Every finding on record at Trinity Oaks

Based on observations, resident and staff interviews, the facility failed to maintain a clean shower room for 1 of 4 shower rooms reviewed for a safe, clean, comfortable, and homelike environment (The C-Hall shower room). The findings included: An interview with Resident #8 on 2/17/25 at 2:27 PM revealed the shower room on the C-Hall where she resides was dirty and there was black mold visible on the walls. Resident #8 stated she did not like using the shower room because it was dirty, and she did not feel clean after her showers. An observation of the C-Hall shower room on 2/18/25 at 11:20 AM revealed there was a buildup of black grime observed around the shower fixtures, along the edges of the floor, and around areas on the wall where the paint was peeling. There was a buildup of black grime around a cabinet hanging on the wall and in the crevices around the cabinet doors. There was also a buildup of black grime observed on the feet of the shower chair and along the bottom of the shower curtain. An interview conducted with Housekeeper #1 on 2/18/25 at 12:30 PM revealed she was assigned the C-Hall shower room and cleaned it on Mondays, Wednesdays and Fridays. She indicated when she cleaned the shower room, she sprayed the walls, the floor, and the shower fixtures with a bleach solution, let it soak, and then wiped everything down. Housekeeper #1 stated she did not monitor the condition of the shower curtain, and the nursing staff were responsible for cleaning the shower chair. She revealed she did not clean the C-Hall shower room on 2/10/25 (Monday), 2/12/25 (Wednesday), or 2/14/25 (Friday) but was unable to recall why. Housekeeper #1 stated she did not work on 2/17/25 (Monday). A phone interview was conducted with Housekeeper #2 on 2/19/25 at 4:15 PM. Housekeeper #2 revealed she covered for Housekeeper #1 on 2/17/25 (Monday) and was assigned to clean the C-Hall shower room. She stated she attempted to clean the shower room after lunch, but it was being used for a resident shower. Housekeeper #2 indicated she had other areas to clean and was unable to clean the shower room before her shift ended at 3:00 PM. An observation and interview was conducted in the C-Hall shower room with the Director of Housekeeping on 2/18/25 at 12:02 PM. He revealed Houskeeper #1 was assigned to the C-Hall shower room, and she was responsible for cleaning it daily including wiping down all surfaces with a disinfectant and mopping the floors. He further revealed Housekeeper #1 was responsible for deep cleaning the shower room on Mondays, Wednesdays and Fridays which included spraying the fixtures, the walls and the floor with a bleach solution, letting it soak, wiping everything down and mopping the floors. He stated the areas observed with a buildup of black grime on walls, around the fixtures and along the edge of the floor needed to be cleaned. The Director of Housekeeping observed the black grime on the cabinet, shower chair and shower curtain and stated Housekeeper #1 was responsible for monitoring these items and should have notified him they were in poor condition and needed to be replaced. A phone interview with the Administrator on 2/20/25 at 10:55 AM revealed the Director of Housekeeping managed the cleaning schedule for the shower rooms and the tasks to be completed when it was cleaned. He stated he was not aware there were several areas observed in the C-Hall shower room with a buildup of black grime or the condition of the cabinet, the shower chair or the shower curtain. The Administrator revealed the housekeepers should be cleaning the shower rooms as scheduled and if they observed equipment that was in poor condition they should report it to the Director of Housekeeping.

Based on record review, and staff and the Responsible Party (RP) interviews, the facility failed to protect a resident's right to be free from staff to resident abuse. While Nurse Aide (NA) #5 was providing care for a cognitively impaired resident, the resident became agitated, was whining and crying. NA #5 placed part of her hand over the resident's mouth and told the resident to Hush, quit that whining. This deficient practice was found for 1 of 3 residents reviewed for abuse (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses which included anxiety, cognitive communication deficit, muscle weakness, dementia, and generalized osteoarthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was severely cognitively impaired and required extensive assistance transfers and toilet use. The MDS further revealed Resident #16 was not coded for any behaviors through the look back period. Review of Resident #16's care plan revised on 11/18/24 revealed the resident may have had altered behaviors, mood, or psychological wellbeing related to changes with health, functioning, and cognitive skills. Resident #16 had the potential or was at risk to be resistive to care, medicines, yelling out, crying and sadness, disrobing, attempting to get out of bed, difficulty to redirect with agitation and anger. The goal was for Resident #16 to maintain comfort and dignity daily by a calm, relaxed manner, and a neat and clean appearance. Interventions included always approaching Resident #16 in a calm and relaxed manner, encouraged activity distraction, explaining all procedures and care before beginning to assist, and monitor and observe and report. Interventions also included when the resident becomes agitated staff would intervene before agitation escalate by guiding away from source of distress, engage calmly in conversation, and if response were aggressive staff would need to walk calmly away, and approach later. Review of the initial facility reported incident dated 01/18/24 at 5:30 PM revealed it was reported that a NA (Nurse Aide) mistreated a resident during care. The report further revealed the employee was suspended during the investigation. It was indicated that residents who were not alert and oriented on the unit of the incident were assessed for visible and mental signs of abuse and residents who were alert and oriented were interviewed. It was revealed Resident #16 showed no signs of physical or mental abuse found during the assessment on 1/18/24. Review of the investigation completed by the Administrator related to Resident #16's incident revealed the following: - Nurse Aide (NA) #5 statement undated read in part, On Thursday 01/18/24 NA #5 was asked to assist to care for Resident #16 because she had tried to take her clothes off and smelled of urine. NA #5 revealed she and a Personal Care Assistant (PCA) #1 took Resident #16 to her room and put her in the resident's bed to be changed. NA #5 further revealed she got the resident laid down in the bed and reassured the resident she was going to be okay once they changed her. NA #5 stated Resident #16 continued to cry while she got a washcloth and started to clean the resident and PCA #1 asked what was wrong with Resident #16. NA #5 indicated she continued to speak to Resident #16 that everything was going to be okay and to stop crying but Resident #16 continued to cry as PCA #1 continued to assist and NA #5 patted her mouth to get her to stop because they were unable to understand what the resident was saying but continued to reassure the resident that everything was okay. NA #5 revealed once care was completed on Resident #16 they got the resident in bed and comfortable to lay down and rest. - Personal Care Assistant (PCA) #1 statement dated 01/18/22 read in part, NA #5 put her hands over Resident #16's mouth while she was crying today and told her to be quiet around 2 PM. A phone interview was conducted with Nurse Aide (NA) #5 on 02/17/25 at 2:50 PM and she revealed on 01/18/25 she and PCA #1 had gone into Resident #16's room and completed incontinence care. NA #5 stated when care began Resident #16 began whining and was agitated. NA #5 indicated throughout care the resident continued to be agitated and she consistently tried to calm the resident down. NA #5 stated halfway through care Resident #16 seemed upset and she took two fingers and tapped Resident #16 on the mouth three times and stated to the resident to hush, quit that whining you are going to be fine. NA #5 indicated looking back she should have never tapped Resident #16 on the mouth. NA #5 revealed she was eventually let go by the facility. NA #5 stated she was not trying to be mean to the resident but should not have tapped her on the mouth. A phone interview conducted with PCA #1 on 02/18/25 at 12:00 PM revealed on 01/18/24 she and NA #5 went into Resident #16's room to give incontinence care. PCA #1 Resident #16 was often upset when staff changed her. PCA #1 further revealed the resident was cognitively impaired and she was unable to understand the resident. PCA #1 indicated Resident #16 started to whine and become agitated at the beginning of care. PCA #1 stated halfway through care NA #5 took her right hand and placed it over Resident #16's mouth and held it for almost 30 seconds and stated, hush, quit that whining, in an aggressive tone. PCA #1 indicated Resident #16's eyes observed to become large in size and appeared to be petrified. PCA #1 indicated she did not say anything to NA #5 and the care continued about 15 more minutes. PCA #1 revealed Resident #16 seemed agitated throughout the whole-time receiving care. A phone interview conducted with Nurse #3 on 02/20/25 at 1:25 PM revealed on 01/18/24 around 5:00 PM it was reported to her by PCA #1 that NA #5 had put her hand over the resident's mouth during care and told the resident to be quiet. Nurse #3 indicated she notified the Administrator and completed an assessment on Resident #16 and found no issues or concerns during her assessment. Nurse #3 indicated Resident #16 was unable to recall any events that occurred that date. An interview conducted with Director of Nursing (DON) on 02/18/25 at 12:15 PM revealed on 01/18/24 she was not present in the facility but was notified there had been an incident with Resident #16 and NA #5 had put her hand over the resident's mouth and told her to hush and stop crying. The DON further revealed on 01/19/24 she spoke to PCA #1 who stated NA #5 had placed her hand over Resident #16's mouth and told the resident to shhhhh, in an aggressive manner. The DON revealed she had completed NA #5's statement and NA #5 stated she admitted to tapping Resident #16 on the mouth three times. The DON indicated the next day skin assessments and interviews were conducted with alert and oriented residents on Resident #16's unit and no concerns were found. The DON indicated after their investigation that the facility did not feel like the incident was considered abuse due to conflicting stories by staff and there were no signs of abuse of the resident. The DON revealed Resident #16 was often confused and was resistive with care. The DON indicated NA #5 and PCA #1 should have walked away if Resident #16 was upset and agitated during care. A phone interview conducted with the Responsible Party (RP) on 02/20/25 at 4:25 PM revealed they had not been notified of the incident that occurred on 01/18/24. The RP further revealed Resident #16 would have been very upset if she was alert and oriented and a facility staff had told her to be quiet or put their hands on her mouth. An interview conducted with the Administrator on 02/20/25 at 1:55 PM revealed on 01/18/24 he was notified later during first shift around 5:00 PM that PCA #1 had observed NA #5 had spoken to Resident #16 harshly and put her hand over the residents' mouth during care. The Administrator revealed when he discussed the incident with NA #5 she denied holding her hand over the residents mouth but touched and patted the residents lips. The Administrator indicated a skin assessment was completed on Resident #16 and no concerns were found. It was revealed after the investigation that the facility did not substantiate the concern due to conflicting stories by staff and no signs of mental anguish.

Based on record review and staff interviews, the facility failed to follow and implement abuse policies in the area of identification, protection and reporting for 1 of 3 residents reviewed for abuse (Resident #16). While Resident # 16 was being abused, Personal Care Assistant (PCA) #1 did not stop Nurse Aide (NA) #5 or intervene and did not report the incident immediately to licensed nursing staff or administrative staff. As a result, NA #5 worked the rest of her shift putting other residents at risk for abuse. The findings included: A review of the facility policy and procedure titled Abuse Investigation and Reporting for Senior Services, with a revised date of 04/26/22, read in part 1.) under Identification and Investigation if the person(s) observing or suspecting incidents of resident abuse, neglect, exploitation or misappropriation of property must report such knowledge or suspicion to the nursing supervisor or his/her department manager as soon as he or she is aware of an incident or potential incident. Read in part 2.) Under Protection while the investigation is pending, accused individuals employed by the facility will be suspended, pending the results of the investigation. Review of the investigation completed by the Administrator related to Resident #16's incident revealed the following: - Nurse Aide (NA) #5 statement undated read in part, On Thursday 01/18/24 NA #5 was asked to assist to care for Resident #16 because she had tried to take her clothes off and smelled of urine. NA #5 revealed she and a personal care assistant (PCA) #1 took Resident #16 to her room and put her in the residents bed to be changed. NA #5 further revealed she got the resident laid down in the bed and reassured the resident she was going to be okay once they changed her. NA #5 stated Resident #16 continued to cry while she got a washcloth and started to clean the resident and PCA #1 asked what was wrong with Resident #16. NA #5 indicated she continued to speak to Resident #16 that everything was going to be okay and to stop crying but Resident #16 continued to cry as PCA #1 continued to assist and NA #5 patted her mouth to get her to stop because they were unable to understand what the resident was saying but continued to reassure the resident that everything was okay. NA #5 revealed once care was completed on Resident #16 they got the resident in bed and comfortable to lay down and rest. - Personal Care Assistant (PCA) #1 statement dated 01/18/22 read in part, NA #5 put her hands over Resident #16's mouth while she was crying today and told her to be quiet around 2 PM. A phone interview was conducted with NA #5 on 02/17/25 at 2:50 PM and she revealed on 01/18/25 she and PCA #1 had gone into Resident #16's room and completed incontinence care. NA #5 stated halfway through care Resident #16 seemed upset and she took two fingers and tapped Resident #16 on the mouth three times and stated to the resident to hush, quit that whining you are going to be fine. NA #5 indicated she worked the rest of the shift. Review of NA #5's time card for 1/18/25 revealed she clocked in at 6:57 AM and clocked out at 3:39 PM. A phone interview conducted with PCA #1 on 02/18/25 at 12:00 PM revealed on 01/18/24 at an estimated time of 2:00 PM she and NA #5 went into Resident #16's room to give incontinence care. PCA #1 Resident #16 was often upset when staff changed her. PCA #1 further revealed the resident was cognitively impaired and was unable to understand the resident. PCA #1 indicated Resident #16 started to whine and become agitated at the beginning of care. PCA #1 stated halfway through care NA #5 took her right hand and placed it over Resident #16's mouth and held it for almost 30 seconds and stated, hush, quit that whining, in an aggressive tone. PCA #1 indicated Resident #16's eyes observed to become large in size and appeared to be petrified. PCA #1 indicated she did not say anything to NA #5 and care continued for about 15 more minutes. PCA #1 revealed she failed to intervene and report the incident immediately due to being shocked. Once care ended PCA #1 did not report the incident she observed until between 5 to 5:30 PM to Nurse #3. A phone interview conducted with Nurse #3 on 02/20/25 at 1:25 PM revealed on 01/18/24 around 5:00 PM it was reported to her by PCA #1 that NA #5 had put her hand over the residents' mouth during care and told the resident to be quiet. Nurse #3 indicated PCA #1 did not report the incident immediately and and she educated the PCA that she should have. An interview conducted with the Administrator on 02/20/25 at 1:55 PM revealed on 01/18/24 he was notified later during first shift, around 5:00 PM, that PCA #1 had observed NA #5 speaking to Resident #16 harshly and put her hand over the residents' mouth during care. The Administrator revealed he was aware PCA #1 had waited to report the incident and did not report immediately after the incident occurred. The Administrator indicated as soon as he was aware he suspended NA #5 pending the investigation.

Based on record review and staff interviews, the facility failed to include reported allegations in the initial report to the State Agency. Details were not accurately reflected for 1 of 3 residents reviewed for abuse (Resident #16). The findings included: Review of the initial facility reported incident dated 01/18/24 at 5:30 PM revealed it was reported that a Nurse Aide (NA) #5 mistreated a resident during care. It was revealed Resident #16 showed no signs of physical or mental abuse found during the assessment on 1/18/24. A phone interview conducted with Nurse #3 on 02/20/25 at 1:25 PM revealed on 01/18/24 around 5:00 PM it was reported to her by Personal Care Assistant (PCA) #1 that NA #5 had put her hand over the resident's mouth during care and told the resident to be quiet. Nurse #3 indicated she notified the administrator immediately what NA #5 had alleged. An interview conducted with the Administrator on 02/20/25 at 1:55 PM revealed he completed the initial report to the State Agency. The Administrator further revealed on 01/18/24 he was notified by Nurse #3 that NA #5 had put her hand over the resident's mouth during care and told the resident to be quiet. The Administrator indicated he did not include the information on the initial State Agency report due to the staff statements were conflicting and did not think to add the alleged allegations.

Based on record review and staff interviews, the facility failed to provide a safe transfer for 1 of 6 residents (Resident #69) reviewed for accidents. The findings included: Resident #69 was admitted to the facility 1/07/25 with diagnoses including muscle weakness, abnormalities of gait and mobility, and mild cognitive impairment. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #69 was severely cognitively impaired and dependent on staff for transfers. The care plan dated 1/21/25 revealed Resident #69 required 2-person assistance for all transfers. An incident report dated 2/07/25 12:25 PM completed by Nurse #2 revealed Nurse Aide (NA) #1 was transferring Resident #69 from the wheelchair to a shower chair when Resident #69 was unable to support herself and NA #1 lowered her down to the floor. NA #1 was transferring Resident #69 without a second person and did not use a gait belt. Resident #69 was assessed, and no injuries were noted. A phone interview conducted with NA #1 on 2/19/25 at 2:38 PM indicated she was assigned to Resident #69 on 2/07/25. She revealed Resident #69 was able to stand and pivot to transfer with 2-person assistance. NA #1 stated on 2/07/25 Resident #69's friend was coming to do her hair, and she needed to give Resident #69 a shower. She stated she was unable to find anyone to help her, so she attempted to transfer Resident #69 on her own. She stated she assisted Resident #69 to a standing position, but her legs started to give out. NA #1 revealed she lowered Resident #69 gently to the floor and called for assistance. She stated Nurse #2 and Nurse #3 responded, completed an assessment and Resident #69 was not injured. NA #1 indicated she knew that she should have waited until she was able to find someone to help, but she felt rushed, so she proceeded to transfer Resident #69 without a second person. An interview with Nurse #2 on 2/18/25 at 2:38 PM revealed she was not Resident #69's assigned nurse on 2/07/25 but she responded to assist when Resident #69 was lowered to the floor. She stated NA #1 was transferring Resident #69 by herself from the wheelchair to a shower chair when Resident #69's legs gave out and she had to lower her to the floor. She indicated Resident #69 was assessed and no injuries were noted. Nurse #2 revealed Resident #69 was able to stand and pivot to transfer with 2-person assistance. She indicated when she asked NA #1 why she transferred Resident #69 without a second person she stated she was unable to find anyone to help. Nurse #2 stated she was at the nurse's station with Nurse #3, and both were available to help, however NA #1 did not ask them for assistance. A phone interview with Nurse #3 on 2/19/25 at 4:01 PM revealed she was Resident #69's assigned nurse on 2/07/25. She stated NA #1 called for assistance from Resident #69's room and when she responded she found Resident #69 sitting on the floor. She stated NA #1 reported she was attempting to transfer Resident #69 by herself from her wheelchair to the shower chair when Reisdent #69's legs gave out and she had to lower her to the floor. She stated she assessed Resident #69, and no injuries were noted. Nurse #3 revealed Resident #69 was able to stand and pivot to transfer with 2-person assistance. She indicated NA #1 reported she was transferring Resident #69 without a second person because she was unable to find someone to assist her. Nurse #3 indicated she was at the nurse's station with Nurse #2 and available to help, however NA #1 did not ask them for assistance. Nurse #3 revealed she told NA #1 she should have asked them to assist her and that transferring Resident #69 on her own was unsafe. A phone interview was conducted with the Director of Nursing (DON) on 2/19/25 at 2:11 PM. She revealed Resident #69 was able to stand and pivot to transfer with 2-person assistance. She stated on 2/07/25 NA #1 reported she was unable to find another staff member to assist, attempted to transfer Resident #69 by herself and had to lower her to the floor. The DON indicated Resident #69 was not injured. She revealed NA #1 stated she was aware that Resident #69 required two staff members for all transfers, and she should not have transferred her until she was able to find a second person to assist. A phone interview was conducted with the Administrator on 2/20/25 at 10:55 AM. He stated if a resident was able to stand and pivot with 2-person assistance to transfer then two staff members should be present during the transfer to ensure the resident was safe.

Based on record review, observations and staff interviews, the facility failed to secure medicated treatment supplies in a locked treatment cart for 1 of 1 treatment cart. Additionally, the facility failed to remove loose pills from a medication cart and failed to label medications which were not stored in their pharmacy or manufacturer packaging for 1 of 3 medication carts reviewed for medication storage (Unit B medication cart). The findings included: 1. During wound care observation on 2/18/25 at 9:30 AM on the D hall, the treatment cart was observed to be in the hallway outside of room D5, unsecured. Residents were noted to be ambulating past the cart without any staff members present. Observation on 2/18/25 at 9:35 AM of the treatment cart revealed it consisted of three- 4 drawer plastic towers, two recycled bedside tabletops (one sitting on top of the plastic towers and one on the bottom) and it was held together by PVC (polyvinyl chloride) piping surrounding the perimeter. There was no locking mechanism on the cart. Observation of the items in the treatment cart drawers on 2/18/25 at 10:15 am with the wound nurse present revealed the following pertinent items: Plastic tower #1 1st drawer-iodine and skin prep pads 2nd drawer-triple antibiotic ointments 3rd drawer-boric acid solution, normal saline, and hydrogen peroxide bottles 4th drawer-resident specific prescription creams and ointments Plastic tower #3 2nd drawer-antibacterial petroleum gauze 3rd drawer-medicated/infused dressings and collagen powders During an interview with the Wound Nurse on 2/18/25 at 10:15 am, she stated she had been in her position for several months. She reported she had used the facility-made treatment cart daily since she started. The Wound Nurse added that she did have the ability to partially lock the cart. She reported during the day, the cart would sit outside various residents' rooms throughout the facility and she would take the necessary items to perform wound care in the rooms with her. During an observation and interview with the Director of Nursing (DON) on 2/18/25 at 2:30 PM she stated she was unaware the treatment cart was unsecured throughout the day. She stated all drawers on the facility treatment cart should have the ability to be secured at all times when there wasn't a staff member present. 49295 2. An observation of the Unit-B medication cart was conducted on 2/18/25 at 10:21 AM in the presence of Medication Aide (MA) 1 and Nurse #1. The medication cart contained 3 loose pills of various shapes, colors and sizes laying in the bottom of cart drawers. The medication cart contained two green caplets that were placed in a white clear bag that did not include the medication name, resident name, and/or dosage instructions. MA #1 was interviewed on 2/18/25 at 10:36 AM indicated that someone placed the two green caplets in the clear white bag and left them in the medication cart. MA #1 further stated that facility will usually place medications in the clear white bag for any over the counter medications that need to be given to residents who were being discharged home. Nurse #1 was interviewed on 2/18/25 at 10:40 AM and indicated each nurse assigned to the medication cart was responsible for cleaning the medication cart and ensuring each medication was labeled. An interview was conducted with the Director of Nursing (DON) on 2/18/25 at 11:11 AM. The DON indicated the medication carts were to be cleaned by the nurses on duty. The DON indicated each nurse should clean, organize the medication carts, and discard any loose pills. The DON indicated the nurses oversaw the medication aides. The DON further indicated each nurse and medication aide must use medication from a labeled container and after removing the medication from the original container, must administer the medication to residents immediately per physician orders.

Based on staff interview and record review the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the 3rd quarter in fiscal year 2023. The facility did not report accurate weekend staffing and did not accurately report licensed nurse coverage 24 hours a day. Findings included: The CMS submission report, PBJ Final File Validation Report for Fiscal Year Quarter 3,2023 (April 1 - June 30) was reviewed and indicated the facility reported excessively low weekend staffing and failed to have Licensed Nurse Coverage 24 hours per day on Sunday, 04/09/23, Saturday, 05/20/23, Sunday, 05/21/23, Sunday 06/04/23, and Sunday 06/18/23. Nurse staff timecards, daily nurse staff schedules, and posted nurse staff documents dated for 4/9/23, 5/20/23, 5/21/23, 6/4/23 and 6/18/23, were reviewed and revealed multiple licensed and unlicensed nurse staff were not recorded accurately or were omitted on the PBJ report (1705D) for the 3rd quarter of Fiscal year 2023. An interview conducted on 10/26/23 at 8:45 AM with the Payroll Manager revealed she was educated minimally about the automated payroll and timecard system used by the facility. She had not been educated to verify nursing staff timecards with data automatically entered by the electronic timecard system prior to quarterly submission of PBJ data to CMS because the electronic system should have transferred the correct data into the PBJ reports. The Payroll Manager revealed she was not aware that data imported to the PBJ report was incorrect and not reflective of actual nurse staff dates and hours worked as reflected on the electronic timecards. On 10/26/23 at 2:42 PM an interview was conducted with the Administrator. The Administrator revealed the Payroll Manager had met the intent of submission to CMS of PBJ data, but the facility had no feedback or other data to check for report accuracy after quarterly PBJ reports were submitted.

Based on observations, staff interviews, and record review the facility failed to 1) remove expired foods/foods with signs of spoilage, 2) record a label on refrigerated and frozen foods that included date of opening and use by date, and 3) store foods in sealed containers. This failure had the potential to affect all residents who received food from the dietary department. The findings included: The Use by Date Storage Chart posted on the walk-in refrigerator, recorded All food items must be properly dated and labeled and must be stored in either containers with lids, foil/film wrappers, sealed food storage bags, or their original container. A continuous observation with the Assistant Dietary Manager (ADM) of the walk-in refrigerator, cook's reach in refrigerator, the freezer and the dry storage occurred on [DATE] from 10:25 AM until 11:15 AM and revealed the following concerns: 1a. The cook's reach in refrigerator was observed at 10:25 AM with the following concerns: - An opened four-pound container of pimento cheese did not record the date opened. 1b. The walk-in refrigerator was observed at 10:40 AM with the following concerns: - Twelve celery stalks that were cut and wrapped in plastic film, were observed brown, discolored, and with a mushy texture. The label recorded an open date of [DATE]. The Use by Date Storage Chart recorded Use cut/prepared fruits/vegetables, within 7 days or by expiration date (whichever is the soonest). - A plastic package of Swiss cheese with four slices remaining, did not record the date opened. 1c. The freezer was observed at 10:55 AM with the following concerns: - One plastic bag of meat, was unlabeled, identified by the ADM as beef tips, was opened and secured with a twist tie but did not record the date opened. - A torn plastic bag with 10 pieces of breaded meat, was unlabeled, identified by the ADM as chicken tenders, the bag was tied in knot, but did not have a label to record date opened. The contents were exposed to air. - A plastic bag wrapped in plastic film with approximately 22 pieces of meat, was unlabeled, identified by the ADM as chicken [NAME] recorded an open date of [DATE], but did not record a label with the use by date. This food item was stored past 90 days. - A torn plastic bag with 6 pieces of meat, was unlabeled, identified by the ADM as boneless chicken breast was exposed to air with discolored pieces. - One plastic bag of brown circular food pieces, was unlabeled, identified by the ADM as hash brown rounds, was opened and tied in a knot but did not record the date opened. - A plastic bag with a zipped closure had a label that recorded garlic bread with 16 pieces of garlic bread remaining, did not record the date opened or a date to use by/discard. The Use by Date Storage Chart did not record a use by date for garlic bread. - A plastic bag with a zipped closure, had a label that recorded garlic sticks with 4 garlic sticks remaining, recorded a date opened as [DATE], but did not record a date to use by/discard. The Use by Date Storage Chart did not record a use by date for garlic sticks. 1d. The dry storage was observed with the ADM at 11:10 AM with the following concerns: - A box of seven, 12-ounce containers of caramel sauce, recorded a received date of [DATE], and a manufacturer expiration date of [DATE]. This food item was stored past the manufacturer expiration date. During the continuous observation, the ADM stated that all staff were responsible to monitor food storage daily for expired foods, packaging and labels that included the date of opening, expiration and/or use by dates. The ADM stated that it had been two weeks since he checked cold storage for expired, labeled, and dated items and he checked dry storage for expired foods, about 1 week ago, saw the box of expired caramel sauce, but forgot to discard it. A phone interview occurred with the Certified Dietary Manager (CDM) on [DATE] at 4:18 PM. The CDM stated that she had been in her role at the facility for 2 years. The CDM stated that all dietary staff were responsible for monitoring dry and cold storage areas for items labeled, dated, and expired. The CDM stated she and the ADM conducted storage rounds at least twice weekly for monitoring and in her absence, the ADM was responsible to conduct monitoring rounds of storage areas. The CDM stated she conducted monitoring rounds on the storage areas last week but may have missed some items. The CDM stated that for frequently used food items, staff just recorded the date of opening, but that all items should be labeled with the date of opening, and date to use by. The CDM further stated that if items were removed from the original package, staff should place a label with the date of storage, date opened, and the expiration or use by date. The CDM stated that if staff find something expired or the package was torn and open to air, staff should discard it, she stated we should discard any items that are not properly sealed. The Administrator confirmed in an interview on [DATE] at 11:27 AM that all foods should be labeled, dated, stored in sealed containers, and discarded according to manufacture expiration dates or use by dates. He stated that all opened frozen foods should be discarded if not used within 90 days of opening.

Based on observations, interviews and record review, the facility failed to remove trash and debris on the ground around a commercial trash compactor and 3 of 3 commercial trash receptacles and maintain the commercial trash receptacle door closed. The findings included: During a continuous observation with the Assistant Dietary Manager (ADM) on 10/26/23 from 09:45 AM until 10:00 AM of three commercial trash receptacles and one commercial trash compactor, the door of one commercial trash receptacle was observed open, the receptacle was odorous, with multiple flies observed and the trash inside the receptacle was exposed. Further observation of the grounds around the commercial trash receptacles and the commercial trash compactor included the following: - Multiple articles of trash and debris - One used blue glove, inverted. - Four empty cardboard boxes - One mattress - One broken broom - One white polyvinyl chloride pipe - Two storage carts, one filled with multiple empty plastic bottles. - A motorized wheelchair. - One empty storage bin - One storage bin filled with table linen. - Three empty buckets - One uncovered small trashcan full of trash (fast food bags and paper cups with straws) - Three concrete pavers - One broken brick During the continuous observation on 10/26/23 from 09:45 AM until 10:00 AM, the ADM stated that he was responsible to monitor the grounds around the commercial trash receptacles for trash and debris and to keep the doors to the receptacles closed. He stated that he checked the grounds daily and when he checked the trash receptacles yesterday (10/25/23), a used glove, one of the empty cardboard boxes and the mattress were not there, but that he did not put the remaining items that were on the ground inside the trash receptacles. The Environmental Director (EVD) was interviewed on 10/26/23 at 10:00 AM during the continuous observation of the trash receptacles. The EVD stated that he was in this role for 3 years and was responsible, collectively with the Dietary Manager (DM) and the Maintenance Director, to monitor the commercial trash receptacles and grounds for trash. He stated that the motorized wheelchair was placed outside about one week ago, the cardboard boxes were outside for a few days, a staff member was scheduled to pick up the storage bin with linen, but he did not know how long the remaining items were left on the ground. He stated he knew the trash was left outside, but he did not place the trash in trash receptacles. The Maintenance Director was interviewed on 10/26/23 at 10:11 AM. He stated he was in this role for three weeks and that he shared the responsibility of monitoring the trash receptacles. He stated that when he arrived there were multiple pallets and large trash items left on the grounds, that he was working to get removed and placed in trash bins. He stated the facility had a construction receptacle that large trash items like storage carts and mattress could be placed in. He stated he was aware that trash should not be left on the ground and that he would continue to work with the DM and the EVD to get the grounds around the commercial receptacles cleared of trash. The Administrator stated during an observation of the commercial trash receptacles on 10/26/23 at 9:48 AM the cardboard boxes and the mattress were discarded yesterday (10/25/23) when a resident's mattress was replaced, he was not sure how long the remaining items were left on the ground, and he was not sure why the trash had not been placed in the receptacles. The Administrator also stated that the commercial vendor emptied the trash receptacles two or three times weekly, and the last pick up was Monday, 10/23/23. The Administrator stated that the grounds were monitored collectively by the EVD, the Maintenance Director and the DM and that trash should not be left on the ground.

Based on record review, observations, resident and staff interviews, the facility failed to maintain a resident's dignity when a nurse used a loud voice directed toward 1 of 1 resident reviewed for dignity (Resident #38). Findings included: Resident #38 was admitted to the facility on ,d+[DATE]/ 23. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had no cognitive impairment. An initial allegation report dated 08/14/23 at 8:45AM documented Resident #38 reported Nurse #11 spoke to her disrespectfully. Nurse #11 was suspended from the facility during the investigation. The 5- day investigative report dated 08/17/23 documented the facility investigation into the incident revealed the exchange between Nurse #11 and Resident #38 was inappropriate and disrespected the Resident. The Administrator interviewed Resident #38 on 08/14/23 and Resident #38 revealed Nurse #11 had been disrespectful and hurt her feelings. Resident #38 felt safe at the facility. Nurse #11 was terminated from employment on 08/17/23. Resident #38 was interviewed on 10/24/23 at 8:42AM. Resident #38 revealed Nurse #11 had taken care of her in the past and Resident #38 believed she and Nurse #11 were friends and Nurse #11 hurt her feelings and was disrespectful when Resident #38 asked her for a full oxygen tank and to please charge the cell phone belonging to Resident #38.Resident #38 revealed Nurse #11 spoke loudly to her in the hall and told her to go to her room because Nurse #11 was busy and Resident #38 would have to wait her turn. Resident #38 revealed her feelings were hurt and Nurse #11 did not listen to her. Resident #38 revealed she called the DON and left a message about her feelings. On 10/25/23 at 10:16 AM Nurse #11 was interviewed. Nurse #11 revealed on she worked on 08/13/23,and Resident #38 requested a new oxygen tank, but Nurse #11 was busy administering medications to other residents. Nurse #11 revealed she told Resident #38 she needed to wait a few minutes and to go back to her room because she needed to wait her turn. On 10/25/23 at 10:31 AM Nurse # 12 was interviewed. Nurse #12 recalled on 08/13/23 Nurse #11 was assigned to Resident #38 and when Resident #38 came into the hall near the medication cart of Nurse #11 she heard Nurse #11 speaking in a loud voice to Resident #38. Nurse #12 revealed she had not heard the conversation but observed Resident #38 upset and tearful. Nurse #12 explained Resident #38 approached her in the hall and told Nurse #12 she was going to report Nurse #11 for being disrespectful to her and not listening to her. Nurse #12 assisted Resident #38 to get a new oxygen tank and charge her cell phone as requested. On 10/26/23 at 10:59 AM an interview with the Administrator and DON revealed the investigation was thorough and Nurse #11 was terminated based on investigation results from 08/14/23 through 08/17/23 and in the best interest of residents and staff that Nurse #11 was terminated for her disrespect and undignified behavior toward residents and staff.

Based on observations, resident, and staff interviews and record review, the facility failed to obtain a physician order for a suprapubic catheter size and balloon size (Resident #82) and failed to keep a catheter drainage bag and tubing from touching the floor to reduce the risk of infection or injury (Resident #246) for 2 of 3 sampled residents reviewed for the use of an indwelling urinary catheter. The findings included: 1. Resident #82 was readmitted to the facility on [DATE] with obstructive and reflux uropathy and retention of urine. A urology visit note dated 2/2/2023 documented the consultation for the insertion of a suprapubic indwelling urinary catheter. The note specified Resident #82 was to return to the urologist on 2/14/2023 for the procedure. A urology visit note dated 2/14/2023 documented the insertion of a suprapubic indwelling urinary catheter. The note documented Resident #82 was to return to the urologist on 3/15/2023 to have the suprapubic catheter charged by the urologist. The size of the suprapubic catheter and balloon was not noted in the documentation. A visit note dated 3/17/2023 documented the suprapubic catheter change at the urologist office. The size of the catheter and balloon was not noted in the documentation. A physician order dated 7/10/2023 specified the suprapubic indwelling urinary catheter was to be changed during the day shift on the 1st of the month starting 8/1/2023. The order did not include the size of the catheter or the balloon size. The significant change Minimum Data Set assessment dated [DATE] assessed Resident #82 to be cognitively intact and to have an indwelling urinary catheter. A review of the Treatment Administration Record (TAR) for August 2023 revealed that Resident #82's indwelling suprapubic catheter was changed on 8/1/2023 by evidence of the nurse initials. The TAR did not document the size of the suprapubic catheter or the balloon size. A review of the TAR for September 2023 revealed on 9/1/2023 the indwelling suprapubic catheter was changed for Resident #82by evidence of the nurse's initials. A nursing note dated 9/1/2023 documented the suprapubic indwelling catheter was changed using a 20 French catheter with a 30-cubic centimeter balloon. A review of the TAR for October 2023 revealed no documentation for the changing of the indwelling suprapubic catheter. Resident #82 was observed on 10/24/20230 at 10:37 AM. Resident #82 reported he had a suprapubic catheter because he couldn't urinate. Resident #82 declined to have the size of the catheter observed. The catheter bag was noted to have a privacy cover and was positioned below the bladder and was not noted to be on the floor. An interview was conducted with Nurse #5 on 10/24/2023 at 4:23 PM. Nurse #5 reported he was assigned to provide care to Resident #82 on Sunday, 10/1/2023 and he did not change the indwelling suprapubic catheter on that date. Nurse #5 explained that Nurse # 6 came in at 3:00 PM on the weekends and she would perform treatments for the facility, including changing catheters as needed. Nurse #5 reported he remembered he had asked Nurse #6 to change Resident #82's suprapubic catheter. Nurse #6 was interviewed by phone on 10/25/2023 at 12:52 PM. Nurse #6 reported she worked on 10/1/2023 and she did change Resident #82's catheter. Nurse #6 reported she used the same size catheter that Resident #82 had previously inserted. Nurse #6 reported the suprapubic catheter supplies had been gathered for her and she used the package with Resident #82's name on it. During an interview with Nurse #7 on 10/26/2023 at 9:14 AM, she explained the orders to change an indwelling urinary catheter should include the size of the catheter and the size of the balloon. Nurse #7 reported she would review nursing progress notes to determine the size to use if there was not an order in the electronic medical record. The Unit Manager (UM) was interviewed on 10/26/2023 at 10:01 AM. The UM reported she was not aware Resident #82 did not have orders for the indwelling suprapubic catheter size or balloon size. The UM indicated the physician should have been contacted to clarify the orders for Resident #82. The physician (MD) was interviewed on 10/26/2023 at 1:57 PM. The MD reported indwelling catheter orders should include the size of the catheter and the balloon size. The Director of Nursing (DON) was interviewed on 10/26/2023 at 3:20 Pm. The DON explained that Resident #82 had been going to a urologist to have his catheter changed and it became too physically difficult for him to go there once a month and his family opted to have the suprapubic catheter changed at the facility. The DON reported the size of the catheter and balloon should have been part of the order to change the catheter monthly and she expected all catheter orders to include the size of the catheter and balloon. 20934 2. The facility's Catheter Drainage Bag and Tubing policy, revised 7/30/23, documented in part, to always attach the drainage bag to the bedframe, keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. Resident #246 was admitted to the facility on [DATE]. Diagnoses included retention of urine, fitting and adjustment of urinary device, traumatic subdural hemorrhage with loss of consciousness, cerebral infarction, transient ischemic attack, displaced fracture of second cervical vertebra and dementia, among others. A nurse admission assessment dated [DATE] recorded on admission, Resident #246 was assessed with a catheter that was patent and draining yellow urine. A physician order dated 10/20/23 recorded Resident #246 had a catheter for urinary retention. A care plan dated 10/20/23 indicated Resident #246 was at risk for complications related to the presence of an indwelling catheter, recent urinary tract infection (UTI) and the use of a prophylactic supplement. The goal was to remain free from catheter-related trauma with no signs of a UTI and interventions that included securing the tubing to prevent injury. An admission Minimum Data Set assessment was in progress and assessed her cognition as severely impaired. Resident #246 was observed on 10/24/23 at 12:30 PM, 1:09 PM and 1:30 PM in her room in her recliner with her feet elevated, positioned to the left, hanging off the footrest. During each observation, the catheter drainage bag, hook, and tubing were lying on the floor on the left side of the recliner. The catheter drainage bag was not in a privacy bag but was also not visible from the doorway. There were approximately 1200 milliliters of dark yellow urine in the catheter drainage bag and tubing. Resident #246 was nonverbal with each observation. An observation of Resident #246 in her room receiving care from Nurse #1, Nurse #2, Nurse Aide (NA) #1 and NA #2 occurred on 10/24/23 at 1:45 PM. Resident #246 was seated in a recliner chair in her room with an indwelling catheter draining dark yellow urine into a catheter drainage bag that was attached to the footrest of the recliner chair. During the observation, Resident #246 was transferred via a mechanical lift to her bed. Nurse #1 stated in an interview on 10/24/23 at 1:48 PM that she just arrived at 1:00 PM, and that she had not observed Resident #246 prior. Nurse #1 stated that catheter drainage bag and tubing were not to be left on the floor due to the risk of injury and infection to the resident. Nurse #2 stated in an interview on 10/24/23 at 1:49 PM that she was not the assigned Nurse for Resident #246 and just entered the room to assist with her care. Nurse #2 stated when she entered the room the catheter was attached to the footrest of the recliner. NA #1 stated in an interview on 10/24/23 at 1:50 PM that she just entered the room to assist NA #2 to care for Resident #246 and when she entered the room, the catheter drainage bag was attached to the footrest of the recliner. NA #2 stated in an interview on 10/24/23 at 1:51 PM that she entered the room of Resident #246 after 1:30 PM and emptied her catheter drainage bag. When asked twice where the catheter drainage bag was located when she entered the Resident's room, she stated it was not on the floor. During an interview with Nurse #3, the assigned Nurse for Resident #246, on 10/24/23 at 1:50 PM, she stated that she last medicated Resident #246 around 10:30 AM that day and the catheter drainage bag was attached to the footrest of the recliner. The Director of Nursing (DON)/Infection Preventionist (ICP) was interviewed on 10/24/23 at 3:30 PM. She stated that per the facility policy and training provided to staff, catheter drainage bags were to be positioned below the resident's bladder and not on the floor. She stated when catheter drainage bags and tubing were left on the floor, this increased the risk of infection to the resident from bacteria that may be on the floor or to other residents due to possible urine spillage on the floor. The DON/ICP stated it was better to position the resident close to the bed and secure the catheter drainage bag to the bed frame to keep it off the floor, rather than on the footrest of a recliner. An interview with the physician occurred on 10/26/23 at 2:20 PM and he stated that Resident #246 was at increased risk of infection due to the use of an indwelling catheter and that the catheter should not be on the floor to prevent contamination and infection.

Based on observations, staff interviews and record review, the facility failed to provide an enteral product (liquid nutrition fed via a tube) continuous per physician order and record the date and time the enteral product was initially opened. This occurred for 1 of 2 sampled residents reviewed for nutrition from tube feedings. The findings included: The facility policy Enteral Nutrition, revised 6/5/23, recorded in part, Continuous feeding is the uninterrupted administration of enteral formula over extended periods of time. Ensure the administration of enteral nutrition is consistent with and follows the practitioner's orders. Document pertinent information such as date and time the procedure was performed. Manufacture recommendations for Isosource 1.5 calories oral liquid nutrition recorded for tube feeding, once opened, the enteral product should be consumed within 24 hours. Resident #246 was admitted to the facility on [DATE]. Diagnoses included dysphagia, gastrostomy status, traumatic subdural hemorrhage with loss of consciousness, cerebral infarction, transient ischemic attack, displaced fracture of second cervical vertebra and dementia, among others. A nurse admission assessment dated [DATE] recorded on admission, Resident #246 was alert and oriented to herself only, and her speech was jumbled. She was assessed with a PEG (percutaneous endoscopic gastrostomy) tube with an abdominal binder (waist belt used to secure enteral feeding tubes) in place. A physician order dated 10/20/23 recorded may turn off PEG-tube for activities. A physician order dated 10/22/23, recorded give Isosource 1.5 calories oral liquid nutrition 45 ml (milliliters) per hour via PEG-tube every shift for nutrition replacement/tube feedings and a regular pureed diet by mouth with thickened liquids. An Admission Nutrition/Enteral Review dated 10/22/23 was completed by the Registered Dietitian (RD) Consultant. The RD documented that Resident #246 currently received a regular, pureed diet with thickened liquids in addition to the enteral nutrition. The RD documented Resident #246 had minimal oral intake noted with six recorded meals, eating 0-25% regarding a traumatic brain injury and dependent on staff for 100% of feeding/eating. The RD documented the addition of an enteral product for nutritional support to run continuously for 22 hours, and off for nursing care. The RD documented no intolerance to the enteral product noted. The RD recommended continued monitoring of oral intake, fluids, and enteral product for the need to increase/decrease the enteral order. A care plan revised 10/23/23 indicated Resident #246 had a PEG tube placed, dependent on PEG tube nutrition and required substantial, maximal staff assistance with eating. Dietary staff would also provide a regular, pureed textured diet with nectar thickened liquids as ordered that honored her preferences. A physician order dated 10/24/23 was clarified and recorded, regular diet, pureed texture, liquids nectar/mildly thick consistency. An admission Minimum Data Set assessment was in progress and incomplete. A review of nurse progress notes dated 10/23/23 and 10/24/23 revealed no documentation of problems with enteral product intolerance or that the enteral product was held. Resident #246 was observed on 10/23/23 at 3:00 PM in a low bed, head of bed elevated and with a cervical collar for neck support. Isosource 1.5 enteral product infused at 45 ml per hour via intravenous (IV) pump with approximately 300 ml of enteral product in the dispensing the bag. The dispensing bag did not include a label with the date and time the enteral product was initially opened. Resident #246 was observed on 10/24/23 at 10:21 AM in her recliner, the head of the recliner was elevated, and she had on a cervical collar for neck support. Speech Therapy (ST) #1 was observed providing cognitive services. A 1000 ml prefilled dispensing bag of Isosource 1.5 enteral product hung from the IV pump, the label recorded 10/23/23, 6:00 PM. The IV pump was off, and approximately 1000 ml of enteral product remained. The tubing was hooked to the IV pump but was not connected to Resident #246. An observation of the same occurred on 10/24/23 at 10:28 AM. ST #1 was interviewed on 10/24/23 at 3:30 PM, she stated she provided ST for cognitive services to Resident #246 that morning around 10:00 AM until about 10:30 AM, she did not recall if the enteral product was infusing at the time, but that she did not request to suspend the enteral product for Resident #246 to provide ST services. Resident #246 was observed again on 10/24/23 at 1:09 PM in her recliner, the head of the recliner was elevated, and she had a cervical collar on for neck support. She was alone in her room and not engaged in any activity or nursing care. A 1000 ml bag of Isosource 1.5 enteral product hung from the IV pump, the label recorded 10/23/23, 6:00 PM. The pump was off, approximately 1000 ml of enteral product remained, and the enteral product had a thickened appearance. The tubing was hooked on the IV pump but was not connected to Resident #246. An observation of the same occurred on 10/24/23 at 1:30 PM and 1:45 PM. The October 2023 Medication Administration Record (MAR) for Resident #246 recorded the initials of Nurse #3 on day shift for 10/23/23 and Nurse #4 on day shift for 10/24/23 for the physician order to provide Isosource 1.5 calories at 45 ml per hour continuous oral nutritional supplement. An interview with Nurse #1 occurred on 10/24/23 at 1:35 PM. Nurse #1 stated she was the hall nurse; she came in at 1:00 PM to help because one of the nurses had to leave. Nurse #1 reviewed physician orders and stated Resident #246 had an order for a continuous enteral product, but that the feeding could be turned off for activities, like nursing care or if she came out of her room to attend an activity and to resume the feeding once the activity was over. Resident #246 was observed in her room with Nurse #1, Nurse #2, and Nurse #3 on 10/24/23 at 1:45 PM. Resident #246 was in a recliner, the IV pump was off, the enteral product was hung and labeled 10/23/23 6:00 PM, approximately 1000 ml of product remained and had a thickened appearance. Nurse #1 removed the bag of enteral product and discarded it. Nurse #1 stated she discarded the enteral product because the product was thickened and there was sediment in the bottom of the bag which could increase the risk of clogging the tube. Nurse #1 confirmed that Resident #246 should have enteral product infusing continuously. Nurse #2 was interviewed on 10/25/23 at 10:10 AM. Nurse #2 stated the COTA (certified occupational therapy assistant) asked her to disconnect the enteral product for Resident #246 on the morning of 10/24/23 before the COTA assisted the Resident with morning care. Nurse #2 stated she did not recall the time. Nurse #2 stated she was not the assigned nurse, but she came in, the enteral product was attached to the PEG site and infusing, so she disconnected the tubing from the Resident, and after therapy finished, she came back and connected the tubing back to the resident and turned the IV pump on, but she did not recall the time. Nurse #2 stated when she returned to the room that same day (10/24/23) around 1:30 pm, the tubing was not connected to the Resident, and she was not sure who disconnected it. An interview with COTA #1 occurred on 10/25/23 at 9:37 AM. The COTA stated that on 10/23/23 sometime before breakfast, about 8:00 or 8:30 AM Nurse #2 came in and turned the enteral product off for Resident #246 so that therapy could work with her. The COTA stated that she provided occupational therapy (OT) services to Resident #246, assisted her with hygiene, dressing and a transfer via a mechanical lift from the bed to the recliner. The COTA stated Resident #246 was not connected to the IV pump and her enteral product was not infusing at the time. The COTA stated Nurse Aide (NA) #2 came in to feed her breakfast when the COTA completed services and the COTA reported to Nurse #2 that she had finished working with Resident #246. An interview with NA #2 on 10/24/23 at 3:17 PM revealed she came to work at 8:00 AM that morning (10/24/23) and when she arrived, Resident #246 was already up and dressed. NA #2 stated Resident #246 received OT services which included morning care, a bed bath, and dressed her. NA #2 stated she fed Resident #246 breakfast, after 8:30 AM, and described that the Resident ate a few bites of her grits and drank some of her fluids, she ate less than 25% and received a pureed breakfast with thickened beverages. NA #2 stated Nurse #4 turned her pump off that morning to give her medication and it remained off while NA #2 fed her breakfast. NA #2 stated she reported to Nurse #4 when she finished feeding Resident #246 her breakfast. NA #2 stated she checked on Resident #246 throughout the morning and stated, I do not recall seeing her tube feeding going the times I checked her, and I checked her several times. NA #2 stated Resident #246 was in her recliner until NA #2 came to lie her down around 1:00 PM and when NA #2 arrived to lie her down, the tube feeding was not on. Nurse #4 stated in a phone interview on 10/24/23 at 3:04 PM that she came on shift at 7:00 AM and worked 4 hours. She received shift to shift report that Resident #246 had no problems on the previous shift. Nurse #4 stated she medicated Resident #246 that morning and provided a water flush that was due at 8:00 AM. Nurse #4 stated I think the tube feeding was infusing, but I am not 100% certain, if it was infusing, I would have turned it off and disconnected the tubing before I did the flush. Nurse #4 stated she did not recall how much enteral product remained in the bag that was hanging, but she documented her initials on the MAR for day shift that day (10/24/23) and when asked if the enteral product was infusing, Nurse #4 stated, I thought it was. Nurse #4 stated that Nurse #3 medicated Resident #246 later that morning and Nurse #4 saw Resident #246 again when she repositioned her in her recliner as she described right before lunch. Nurse #4 stated she was not asked to turn the enteral product off that morning for staff to give her care. Nurse #4 stated Resident #246 did not have concerns with product intolerance or residuals that morning (10/24/23). Nurse #3 was interviewed during an observation of Resident #246 on 10/24/23 at 1:50 PM. Nurse #3 stated she was one of the assigned nurses for Resident #246 that morning and last saw the Resident around 10:25 AM, when she medicated her. Nurse #3 confirmed that at the time of the interview, the enteral product was not infusing, the pump was turned off and the tubing was not connected to the Resident. Nurse #3 stated I did not turn it off, she stated that she completed a flush and medicated Resident #246 via the PEG tube at 10:25 AM, but that I did not mess with the tube feeding, I did not turn it on or off, I assumed it was infusing by the nurse who had her at 7:00 AM, I think I would have noticed if it was not infusing. Nurse #3 stated I just went in and medicated her at 10:25 AM and did the flush at the same time, speech therapy was in the room working with her. Nurse #3 was asked if she recalled if she turned the enteral product off to medicate and give a water flush, she stated I have been passing meds all day, sorry I just don't remember, I just know I did not mess with her tube feeding pump. Nurse #3 stated Resident #246 did not have any problems with enteral product intolerance or residuals on 10/24/23 and assumed her enteral product was infusing. She stated that she recorded her initials on the MAR on the 7AM - 3PM shift on 10/23/23 but could not recall if she initiated the enteral product that day or if it was already dispensing when she arrived on shift. She stated her practice was to label the enteral product dispensing bag with the date and time she initiated the product. NA #1 was interviewed on 10/24/23 at 2:08 PM and stated she fed Resident #246 her lunch meal that day after 12:30 PM and Resident #246 ate about 25% of her pureed meal, ate 50% of her pudding and drank all the thickened tea. NA #1 stated I don't recall seeing her tube feeding connected or her pump on, I would not turn it off, I would ask the nurse to do that, but I did not ask the nurse to turn the pump off when I fed her lunch. An interview with the Director of Nursing (DON) on 10/24/23 at 3:30 PM revealed, Resident #246 had a physician order to receive Isosource 1.5 at 45 ml per hour, continuous, for nutritional support. The DON stated her nutritional support could not be maintained with her pureed diet due to a neck fracture which made eating too painful for her to meet her nutritional needs. The DON stated her enteral product should be provided continuously, and because the Resident ate less than 25% of her meals, the pump did not have to be turned off during meals. The DON stated the order for continuous feeding should be followed and enteral feedings should be provided per facility policy unless Resident #246 displayed signs/symptoms of intolerance and then the Nurse would need to notify the Physician to obtain an order to hold the enteral product. The DON stated once an enteral product was dispensed, the dispensing bag should record the date/time to ensure the product did not infuse for more than 24 hours. A phone interview with the Registered Dietitian (RD) Consultant occurred on 10/24/23 at 4:52 PM. The RD stated she consulted at the facility monthly and reviewed all high-risk residents which included residents who received enteral products. The RD stated she assessed product tolerance, weight fluctuations, and that she typically calculated calorie needs based on 22 hours for residents with a physician order for a continuous product to allow time for the product to be turned off for care or activities. The RD stated Resident #246 had a physician order for a continuous enteral product. The RD further stated, In a perfect world if Resident #246 tolerates the product as ordered that's what we would expect, but since I don't know if there were concerns with residuals or intolerance, I think the nurse would hold the product if there were any concerns with intolerance, otherwise we expect the product to be provided as ordered, but I am not there so I don't know what occurred with this resident. The Physician was interviewed on 10/26/23 at 2:20 PM and stated Resident #246 received nocturnal enteral feedings in the hospital, but he was concerned that this would not meet her nutritional needs, so he changed the order to continuous feedings with meals to supplement her intake. The Physician stated that he did not know the circumstances surrounding Resident #246 and her enteral product on 10/24/23, but if the enteral product was held, he would expect the Nurses to get a clarification order to hold the enteral product and not make that decision on their own. The Physician stated that the order was for continuous enteral feeding and the order and facility policy should be followed to meet her nutritional needs.

Based on record reviews, observations, and staff interviews, the facility failed to discard expired insulin injection pens in 1 of 3 medication rooms (Medication room on A/B Hall) and in 1 of 5 medication carts (the secured unit medication cart) and monitor the temperature daily in 1 of 3 medication refrigerators (the C/D Hall medication refrigerator). The findings included: 1. A. The medication room on the A/B side of the facility was observed on [DATE] at 9:21 AM with Nurse #9. A basket with insulin pens was noted to be in the medication room and Nurse #9 explained that she was going to take the insulin pens with her to the medication cart to administer insulin. Two insulin pens were noted with an open date of [DATE] and a discard date of [DATE]. Nurse #9 admitted she had not noticed the expiration dates on either insulin pen. B. The medication cart on the secured unit was observed on [DATE] at 12:05 PM. An insulin pen with an open date of [DATE] and a discard date of [DATE] was noted on the medication cart. Nurse #8 was interviewed at the time of the observation. Nurse #8 reported she had not noticed the discard date on the insulin, and she felt it was human error it was not discarded. The DON was interviewed on [DATE] at 3:23 PM and she expressed the insulin pens should have been discarded on the date written on the pens. 2. The medication refrigerator on the C/D hall was observed on [DATE] at 10:45 AM. No temperature had been recorded on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Inside the refrigerator were multiple medications, including vaccines and intravenous antibiotics. The Unit Manager was interviewed at the time of the observation, and she reported that the night shift (11:00 PM to 7:00 AM) was responsible for checking the medication refrigerator temperature every night. The UM explained an agency nurse worked on those dates, and she may not have been aware to check and document the medication refrigerator temperature. The DON was interviewed on [DATE] at 3:23 PM and she reported the medication refrigerator should have the temperature checked and documented each day.

Based on record reviews, and staff interviews, the facility failed to accurately document changing an indwelling suprapubic urinary catheter for 1 of 3 residents reviewed for urinary catheter documentation (Resident #82). The findings included: Resident #82 was readmitted to the facility on [DATE] with obstructive and reflux uropathy and retention of urine. A physician order dated 7/10/2023 specified the suprapubic indwelling urinary catheter was to be changed during the day shift on the 1st of the month starting 8/1/2023. The significant change Minimum Data Set assessment dated [DATE] assessed Resident #82 to have an indwelling urinary catheter. A review of the Treatment Administration Record (TAR) for August 2023 revealed that Resident #82's indwelling suprapubic catheter was changed on 8/1/2023 by evidence of the nurse initials. A review of the TAR for September 2023 revealed on 9/1/2023 the indwelling suprapubic catheter was changed for Resident #82 by evidence of the nurse's initials. A review of the TAR for October 2023 revealed no documentation for the changing of the indwelling suprapubic catheter. No nursing note documented the indwelling suprapubic urinary catheter had been changed. Nurse #6 was interviewed by phone on 10/25/2023 at 12:52 PM. Nurse #6 reported she worked on 10/1/2023 and she did change Resident #82's indwelling urinary catheter. Nurse #6 reported she used the same size catheter that Resident #82 had previously inserted, but she was not able to recall the size of catheter or the balloon size. Nurse #6 reported the suprapubic catheter supplies had been gathered for her and she used the package with Resident #82's name on it. Nurse #6 didn't know who gathered the supplies and was not certain why she had not documented the catheter change and reported, it's usually busy on the weekend, it might have slipped my mind. The Director of Nursing (DON) was interviewed on 10/26/2023 at 3:20 PM. The DON reported catheter changes should have been documented in the TAR.

Based on record review and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place following the 3/30/2022 recertification and complaint investigation survey. The deficiency was in the area of label and store drugs and biologicals (F761). The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: The tag is cross referenced to: F761-Based on record reviews, observations, and staff interviews, the facility failed to discard expired insulin injection pens in 1 of 3 medication rooms (Medication room on A/B Hall) and in 1 of 5 medication carts (the secured unit medication cart) and monitor the temperature daily in 1 of 3 medication refrigerators (the C/D Hall medication refrigerator). During the recertification and complaint investigation survey conducted 3/30/2023 the facility was cited for failing to discard expired medications from three medication carts and one storage room. On 10/26/2023 at 2:49 pm an interview was conducted with the Administrator, and he stated the facility's Quality Assurance and Performance Improvement (QAPI) meeting is held monthly and quarterly. He stated the department managers (Director of Nursing, Unit Manager, Staff Development Coordinator, Infection Control Nurse, Maintenance Director, Environmental Services Manager, and Dietary Manager) are present at the monthly QAPI meetings and the at the quarterly QAPI meetings, and the physician and pharmacist attends the quarterly meetings. The Administrator stated the facility strived to improve in all areas, but they should have improved in the area of drug labeling and storage which was identified in the previous survey.

Based on observations, staff interviews and record review, the facility failed to discard expired medications for 3 of 3 medication carts (B hall, A hall, and C hall) and 1 of 3 medication storage rooms (C/D Medication room). Findings included: 1a. An observation on 3/29/22 at 11:58am of the medication cart on the B hall revealed one jar of [MEDICATION(S)] prescribed to Resident # 20 with an expiration date of 2/27/22. Further observation revealed Cetirizine HCL 10 mg (milligram)(antihistamine) prescribed to Resident # 15 with an expiration date of 7/21/21 and [MEDICATION(S)] HCL (antiviral) one-gram tablets with an expiration date of 7/20/21. A continued observation revealed [MEDICATION(S)] HCL (antiemetic) 4mg prescribed to Resident # 70 with an expiration date of 1/23/22. Further observation revealed [MEDICATION(S)] HCL (antiemetic) 4mg prescribed to Resident # 41 with an expiration date of 1/22/22. An interview with the Medication Tech #1 on 3/29/22 at 12:05pm revealed that the nurses check the medication cart for expired medications. She further revealed that she usually checked the daytime medications. She stated that it was each nurse's responsibility to check the medication carts and discard expired medications. She further revealed that the antiemetic medication was only given prn (as needed) and was not used often. 1b. An observation on 3/29/22 at 12:39pm of the medication cart on the A hall revealed [MEDICATION(S)] HCL (antiemetic) 4mg prescribed to Resident # 94 with an expiration date of 2/16/22. An interview with the Nurse #1 on 3/29/22 at 12:39pm revealed the expired medication should have been taken from the medication cart and sent back to the pharmacy. She further revealed she would remove the expired medication at this time. Nurse # 1 stated the antiemetic was prn and the nurses should have removed it from the medication cart. 1c. An observation on 3/29/22 at 1:52pm of the medication cart on C hall revealed [MEDICATION(S)] (antibiotic) 250 mg prescribed to Resident # 13 with an expiration date of 2/7/22. An interview with the Medication Tech #2 on 3/29/22 at 1:52pm revealed every nurse assigned to the hall was responsible for checking the medication cart for expired medications. She further revealed the expired medications should have been sent back to the pharmacy. 1d. An observation on 3/29/22 at 2:12pm of the C/D medication storage room refrigerator revealed one vial of [MEDICATION(S)] (referred to as a clot busting drug) in the refrigerator as a stock medication with an expiration date of 12/21. An interview with Nurse #2 revealed the expired medication should have been taken out of the refrigerator and sent back to the pharmacy. She further revealed nurses should have checked the refrigerator and pulled it out to be send back to the pharmacy. An interview with the Administrator on 3/30/22 at 3:36pm revealed that the night shift nurses were responsible for checking the medication carts and storage rooms for expired medications. He further revealed that the pharmacy also checked the medication carts monthly. An interview with the Director of Nursing (DON) on 3/29/22 at 3:42pm revealed that expired medications should be remove from the cart and sent back to the pharmacy. She further revealed the cart should be audited at least one time weekly for expired medications by the night shift nurse. She stated the night shift nurses should have pulled the expired medications off and sent them back to the pharmacy.

Based on record reviews, staff, and pharmacist interviews, the facility failed to act on recommendations made by the consultant pharmacist and retain documentation of the provider's review and response to the pharmacist's findings/recommendations in the resident's medical record for 1 of 2 residents reviewed for antibiotic use (Resident #90). The findings included: Resident #90 was admitted to the facility on [DATE]. Her cumulative diagnoses included [CONDITION(S)], obstructive and reflux [CONDITION(S)], encounter for fitting and adjustment of urinary device. Resident #10 had a physician's order dated 11/26/21 for 100 milligram (mg) [MEDICATION(S)] (an antibiotic) to be given orally each morning for prophylaxis. Further review revealed a physician's order dated 11/26/21 for [MEDICATION(S)] 2% ointment (a topical antibiotic) to be applied topically to back of both legs each morning for a diagnosis of skin ulcer. A review of a copy of Resident #90's Note To Attending Physician/Prescriber dated 1/6/22, which was provided by Pharmacist #1, revealed two recommendations. The first was, In light of antibiotic stewardship efforts, please evaluate continued need for antibiotic prophylaxis with [MEDICATION(S)] 100 mg QD and comment for clinical record. The second was, Does she need to continue long term use of antibiotic ointment, [MEDICATION(S)] ointment, QAM (every morning) to the back of both legs or should a stop date be added? The provided note was not signed off as having been reviewed by the resident's physician. Review of Resident #90's EMR revealed the pharmacist's January 2022 Note To Attending Physician/Prescriber was not included in the resident's medical record. Additionally, there was no documentation in Resident #10's medical record to indicate the consultant pharmacist's findings/recommendations were reviewed or a response was received from the provider with regards to the January pharmacist's Consultation Report. Review of Resident #90's March Medication Administration Record (MAR) for the period of 3/1/22 through 3/29/22 revealed [MEDICATION(S)] 100 mg and to have been signed off as administered each of the 29 days reviewed. Further review revealed [MEDICATION(S)] 2% ointment was administered from 3/1/22 through 3/23/22. The medication was documented as discontinued on 3/24/22. Resident #90's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The medication section of her assessment indicated Resident #90 received an antidepressant and an antibiotic each day of the 7-day look back period. The resident was not coded as having had a Urinary Tract Infection ([CONDITION(S)]) in the past 30 days. The Resident #90's electronic medical record (EMR) revealed a Note To Attending Physician/Prescriber dated 3/4/22 had three recommendations. The first was, In light of antibiotic stewardship efforts, please evaluate continued need for antibiotic prophylaxis with [MEDICATION(S)] 100 mg QD and comment for clinical record. The resident's physician/prescriber's response was the resident's urologist had put the resident on the medication and to not make any changes because the medication was for urinary tract infection ([CONDITION(S)]) prophylaxis. The second was, Does she need to continue long term use of antibiotic ointment, [MEDICATION(S)] ointment, QAM (every morning) to the back of both legs or should a stop date be added? The resident's physician/prescriber's response was to discontinue the medication. The third recommendation was, please consider checking her CBC (Complete Blood Count) to monitor [MEDICATION(S)]. Last CBC was from September 2021. The physician/prescriber had circled CBC. The physician/prescriber's response was to check the CBC and to discontinue the [MEDICATION(S)] ointment. The physician/prescriber signed the note with a date of 3/17/22. During a phone interview conducted on 3/30/22 at 9:42 AM with the pharmacist she stated she had made recommendations regarding [MEDICATION(S)] and [MEDICATION(S)] in January for Resident #90, but she did not receive a response about her recommendations. She further stated she made recommendations regarding the same two medications in March because she had not received a response and when she reviewed the resident's medical record, she saw both of the medications remained on the residents medical record with no changes to their use or dosage. She stated because of the lack of response, and there having been no changes to the medications, she repeated the recommendations in a March recommendation, or Note To Attending Physician/Prescriber. She said she sends all of the recommendations, after her monthly consultation visit to the facility, to the Director of Nursing (DON) and the Administrator. She said the DON then would distribute the recommendations to unit managers, who would provide them to the residents' physician. She explained she expected for the recommendations to be delivered and reviewed by the residents' physician and then for the recommendation to be placed into the resident's medical record. An interview was conducted with the DON on 3/30/22 at 2:10 PM. The DON stated she received the pharmacist's recommendations and then distributes them to the Unit Managers. She explained the Unit Managers would then address the recommendations with the residents' physicians, the physician would write on the form what they wish, the physician would initial the form, and the form would be returned to the UM. The UM would then address the physician's recommendation(s), the form would be scanned, and the scanned form would become part of the resident's medical record. She said she was not aware of any concerns regarding pharmacy recommendation forms having not been followed up on. She further stated the physicians have 10 days to complete the recommendation forms, and if they did not receive a response regarding the recommendations on the forms, she would follow up on the forms. The DON stated she was unable to find the pharmacist's recommendations regarding Resident #90 from January 2022. The Administrator stated during an interview conducted on 3/30/22 at 3:07 PM he did not have the January pharmacist recommendations for Resident #90. He further stated it was important for the pharmacist's recommendations to be delivered and reviewed by the residents' physicians and it was his expectation for that process to be conducted for each of the pharmacist's recommendations.

Based on record review, observations, and staff interviews the facility failed to assess 1 of 1 resident, Resident #88, for the ability to self-administer medications safely. Findings included: Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#88 may apply an antifungal powder to her abdominal fold topically 2 times a day and she may apply Icy Hot Smart Relief, a topical pain reliever, as needed and keep it at her bedside. A review of Resident #88's Care Plan revealed a Memory and Communication Care Plan updated on 7/11/19 that stated she had a short attention span and may be unable to make good decisions for herself and her health. The most recent Annual Minimum Data Set assessment dated [DATE] revealed Resident #88 was cognitively intact and required limited assistance with bed mobility and transfers. During an interview with Resident #88 on 7/29/19 at 10:31 am she stated she had a rash to her left axillary and under her breasts. She stated she had a powder she applied to the area herself. She indicated she kept the medication in her night stand. A Self Administration of Medication assessment dated [DATE] revealed Resident #88 was able to self-administer the antifungal powder that was ordered on [DATE]. There was not a Self Administration of Medication Assessment completed before 7/31/19. During an interview with the Director of Nursing on 7/31/19 at 9:45 am she stated Resident #88 treated her rash herself and kept the medication in her room. During an interview with the Nurse Practitioner on 8/1/19 at 9:15 am she stated that Resident #88 was given an order to apply antifungal powder to her abdominal fold as needed and she was safe to apply her own medications. The Nurse Practitioner also stated she was not aware Resident #88 had a rash to her left axillary area or under her breast or that Resident #88 was using the antifungal powder for those areas. During an observation and interview with Resident #88 on 8/1/19 at 10:41 am she stated the rash on her left underarm and under her breasts had healed. An interview with the Unit Manager #1 on 8/1/19 at 12:23 pm revealed Resident #88 had an order to self-administer a powder and cream at her own discretion until yesterday, 7/31/19. She stated the orders were discontinued on 7/31/19. A follow up interview with the Unit Manager on 8/1/19 at 12:23 pm revealed Resident #88 had a Self-Administration of Medication Assessment completed on 7/31/19 but did not have the assessment completed when the order was received for Resident #88 to self-administer her own medications. The Director of Nursing was interviewed on 8/1/19 at 3:54 pm and stated she expected the Medication Administration Assessment to be completed prior to a resident receiving a self-administer medication. She stated the resident should be assessed to ensure they are competent to administer the medication. An interview with the Administrator on 8/1/19 at 4:42 pm revealed his expectation of staff would include an assessment of the resident before giving them a medication to self-administer. He indicated he expected the staff to ensure the safety of the residents when allowing them to administer their own medications.

Based on record review, resident, family member and staff interviews, the facility failed to honor a resident ' s sleeping schedule for 1 of 1 resident reviewed for choices (Resident #64). Findings included: Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #64 to be without physical or verbal behaviors and no rejection of care, and he required extensive 2-person assistance with bed mobility, transfers and toileting. The admission MDS dated [DATE] assessed him to be frequently incontinent of urine and always incontinent of bowels and having moderate cognitive impairment. Resident #64 was interviewed on 7/30/2019 at 8:27 AM. Resident #64 reported he had told the nursing staff prior to 7/20/2019 he did not want to be disturbed from 10:30 PM until 6:30 AM to prevent interrupting his sleep. Resident #64 reported he was not certain who he told, but he and his family member had expressed his choice to the nursing staff on two different occasions. Resident #64 stated on 7/20/2019 at approximately 1:00 AM, Nurse #3 and nursing assistant (NA) #3 woke him up to provide incontinence care and he told them to leave him alone. Resident #64 explained that Nurse #3 told him his wet incontinence brief needed to be changed and proceeded to change the brief with the assistance of NA #3. Resident #64 reported the incident made him feel angry that his sleep was interrupted. Resident #64 ' s family member (FM)#1 was interviewed on 7/30/2019 at 4:41 PM. FM #1 reported prior to 7/20/2019 she had made requests to two floor nurses not to disturb Resident #64 ' s sleep during the night from 10:30 PM until 6:30 AM for incontinence care. Nurse #3 was interviewed on 7/31/2019 at 5:40 AM and she reported she had performed incontinence care on Resident #64 at 1:00 AM on 7/20/2019 because he was saturated with urine and she was concerned about the condition of his skin. Nurse #3 reported that she was aware that Resident #64 did not want his sleep to be disturbed at night prior to 7/20/19. Nurse #3 went on to describe Resident #64 had reddened perineal skin and she was worried if he laid in a urine saturated incontinence brief, the skin would breakdown and he would develop a wound. Nurse #3 further reported Resident #64 had intermittent confusion. NA #3 was interviewed on 7/31/2019 at 2:42 PM and he reported he had assisted Nurse #3 with incontinence care for Resident #64 on 7/20/2019. NA #3 reported he had written instructions given by Nurse #3 to check Resident #64 for incontinence at 1:00 AM, 3:00 AM and 5:00 AM. NA #3 reported he had checked on Resident #64 at 1:00 AM on 7/20/2019 and Resident #64 refused incontinence care, so NA #3 reported to Nurse #3 the refusal. NA #3 explained he had assisted Nurse #3 to change Resident #64 ' s wet incontinence brief by retrieving a clean and dry pad, as well as a clean brief. The Director of Nursing (DON) was interviewed on 8/1/2019 at 4:25 PM and she reported Nurse #3 was concerned about the condition of Resident #64 ' s skin and had instructed NA #3 to check on him for incontinence to prevent skin breakdown related to exposure to urine. The DON went on to explain both Nurse #3 and NA #3 had received 1:1 instruction and training regarding resident choice and to document the refusal of care, and communicate that refusal to the facility staff, physician and family. The DON concluded by reporting a resident had the right to refuse care, the facility staff should respect and honor their refusal. The Administrator was interviewed on 8/1/2019 at 4:56 PM and he reported that Nurse #3 ' s intentions were to prevent skin breakdown for Resident #64. The Administrator reported the facility had performed 100% education of all staff regarding resident ' s right to refuse care and choices but did not have a procedure in place to monitor the results of the training. The Administrator went on to explain it was his expectation that all residents had the right to choose their care and the right to refuse care, even if that refusal was not in the resident ' s best interest and the Administrator expected staff to honor the choices of the residents.

Based on observation, record review, and staff interviews the facility failed to assist 1 of 4 residents (Resident #13) with nail care and 1 of 4 residents (Resident #62) with feeding assistance, for resident's dependent for care with activities of daily living. Findings included: 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 required extensive assistance with bathing. The assessment further revealed Resident was moderately cognitively impaired. During an observation on 7/29/19 at 9:55 am Resident #13's fingernails were ¼ inch long and there was dark brown material under his nails. Resident #13 had a splint on his left hand. An observation of Resident #13 on 8/1/19 at 9:50 pm revealed he had a splint to his left hand and his fingernails were 1/4-inch-long and there was dark brown material under his nails. During an interview with Nurse Aide #1 on 8/1/19 at 11:30 am she stated the Nurses trimmed the resident's nails. She stated when she puts the splint on Resident #13 and takes it off, he will pull his hand away from you, but he is not combative. An interview and observation on 8/1/19 at 2:58 pm with Nurse #1 revealed the Nurses addressed the resident's nails during the skin assessment done every week and as needed. She stated the Nurse either trim the resident's nails or they can assign it to a Nurse Aide. Nurse #1 stated everyone should be assessing Resident #13's nails due to the splint he had on his left hand. Resident #13's nails were observed with Nurse #1 and she stated the nails were ¼ inch long and needed to be cleaned. Nurse #1 held Resident #13's left hand and inspected his nails and he did not pull away from her. During an interview with the Director of Nursing on 8/1/19 at 3:56 pm she stated the resident's nails should be trimmed during the skin check that are completed weekly and as needed. She also stated Resident #13's left hand should be assessed frequently due to the splint he wears daily. On 8/1/19 at 4:40 pm the Administrator stated all resident's nails should be clean and a safe length. 2. Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 6/28/19 stated Resident #62 was at risk for choking due to chewing difficulties and required set up and assistance with meals. The most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was severely cognitively impaired and required extensive assistance with eating. On 7/30/19 at 8:03 AM Resident #62 was observed sitting up in bed with her breakfast tray on the table over her bed. Resident #62 was not able to bring food to her mouth and attempted multiple times. She stated she was not able to eat her breakfast. Resident #62 was observed attempting without success to bring a cup with a straw to her mouth. An interview with the family member on 7/30/19 at 8:35 AM revealed Resident #62 required assistance with meals. During an interview with Nurse Aide (NA) #2 on 8/1/19 at 12:06 PM, she stated Resident #62 needed to be assisted with feeding. NA #2 stated the staff knew who needed to be assisted with meals because it was on the electronic Kardex in the computer. On 8/1/19 at 12:10 PM an interview with Nurse #2 revealed Resident #62 required assistance with meals and should not be allowed to eat without assistance. Nurse #2 stated Resident #62 was identified by nursing to require assistance with meals and could not be left alone during meals. Nurse #2 stated Resident #62's tray should not be set up and left without staff being with her. Nurse #2 provided a list of residents that required assistance with meals that included Resident #62. The Director of Nursing (DON) stated, during an interview on 8/1/19 at 3:58 pm, that nurse staff made the determination if a resident should be fed. The DON stated Resident #62 should have been assisted with breakfast on 7/30/19 since she was on the facility list of residents to be assisted with meal. The DON stated the tray should not have been left without nursing supervision. The DON stated she did not know why Resident #62's tray was set up on 7/30/19 by staff when she should have been assisted with her all meals. She stated all residents on the list for assistance with meals should be assisted. During an interview with the administrator on 8/1/19 at 4:45 pm he stated all residents that were listed as needing assistance with feeding should have someone with them at all meals. The Administrator stated expected the staff to assist residents that needed assistance with meals.

Based on staff interview and record review the facility failed to assess and identify fall risk factors after a fall incident and failed to implement interventions to reduce fall risk based on this information for 1 (Resident #70) of 3 residents with falls in the facility. The findings included: Resident # 70 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #70 also had a right partial hip replacement in April 2013. The Care Plan dated 6/14/13 had the following problem statement regarding falls " I have a history of falls with injury and the potential for falls manifested by history of falls, impaired sense of balance, poor leg control and unsteady gait dizziness. " The goal was no injury due to falls for 3 months and the interventions included observe, record and report all unsafe situations and conditions, postural dizziness (dizziness on standing often related to a drop in blood pressure upon standing), encourage to ask for assistance, monitor closely, assess change in level of consciousness, instruct on safety, call light on reach, assist with ambulating and toileting, do not leave unattended while toileting, bed in locked position. On 9/17/13 the Nursing Notes revealed that at 5 PM a new order for Ativan (lorazepam) 0.5 mg (milligrams) every 6 hours as needed for anxiety was obtained (ativan is an anti-anxiety medication with adverse effects that can include dizziness, unsteadiness and delirium). The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 70 was moderately cognitively impaired and required extensive assistance of two people for transfers and was only able to be steady while standing or transferring with human assistance. It also indicated he had no impairment of his upper or lower extremities. The MDS also indicated Resident #70 had no falls since admission. Review of the electronic medical record dated 9/30/13 at 5:44 PM revealed documentation of a fall incident. According to the notes Resident #70 was observed on the floor at 5 PM and he was confused. Under the heading ' Contributing Factors ' the note stated " sat down Resident started sliding out of chair and stated he just slid out of chair onto floor. " The location of the incident was the resident ' s room and the activity at the time of the incident was " unknown. " There were no witnesses or staff involved indicated in the note. The following vital signs were documented pulse (P) 100, respirations (R) 24, temperature (T) 98.4 and blood pressure (BP)106/40; whether this was a standing or sitting blood pressure was not indicated. Blood glucose was not indicated. Under " Neuro (Neurological) Checks " the note said " Pupils equal and reactive to light, (immediately after). Bilateral hand grip firm. " There was no apparent injury and the teaching done was " instructed resident on use of call light " . The immediate actions taken were " Resident assisted back to reclining chair. Resident reclined with feet up. " Nurse #1, who worked with Resident #70 on the evening of 9/30/13 when he had a fall incident (slipped from his recliner chair), was interviewed on 11/15/13 at 3:30 PM and stated that she vaguely, remembered Resident #70 sliding out of his chair on 9/30/13. When asked about the position of the recliner chair he slid out of she stated she did not remember and she did not remember what footwear he was wearing at the time, but believed he always wore gripper socks. She stated that she recalled him having bed and chair alarms and a personal alarm. She did not recall if she heard an alarm ringing when he slipped off the recliner chair or if she was the staff member who initially found the resident sitting on the floor. Nurse #1 did not know what the resident had been trying to do as he slipped to the floor, how long he had been in the chair or who helped him to the chair or if he got in the chair himself. She did say that the resident ' s call bell had been in his recliner within reach but that he would forget to use it. She acknowledged that her documentation did not include any of the details she was being asked about and she had not asked any of the Nursing Assistants for information about what the resident had been doing, or what care had been provided and when. She said that she had also not been asked for more information by anyone who attended the weekly Interdisciplinary Team meeting. Nurse #1 added that the falls were also reviewed in the weekly Interdisciplinary Team meeting and new interventions were sometimes added at that time. On 10/7/13 at 11:09 AM, Nurse #2 discontinued the falls Care Plan problem statement, goals and interventions in the electronic medical record. The same problem statement, goal, and interventions for Resident #70 ' s fall risk that had been originally written on 6/14/13, were then reinstated in the electronic medical record by Nurse #2, on 10/7/13 at 11:09 AM, with a new 3 month review date. There were no changes to the care plan when it was reinstated. Review of the Supportive Devices orders dated 10/7/13 at 12:04 PM revealed " Resident does not have floor mat. Still has low bed and side rails for mobility. " On 10/8/13 at 2:51 PM ativan (lorazepam) was documented in the Nursing Note as being given for agitation. On 10/8/13 at 3:04 PM the Nursing Note revealed Resident #70 pulled out his indwelling urinary catheter and he was then transferred to the emergency room by EMS (Emergency Medical Services) for treatment and evaluation. A Readmission Note dated 10/8/13 revealed Resident #70 returned to the facility at 6 PM with a new urinary catheter inserted. Review of the Plan of Care Note dated 10/8/13 at 4:31 PM, indicated the Interdisciplinary Team met to discuss Resident #70 ' s plan of care and that they discussed that he had " No falls " . This was the first Plan of Care meeting note following the residents first fall in the facility on 9/30/13. Review of the electronic medical record dated 10/8/13 revealed documentation of a second fall incident. According to the notes Resident #70 was observed on the floor at 7:30 PM and he was confused. Under the heading ' Contributing Factors ' the note stated " history of falls did not call for staff assist Resident did not use call bell. " The location of the incident was the resident ' s room and the activity at the time of the incident was " unknown. " There were no witnesses or staff involved indicated in the note. The following vital sign was documented BP 130/70. Under the heading " Injury " the note said " Right leg appears to be broken. EMS (Emergency Medical Services) called immediately. Resident not moved until EMS arrived. " Another Nursing Note dated 10/8/13 at 10:34 PM indicated that at 7:30 PM Resident #70 was observed on the floor with right swollen leg and upper thigh and his right lower leg at a 90 degree angle. At 7:45 EMS arrived and stabilized the resident for transfer to the hospital and the family was notified. Nurse #1 also worked with Resident #70 on 10/8/13 when he had his second fall. During interview on 11/15/13 at 3:30 PM she stated Resident #70 returned to the facility after supper but they had kept his meal tray for him. Nurse #1 said that one of the Nursing Assistants brought Resident #70 ' s tray and she (Nurse #1) and the Nursing Assistant set Resident #70 up for supper. Nurse #1 said she went back to Resident #70 ' s room to check on him because he couldn ' t give very coherent answers when she had tried to ask him questions on his return from the hospital and did not seem like his normally pleasant self. She said the next time she went to check on him he was on the floor. She could not recall if an alarm was ringing at that time. Nursing Assistant #2 (NA #2) who worked with Resident #70 on 10/8/13 when he had his fall was interviewed 11/15/13 at 5:20 PM. She stated that the fall on 10/8/13 happened around supper time, but it was a late supper because they had to hold his tray for him. She also remembered family was in to visit before he fell but had already left. NA#2 said she was not the staff member who set up the resident ' s tray for dinner but that he had been set up to eat in his bed, which was where he usually ate. She said that he was sometimes confused or anxious but that on the evening of 10/8/13 he seemed more confused than usual and that she thought maybe it had something to do with his transfer to and from the hospital that day. NA #2 added that because the resident was eating dinner in bed the bed was not in the low position, since the over bed table would not reach low enough. She added that otherwise the bed was always low. NA#2 also said that Resident #70 usually had a floor mat on the floor but it was not on the floor at that time. NA#2 said Resident #70 usually wore protective booties on his feet but he did not have them on when she was called to his room and saw him on the floor and she didn ' t think he had socks on either. NA #2 also indicated that Resident #70 had an alarm on his bed and recliner but she did not recall if alarmed or not when he fell . The Hospital History and Physical dated 10/8/13 revealed " presents (with) mechanical fall from standing at SNF (Skilled Nursing Facility) just PTA (prior to arrival) with R (right) femur deformity. Per facility pt (patient) got OOB (out of bed) and tried to walk to bathroom, fell , and was found on floor. " The Problems list dated 10/9/13 revealed " Falls: Reported as mechanical by EMS, but also noted that he was found lying on the floor by SNF staff, which suggests it may have been un-witnessed. Possibly due to orthostatic hypotension (postural hypotension), afib with RVR ([DIAGNOSES REDACTED]with rapid ventricular response) or lorazepam (ativan). The Plan included " discontinue home lorazepam (ativan). " The Hospital Discharge Summary dated 11/1/13 revealed Resident #70 had a peri-prosthetic femoral shaft fracture (a break near the top of the femur which is the thigh bone and near or at the area of a previous hip replacement) and underwent open reduction with external fixation surgery (surgery requiring a surgical opening to repair a bone using plates and screws into the bone). Resident #70 was discharged from the hospital on [DATE] to another Skilled Nursing Facility. Interview with the Director of Nursing (DON) on 11/15/13 at 6 PM revealed that falls were discussed at the weekly TRECK meetings (Interdisciplinary Team meetings/Plan of Care meetings) and that the team focused on what could be done differently to prevent future falls. She added that they also looked at whether or not residents had started new medications. However, she did not indicate why there were no new interventions for Resident #70 after his fall on 9/30/13. The DON did state that new falls were discussed every morning in the weekly standup meeting. When asked how a resident ' s fall could be adequately investigated when so few details were documented she indicated that they did have more detailed data. Interview with the Minimum Data Set (MDS) Coordinator on 11/15/13 at 6:20 PM revealed that on 10/7/13, the day before Resident #70 fell and broke his leg, she and another staff member who was on leave at the time of the survey, did rounds in the facility to see who had supportive devices that could be discontinued. The MDS Coordinator stated that she recalled Resident #70 never had any bed or chair alarms because she did periodic rounds of supportive devices to ensure the Supportive Devices orders and Care Plans were consistent with what devices residents had and needed. She also pointed out that Resident #70 never had a Supportive Devices order for any bed or personal alarms although sometimes nurses initiated them as an intervention. The MDS Coordinator said that on 10/7/13 she and the other staff member (a Nursing Supervisor) discontinued the floor mat for Resident #70 as he hadn ' t gotten out of bed on his own and didn ' t seemed to want to because he had complaints of dizziness several months ago. She also stated that the fall on 9/30/13 was not a fall out of bed and was therefore unrelated to the floor mat. The MDS Coordinator indicated that the fall on 9/30/13 involved sliding out of a geri-chair. During this interview the MDS Coordinator indicated that the Plan of Care meeting documentation dated 10/8/13, which said Resident #70 had " No falls " , was what was discussed at the weekly TRECK (Interdisciplinary Team meeting) about Resident #70 following his fall on 9/30/13.