that the area on R9's left lower back was indeed a pressure area. Administrative Nurse G reported that after R9 had lost weight, the area was noted over a bony prominence. Administrative Nurse G reported when the area was first noted in October 2024, it appeared to be from the full body sling as shearing when staff removed the sling or pulled on the sling to position R9. She reported that R9 did not like the air mattress and preferred her head bed elevated and not to lay flat. During an interview on 12/04/24 at 08:45 AM, Consultant Staff DD Occupational Therapist reported that therapy did not decide what sling size to use for mechanical lifts. Consultant Staff DD reported the staff use what sling is available. He did report that the weight rating should be on the slings and confirmed that an extra-large Invacare sling for a resident that weighed 154 pounds, was too big of a sling and could cause an unsmooth surface and shearing of skin. During an interview on 12/04/24 at 10:30 AM, CNA V, CMA L, and CNA M reported the sling in the residents' room was the sling they used. They all reported they did not realize the slings came in different sizes and the sling had a tag to state what size it was. During an interview on 12/04/24 at 10:40 AM, CMA X reported she did not realize slings had different sizes and the sling under R26 was illegible. She reported the staff just grabbed a sling and used it. However, she would position the sling from the resident's head to below the resident's buttocks. During an interview on 12/05/24 at 11:14 AM, Administrative Nurse B reported she did not realize the mechanical lift slings were different sizes. Additionally, she did not realize that Invacare had a warning in the manual to use the Invacare slings for the Invacare lifts. She reported that staff would look at the resident's size to determine the appropriate sling to use. Administrative Nurse B confirmed that the facility does purchase slings from other companies and the sling used for R9 was too large for her. During an interview on 12/05/24 at 01:55 PM, Administrative Nurse G reported the air mattress for R9 was placed on her bed on 10/29/24 and was removed on 11/18/24 per R9's request. She confirmed that the air mattress was not placed on the care plan but did show the documentation on PCC under the tasks charting. She also reported that R9 was admitted on [DATE] and had a healing pressure ulcer on right buttock and did not require skin wound notes. Review of the facility's Invacare Manual undated revealed a warning: slings and accessories designed by other manufactures are not to be utilized as a component of the Invacare lift system. The facility's Pressure Ulcer Prevention policy dated 09/2024 documented the following: To provide care and services to promote good skincare and to prevent pressure ulcer development. The facility failed to place interventions to prevent pressure injuries for R9, who developed one preventable, facility acquired, unstageable pressure injury. This placed the resident at risk to worsen his current pressure ulcer or develop more skin issue. - Review of the Electronic Medical Record (EMR) R26, included diagnoses of hypertension (HTN- elevated blood pressure), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), obesity (excessive body fat), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and polyneuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The 01/10/24 Significant Change Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. R26 had behaviors which included delusions, and verbal behavioral symptoms directed towards others t interfered with his care, disrupted the living environment. He rejected care and wandered. R26 used a walker and wheelchair and required partial to moderate assistance with bed mobility and transfers. He required substantial to maximal assistance with toileting hygiene and was dependent on staff with wheelchair mobility. He was frequently incontinent of urine and always incontinent of bowel. The MDS documented two or more noninjury falls and one injury fall. Review of the Falls Care Area Assessment (CAA) dated 01/10/24, identified R26 required staff assistance. R26fell three times in two days, which caused injuries due to frequent attempts to self-transfer. He required assistance of two staff with transfers and toileting needs. Review of the Cognitive Loss/Dementia (CAA) dated 01/10/24, identified R26 had a diagnosis of dementia. The 10/8/24 Quarterly MDS documented a staff interview, which indicated the resident had long term and short-term memory problems. He was always incontinent of urine and frequently incontinent of bowel. He was dependent on staff for transfers, toilet hygiene, and mobility. He had one injury fall documented. Review of the resident's Care Plan on 12/02/24 revealed the following interventions: 12/28/21- R26 was at high risk for fall due to being unaware of his safety needs. Interventions at that time to anticipate his needs and have the call light in place. 01/07/24 - Staff would know the resident was not to be left unattended in the bathroom. Staff could stand outside the door with it being ajar for the resident's privacy. 07/26/24 - The facility provided staff education on following resident care plans. Review of the Nurses Notes on 07/26/24 at 07:00 PM document R26 unhooked his sit to stand sling and sat himself on the floor beside the toilet. No injuries were noted. Review of the Fall Packet dated 07/26/24 revealed staff completed a root cause analysis and found that staff needed education on the resident's care plan and the facility provided education as an intervention for the fall. During observation on 12/03/24 at 01:32 PM, CMA BB and CNA X transferred R26 with full body mechanical lift using a sling with yellow around the edge. During an interview on 12/04/24 at 01:15 PM, CMA AA reported staff were aware they could not leave any resident unattended and attached to any lift. During an interview 12/04/24 at 01:15 PM, Licensed Nurse (LN) R reported staff were aware they could not leave any resident unattended and attached to any lift. During an interview on 12/04/24 at 01:22 PM, Administrative Nurse B revealed R26 had a fall after being left on the toilet and attached to the sling with no staff present. Staff returned later to find him on the floor. Administrative Nurse B confirmed staff did not follow the resident's care plan and that additional training was needed. The facility's Safe-Lift policy dated 10/24 documented for staff to use mechanical lift devices in accordance with instructions and training. The facility failed to implement effective fall prevention interventions to prevent falls for cognitively impaired R26, who had repeated falls. - Review of the Electronic Medical Record (EMR) for R26 included diagnoses of hypertension (HTN- elevated blood pressure), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), obesity (excessive body fat), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), polyneuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), cellulitis of the toes (skin infection caused by bacteria). The 01/10/24 Significant Change Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The resident had a total mood severity score of 0, which indicated no depression. R26 had behaviors which included delusions, and verbal behavioral symptoms directed towards others that interfered with his care and disrupted the living environment. He rejected care and wandered. R26 used a walker and wheelchair and required partial to moderate assistance with bed mobility and transfers. He required substantial to maximal assistance with toileting hygiene and was dependent on staff with wheelchair mobility. He was frequently incontinent of urine. The MDS identified R26 as at risk for pressure ulcers. No pressure related skin issues were identified on the assessment, and he had a pressure reducing device for his chair. The 01/10/24 Pressure Ulcer/Injury Care Area Assessment (CAA) stated R26 had trace edema to both legs but did not wear any compression socks as he preferred to wear regular shoes and socks. A care plan would be initiated to address skin impairment of the lower legs. The assessment identified that he was incontinent, had no pressure areas, and used a cushion to his wheelchair. The 10/08/24 Quarterly MDS documented a staff interview for cognition, which indicated long term and short-term memory problems. He did not know the season, room location, staff, or that he was in a nursing home. The resident had a total mood severity score of 0, which indicated no depression. He had no hallucinations or delusions. He was always incontinent of urine and frequently incontinent of bowel. The assessment documented the resident was on a toileting program. The MDS documented he had difficulty with meals, lost food from his mouth when he ate, held food in his mouth, and coughed with meals. He had a stage two pressure ulcer, was on a turning and repositioning program and had a pressure reliving device for his wheelchair. Review of the resident's Care Plan on 12/02/24 revealed the following interventions: 04/11/24 - staff were to turn and reposition the resident every two to four hours. 09/04/24 - staff were to turn and reposition the resident at least every two hours and more often as needed or requested, because he was dependent on staff for repositioning. 09/04/24 - Staff would know R26 was dependent on two staff for repositioning and turning in bed as necessary. 09/04/24 - R26 required assistance with meals. Review of the resident's Physician Orders dated 08/22/24 revealed R26 had an order to Offload bottom throughout shift. Do not keep resident up in wheelchair for prolonged periods of time. Review of the resident's Tasks on 12/02/24 revealed R12 had a task for Certified Nurse Aides (CNA)s to record turning and repositioning every two hours. On 12/03/24, Certified Medication Aide (CMA) BB recorded that she turned and repositioned R26 at 08:00 AM, 10:00 AM, and 12:00 AM. Review of the Medication Administration Record (MAR) for December 2024 revealed staff documented they followed the order to offload the resident's bottom every shift and to not keep the resident up in the wheelchair for prolonged periods of time on every shift. Review of the resident's Braden assessment dated [DATE] revealed R26 had a score of 12, which indicated a high risk for pressure ulcers. Review of the resident's Skin Assessment on 12/02/24 revealed and area to his coccyx, which was treated with preventative cream and areas to his toes which were treated as ordered. Review of the Skin /Wound Notes dated 08/19/24 at 09:24 AM revealed the resident had a dark, red, non-blanchable area to his right upper buttocks that measured 3 centimeters (cm) x 2.5 cm. A treatment was initiated, and staff were to offload as much as possible. A turning and repositioning schedule was documented as already in place. Staff were educated on offloading the resident bottom. The residents nutritional supplement increased to three times daily to help with meeting nutritional needs/wound healing. Review of the Skin/Wound Notes dated 11/25/24 at 09:30 AM revealed the resident had a non-healing pressure ulcer with eschar to the tip of right great toe that measured 0.5 cm x0.5 cm, which presented as [NAME] ar (dead tissue). The area on the tip of left great toe remained resolved. Observation on 12/03/24 at 08:03 AM revealed R26 sitting in the dining room in his broda chair (specialized wheelchair with the ability to tilt and recline) with his feet dangled six inches off the floor. Observation on 12/03/24 at 08:48 AM revealed staff approached R26 in the dining room and did not offer repositioning at this time. Observation on 12/03/24 at 09:21 AM revealed the resident remained in same position. Observation on 12/03/24 at 10:20 AM revealed staff provided the resident with food but did not offer to reposition him at this time. Observation on 12/03/24 at 10:28 AM revealed the resident fidgeted in his chair and moved his bottom around. A facial grimace was noted with movement. As the resident continued to lean forward and fidget staff made no attempt to reposition him. Observation on 12/03/24 at 10:48 AM revealed the resident continued to fidget in his chair, move his bottom, and grimace, but remained in the same position. Observation on 12/03/24 at 11:09 AM revealed a staff member requested assistance from another staff member to reposition R26 up in the wheelchair. The staff members lowered the back of the resident's chair and slid him up in the wheelchair. Observation on 12/03/24 at 12:18 PM revealed R26 continued to fidget and slid down in his wheelchair. CNA X asked another staff member to assist her to lift him up in the chair. They repositioned him and she continued to assist him with his lunch. Observation on 12/03/24 at 01:30 PM surveyor asked for R26 to be taken to his room. Skin assessment completed with Licensed Nurse (LN) R. LN R identified a pea sized black eschar on the right great toe. When the resident's brief was removed there was a dark red line on his gluteal fold where his brief elastic was with blanchable redness surrounding it. The nurse applied firm pressure to the area and the darker line did not lighten. The area around did lighten and then returned to red. Staff finished changing R26 and did not place barrier cream on the resident during this observation. During an interview on 12/03/24 at 01:29 PM, CNA X revealed that R26 did not have a wheelchair cushion, and they elevated his feet so he could not touch the ground to keep him from walking. CNA X stated, If his feet touch the ground, he thinks he can walk, and we can't pick him up. When shown how his calf hit the bottom of the leg rest on the chair and dangled off, she informed the surveyor that there was not another part of the chair for his legs to rest on. During an interview on 12/03/24 at 01:29 PM, CNA X revealed that staff were aware R26 required frequent repositioning. During an interview on 12/03/24 at 05:28 PM, Certified Medication Aide (CMA) AA revealed staff did not know R26 had a footrest and stated they had not been using it. Another staff member found the footrest and applied it to the wheelchair when it was found. During an interview on 12/04/24 at 08:43 PM, CMA Y stated they followed the plans of care for the residents and staff were aware of how to look at the residents' care plan. During an interview on 12/04/24 at 11:19 AM, LN R revealed staff knew how to read the care plan and staff were aware R26 required frequent repositioning. During an interview on 12/04/24 at 02:47 PM, Administrative Nurse G revealed she was not aware that R26 had previous skin issues on his buttock, but that it was an expectation to provide repositioning and not to leave any residents in a wheelchair with feet dangling. During an interview on 12/04/24 at 05:00 PM, Administrative Nurse A stated it was her expectation that the chair would have a pressure relieving cushion. She also had an expectation that staff would not leave a resident without repositioning for a long amount of time. The facility policy Pressure Ulcer Prevention last reviewed on 09/2024 documented that staff would implement appropriate pressure reducing measures which included reposition chair -bound residents at least every two hours or more often and implement pressure reducing devices. Also, reduce shear and friction, reduce moisture on the skin, protect the skin, and promote circulation. The following guidelines were to be used for a high-risk resident: a turning and repositioning schedule, wheelchair cushions, and moisture barrier cream. The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for R26.

The facility reported a census of 45 residents with 12 residents in the sample and ## residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide an environment that remained free from accident hazards for five residents. The facility failed to use the appropriate size full body lift sling for transfers with a mechanical lift for Resident (R)9. The facility failed to follow R26's care plan and left R26 unattended in the bathroom and connected to a mechanical lift, which resulted in a non-injury fall. Additionally, R1 who had lower extremity weakness, the facility failed to apply foot pedals to wheelchair, which resulted in a non-injury fall. These deficient practices could potentially result in an injury. Findings included: - Resident (R) 9 's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 11, which indicated moderately impaired cognition. R9 required total assistance with activities of daily living (ADLs), which included toileting, transfers, bathing, and wheelchair mobility. R9 required maximal assistance with bed mobility, hygiene, dressing, footwear, and oral care R9 was always incontinent of bladder. The Functional Abilities (Self-Care and Mobility) CAA dated 11/01/24, documented R9 required substantial to dependent care provided by staff. R9 used a full mechanical lift for all transfers. The Admission MDS dated [DATE], documented a BIMS of 14, which indicated intact cognition. R9 was independent with eating, required supervision with oral care, and personal hygiene. She required maximal assist with upper body dressing and required total assistance with bed mobility, transfers, and toileting. The Functional Abilities (Self-Care and Mobility) dated 08/22/24, documented R9 was totally dependent on staff for most ADLs. The resident's Care Plan documented the following: 08/14/24 - Staff instructed R9 required a full body lift sling and mechanical lift for all transfers with assistance of two staff members. The care plan lacked any further direction to staff regarding sling size. The 12/01/24 Weight Summary documented a weight of 154 pounds. During an observation on 12/03/24 at 08:44 PM, Certified Nurse Aide (CNA) S and Certified Medication Aide (CMA) CC assisted R9 to bed from her wheelchair. CNA S and CMA CC utilized the mechanical lift, R9 had a full body mesh sling with a light blue binding around the edge of lift. R9 held onto the bar of the lift, the sling was noted to be quite large, the top of the sling was hanging over R9's head on her face near her eyes and the bottom of the sling was near R9's knees. During an interview on 12/03/24 at 09:00 AM, CMA CC reported care plans do not state what size or type of sling to use when transferring a resident with a mechanical lift. During an interview on 12/03/24 at 09:00 AM CNA S reported staff would just grab a sling from the linen closet to use if resident did not have one in their room CNA S reported she was not trained to use a sling by size and did confirm the sling covered R9's head to her eyes. During an interview on 12/03/24 at 09:40 AM, Administrative Nurse H reported that she would not care plan the size or what type of sling to use for transfers with a mechanical lift. She reported that the facility did not use weight or height of a resident to determine what sling to sue. Administrative Nurse H reported R9lost weight since admission and that the same sling was being used. She also reported that if staff used a bigger sling the resident would be safer that using a smaller sling. During an interview on 12/04/24 at 08:45 AM, Consultant Staff DD Occupational Therapist reported that therapy would make recommendations for a resident to be a mechanical lift. He also reported the weight rating should be on the lift slings and confirmed that an extra-large Invacare sling for a resident that weighed 154 pounds was too big of a sling. During an interview on 12/04/24 at 10:30 AM, CNA V, CMA L, and CNA M reported the sling that was in the residents' room was the sling they used. They all reported they did not realize the lift slings came in different sizes and the sling had a tag to state what size it was. During an interview on 12/05/24 at 11:14 AM, Administrative Nurse B reported she did not realize the mechanical lift slings were different sizes. Additionally, she did not realize that Invacare had a warning in the manual facility provided to use the only the Invacare slings for the Invacare lifts. She reported that staff would look at the resident's size to determine the appropriate sling to use. Administrative Nurse B confirmed the facility purchased slings from other companies and the sling used for R9 was too large for her. Review of the Invacare Patient Sling Guide dated 04/2007, documented the light blue trimmed sling size was for weighs 200 pounds to 400 pounds. Review of the facility's Invacare Manual undated revealed a warning, slings and accessories designed by other manufactures are not to be utilized as a component of the Invacare lift system. The facility's Safe-Lift dated 10/24 documented the following: Ensure that employees use safe resident handling and movement techniques. Mechanical lift equipment should be used to prevent lifting and handling of residents except when absolutely necessary, such as a medical emergency. Use mechanical lift devices in accordance with instructions and training. The facility failed to use the appropriate size full body lift sling for transfers with a mechanical lift which may have contributed to a pressure ulcer This placed the resident at risk to worsen his current pressure ulcer or develop more skin issue. - Review of the Electronic Health Record (EHR) for Resident (R)1 included diagnoses of generalized muscle weakness, dementia (progressive mental disorder characterized by failing memory, confusion), and unsteadiness on feet. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The assessment documented that R1 utilized a walker and/or wheelchair for locomotion and documented no falls since the previous assessment. The Falls Care Area Assessment (CAA) dated 01/24/24, documented R1 last fell on [DATE]. The Quarterly MDS dated [DATE], documented a BIMS score of 14, which indicated intact cognition. The assessment documented that R1 utilized a walker and/or wheelchair for locomotion and documented one non-injury fall since the previous assessment. The 09/26/24 Care Plan documented R1 was at risk for falls related to gait (manner or style of walking) and balance problems and poor balance and listed the following interventions: On 10/09/15, staff would anticipate and meet the resident's needs. On 10/09/15, staff would ensure that R1's call light was within reach and encourage R1 to use it for assistance and staff would provide prompt response to all requests for assistance. On 10/09/15, the facility would educate resident/family/caregivers about safety reminders and actions to be taken if a fall occurred and the staff would follow the facility's fall protocol. On 01/02/21, following an actual fall, R1 would sit down when applying a facemask. On 12/09/23, following an actual fall, R1 was educated to ensure that the wheelchair was placed at the foot of the bed with wheels locked to provide added stability when standing. Review of the five Fall Risk assessments from 01/24/24 through 10/16/24, revealed R1 was at risk for falls. Review of the Fall Report dated 05/13/24 at 01:12 PM documented the resident put her feet down while being pushed in a wheelchair and staff assisted the resident to the ground, without injury. The report identified the root cause of the fall as lack of foot pedals while staff pushed the resident. The care plan intervention, dated 05/13/24, included staff to offer to place foot pedals on the wheelchair when R1 went out for activities. The Progress Notes dated 05/13/24 at 01:12 PM, documented staff assisted R1 to the floor after she fell out of her wheelchair, on the way to her room. R1 reported to staff that she put her feet down, her feet caught on the carpet underneath the wheelchair, and she fell forward. Staff documented R1 was reeducated to use foot pedals and staff were educated to offer foot pedals on the wheelchair when R1 went out for activities. The resident's care plan documented on 05/13/24 staff would offer foot pedals on the wheelchair when R1 went out for activities. Observation on 12/04/24 at 07:50 AM, revealed R1 self-propelling herself in her wheelchair down the hallway, the wheelchair lacked foot pedals. On 12/03/24 at 12:22 PM, Certified Medication Aide (CMA) W stated when a resident fell , Certified Nurse Aide (CNA) and/or CMA staff would ensure the resident was safe, then alert other staff that assistance was required, and would notify the nurse. Upon the arrival of the nurse, then staff would follow the instructions of the nurse. On 12/03/24 at 03:00 PM, CNA O stated that when a resident fell , staff would ensure the resident was safe and call for help, which included calling the nurse. Once the nurse arrived, then CNA staff would follow the instructions of the nurse. On 12/03/24 at 03:00 PM, CMA Z and CMA AA stated all residents should have foot pedals on their wheelchair when being assisted by staff. On 09/16/24 at 12:24 PM, Licensed Nurse (LN) N stated the care plan would document if a resident did not require the use of foot pedals on their wheelchair during transport. LN H stated if a resident self-propelled in their wheelchair, became tired and requested assistance, staff should instruct the resident to wait for staff to install the resident's foot pedals the wheelchair before continuing to the resident's room. On 12/03/24 at 03:58 PM, Administrative Nurse B stated that residents with a history of lower extremity weakness should have foot pedals as an option on their wheelchair. Additionally stated that foot pedals are not necessarily required to be on the wheelchair, but if a resident was self-propelling and became weak and requested assistance, staff should ask the resident to wait and retrieve the foot pedals from the room before assisting the resident to their room. Administrative Nurse B confirmed the fall report dated 05/13/24 at 01:12 PM documented that R1 dropped her feet when pushed in the wheelchair (by staff). The facility did not provide a policy related to wheelchair pedals. The facility failed to provide an environment free of accident hazards when on 05/13/24 facility staff pushed R1 in her wheelchair without foot pedals and R1's feet caught on the floor which caused her to experience a fall without injury. This deficient practice had the potential to lead to additional falls with the potential for injury or actual harm. 51334 - Review of R26's Electronic Medical Record (EMR) included diagnoses of hypertension (HTN- elevated blood pressure), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), obesity (excessive body fat), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and polyneuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The 01/10/24 Significant Change Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. R26 had behaviors which included delusions, and verbal behavioral symptoms directed towards others t interfered with his care, disrupted the living environment. He rejected care and wandered. R26 used a walker and wheelchair and required partial to moderate assistance with bed mobility and transfers. He required substantial to maximal assistance with toileting hygiene and was dependent on staff with wheelchair mobility. He was frequently incontinent of urine and always incontinent of bowel. The MDS documented two or more noninjury falls and one injury fall. Review of the Falls Care Area Assessment (CAA) dated 01/10/24, identified R26 required staff assistance. R26fell three times in two days, which caused injuries due to frequent attempts to self-transfer. He required assistance of two staff with transfers and toileting needs. Review of the Cognitive Loss/Dementia (CAA) dated 01/10/24, identified R26 had a diagnosis of dementia. The 10/8/24 Quarterly MDS documented a staff interview, which indicated the resident had long term and short-term memory problems. He was always incontinent of urine and frequently incontinent of bowel. He was dependent on staff for transfers, toilet hygiene, and mobility. He had one injury fall documented. Review of the resident's Care Plan on 12/02/24 revealed the following interventions: 12/28/21- R26 was at high risk for fall due to being unaware of his safety needs. Interventions at that time to anticipate his needs and have the call light in place. 01/07/24 - Staff would know the resident was not to be left unattended in the bathroom. Staff could stand outside the door with it being ajar for the resident's privacy. 07/26/24 - The facility provided staff education on following resident care plans. Review of the Nurses Notes on 07/26/24 at 07:00 PM document R26 unhooked his sit to stand sling and sat himself on the floor beside the toilet. No injuries were noted. Review of the Fall Packet dated 07/26/24 revealed staff completed a root cause analysis and found that staff needed education on the resident's care plan and the facility provided education as an intervention for the fall. During observation on 12/03/24 at 01:32 PM, CMA BB and CNA X transferred R26 with full body mechanical lift using a sling with yellow around the edge. During an interview on 12/04/24 at 01:15 PM, CMA AA reported staff were aware they could not leave any resident unattended and attached to any lift. During an interview 12/04/24 at 01:15 PM, Licensed Nurse (LN) R reported staff were aware they could not leave any resident unattended and attached to any lift. During an interview on 12/04/24 at 01:22 PM, Administrative Nurse B revealed R26 had a fall after being left on the toilet and attached to the sling with no staff present. Staff returned later to find him on the floor. Administrative Nurse B confirmed staff did not follow the resident's care plan and that additional training was needed. The facility's Safe-Lift policy dated 10/24 documented for staff to use mechanical lift devices in accordance with instructions and training. The facility failed to implement effective fall prevention interventions to prevent falls for cognitively impaired R26, who had repeated falls.

The facility reported a census of 50 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included: - On 01/17/23 at 10:58 AM, during a kitchen tour with Dietary Staff AA, revealed two dumpsters which had open lids. Several bags of garbage piled above the dumpster opening, whereas the lids were unable to close. Dietary Staff AA confirmed the findings and reported the dumpsters should be closed to maintain dispose of garbage and refuse for the facility. On 01/19/23 12:15 AM, observation with dietary staff AA, revealed two dumpsters with lids propped open over bagged garbage which prevented the lid to close and contain the facility garbage. Dietary staff AA confirmed the findings and stated staff should close the dumpster lids to maintain dispose of garbage and refuse for the facility. The facility lacked a policy for maintaining and disposal of garbage and refuge. The facility failed to maintain the dumpster area in a sanitary condition, and/or dispose of kitchen garbage and refuse properly.

The facility reported a census of 50 residents that resided on 3 halls. Based on observation, interview and record review, the facility failed to ensure a clean, sanitary environment by the failure of housekeeping staff to know the manufacturer's contact wet times of the cleaners used to clean the resident rooms. This failure had the potential to affect all the resident areas. Findings Included: - On 01/19/23 at 09:15 AM, observation revealed housekeeping staff U as she cleaned rooms on the 100 hall. She completed a room clean, and stood at her housekeeping cart. Interview on 01/19/23 at 09:15 AM, Housekeeping staff U reported she used a disinfectant called AF-79 (a multi-purpose germicidal detergent that disinfects, cleans and deodorizes) to clean the bathroom surfaces. Housekeeping staff U reported she did not know how long the disinfectant needed to stay wet or what germs/bacteria it was designed to be effective to kill. She then looked at the label of the spray bottle and the bottle failed to list a contact wet time or specific surfaces, germs/bacteria designed to clean. She reported she wiped the room surfaces down with a wet cloth of Quat (cleanser). She was unaware of the contact wet time and reported she just let the liquid solution dry on any surface she used to clean. The Quat label lacked a contact wet time or what the solution was effective for cleaning/ disinfecting. Interview on 01/19/23 at 09:30 AM, housekeeping staff V reported she did not know the contact wet times of either of the cleaners/disinfectants. She would have to look them up on her computer. She did have a chart on the janitor closet on hall 200 that revealed the Quat had a wet time of five minutes, however the chart failed to list what the solution was effective (germs/bacteria). She was unaware of the contact wet times for the AF-79. On 01/19/23 at 10:20 AM, Housekeeping staff V produced a Safety Data Set sheet (form that includes information such as the properties of each chemical: the physical, health, and environmental health hazards, protective measures, and safety precautions for handling, storing, and transporting the chemical) for the AF-79. The sheet contained emergency information for the cleaner, however the form lacked contact wet times or what the chemical should be used for. On 01/19/23 at 11:30 AM, Administrative staff A reported she was just told by housekeeping staff V about the situation with the cleaners and housekeeping staff should be educated to ensure the cleaners used properly. Review of the facility's policy for Infection Control revised 11/22, revealed the facility would follow standard precautions with cleaning and disinfection by routine cleaning and disinfection of frequently touched or visible soiled surfaces in common areas and resident rooms with an EPA (environmental protection agency) registered disinfectants, following manufacturers' instructions for amount, dilution, and contact times. The facility failed to ensure a clean, sanitary living environment by the failure of housekeeping staff to know the wet times of cleaners used to clean resident rooms. This failure had the potential to affect all the resident areas.

The facility reported a census of 41 residents, with one main kitchen. Based on observation and interview the facility failed to store foods in a safe and sanitary manner by the failure of staff to date open items, date and reseal opened food items, and failure to discard expired food items. Findings included: - On [DATE] at 08:30 AM during initial tour of the main kitchen the following expired items were observed: One can of Rotel that expired on [DATE]. One can of diced peppers that expired on [DATE]. One bottle of red wine that expired on [DATE]. One jar of chicken base that expired on [DATE]. Two jars of horseradish that expired on [DATE]. Five bags of Bran Flakes that expired on [DATE]. Six boxes of Nestle Hot Cocoa that had expired on ,d+[DATE]. Three bags of Raisin Bran cereal that expired on ,d+[DATE]. One jar of relish that expired on ,d+[DATE]. 13 bags of Au Jus mix that expired on [DATE]. The following items without expiration dates with, a one-year shelf life per the facility policy were further observed during the initial tour of the main kitchen on [DATE] at 08:30 AM: White pepper opened [DATE]. Rubbed sage opened [DATE]. Celery seed opened [DATE]. Ground [MEDICATION(S)] opened [DATE]. Cream of tartar opened [DATE]. Ground nutmeg opened [DATE]. Ground ginger opened [DATE] and observed with no lid. Bay leaves opened [DATE]. Italian season opened [DATE]. Ground cloves opened [DATE]. Sliced roast beef found in the fridge, opened on [DATE]. The following items were observed opened and undated during the initial tour of the main kitchen on [DATE] at 08:30 AM: Undated open onion powder, with no lid present along with garlic powder, ground oregano, steak seasoning, green food coloring, yellow food, coloring, blue food color, onion ring frozen, ground thyme, potato, and coconut flakes. Sweet potato tots in the freezer, opened with no date. Egg noodles opened with no date. Other items noted during the initial tour of the main kitchen on [DATE] at 08:30 AM included: : Chicken fried chicken in the freezer, opened on [DATE], with the bag not sealed closed. Rice crispies with a date opened of ,d+[DATE] and no year indicated. 6 containers of strawberries found in the walk-in fridge with mold noted throughout. During an interview on [DATE] at 09:30AM Dietary Staff (DS) D removed all items and verified that all items opened should be dated and resealed, and she stated opened food in the fridge needed to be used within 3 days, and the large bulk items had to be used within one month of opening it. Review of facility policy regarding Dating Food and Nourishment reviewed date ,d+[DATE] documented to ensure residents are not served food that is spoiled or unsafe any items will be labeled, dated and perishable items discarded after three days. Any questionable food should be discarded immediately. She expected staff to write the date items were opened on all items and the date an item arrived from the supplier so they could determine expiration date if not listed. The facility failed to store foods in a safe and sanitary manner by the failure of staff to date and reseal opened food times, and failure to discard expired food items.

The facility reported a census of 41 residents with 12 sampled including one for respiratory care. Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for Resident (R) 24 by not changing and dating a humidifier bottle and tubing for oxygen therapy. Findings Included: - Review of Resident (R) 24's Electronic Health Record (EHR) documented the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 24's Significant Correction Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental status (BIMS) of 8, indicating moderately impaired cognition. R24 used oxygen. Review of R24's ADL Function/ Rehabilitation Potential Care Area Assessment (CAA) dated 05/05/21 documented R24 required extensive one to two-person assistance with activities of daily living and had oxygen continuously. Review of R24's Care Plan dated 09/03/13 documented the resident required oxygen therapy related to ineffective gas exchange. Review of 24's EHR Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) on 06/15/21 revealed there were no initials on 05/15/21 or 05/16/21 indicating staff changed or dated the resident's humidifier and tubing. Observation on 06/15/21 at 9:45AM in R 24's room revealed an oxygen concentrator sitting on the floor by the wall with tubing on top and a humidifier dated 04/15/21. Interview on 06/15/21 at 10:01 AM with Certified Medication Aide (CMA) A revealed it was the responsibility of the CMA's to change and date the humidifier and tubing on the 17th of every month. Interview on 06/15/21 at 10:09 AM with Licensed Nurse (LN) B revealed the night nurse was responsible to change and date the humidifier and tubing once a month. Interview on 06/17/21 at 10:46 AM Administrative Staff C revealed she expected all policies and procedures to be followed. She also stated she expected the oxygen tubing changes to be documented and dated monthly. Review of the facility's Oxygen Tubing Protocol reviewed 01/20/21 documented oxygen tubing should be routinely replaced every month. The facility failed to provide respiratory care consistent with professional standards of practice for Resident (R) 24 by not changing and dating humidifier bottle and tubing for oxygen therapy.

The facility census totaled 41 residents with five residents reviewed for unnecessary medications. Based on interview, and record review the facility failed to ensure one of five residents did not receive unnecessary medications due to the failure of not providing sliding scale insulin as per blood glucose parameters for Resident (R)12. Finding included: - Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed R12 had a Brief Interview for Mental Status (BIMS) of 11, indicating moderately impaired cognition and received insulin daily. Review of the Cognitive Loss/Dementia Status Care Area Assessment (CAA) dated 04/07/21 revealed R12 usually understood others and was usually understood when communicating with staff. Review of Depression Care Plan revised 04/01/21, staff were to administer medications as ordered and monitor/document for side effects and effectiveness. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .), inject subcutaneously as per sliding scale: if blood sugars were 250 milligrams/Deciliter (mg/dL)(Milligrams per deciliter; a unit of measure that shows the concentration of a substance in a specific amount of fluid) - 349 mg/dL, staff would administer an extra four units of insulin; if blood sugars were 350 mg/dL- 399 mg/dL, staff would administer an extra six units of insulin. Review of the May 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 05/19/2021 at 05:14 PM for a blood sugar of 291.0 mg/dL 05/19/2021 at 07:36 PM for a blood sugar of 285.0 mg/dL 05/23/2021 at 05:13 PM for a blood sugar of 260.0 mg/dL 05/24/2021 at 04:53 PM for a blood sugar of 276.0 mg/dL 05/26/2021 at 05:12 PM for a blood sugar of 291.0 mg/dL 05/26/2021 at 08:47 PM for a blood sugar of 266.0 mg/dL 05/28/2021 at 05:15 PM for a blood sugar of 260.0 mg/dL 05/28/2021 at 08:33 PM for a blood sugar of 274.0 mg/dL 05/30/2021 at 07:49 PM for a blood sugar of 291.0 mg/dL Review of the June 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 06/07/2021 at 11:31AM for a blood sugar of 252.0 mg/dL 06/11/2021 at 11:15 AM for a blood sugar of 256.0 mg/dL 06/14/2021 at 11:11 AM for a blood sugar of 317.0 mg/dL During an interview on 06/17/21 at 11:44 AM, Licensed Nurse (LN) E stated R12's blood glucose was checked fasting, at bedtime, and before each meal. LN E stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/17/21 at 12:00 PM, Administrative Staff C stated with a blood glucose of over 250 mg/dL, a sliding scale insulin dose should be given per the physician order. Administrative Staff C stated because the order stated as needed it could be given with each blood glucose check if the blood glucose was over 250 mg/dL. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure R12 received sliding scale insulin as ordered for blood sugars above 250 mg/dL.

The facility reported a census of 52 residents, with one main kitchen serving all residents. Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety as evidenced by several open, undated food items noted during the kitchen tour Findings included: - Observation during kitchen tour on [DATE] at 12:50 PM revealed open, undated peanut butter drops and spinach in the walk-in fridge. Observation of the contents of the silver fridge with the double doors included items such as opened, undated chocolate syrup, opened, undated grated cheese, and opened, undated, and expired Dorothy[NAME]dressing with a best before date of [DATE]. Observation further revealed an opened bottle of mustard dated ,[DATE] with no expiration date noted. The small freezer ice cream fridge contained 1 Breyers Vanilla ice cream opened and undated. Interview with Dietary Staff (DS) B on [DATE] at 01:03 PM revealed any food that was opened must be dated for the day it was opened so that it can be discarded appropriately. DS B said the staff knew that, but she was unsure why the opened food items were not dated. Review of Dating Food and Nourishment policy dated ,[DATE] revealed the policy was to ensure the residents were not served food that was spoiled or unsafe. Any items placed in the refrigerator would be labeled and dated. Perishable items removed from their original container would be labeled, dated and discarded after 3 days. The facility failed to store food in accordance with professional standards for food service safety as evidenced by several open, undated food items in the one main kitchen

The facility identified a census of 52 residents with 13 residents included in the sample. Based on observation, interview, and record review the facility failed to ensure staff treated Resident (R) 25 with dignity when he sat outside on the patio with food debris on his pants and when R25 appeared to be asleep in his wheelchair in his room with the lunch clothing protector still on him, about 3 hours after lunch service. Findings included: - An observation on 09/10/19 at 02:38 PM revealed R25 seated in his wheelchair on the patio with food on his pants from lunch. The resident attempted to brush the food which appears to look like dried cereal from his pants. Further observation of R25 on 09/11/19 at 03:34 PM revealed R25 seated in his wheelchair with his head down and eyes closed. The resident appeared to be asleep in his room with a clothing protector on which had food which appears to look like gravy on it from the lunch time meal. Interview with Certified Nurse Aide (CNA) H on 09/12/19 at 3:00 PM revealed R25 will refuse to change his clothes after a meal due to wanting to spending as much time outside as he can. Interview with Licensed Nurse (LN) A on 09/12/19 at 4:19 PM revealed he liked to be outside right after eating and he will not let the staff change his clothing until later in the day. LN A stated the resident liked to leave the clothes protector on and would refuse to let the staff take it off. LN A said there was nothing on the plan of care regarding his preference of not changing clothes, but it should be added to his plan of care. Interview with Administrative Nurse F on 9/16/19 at 10:25 AM revealed she expected the plan of care to be updated if this was an ongoing behavior for him (having food on his clothes from meal times and refusing to have the staff change him prior to going outside). Review of the policy Dignity revised (MONTH) (YEAR) revealed each resident has a dignified existence, will protect, promote and assist the elder in exercising his or her right as an elder of the facility. The facility failed to ensure the staff treated R25 with dignity when he sat outside on the patio with food debris on his pants and when R25 appeared to be asleep in his wheelchair in his room with the lunch clothing protector still on him, about 3 hours after the lunch service.

The facility reported a census of 52 residents with 13 included in the sample. Based on observation, interview, and record review the facility failed to notify Resident (R) 43's physician when her pulse registered at outside of normal limits on multiple occasions. Findings included: - Review of R43's pertinent [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS of 15, indicating intact cognition. Review of Physician order [REDACTED].>05/23/19 - Staff would take the resident's vital signs every Thursday, in the evening. Review of the Weekly Vital Sign documentation revealed: On 08/04/19 at 09:04 AM the resident had a pulse of 121 beats per minute (BPM). On 08/19/19 at 08:53 AM the resident had a pulse of 122 BPM and at 4:57 PM the resident had a pulse of 114BPM. On 08/20/19 at 08:55 AM, the resident had a pulse of 133 BPM and at 3:29 PM the resident had a pulse of 101 BPM. On 08/28/19 at 08:29 AM the resident had a pulse of 129 BPM. On 08/30/19 at 08:35 AM the resident had a pulse of 112 BMP and at 4:58 PM the resident had a pulse of 108 BPM. On 08/31/19 at 08:55 AM the resident had a pulse of 104 BPM. On 09/19/19 at 04:57 PM the had a pulse of 104 BPM. Review of Call/Faxed Communication to the resident's physician from 07/2019 to 09/2019 lacked evidence staff notified the resident's physician of her increased pulse rate. Review of the residents Progress Notes from 07/2019 to 09/2019 lacked evidence staff notified the resident's physician of her increased pulse rate. Review of a Progress Note dated 09/09/19 at 11:40 AM revealed the resident complained of being light headed and weak. The resident had a pulse of 130 BPM, respirations of 18 breaths per minute, and an oxygen saturation level of 85-88% on room air with an oral temperature of 100 degrees Fahrenheit. Physician G sent an order to send the resident to the emergency Department. Review of a Progress Note dated 09/9/19 at 04:54 PM revealed the writer called the hospital for an update on the resident and nursing staff reported prepared the resident to transfer to another hospital related to the on-set of [MEDICAL CONDITION] and possible pneumonia. Review of the Physicians Interagency Transfer Record dated 09/12/19 revealed the resident admitted to the hospital with [REDACTED]. Observation of R43 on 09/12/19 at 04:08 PM revealed the resident in her room, up and walking with no concerns. Interview with R43 on 09/12/19 at 04:02 PM revealed nurses took her pulse and if it was high, Staff re-checked it. The resident reported she started not feeling well on 09/09/19 and she went to the hospital for further evaluation. R43 stated the hospital diagnosed her with [MEDICAL CONDITION]. R43 stated she never felt bad with high pulses until the day she went to the hospital. The resident reported [MEDICAL CONDITION] was hereditary and ran in her family. Interview with Certified Medication Aide (CMA) C on 09/12/19 at 03:56 PM revealed he would notify the nurse if the resident had a high or low pulse rate. Interview with Licensed Nurse [NAME] on 09/12/19 at 10:35 AM revealed if a resident had a vital sign which measured out of normal range for a resident, she would contact the resident's doctor. She would expect the CMA/CNA's to notify the nurse if there was a high/low vital sign, which measured out of the normal range for the resident. The facility did not use parameters unless the physician instructed them to do so. Interview with Administrative Nursing Staff F on 09/12/19 at 04:11 PM revealed the resident was physician G resident and she has said to treat the patient, not the vital sign. Physician G did not have parameters for calling her, she expected nursing judgement for calls about high/low vital signs. For high pulses and blood pressures, nurses would recheck vitals after 45 minutes and if consistently high/low, then the physician would be notified. Interview with Physician G on 09/12/19 at 04:38 PM revealed she did not if she was notified for any of R43 high pulses until staff notified her on 09/09/19 the resident did not feel well, and she had staff send the resident to the ER. Physician G expected nurses to call her for consistently high pulses. Physician G felt like if a resident's pulse measured over 120 BPM, she should be notified. Physician G stated high pulses were not the only symptom of [MEDICAL CONDITION], but pulses above 130 BPM could be a clue the resident had [MEDICAL CONDITION]. Review of Wheatland's Health Care Center Physician Standing Orders dated 04/05/19 revealed licensed staff would follow the facility's vital sign protocol unless otherwise indicated by the resident's attending physician. Review of the Vital Signs Protocol policy dated 12/2016 revealed vital signs would be taken anytime at the nurse discretion and based on an assessment of the elder's condition. Nurses would contact physicians as necessary. The facility failed to notify Resident (R)43's physician when her pulse registered outside of normal limits on multiple occasions.

The facility reported a census of 52 residents with 13 residents included in the sample. Based on observation, interview, and record review the facility failed to protect private electronic resident information when a licensed nurse stepped away from her mobile cart computer screen with resident electronic health information displayed, was not locked, and in an area highly visible to any resident or visitor who walked by. Findings included: - Observation of Licensed Nurse (LN) A on 09/12/19 at 07:22 AM completing the blood pressure checks for the required residents, she stepped away from her mobile cart computer screen with resident electronic health information displayed, was not locked, and in an area highly visible to any resident or visitor who walked by. Interview with LN A on 09/12/19 at 07:23 AM revealed she did not usually leave the resident information screen unlocked when leaving the computer, and all staff were supposed to lock the screen when stepping away from the computer. Interview with Administrative Nursing Staff F on 09/16/19 at 5:00 PM revealed that computer screens must be locked when staff leave the cart area to protect resident information/privacy. Review of Confidentiality of Resident Information policy dated 01/2019 revealed it was the policy of the facility to ensure all information pertaining to residents remained confidential. Requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) would be strictly enforced and applied to employees, vendors and volunteers in all departments. The facility failed to protect private electronic resident information when a licensed nurse stepped away from her mobile cart computer screen with resident electronic health information displayed and not locked, in an area highly visible to any resident or visitor who walked by.

The facility identified a census of 52 residents with 13 residents included in the sample. Based on observation, interview, and record review the facility failed to revise Resident (R) 25's care plan to reflect his preference to not have his clothing changed after meals. Findings included: - Review of R25 signed physician order [REDACTED]. Review of the R25's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. Review of the activities of daily living (ADL) Care Assessment Area (CAA) dated 07/23/19 revealed R25 required extensive assistance of two staff with dressing, and required setup help only with eating meals. Review of the Care Plan dated 12/15/19 revealed R25was able to feed himself and needed set up help only with meals. R25 required extensive assistance of 2 staff to dress. The care plan lacked evidence of the resident's preference to not have his clothing changed after meals. An observation on 09/10/19 at 02:38 PM revealed R25 seated in his wheelchair on the patio with food on his pants from lunch. The resident attempted to brush the food which appears to look like dried cereal from his pants. Further observation of R25 on 09/11/19 at 03:34 PM revealed R25 seated in his wheelchair with his head down and eyes closed. The resident appeared to be asleep in his room with a clothing protector on which had food (which appears to look like gravy) on it from the lunch time meal. Interview with Certified Nurse Aide (CNA) H on 09/12/19 at 03:00 PM revealed R25 will refuse to change his clothes after a meal due to wanting to spend as much time outside as he can. Interview with Licensed Nurse (LN) A on 09/12/19 at 04:19 PM revealed R25 liked to be outside right after eating and he will not let the staff change his clothing until later in the day. LN A stated the resident liked to leave the clothes protector on and would refuse to let the staff take it off. LN A said there was nothing on the plan of care regarding his preference of not changing clothes, but it should be added to his plan of care. Interview with Administrative Nurse F on 9/16/19 at 10:25 AM revealed she expected the plan of care to be updated if this was an ongoing behavior for him (having food on his clothes from meal times and refusing to have the staff change him prior to going outside). The facility failed to provide a policy regarding Care Plan Revision as requested on 09/16/19. The facility failed to ensure the staff revised the care plan of R25 to include his refusal to allow staff to change his clothing and or clothing protector after completing a meal.

The facility census totaled 49 residents with 14 residents who lived on the TLC unit (memory unit). Based on observation, interview, and record review the facility failed to ensure foods served from the steam table remained at 135 degrees Fahrenheit (F) or higher in order to prevent foodborne illnesses and failed to ensure staff washed their hands between resident contact and plating of food in order to prevent possible cross contamination to serving utensils. Findings included: - Observation on 9/7/16 at 12:04 PM dietary staff A brought the steam table from the main kitchen to the TLC unit. Staff A took the temperature of the fiesta hamburger, cauliflower, and rice with each item measuring above 135 degrees F. Staff A did not obtain the temperature of the chicken strips, grilled cheese sandwiches, ground hamburger, hamburger patties, green beans, mashed potatoes, french fries or the gravy. At 12:15 PM dietary staff A left and told direct care staff B the cart was ready to serve. Direct care staff B then went to the cabinet and took out 2 plates and started to plate food. Staff B put a scoop of mashed potatoes on the plate without taking the temperature of the food. When asked if he/she planned to take the temperature of the food prior to serving staff B reported he/she thought the kitchen had done that and he/she was just making 2 plates so the residents could see their choices of food for the meal. Staff B put each food item on the plates and other direct care staff took the plates around to see what the residents wanted to eat. Staff B then took the temperature of the mashed potatoes which measured 48 degrees F. Staff B preceded to obtain the temperature of the foods that were not previously measured by dietary staff A. The following food items measured below 135 degrees F: chicken strips- 132 degrees F, Grilled cheese sandwich- 124 degrees F, ground hamburger- 110 degrees F, gravy- 100 degrees F, and french fries- 110 degrees F. Staff B left the serving area after obtaining the temperature of the french fries and called the kitchen to bring more to the TLC. Staff B then proceeded to take the temperature of the other food items and had someone else call the kitchen to order more food items. Staff B did not wash his/her hands at any after leaving the area, using the telephone and then returning to the area to continue taking temperatures of the other food. At 12:40 PM dietary staff C brought a tray with steam table pans on it to replace the foods previously not above the safe serving temperature. Direct care staff B took the temperature of the food items brought to the TLC unit and all food items except for the ground meat were at or above the 135 degrees F. The ground hamburger measured 126 degrees F. At 12:44 PM direct care staff B left the serving area and went to the nurses station and called the kitchen about the ground hamburger and reported he/she was told to reheat it in the microwave. Staff B then proceeded to get a scoop out of the plastic tub and put 4 scoops of ground meat in a bowl he/she had gotten out of the cabinet without washing his/her hands after using the phone at the nurses station. Staff B handed the bowl to another direct care staff to put in the microwave. Staff B checked the temperature of the ground meat which measured 166 degrees. Staff B then washed his/her hands and started to plate the foods. At 12:51 PM staff B went over to a resident and put his/her arm partially around the resident's back and rubbed the resident's back while he/she asked the resident a question. Staff B then returned to the serving area and picked up a plate and preceded to plate foods without washing his/her hands. At 1:01 PM staff B left the serving area, touched 2 other residents around their shoulders and then proceeded to get the plastic wrap box and pulled out some plastic allowing the surface area of the plastic to touch the handle of the oven and then covered a plate of food to save for later without washing his/her hands. Staff B then sat down between 2 residents and visited and cued the residents to eat. At 1:08 PM staff B got up and got 2 small plates out of the cabinet and used the cake server to get put cake on each plate and served them the residents and sat back down. Staff B again failed to wash his/her hands prior to plating the cake. At 1:11 PM staff B got up from the table and then got 2 bowls out of the cabinet and checked the temperature of some additional chicken strips and diced carrots that were brought from the main kitchen. Staff B got a slotted spoon out of the plastic container and then plated the carrots and chicken strips and served the food items without washing his/her hands and then sat down to assist residents. During an interview on 9/7/16 at 2:41 PM direct care staff B reported he/she would have served the chicken strips, ground meat, grilled cheese and other foods without obtaining the temperature because he/she thought the kitchen always temped the foods before they left the unit. During an interview on 9/7/16 at 3:12 PM dietary staff C reported he/she expected staff to take the temperature of all food items on the steam table and expected them to peak at 160 degrees F depending on what the food item was. He/she also stated staff needed to wash their hands anytime they touched a resident or anything else not considered clean. During an interview on 9/7/16 at 3:27 PM administrative nursing staff D reported he/she expected staff to wash their hands during the service of food if they had touched a resident. Review of the personnel adherence to sanitary procedures dated 10/14 revealed staff needed to wash their hands any time when contamination could occur. Review of the Portable serving cart policy dated 10/12 revealed staff needed to obtain the temperature of foods and record to ensure appropriate holding temperatures are reached. The facility failed to ensure foods remained at or above 135 degrees F when on the steam table and failed to ensure staff washed their hands after touching residents and other unclean items in order to prevent cross contamination and foodborne illness.

The facility census totaled 48 residents with 3 residents in the sample. Based on observation, interview and record review the facility failed to assess and notify the physician as he/she requested of decreases in the resident's oxygen saturations (level of oxygen in the blood) for 1 of three residents reviewed for nurse assessment and notification of the physician with changes. (#1) Findings included: - Review of resident #1 ' s signed physician orders [REDACTED].(inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). Review of the admission MDS (minimum data set) dated 2/23/16 revealed a BIMS (brief interview for mental status) score of 10, indicating moderate cognitive impairment. The resident required extensive assistance with all daily care. The resident was unsteady and required assistance to steady him/herself. The resident had no shortness of breath or difficulty breathing with exertion, sitting at rest or lying flat. Medications included a diuretic (a medication used to rid the body of excess fluids) daily during the 7 day observation period. The resident used oxygen (O2) prior to admission and during his/her stay at the facility. The resident received Occupational (OT) and Physical therapies (PT) 5 days a week. Review of the ADL (activities of daily living) CAA (care area assessment) dated 2/23/16 revealed the resident needed extensive assistance of 1 to 2 staff for bed mobility, transfers, and ambulation with a walker. Review of the care plan dated 2/17/16 revealed: The resident had [MEDICAL CONDITION]. Approaches included: Check breath sounds and monitor/document for labored breathing, monitor/document for the use of accessory muscles while breathing, give cardiac medications as ordered, and provide O2 via nasal cannula (NC-tubing in the nose) at 4 liters per minute (L/min) continuously. Review of the physician orders [REDACTED]. Give [MEDICATION NAME] 0.5 mg PO BID, and for the resident to take weekly weights. Review of the nurse's admission note dated 2/16/16 revealed the resident received skilled services for abdominal aortic aneurysm surgical repair on 2/12/16. The resident had an incision to the right groin and small incision to left groin (both had staples). The resident's O2 saturation read 94% (normal range 92-100%) on 4 L/min via NC. The resident had a [MEDICAL CONDITION] machine (continuous positive airway pressure), but did not often choose to use it. Lung sounds were clear however diminished in the bases. The resident had +3 [MEDICAL CONDITION] ([MEDICAL CONDITION] in tissue that remains indented after pressure relieved) to BLE (bilateral lower extremities), left hand, and slightly [MEDICAL CONDITION] genitals. Review of the nurse's note dated 2/20/16 revealed the resident had no signs of SOA (shortness of air) and an O2 saturation of 95% at 4 L/min via NC. He/she did have bilateral lower extremity [MEDICAL CONDITION] and his/her left hand was puffy, which his/her spouse said it had been that way ever since he/she stayed in the hospital. It looked like maybe an IV site might had infiltrated. Review of the nurse's note dated 2/23/16 at 7:19 p.m. revealed a direct care staff reported concerns of low O2 readings. The nurse adjusted the resident's concentrator. The resident's O2 saturations fluctuated from 50-90% and he/she had blue/purple lips. The nurse turned the resident's O2 up to 4.5 L/min. The nurse notified the resident's physician who wanted the nurse to monitor the resident's oxygen level and if he/she had further issues with maintaining his/her O2 saturation, staff were to call him/her. Review of the care plan conference notes dated 2/23/16 revealed the resident was not to have O2 off during therapy per family instructions. Review of the nurse's note dated 2/24/16 at 3:02 p.m. revealed the resident had a problem getting his/her O2 saturations into the 90%s after he/she worked with PT that morning. It took 10 minutes for his/her O2 to increase from 55% to 91%. The resident did not have any acute (immediate) signs of SOA (shortness of air), but needed cueing frequently to inhale deeply through his/her nose and exhale through his/her mouth. His/her O2 at the time of the note read 92% at 4 L/min of O2 per NC. The note lacked evidence the notified the physician of the low O2 saturations as he/she requested or assessed the resident ' s lung sounds. Review of the nurse's note dated 2/25/16 at 5:53 p.m. revealed the resident had eaten all meals in his/her room as he/she preferred. [MEDICAL CONDITION] remains at 3+ in BLE and the left hand. The resident has not had any SOA today and recuperated from PT faster. It took about 5 minutes for O2 saturation to go from 65% to 92%. The note lacked evidence the notified the physician of the low O2 saturations as he/she requested or assessed the resident ' s lung sounds. Review of the nurse's note dated 3/3/16 revealed the resident chose to go to PT without wearing a shirt. He/she reported he/she got hot at therapy and when he/she got hot, it made it harder to breathe. The nurse wrote it took the resident 7 minutes after PT for his/her O2 to get back into the 90% ' s after having gone down briefly to 73%. The resident ' s O2 remained on continuously at 4 L/min via NC. The resident had 3+ pitting pedal [MEDICAL CONDITION] and left hand swelling which has been the same since admission. The note lacked evidence the notified the physician of the low O2 saturations as he/she requested or assessed the resident ' s lung sounds. Review of the nurse's note dated 3/8/16 at 3:33 p.m. revealed the resident ' s O2 saturations went down to 55% and it took about 10 minutes for it to go back up. The residents physician was in the building and aware of the resident ' s O2. Review of the nurse's note dated 3/8/16 at 4:22 p.m. revealed the physician saw the resident that day. The resident had an increase in [MEDICAL CONDITION]. The physician wrote orders for daily intake and output, a 2000 cc (cubic centimeter) per 24 hour fluid restriction, and daily weight. The physician also ordered laboratory (lab) values that day and for 3/11/16, increased the resident ' s [MEDICATION NAME] (diuretic) to 1 mg (milligram) po (by mouth) twice daily, ordered ace wraps to BLE on in the morning and off at bedtime, and ordered Metalozone (a diuretic) 2.5 mg po every morning for 1 week. Reviews of the nurse's note dated 3/8/16 at 5:05 p.m. revealed the nurse received lab results, and called the results to the physician. The physician reported he/she would wait to see what the lab results were on 3/11/16 but told staff the resident may need admission to the hospital to get remove excess fluid. Review of the nurse's notes dated 3/8/16 at 10:09 p.m. revealed at approximately 9:15 p.m., the resident was up in his/her recliner with O2 on. The resident trembled and used his/her abdominal muscles to breathe. The resident could not keep his/her O2 saturations up within normal range. The nurse sat with resident and instructed him/her to take some deep breaths. The resident ' s O2 saturation read 53% at 3.5 L/min and adjusted up to 4 L/min. Vital signs read blood pressure 86/51 (normal range would be 120/80, pulse 166 (normal range 60-100). The resident had [MEDICAL CONDITION] 3+ pitting to upper extremities and 2+ non-[MEDICAL CONDITION] to lower extremities. At approx. 9:30 p.m., the nurse contacted the physician and the physician gave an order to transport to the hospital per ambulance. During an interview on 4/12/16 at 11:30 a.m., direct care staff C reported the resident had to have his/her O2 on at all times. If staff tried to remove it for any reason, the resident would tell them he/she needed it on. His/her family member always checked his/her oxygen and had his/her own tester (pulse oximeter). During an interview on 4/12/16 at 11:20 a.m., licensed nurse B reported the resident had O2 on at all times. The resident would go to therapy and his/her O2 saturations would drop but he/she had no problem when the resident returned to his/her room. The resident was very involved in his/her own care and had his/her own pulse oximeter and a family member checked it often. He/she did have an episode where he/she became very short of air and could not get his/her O2 level up. The resident went to the hospital. During an interview on 4/12/16 at 12:00 p.m. administrative nurse A reported the resident was on continuous O2. During his/her care plan meeting the resident ' s family members informed the care plan team the resident was not to have O2 removed during therapy for trials without O2. The resident had been O2 dependent for several years. Therapy attended the meeting and reported therapists did not remove the resident's O2 during therapy. The resident showed no signs of being SOA even when his/her O2 saturations were low. Staff A reviewed the nurse ' s notes and reported the nurses should have followed up on the resident ' s low O2 saturations and documented the assessment in the nurse ' s notes. The facility failed to assess the resident's condition when he/she had low O2 saturations and failed to notify the physician as he/she requested of the low O2 saturations.

The facility census totaled 47 residents. Based on observation and interview the facility failed to provide a safe, clean, and homelike environment for residents in co-mingled rooms by the failure to properly label towel bars in the 22 semi-private rooms on the Lilac Lane unit. This had the potential to affect all residents residing on Lilac Lane. Findings included: - On 12/4/13 at 1:32 p.m., observation during the environmental tour revealed towel bars in co-mingled bathrooms on Lilac Lane were not labeled to identify which towels belonged to which resident. On 12/4/13 at 1:32 p.m., an interview with maintenance staff K revealed he/she did not know why the towel bars were not labeled and it would be a nursing issue. On 12/4/13 at 2:36 p.m., an interview with direct care staff W revealed the towel bars in the co-mingled rooms were not labeled but stated they were in the past. Staff W was unsure why they were not labeled anymore. Staff W reported if a family member or visitor came in, they would not know which resident each towel belonged to. On 12/4/13 at 2:43 p.m., an interview with licensed nursing staff T revealed the residents just knew which towels were theirs and reported the bars were labeled at one time, but the labeling had kind of gone by the wayside lately. Staff T reported there was no way for a first time visitor in the facility to know which towels belonged to which residents. On 12/4/13 at 3:01 p.m., an interview with administrative staff B revealed the towels on the towel bars were only used once by the residents and then discarded or sent to laundry. Staff B reported he/she thought they had got in trouble for labeling the bars in the past, so they stopped. Staff B stated the staff knew which set of towels were for which resident and if family or a visitor came in they would not use the items anyway, they would call for the staff. The facility failed to provide a policy regarding the labeling of towel bars in co-mingled resident rooms. The facility failed to provide a safe and clean homelike environment by the failure to properly label the towel bars in 22 co-mingled bathrooms on Lilac Lane.

The facility census totaled 46 residents with 17 residents included in the sample, and all 17 of those residents were reviewed for comprehensive care plans. Based on observation, interview, and record review, the facility failed to complete comprehensive care plans for 4 of 17 residents in regards to pressure ulcers and behaviors. (#55, #21, #59, #16) Findings included: - Review of resident #16's admission orders [REDACTED]'s not enough insulin made or the body can ' t respond to the insulin), [MEDICAL CONDITION] (an abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), and shortness of air. Review of the resident's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact), needed extensive assistance of 2 staff members for bed mobility, transferred only 1-2 times in the previous 7 days with assistance of 2 staff, and walking and locomotion did not occur. The assessment also revealed the resident did not have a pressure ulcer, was at risk for pressure ulcers, used a pressure reducing device for his/her chair, and had a turning and repositioning program in place. Review of the Pressure Ulcer CAA (Care Area Assessment) for the 9/13/13 admission MDS assessment revealed due to the resident's immobility, the resident had risk for pressure ulcers. He/She currently had a pressure reducing mattress and had a Foley Catheter that helped the resident's skin by not being incontinent. The assessment revealed the resident had numerous [DIAGNOSES REDACTED]. The assessment also revealed the resident admitted to the facility on [DATE] and admitted to Hospice services at that time with the [DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan initiated on 9/26/13 revealed the resident had an ADL (activities of daily living) self-care performance deficit related to activity intolerance. It revealed the resident totally dependent on 1 or 2 staff for repositioning and turning in bed every 2 hours and as necessary, and the resident transferred using the full sling at that time due to increased weakness. The care plan did not identify the resident's risk for pressure ulcers, pressure ulcer treatments, or any care staff needed to provide to reduce the risk for ulcers. Review of the Admission Nursing assessment dated [DATE] revealed the resident had a red area to the midline area between the buttocks, and red heels. It also revealed, "red area on bottom (blanchable) with red open area appr. (approximately) 0.5 cm (centimeters)," and bilateral red, non-blanchable heels. Review of an EZ Graph brand wound documentation form on 10/8/13 revealed a pressure ulcer to the posterior right hip, and a [MEDICATION NAME] being used as a dressing. The assessment also revealed the wound a stage 2, partial thickness wound with measurements of 0.7 cm x 0.5 cm x 0.1 cm. During an interview at 12:15 P.M. on 12/5/13, administrative nursing staff H reported he/she looked at the care plan, and the care plan did not address the resident's pressure ulcers, pressure ulcer history or directions to staff on how to care for these issues. Staff H reported the care plan needed to reflect these issues. During an interview at 2:25 P.M. on 12/5/13, administrative nursing staff B reported he/she expected a resident at risk for ulcers or with current ulcers to have a comprehensive pressure ulcer care plan. The facility failed to have a comprehensive care plan to identify and address the resident's pressure ulcers and skin issues - Review of resident #59's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview of Mental Status) score of 3 (severe cognitive impairment). The resident was totally dependent on 2 people for bed mobility, needed extensive assistance of 2 for transfers, walking did not occur, and was totally dependent on 1 person for locomotion, had no open pressure ulcers, and had a pressure reducing mattress and device for his/her chair. Review of the Pressure Ulcer CAA (Care Area Assessment) for the /17/13 Admission MDS revealed, at that time the resident did not have any pressure ulcers. The CAA revealed the resident at risk for developing pressure ulcers due to not being able to reposition himself/herself without assistance. Review of the resident's comprehensive care plan with an initiated date of 6/28/13 lacked any indication the resident had a pressure ulcer, history of pressure ulcers, or any interventions staff provided to help reduce the risk for acquiring more pressure ulcers. Review of a nurse's note dated 6/17/13 at 6:00 P.M. revealed the resident had a potential for skin breakdown and would require an air mattress and cushion for his/her wheelchair. Review of a nurse's note dated 6/23/13 at 5:15 P.M. revealed the resident had an approximately nickel-sized bruised area on the coccyx. The note revealed the area had no breakdown at that point, but staff encouraged the resident and assisted him/her to lie on his/her side as he/she could tolerate. Review of another nurse's note dated 6/28/13 at 4:45 P.M. revealed the resident had a red area on the lateral aspect of the right foot. Staff offloaded heals when the resident ly in bed. Review of a nurse's note dated 7/1/13 at 5:00 P.M. revealed the resident helped to bed with extensive assist of two staff and peri-care performed at 4:45 P.M. The nurse noted 3 open areas surrounding the sacrum/coccyx with measurements: 1.5 cm x 1.5 cm open area on the left upper coccyx, 1.5 cm x 1 cm open area midline at the coccyx, and a 0.5 x 0.25 cm open area on the right upper coccyx. The note also revealed staff turned the resident every 1-2 hours to prevent further breakdown During an interview at 2:02 P.M. on 12/5/13, administrative nursing staff H reviewed the record and comprehensive care plan. Staff H reported the care plan did not include the resident's risk for pressure ulcers, history of pressure ulcers, or interventions staff had in place or changed to help with healing and prevention of further pressure ulcers, but should have included those things. During an interview at 2:25 P.M. on 12/5/13, administrative nursing staff B reported he/she expected a resident at risk for ulcers or with current ulcers to have a comprehensive pressure ulcer care plan. The facility failed to have a comprehensive care plan to identify and address the resident's pressure ulcers and skin issues. - Review of resident #21's annual MDS (minimum data set) dated 5/14/13 revealed a BIMS (brief interview for mental status) score of 3 (severe cognitive impairment). The resident had a total severity score of 00 for depression (abnormal emotional state characterized by exaggerated feelings of sadness worthlessness and emptiness), indicating no depression. The resident had no overall behaviors and no rejection of care behaviors exhibited. The resident received antianxiety medication 1 of 7 days of the look back period and received antidepressant medication 7 of 7 days of the look back period. Review of the resident's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3 (severe cognitive impairment). The resident had a total severity score of 10 for depression (moderate depression). During the 7 day look back period, the resident had physical behavioral symptoms directed towards others and rejection of care behaviors 1 to 3 days. The resident received antianxiety medication and antidepressant medication 7 of 7 days of the look back period. Review of all the CAAs (care area assessment) dated 5/14/13 revealed the following areas triggered but had no analysis of findings documented: [MEDICAL CONDITION] Drug Use, Cognitive Loss/Dementia, Urinary Incontinence and Indwelling Catheter, Activities, Dehydration/Fluid Maintenance, Visual Function, Falls, Communication, Nutritional Status, and Pressure Ulcers. The facility was unable to produce any analysis of findings for the above listed CAAs. Review of the care plan with a date of 9/20/13 revealed the resident took [MEDICATION NAME] (a medication used to treat depression). The care plan lacked any specific behaviors the resident displayed, lacked information regarding an increase in behaviors, and lacked any non-pharmacological interventions that helped reduce behaviors. On 12/3/13 at 1:45 p.m., an interview with direct care staff E revealed the resident had more behaviors lately and was put on [MEDICATION NAME] (a medication for anxiety). Staff E reported redirecting the resident helped with behaviors and also making sure the resident had a nap reduced his/her agitation. Staff E reported it was important the resident got enough sleep. Staff E also stated taking the resident outside when the weather was nice or talking with him/her about family, were also ways to help calm the resident when he/she was agitated or anxious. On 12/3/13 at 3:30 p.m., an interview with direct care staff F revealed if the resident had combative behaviors, talked about going home, had increased agitation, was more demanding, or had become more harsh, the staff redirected the resident, took him/her outside when the weather was nice, tried talking to him/her about things outside, tried toileting the resident, or tried to find out about pain. Staff F reported the behaviors came on faster and were more aggressive lately and staff could not redirect the resident as easily. Staff F also confirmed the aides did not have any information on the computer about specific behaviors to monitor for each resident. On 12/3/13 at 3:09 p.m. an interview with licensed nursing staff G revealed the resident had behaviors and a lot of times, laying him/her down for a nap helped. Staff G reported sometimes when the resident was more agitated staff tried to give the resident pain medication. Staff G also reported the resident did not like to be around a lot of people or a lot of noise. Staff G stated behaviors for this resident included being argumentative, stubborn, agitated with staff, and verbal aggression toward staff. Staff G reported information about the residents was communicated to the aides through verbal report. Staff G also reported he/she would expect the non-pharmacological approaches to be on the resident's care plan to help guide staff on the residents care and confirmed the aides didn't have a written reference to tell them what to monitor for specifically for each resident. On 12/4/13 at 9:16 a.m., an interview with administrative nursing staff B reported the purpose of the care plan was to have information about the resident communicated to the staff and should be specific to each resident. Staff B stated the nursing staff had access to the care plan, and could add information and interventions to the care plan if needed and then that information was communicated verbally to the aides. Staff B stated he/she expected behaviors that were frequently displayed by the resident to be on the care plan. Staff B also reported he/she expected all residents on the TLC Angels unit to have behaviors and the staff on that unit received extra training on how to handle those behaviors. Staff B stated the staff used the same interventions for all residents on that unit. After further discussion, staff B affirmed the necessity to have the specific behaviors for each resident on the care plan because not every resident had the same type of behaviors. On 12/4/13 at 11:17 a.m., an interview with administrative staff H revealed the CAAs were used to help develop the care plans. Staff H reported the CAAs should paint a picture of the resident as an individual. Staff H confirmed the resident's past history should be included in the CAA and that information should be transferred to the care plan. The facility failed to provide a policy regarding comprehensive care plans. The facility failed to develop a comprehensive care plan to include specific behaviors the resident displayed, and failed to include non-pharmacological interventions used to reduce the residents behaviors. - Review of resident #55's annual MDS (minimum data set) dated 8/20/13 revealed a BIMS (brief interview for mental status) score of 14 (cognitively intact). The resident had a total severity score of 8 (mild depression) for depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The resident displayed verbal behavioral symptoms directed towards others 1 to 3 days of the 7 day look back period. The resident received antianxiety medication and antidepressant medication for 7 of 7 days of the look back period. Review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14 (cognitively intact). It identified the resident had a total severity score of 2 for depression indicating minimal depression. The resident received antianxiety medication and antidepressant medication for 7 of 7 days of the look back period. Review of the [MEDICAL CONDITION] Drug Use CAA (care area assessment) dated 8/20/13 revealed the following analysis of findings: The resident was sometimes very sleepy and staff had a hard time waking him/her up. The resident needed assistance of 2 staff for transferring and used the sit-to-stand lift. The resident had a history of [REDACTED]. During an interview with the resident, he/she stated feeling tired and had little energy. Review of the care plan with a date of 9/6/13 revealed the resident took several medications that had black box warnings. The care plan lacked any information about the resident's depression or anxiety and did not include what the staff monitored for with the depression and anxiety. It also lacked any information about the resident's past medical history which staff reported had contributed to the resident's anxiety and depression. On 12/3/13 at 1:45 p.m., an interview with direct care staff I revealed lately the resident had very different sleep patterns. Staff I also reported he/she had let the nurse know and the nurse directed him/her what to do, whether to let the resident sleep or try to wake him/her up. On 12/4/13 at 8:06 a.m., an interview with licensed nursing staff J revealed staff monitored the resident's depression and anxiety by interacting with him/her. Staff J expected the information about the residents anxiety and depression to be on the care plan in order to guide the staff on how to care for the resident as an individual. On 12/4/13 at 9:16 a.m. an interview with administrative staff B revealed some days the resident would wake up and some days he/she was very sleepy and there wasn't anything that would wake him/her. Staff B stated the resident had an extensive history contributing to his/her depression and anxiety. Staff B confirmed the resident's care plan lacked information about him/her sleeping for several days, that it was normal for him/her to do so, his/her depression or about his/her past related to the depression and anxiety. Staff B reported the purpose of the care plan was to have as much information about the resident as possible and the care plans should be specific to each resident. Staff B also stated the nursing staff had access to the care plans and could make changes as necessary. Staff B stated he/she expected behaviors that were frequently displayed by residents to be on their care plan and affirmed the necessity to have the specific behaviors listed because not every resident had the same type of behaviors. On 12/4/13 at 11:17 a.m., an interview with administrative staff H revealed the CAAs were used to help develop the care plans and stated they should paint a picture of the resident as an individual. Staff H confirmed the resident's past history should be included in the CAA and should be transferred over to the care plan. Staff H confirmed information about resident #55's past was not included on the CAA or the care plan, but stated it should have been because his/her history could contribute to his/her anxiety and depression. The facility failed to provide a policy relating to comprehensive care plans. The facility failed to develop a comprehensive care plan to include information about the resident's anxiety and depression, contributing factors to the resident's depression and anxiety, and interventions related to his/her depression and anxiety.