Every finding on record at Vanayer Senior Living and Rehabilitation

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 2 Nurses (Licensed Practical Nurse (LPN) A ) failed to perform hand hygiene during wound care for 1 of 2 sampled residents (Resident #2) were reviewed for wounds, and when 1 of 11 staff members (Certified Nursing Assistant (CNA) B) failed to wear gloves when handling food for 1 of 58 sampled residents (Resident #15) reviewed during dining. The findings include: 1. Review of the facility policy titled, Hand Hygiene, dated 1/2025, revealed .Hand hygiene is one of the most effective measures to prevent the spread of infection .Procedure .Use an alcohol-based hand rub .or soap and water for the following situations .Before handling clean or soiled dressings, gauze pads .After handling used dressings .After removing gloves . Review of the facility policy titled, General Food Handling, dated 11/2019, revealed .Food will be.served.with suitable implements to avoid manual contact of prepared foods. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Dementia, and Hypertension. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #2 was severely cognitively impaired. Resident #2 was assessed for 2 unstageable pressure ulcers (pressure ulcers whose wound bed is not visible due to slough or eschar). Review of the Physician's Order dated 6/12/2025, revealed .Betadine [antiseptic solution]- clean left heel with normal saline, pat dry, paint with betadine and leave open to air every day and PRN [as needed] .for blister . Observation in Resident #2's room during wound care on 9/30/2025 at 2:15 PM, revealed LPN A cleaned right heel with saline soaked gauze, removed gloves, failed to perform hand hygiene before putting on clean gloves, and completed the wound care on the right heel. LPN A removed her gloves, put on a clean pair of gloves and failed to perform hand hygiene and completed the wound care on Resident #2's left heel. During an interview on 10/01/2025 at 10:02 AM, the Director of Nursing (DON) was asked if hand hygiene should be performed between glove changes when providing wound care. The DON stated, Yes, ma'am. 3. Observation in Resident #15's room during dining on 9/27/2025 at 2:15 PM, revealed CNA B removed a wrapped ice cream sandwich from Resident #15'a tray, removed the wrapper, then broke the ice cream sandwich in half with her ungloved bare hands before placing it back onto the resident's tray. During an interview on 10/1/2025 at 10:30 AM, the DON was asked if staff members should handle resident's food with ungloved bare hands. The DON stated, No, ma'am.

Based on policy review, medical record review, and interview, the facility failed to ensure care and services were provided when the use of a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to administer medications and food supplements) was documented inaccurately in the medical record for 1 of 1 sampled resident (Resident #6) reviewed for enteral feedings. The findings include: 1. Review of the facility policy titled, .Enteral Feeding Administration ., dated 7/2025, revealed .Document any necessary information .placement check done .residual .any difficulties and resident's tolerance to the procedure on the progress notes . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Dementia, Dysphasia, and Gastrostomy. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 4, which indicated Resident #6 was severely cognitively impaired and had a feeding tube. Review of the Physician's order dated 9/4/2025, revealed .Jevity [high calorie supplement for tube feeding] 1.5 Cal [Calories]/Fiber .at 50 ml/hr [milliliters per hour] . Review of the Progress Notes revealed .Jevity 1.5 continuous at 65ml/hr . on the following dates, 8/24/2025, 8/28/2025, 8/30/2025, 9/1/2025, 9/5/2025, 9/8/2025, 9/9/2025, 9/20/2025, 9/21/2025, 9/25/2025, and 9/29/2025. The facility failed to document Jevity 1.5 at 50ml/hr per the Physician's Orders. During an interview on10/1/2025 at 9:20 AM, the Director of Nursing was asked if the order for the use of the PEG Tube was for Jevity at 50 ml/hr and the Medication Administration Record indicated it was administered at 50 ml/hr, but in the progress notes it is documented as 65ml/hr, would this be inaccurate documentation. The DON stated, Yes.

Based on policy review, medical record review, observation, and interview, the facility failed to implement care plan interventions for 1 of 2 (Resident #3) sampled residents reviewed for falls. The findings include: 1. Review of the facility policy titled, Comprehensive Person-Centered Care Planning, dated 1/2025, revealed .The facility IDT [Interdisciplinary Team] will develop and implement a comprehensive person-centered .care plan .The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment .The care plan process will be .ongoing to meet the residents' needs . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Dementia, and Osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #3 was severely cognitively impaired, used a wheelchair for mobility, was dependent on staff for assistance for Activities of Daily Living (ADLs) and had one fall with injury. Review of the Care Plan dated 1/2/2025, revealed that Resident #3 had falls on 1/31/2025, 2/2/2025, 2/6/2025, 2/17/2025, 2/25/2025, 3/3/2025, 3/5/2025, 3/15/2025, 5/29/2025, 7/18/2025, 7/28/2025, 8/2/2025, and 8/10/2025. Further review of the care plan dated 1/2/2025 revealed, .2/2/25 [2/2/2025] Place dycem [Non-Abrasive Grip Tape] in geri [geriatric] chair [reclining chair with more support than a wheelchair] .7/18/25 [7/18/2025] anti roll backs [prevents the wheelchair from tipping over while standing] to w/c [wheelchair] .9/26/25 [9/26/2025] Apply nonskid [socks with grippers on the bottom to prevent sliding] socks . Observation in Resident #3's room on 9/29/2025 at 9:02 AM and 10:39 AM, revealed Resident #3 had on socks with no grippers on the bottom, no shoes and was sitting in a wheelchair without anti rollback wheels. Observation on the 200 Hall on 9/30/2025 at 7:58 AM, revealed Resident #3 had on socks with no grippers on the bottom and no shoes. During an observation and interview in Resident #3's room on 9/30/2025 at 2:25 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked if there was dycem in Resident #3's wheelchair or geri chair since it was care planned as an intervention. The ADON stated, .dycem should have been in the chairs . The DON and ADON were asked if Resident #3 should have been in a standard wheelchair without anti rollback wheels if she was care planned for a wheelchair with anti-rollback wheels. The DON and ADON stated, No. The ADON was asked if the Resident should be wearing socks without grippers if she was care planned for nonskid socks. The ADON stated, .she should have had nonskid socks on if it's on the care plan.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure that resident medication was administered as ordered when 1 of 1 (Resident #70) random residents observed self-administered a nebulizer treatment without staff present. The findings include: Review of the facility policy titled, Self Administration of Medications, dated 1/2025, revealed . maintain the safety and accuracy of medication administration.interdisciplinary team will assess and periodically re-evaluate the resident based on change in resident status.resident candidate for self-administration of medications will be indicated in the chart. Review of the facility policy titled, Administration of Drugs, dated 1/2025, revealed .medications shall be administered as prescribed by the attending physician.Medication must be administered in accordance with the written orders of the attending physician. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE], with diagnoses including Pneumonia, Chronic Respiratory Failure, and Malignant Neoplasm of the Bronchus and Lung. Review of the Care Plan dated 9/25/2025, revealed Administer small-volume nebulization (SVN) as ordered . Review of Physician's orders dated 9/25/2025, revealed .Ipratropium-Albuterol Inhalation Solution [a liquid solution used in a breathing machine to assist with breathing easier] 0.5-2.5 (3) MG [Milligrams]/3ML [Milliliter] .1 vial inhale orally every 6 hours for nebulizer while awake.to be administer by clinician. The facility was unable to provide documentation that a Self-Administration assessment had been completed for Resident #70. During a random observation in Resident #70's room on 9/29/2025 at 2:29 PM, revealed the resident was lying in bed wearing a nebulizer mask, with the nebulizer machine on, and no staff present to monitor the administration of the medication. During an interview on 10/1/2025 at 9:19 AM, the Director of Nursing (DON) was asked if the nurse should be present during a nebulizer treatment if the resident has not been assessed for self-administration of medications. The DON stated Yes .

Based on facility policy review, medical record review, facility investigation, Quality Assurance and Performance Improvement (QAPI) Committee documentation review, and interview, the facility failed to provide adequate assistance and supervision to prevent falls for 1 of 12 (Resident #1) sampled residents reviewed for accident hazards. Resident #1, who was dependent on staff for bed mobility, fell from her bed on 1/14/2025 when Certified Nursing Assistant (CNA) A rolled the resident on her side then CNA A turned her back on the resident during incontinence care. Resident #1 sustained a right distal femoral shaft fracture (break in the lower part of the thighbone, just above the knee joint), left distal femoral shaft fracture, and left proximal tibia fracture (break in the upper part of the shinbone near the knee joint) from the fall, which resulted in actual HARM to the resident. The facility was cited past noncompliance for F689, and is not required to submit a plan of correction. The findings include: 1. Review of the facility's policy titled, Fall Management System, with a revision/review date of 12/2023, revealed .It is the policy of this facility to provide an environment that remains as free of accident hazards as possible .to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs .Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of overwhelming external force .Review of the fall incident will include investigation to determine probable causal factors . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Fracture of Left Proximal Tibia, Fracture of Left Distal Femoral Shaft, Fracture of Right Distal Femoral Shaft, Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant Side, Leukemia, Contracture of the Right and Left Hand (permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joint to shorten and become very stiff), Parkinson's Disease, Vascular Dementia, and Osteoporosis. Review of the Fall Risk Evaluation dated 11/9/2024, revealed Resident #1 scored an 11 which indicated she was at high risk for falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated moderate cognitive impairment. Resident #8 experienced limited range of motion in bilateral upper and lower extremities and was totally dependent on staff for mobility. Review of Resident #1's Care Plan dated 11/20/2024 with a revision date of 12/14/2024, revealed .ADL [activities of daily living] self-care performance deficit r/t [related to] .ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, transfers .BED MOBILITY: Assist with bed mobility as needed .pressure reducing mattress, position for comfort .Turn/reposition every 2 hours/prn [as needed] .TRANSFERS .[Named brand] lift x [times] 2 staff for transfer bed to chair .The resident is at risk for falls r/t Unaware of safety needs, functional/cognitive deficits .The resident will be free of falls .Anticipate and meet the resident's needs . Review of the Nursing Progress Note for Resident #1 dated 1/8/2025 at 1:14 PM, revealed Temp [temperature] 99.3 observed with cough and runny nose. Received new order .for CXR [Chest xray], COVID test and Flu [influenza] test. Review of the Nursing Progress note for Resident #1 dated 1/9/2025 at 9:52 AM, revealed .flu test came back with positive results for flu A. MD [Medical Doctor/Director] made aware with new order . Review of the [Named Hospital] Laboratory Report for Resident #1 dated 1/9/2025, revealed Resident #1 tested positive for Influenza A and a new order for Tamiflu (medication to treat influenza) 75 milligrams (mg) twice daily for 5 days was received from the physician. Review of the [Named Company] Radiology Report for Resident #1 dated 1/9/2025, revealed a chest xray was obtained and no active cardiopulmonary disease was seen. Review of the Physician's Order for Resident #1 dated 1/9/2025, revealed .cefTRIAXone Sodium Injection [an antibiotic given for bacterial infections] .1 GM [gram] Inject 1 gram intramuscularly one time a day for congestion for 3 days. Review of the Nursing Progress Note for Resident #1 dated 1/13/2025 at 3:59 AM, revealed .Resident continues to receive Tamiflu .d/t [due to] positive for flu .Occasional cough still noted and generalized malaise [feeling of weakness, overall discomfort, illness, or simply not feeling well]. Review of the Nursing Progress Notes for Resident #1 revealed no documentation of the fall Resident #1 sustained on 1/14/2025 at approximately 9:15 to 9:30 AM. Review of the Nursing Progress Note for Resident #1 dated 1/14/2025 at 1:27 PM, revealed O2 [oxygen] applied to resident due to decreased SpO2 [oxygen saturation-measurement of how much oxygen the blood is carrying] .MD made aware of current condition and Xray results with new orders for bilateral knee immobilizers and Albuterol [medication to treat wheezing, difficulty breathing, and chest tightness] 2 puffs per inhaler [small handheld device that delivers medication in a spray or powder form directly to the lungs through inhalation] QID [four times a day] . Review of the Nursing Progress Note for Resident #1 dated 1/15/2025 at 4:09 PM, revealed Called and updated daughter .on patient's condition. Respiratory status is declining . Review of the Nursing Progress Note for Resident #1 dated 1/18/2025 at 11:54 AM, revealed .Resident with no B/P [blood pressure], heart tones or spontaneous respirations. Time of death 11:50a.m. [11:50 AM] . 3. Review of the facility investigation Incident Report dated 1/14/2025, revealed Resident [#1] .Incident Location: Resident's Room .Nursing Description: While receiving incontinent care CNA [A] rolled resident on her side and turned to grab a pad and resident slid off the bed .MD in facility and examined resident with new orders received. 2 person assist with turning and repositioning [new intervention implemented after Resident #1's fall] .Predisposing Physiological Factors .Recent illness . The report was completed by Licensed Practical Nurse (LPN) B. Review of the facility investigation FALL QUESTIONNAIRE dated 1/14/2024, revealed .[Named Resident #1] .calm, let me [CNA A] get her cleaned up .Incontinent .As I [CNA A] was changing [Resident #1] I turned to grab a pad to put under her and she slid off of the side of the bed . The document was documented by LPN B and signed by CNA A. Review of the radiology report for Resident #1 dated 1/14/2025 at 11:44 AM, and reported at 12:09 PM, revealed .KNEE .LEFT .Fracture of the distal femoral shaft with malalignment .Proximal tibia fracture with mild displacement . KNEE .RIGHT .Fracture of the distal femoral shaft with malalignment . Review of the typed investigation signed by the Administrator and dated 1/15/2025, revealed On Tuesday, January 14 [2025], at approximately 9:30 am, it was reported to this staff member that [Named Resident #1] .was being changed by [Named CNA A]. [Named CNA A] had turned [Named Resident #1] towards the window, away from her [CNA A], in order to tuck a clean pad underneath [Named Resident #1]. [Named Resident #1] has transfer rails [grab bars] on her bed and usually holds to the bar when she is turned. Prior to this time, [Named Resident #1] had been sick and was weaker than baseline. According to [Named CNA A], she turned to grab a pad to put under [Named Resident #1] and [Named Resident #1] started to slide off the side of the bed. [Named CNA A] stated she tried to get to [Named Resident #1] in time to stop the fall but was not quick enough. [Named Resident #1] fell on her bottom, hitting her knee on the floor .An Xray of both knees was obtained on 1/14/2025 at 12:08 [PM] .left leg: Acute appearing femoral and tibial fracture. Right leg: Acute appearing femoral fracture . Review of the handwritten statement for Resident #1 documented by CNA A on 1/17/2025 for the incident that happened on 1/14/2025, revealed I [CNA A] went into the room [Resident #1's room] around 9am [9:00 AM]. I gathered all of my things to assist [Named Resident #1]. As I finished cleaning her [Resident #1] up in the front I rolled her away from me, towards the window. I turned to grab a pad and sheet to put under her. As I was turned I heard her start to slide off of the side [of the bed]. I tried to get to her in time to keep her on the bed but I wasn't quick enough. She fell on her bottom hitting her knee on the ground. I ran out the door to grab a nurse to assist me. We were able to get her on her back with the help of two others and [Named Brand lift] her back into the bed, where I finished up with help. 4. During a telephone interview on 2/4/2025 at 10:36 AM, Family Member (FM) C denied Resident #1 received hospice services. FM C stated, .I had signed for her a DNR .no she was not in hospice because as I understood if she were in hospice care she would not be able to be taken to the hospital .[Resident #1] was a fighter and had made it to 94 [years old] .apparently the CNA was trying to change her and she [CNA] dropped her out of the bed and it fractured both of her femurs . FM C was asked was there only one CNA in the room. FM C stated, Yes .quite often there was two because she was immobile from the waist down and had lost a lot of her upper arm strength. FM C stated, .somewhere in there I made the decision for them not to move her to the hospital because [Named Medical Director] had said he didn't believe she would make it through surgery .the only objection, with a patient who is 94, immobile from the waist down, [had] just gone through the flu, [was given] antibiotics for chest congestion, that instead of two CNAs to change her they had one and that's how the accident happened .I'm just so unhappy about the accident because it was avoidable .her hands had contractures . During an interview on 2/5/2025 at 9:27 AM, CNA A read and verified her handwritten statement dated 1/17/2025. CNA A was asked if she was familiar with [Resident #1's] care. CNA A stated, A little bit .I hadn't been working with her for maybe a month or so prior to that because my hours went down because I had gone back to school .I usually work when someone calls off or they're short staffed . CNA A confirmed she worked in the facility as the shower aide, also. CNA A was asked was she scheduled as the shower aide that day [1/14/2025]. CNA A stated, I think in the schedule I was, but someone had called off, so they put me on the floor. CNA A was asked did she look at Resident #1's Kardex (system that summarizes care a resident requires for the CNA staff) or Care Plan before she went in Resident #1's room. CNA A stated, No, I didn't get a chance to. CNA confirmed she did not receive a shift report from the off-going CNA prior to beginning her shift. CNA A stated, I was [here] as a shower aide and they didn't know someone had called out, so I didn't get report before starting. CNA A acknowledged that she was not aware Resident #1 had been sick with the flu and chest congestion over the past few days prior to the fall and that information would have been important for her to know. CNA A was asked what interventions to prevent falls were in place before the accident occurred. CNA A stated, I do not know, it was never brought up to me. CNA A was asked if Resident #1 was one or two-person assist for ADLs. CNA stated, A lot of times people did her one person but I think she should have been two person [that day] .I had her before and she used to be able to hold herself up, but I didn't know she was sick and wasn't as strong as she usually was. CNA A stated, I went in there roughly 9 or 9:15ish, I had grabbed my pad, brief, rags, and gloves as I went in there, cleaned up the front side [while she was lying on her back] .rolled her toward [the] window .[CNA A confirmed she was behind Resident #1 when she rolled her over] .With her right hand [Resident #1 grabbed the grab bar on the bed] .I proceeded to clean up her back side, took the old brief out, tucked the old pad under her. I turned around to grab the new pad and the new brief and as I was turned, I heard her sliding but wasn't sure what I was hearing, so I turned around and by the time I turned she was already on the floor. CNA A stated she turned around to the overbed table to grab the brief and pad. CNA A was asked if her hands were on the resident or was she completely turned around. CNA A stated, I was completely turned around .I yelled for help and went to open the door. My nurse [named LPN B] was there in the hall . CNA A was asked did Resident #1 complain of pain. CNA A stated, She was saying Ow, Ow . CNA A stated Resident #1 was sitting on her bottom with her legs in front of her and was leaning against the wall the window was on. CNA A confirmed LPN B obtained Resident #1's vital signs while she got two other CNAs to help them get the resident up with the mechanical lift. CNA A stated, After the fall she was kind of out of it .she couldn't keep her eyes open .now that I know she was sick, she didn't look too good .looked like she was in a lot of pain and didn't feel too good. I did let the nurse know [that it] looked like she was going in and out of consciousness and didn't feel too good. CNA A stated Resident #1 was on an air mattress (alternating pressure mattress). CNA A was asked did she believe the air mattress contributed to the fall. CNA A stated, A little bit. It wasn't as firm [as the regular mattresses], it was soft, you would put your hand on it, and it would go down. CNA A stated this incident taught her to get the help she needed and trust her instincts. CNA A was asked to explain what she meant by trust her instincts. CNA A stated, When I went in there, she wasn't looking too good because she was sick, so I definitely should've gotten help. During an interview on 2/5/2025 at 10:39 AM, LPN B acknowledged she was familiar with Resident #1. LPN B stated, .She was total assist .she could feed herself, but you would have to watch her plate and turn it and sometimes assist [with eating] .Yes [contractures] of her hands .one hand she kept closed but the other you could have her open up and she could drink her coffee and used her spoon . LPN B was asked how the flu [positive for flu A on 1/9/2025] affected her. LPN B stated, .You could just tell she didn't feel good. LPN B was asked what were [Resident #1's] risk factors for falling. LPN B stated, She didn't get out of bed, no falls .I was kind of shocked when [Named CNA A] came and got me [after Resident #1 fell out of bed on 1/14/2025] .never dreamed [Named Resident #1] would fall. LPN B stated, She was on an air mattress and they [facility Administration] think that contributed to the fall .[Resident #1 had] No falls in the time I've been here [2 years in June or July 2025] . LPN B was asked what caused the accident. LPN B stated, .what [Named CNA A] said is all I know. She said she turned her [Resident #1] away from her [CNA A] towards the window and reached to grab the pad .and she [Resident #1] just tumbles over .She had a hematoma on her right knee. [Named Medical Director] was in the facility, and I wanted him to see it. I had put ice on it [right knee] and he said we needed to xray [her] bilateral lower extremities .he said he thought she had a fracture, so we got xrays and she had 2 fractures [Resident #1 had 3 fractures per xrays]. LPN B stated, She was sitting in the floor with her back against the window [wall the window was on] and her legs were kind of to the side [LPN B sat in the floor and demonstrated how she found Resident #1, sitting on her bottom with her legs bent at the knees, out to the right of the resident, and angled towards her bottom]. LPN B was asked was it safe for CNA A to turn Resident #1 on her side then turn her back and leave the resident on her side. LPN B stated, .I wouldn't have done that myself. During a telephone interview on 2/6/2025 at 3:32 PM, the Family Nurse Practitioner (FNP) stated Resident #1 was on her caseload and she saw her once a month and as needed. The FNP was asked was she aware of the resident's fall from bed on 1/14/2025. The FNP stated, Yes, I was aware of the fall, [I was] actually rounding in the facility. Actually [Named Medical Director] and I went in there together. He looked her [Resident #1] over .She was laying in bed, did not appear to be in any pain, [we] asked her several times if she was hurting, and she said no .could tell by looking at her legs she probably had fractures. The FNP stated she was not aware how the fall happened, but she thought it was during patient care. The FNP was asked in her professional opinion did she believe it was safe for a staff member to turn her (Resident #1) on her side and turn their back to retrieve items from the over bed table. The FNP stated, You and I both know the answer to that. It could have been a safety concern, obviously . The FNP was asked in her professional opinion did she believe the fall where Resident #1 sustained a left femur fracture, left tibia fracture, and a right femur fracture on 1/14/2025 may have contributed to her death 4 days later (1/18/2025). The FNP stated, That's too hard to say, she already had flu and had respiratory illness .with fracture of long bones there's always a risk of death. She was in very poor health and very fragile . During an interview on 2/7/2024 at 10:40 AM, the Staffing Coordinator was asked how she taught CNA students to recognize when two staff members were needed for resident care. The Staffing Coordinator stated, [I] teach them if the patient cannot physically hold on to the side rail, to make sure they have two people .prior to this incident when you rolled her [Resident #1] she would hold on .with her wrist and hand .around the grab bar kind of like hugging it. The Staffing Coordinator was asked if Resident #1 was in a weakened state physically from the flu. The Staffing Coordinator stated, Yes, I think she was. During an interview on 2/10/2025 at 3:44 PM, the Director of Nursing (DON) stated, On some days she [Resident #1] could feed herself, some days she couldn't, [staff] would always pop in to make sure she didn't need extra help. She was incontinent of bowel and bladder. The DON stated she was made aware of Resident #1's fall on 1/15/2025, because she was not working on 1/14/2025 when the fall occurred. The DON was asked was it safe for CNA A to leave Resident #1 on her side and turn her back to retrieve a clean brief and pad. The DON stated, It's hard for me to say because I wasn't in there to see if she [CNA A] made sure she [Resident #1] was safe. The DON was asked did she believe it was safe for CNA A to completely turn her back on the resident. The DON stated, No, I do not. During an interview on 2/11/2025 at 11:08 AM, the Administrator stated she went to Resident #1's room immediately after her fall, .[I] observed her on the bed .looked at her mattress .She has a transfer rail .she would typically hold to it but she had been weak and sick, she had the flu and she didn't do that this time evidently [hold to the transfer rail/grab bar]. The Administrator was asked with Resident #1 being weak and sick, should two people have been used to provide care for the resident. The Administrator stated, It depends, this girl [CNA A] had done her before [provided care alone] like I said, she wasn't labeled as two-person . The Administrator was asked was Resident #1 harmed when CNA A left her on her side, turned her back to retrieve supplies, and she fell out of bed. The Administrator stated, Yeah, she fell out of bed and was harmed for sure. The Administrator was asked what the QAPI Committee identified as the root cause of the fall. The Administrator stated, I named 4 factors that contributed .determined because of these 4 things the safest practice would be to have a 2nd staff member on the other side of the alternating mattress [5 Whys but they only identified 4 Whys] . 5. Review of the QAPI Committee documentation revealed the following: A typed summary of the incident and corrective action steps taken dated 1/15/2025, revealed the following: a. Resident #1's alternating pressure mattress was examined and determined to be in the proper working order with normal pressure indicated. Of significance the pressure mattress was noted to give downward when the edge of the mattress was weighted which could allow a weak resident to slide downward when weight was applied to the edge of the mattress. CNA instructor/Staffing Coordinator was consulted regarding instructions for CNA students when turning a resident for occupied bed care, such as changing linens. b. Resident #1's transfer rails were properly installed and sturdy. c. All alternating pressure mattresses in the facility were assessed on the afternoon of 1/14/2025 and it was determined that bedbound residents on alternating pressure mattresses who lacked core body control were also at risk. d. The 5 Whys were used to determine the root cause of the fall. e. An in-service was initiated on 1/15/2025 for all nursing staff. f. An Ad Hoc QAPI Clinical meeting was conducted on 1/15/2025. Review of the undated Root Cause Analysis document revealed, Problem Identified: Fall with Major Injury .During the committee's investigation, the 'Five Whys' method was utilized to identify the root cause of the problem so that appropriate approaches can be planned. Slid out of bed . a. Why did this occur? Turned on left side for the CNA to change pad, slid out of bed. b. Why did this occur? Alternating Pressure Mattress gives downward on edges when direct weight is applied. c. Why did this occur? Alternating air mattress edge is not as firm as regular mattresses. d. Why did this occur? Resident's legs were believed to have slid off the edge of the bed pulling her torso with her. The QAPI Committed concluded the root cause of the problem was the design of the alternating pressure mattress, and the resident was weak from illness and was unable to stabilize her torso when turned on her side. Review of the Performance Improvement Plan (PIP) began on 1/14/2025 and completed on 1/31/2025, revealed the following Action Plan for Improvement: a. Investigation and Root Cause Analysis completed. b. All facility residents on air mattresses requiring assistance with turning and repositioning have been identified as having the potential to be affected. c. 100 percent (%) audit of air mattresses to ensure proper working order was completed by the Administrator (who is a Registered Nurse). No concerns were identified. d. Education was initiated on 1/15/2025 to CNAs and licensed nurses by the Administrator regarding residents on air mattresses requiring assistance with turning and repositioning shall have 2 staff members present to assist. e. 100% audit of residents' care plans and Kardex reviewed and revised between 1/15/2025 and 1/31/2025 to include revised intervention of two person assistance with bed mobility for all residents with alternating pressure mattresses. f. Knowledge checks to demonstrate nurses and CNAs competency of education received were initiated by the Staffing Coordinator on 1/29/2025 and completed on 1/31/2025. g. Competency return demonstrations regarding making an occupied bed and positioning a resident on side their was initiated for CNAs by the Staffing Coordinator on 1/30/2025 and will be ongoing with random checks. h. An Ad Hoc QAPI meeting was held on 1/31/2025 to review current corrective actions plans. Further review of the PIP dated 1/31/2025, revealed the subsequent follow up to monitor the corrective action plan: a. Nurse Administration and charge nurses will perform knowledge checks and random observations, each rotation (shift) weekly for 4 weeks and then bi-monthly for 2 months. b. Nurse Managers and Administrator will perform air mattress audits to ensure proper functioning, weekly for 4 weeks, and then bi-monthly for 2 months. c. Findings will be reported to the QAPI committee for the 1st QAPI quarter, 2025. d. If substantial compliance is not met, staff will be re-educated and facility audits will continue, until substantial compliance is met. Review of the facility's investigation and corrective action plan revealed the facility returned to substantial compliance on 1/31/2025.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were stored appropriately when an unsecured medication was observed in 1 of 38 resident rooms (Resident #4's room) which could have potentially affected the 4 identified wandering residents (Resident #11, #12, #13, and #14) in the facility. The findings include: Review of the facility's policy titled, Medication Storage, dated 1/2025, revealed .It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals .Drugs and/or biologicals should not be left unsecured/unattended . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses of Chronic Ischemic Heart Disease, Anemia, Cardiomegaly, Bipolar Disorder, Major Depressive Disorder, Allergic Rhinitis, Generalized Anxiety Disorder, and Polyosteoarthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #4 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment indicating Resident #4 was cognitively intact. No behaviors were documented during the 7-day lookback period. Review of the Care Plan dated 10/9/2024 with a revision date of 12/28/2024, revealed Resident #4 was not care planned to self-administer medications. Review of the Physician's Order for Resident #1 dated 1/10/2025, revealed .Breo Ellipta 100-25 MCG [microgram]/ACT [Actuation-a mouthpiece to allow the patient/resident to operate the inhaler and directs the medicine into the lungs] Aerosol Powder .INHALE ONE PUFF INTO THE LUNGS EVERY DAY. RINSE MOUTH AFTER USE AND SPIT OUT . Observation and interview in Resident #1's room on 2/7/2025 9:02 AM, revealed a Breo Ellipta 100 mcg/25 mcg inhaler (a small handheld device that delivers medication in a spray or powder form directly to the lungs through inhalation) on the foot of Resident #4's bed. When asked if she kept the inhaler in her room, Resident #4 stated, No, the nurse left it for me to use .She gave it to me and will come to get it on her way back. If not, I'll take it to her. During an interview on 2/10/2025 at 11:42 AM, the Director of Nursing (DON) was asked should medications be left unattended in the residents' rooms. The DON stated, No, ma'am. The DON confirmed Resident #4 had not been assessed by the Interdisciplinary Team (IDT) to self-administer the Breo-Ellipta inhaler. The DON was asked if self-administration of medications was on the resident's care plan. The DON stated, I'm pretty sure it's not . During an interview on 2/10/2025 at 3:44 PM, the DON confirmed Resident #4's care plan did not include self-administration of medications.

Based on policy review, observation, and interview, the facility failed to follow appropriate infection control measures when 4 of 8 staff members (Family Nurse Practitioner (FNP), Certified Nursing Assistant (CNA) #1, #3 and #4) failed to apply proper Personal Protective Equipment (PPE) before entering droplet precaution rooms, failed to perform hand hygiene, and failed to clean reusable equipment after use for 12 of 18 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) reviewed in isolation precautions for COVID-19. The facility had a census of 49 residents with 18 COVID-19 positive residents residing on the Covid Unit. The findings include: Review of the signs on the resident room doors of the COVID Unit (200 Hallway), revealed SPECIAL DROPLET/CONTACT PRECAUTIONS .Everyone Must: including .doctors and staff .Clean hands when entering and leaving room .Wear face mask .Wear eye protection (face shield or goggles) .Gown and glove at door .clean and disinfect shared equipment . Review of the facility's policy titled, Infection Prevention and Control Program, revised 6/9/2021, revealed .The reusable equipment will be decontaminated using a germicidal detergent prior to storing for reuse . Observation on the 200 Hallway on 9/13/2021 at 9:59 AM, revealed CNA #1 exited Resident #7 and Resident #8's room with a gown on, CNA #1 removed the gown in the hallway and placed the gown in the trash. Observation on the 200 Hallway on 9/13/2021 at 10:46 AM, revealed CNA #4 entered Resident #9 and Resident #10's room with no eye protection. Observation on the 200 Hallway on 9/13/2021 at 11:07 AM, revealed CNA #1 was rolling Resident #2 down the hallway in his wheelchair with her goggles on top of her head, CNA #1 assisted Resident #2 to his room, entered the room with her goggles on top of her head and positioned the resident at his bedside. Observation on the 200 Hallway on 9/13/2021 at 11:23 AM, revealed CNA #3 entered Resident #9 and Resident #10's room with no eye protection. Dining Observation on the 200 Hallway on 9/13/2021 at 11:25 AM, revealed CNA #1 entered Resident #3's room, with her goggles on top of her head, placed the tray down on the bedside table, picked up the tray and went to Resident #4's room and placed a tray down on the bedside table, CNA #1 exited the room with her goggle on top of her head. Dining observation on the 200 Hallway on 9/13/2021 at 11:26 AM, revealed CNA #1 entered Resident #5's room, with her goggles on top of her head and placed the tray on the bedside table. Dining observation on the 200 Hallway on 9/13/2021 at 11:38 AM, revealed CNA #4 in was in the hallway in her gown, she removed the gown and placed the gown in the trash can. Dining observation on the 200 Hallway on 9/13/2021 at 11:47 AM, revealed CNA #3 entered Resident # 3's room, with no eye protection for tray setup, CNA #3 exited the room in a gown, removed the gown, walked to the beauty shop and placed the gown in the trash can. Dining observation on the 200 Hallway on 9/13/2021 at 11:50 AM, revealed CNA #3 entered Resident #6's room with no eye protection, for tray setup, CNA #3 exited the room and removed the gloves and gown in the hallway, walked down to room [ROOM NUMBER], opened and closed the door and walked back down the hall with the gown and gloves in her hand to the beauty shop and placed the items in the trash can. Observation on the 200 Hallway on 9/13/2021 at 11:56 AM, revealed the FNP entered Resident #1's room, with no eye protection or gloves, exited the room and failed to perform hand hygiene and remove her gown. The FNP picked up the clipboard off the arm rail outside of Resident #1's room, documented a note, walked down the hallway to Resident #11 and Resident #12's room, placed her clip board on the arm rail outside the room, entered the room in the same gown with no eye protection or gloves on, exited the room picked up her clipboard. The FNP did not remove her gown, walked down the hallway to the South Nurses' Station, and sat down. The FNP failed to remove her gown and perform hand hygiene between each resident in droplet precautions. During an interview on 9/13/2021 at 12:15 PM, the FNP confirmed that she should have changed her PPE and performed hand hygiene between each resident's room. The FNP confirmed that she should have put on a new gown, gloves, face protection/goggles, and mask before entering each resident's droplet precaution room. Observation in the resident's room on 9/13/2021 at 1:26 PM, revealed CNA #3 and CNA #4 entered Resident #1's room without any eye protection, assisted the resident with her weight, exited the room with the weight lift. CNA #3 did not remove her gown and gloves, placed a plastic bag on the end of the weight lift, rolled the weight lift down the hall and sat the weight lift against the wall. CNA #3 removed her gown and glove and placed them into the trash. The staff members failed to clean the reusable equipment prior to storing. During an interview on 9/13/2021 at 1:46 PM, the Administrator stated, .when they go into the droplet precaution rooms .they put on goggle or face shield, N 95 mask, gown, and gloves. The Administrator confirmed that the staff should remove their PPE before coming out of each droplet precaution room and sanitize their hands. The Administrator confirmed that the staff members should not walk down the hallway in their PPE. The Administrator confirmed that the staff should clean the reusable equipment after each use. During an interview conducted on 9/13/2021 at 3:49 PM, CNA #3 confirmed that she should don her eye protection before entering each droplet precaution room. CNA #3 confirmed that she should remove her PPE before exiting the residents' droplet precaution rooms. CNA #3 confirmed that she should have cleaned the reusable equipment before and after each use.

Based on policy review, observation, and interview, the facility failed to ensure food was stored under sanitary conditions as evidenced by carbon build-up on pots and pans, expired food items in the Kitchen, open and undated food items in the Kitchen, dirty equipment in the Kitchen, staff failed to clean the thermometer during tray line temperature checks, and 5 of 10 staff members (Certified Nursing Assistant (CNA) #1, #2, #3, #4, and #5) placed contaminated cups back onto a clean dining cart, entered a droplet isolation room without the proper Personal Protective Equipment (PPE), and failed to perform hand hygiene during dining observations. The facility had a census of 59 with 59 of those residents receiving a meal tray from the kitchen. The findings include: Review of the facility's policy titled, Dietary: Food Service, revised [DATE], revealed .Leftover foods are stored in appropriate containers .Leftovers should be used within three (3) days .All stored items should have an expiration date or a purchase/delivery date . Review of the facility's policy titled, Dietary: Cleaning, dated [DATE], revealed .Adequate Cleaning and sanitizing will minimize the risk of food born illness .Kitchen Supervisor will post a weekly cleaning schedule that identifies .The equipment .to be cleaned .The frequency of cleaning . Review of the CLEANING SCHEDULE, revealed, .Refrigerator/Reach in Cooler .check Dates .Daily . Review of the facility policy's titled, Hand Hygiene, revised [DATE], revealed .Staff will perform hand hygiene when indicated .Between resident contacts . Review of the facility's policy titled, Transmission-Based Precautions revised ,d+[DATE], revealed .Donning personal protective equipment (PPE) upon entry . Observation in the Kitchen on [DATE] at 8:48 AM, 8:57 AM, and 9:04 AM, revealed the following: a. 1 medium and large skillet with a large amount of carbon buildup b. 1 open and undated carton of a thickened liquid lemon flavored water c. 1 open and undated carton of a thickened dairy drink in the refrigerator d. 2 cartons of buttermilk with an expiration date of [DATE] in the refrigerator e. 1 open and undated carton of buttermilk in the refrigerator f. 4 cartons of 4-ounce orange juice with an expiration date of [DATE] in the refrigerator g. 10 sheet pans with carbon build up on the bottom and the inside corners h. An air fryer sitting on the preparation table with large amount of greasy buildup i. 1 container of American sliced cheese with an open date of [DATE] in the refrigerator j. 1 open and undated container of sliced Swiss cheese in the refrigerator k. 1 container of chicken salad with an open date of [DATE] in the refrigerator l. 1 container of [MEDICATION(S)] salad with an open date of [DATE] in the refrigerator m. 1 open and undated container of pimento cheese in the refrigerator n. 1 open and undated bag of French fries in the freezer Observation outside of Resident #164's room on [DATE] at 11:40 AM, revealed a SPECIAL DROPLET/CONTACT PRECAUTIONS, sign posted on the door, with the following instructions .Clean hands when entering and leaving room .wear face mask .wear eye protection (face shield or goggles) .Gown and glove at door . Observation in the resident's room on [DATE] at 11:40 AM, revealed CNA #1 entered the isolation room without donning proper PPE and picked up two cups from Resident #164's bedside, entered the bathroom and emptied the cups, exited the resident's room and placed the cups on the bottom of the dining cart with meal trays waiting to be served. Observation in the resident's room on [DATE] at 11:56 AM, revealed CNA #2 entered Resident 3's room in droplet precautions without donning the proper PPE to assist the resident with her meal. Observation in the resident's room on [DATE] at 12:02 PM, revealed CNA #3 delivered a lunch tray to Resident #7's room, set the tray down on the overbed table, touched the resident's bedding and repositioned the resident, then left Resident #7's room without performing hand hygiene, returned to Resident #7's room, uncovered the tray, walked back out of Resident #7's room while touching her own hair, returned to the room with a folding chair, touched her hair again, touched the bed controls, failed to perform hand hygiene, then proceed to open Resident #7's straw with her bare hands and placed it in her drink cup. Observation in the Kitchen on [DATE] at 7:06 AM, revealed during the tray line temperatures, the Dietary manager failed to clean the thermometer between each food item. Dining observation in the resident's room [DATE] at 7:37 AM, CNA #1 entered Resident #164's room without donning the proper PPE in a droplet isolation room. Dining observation in the resident's room on [DATE] at 7:40 AM, revealed CNA #1 entered Resident #3's room without donning proper PPE in a droplet isolation room. Dining observation in the residents' shared room on [DATE] at 7:48 AM, revealed CNA #4 touched Resident #26's bed controls and bedding, failed to perform hand hygiene, then helped reposition Resident #4 up in the bed. CNA #4 exited the room and failed to perform hand hygiene. Observation in the 200 Hall on [DATE] at 7:50 AM, revealed CNA #4 touched her goggles, removed a meal tray from the meal cart and delivered the tray to Resident #24, and placed the tray on the over bed table, then CNA #4 moved Resident #24's bedside table and exited the room, and failed to perform hand hygiene. CNA #4 removed the tray from the meal cart and delivered it to Resident #17. CNA #4 placed a towel over the Resident #17's chest, removed the lid from the plate, and started assisting Resident #17 with her meal and failed to perform hand hygiene. Observation in the resident's room on [DATE] at 8:08 AM, revealed CNA #5 delivered a breakfast tray to Resident #35, touched personal items on the bedside table, bed controls and blankets, uncovered Resident #35's plate, and then exited Resident #35's room without performing hand hygiene. CNA #5 then went to the medication cart, returned back to Resident #35's room, touched the light switch, failed to perform hand hygiene, opened the butter and stirred it into the oatmeal with a spoon, and opened and placed a straw in the juice. Observation in the Kitchen on [DATE] at 9:52 AM, revealed black discolored substance on the sides and the top lid of the ice machine. Observation in the Kitchen on [DATE] at 8:43 AM, revealed the following: a. 8 sheet pans with carbon build-up on the bottom and and inside corners b. 1 large cake pan with carbon build-up on the outside c. 1 large steam table pan with carbon build-up outer rim d. 1 large skillet with carbon build-up on the outside and outer rim During an interview on [DATE] at 7:10 AM, the Dietary Manager confirmed that she should have cleaned the thermometer between tray line temperature checks. During an interview on [DATE] at 7:40 AM, Licensed Practical Nurse (LPN) #1 confirmed staff should don gown, gloves, goggles, and mask before entering a droplet isolation room. During an interview on [DATE] at 7:46 AM, the Director of Nursing (DON) confirmed that the staff members should don gloves, gown, mask, and goggles before entering a droplet isolation room. The DON confirmed that staff members should sanitize their hands before each tray. During an interview on [DATE] at 8:19 AM, CNA #1 confirmed that she should not remove dirty cups from a droplet isolation room and place them on a dining cart of meal trays. During an interview on [DATE] at 9:53 AM, the Registered Dietitian confirmed that the black substance inside the ice machine was mildew. During an interview on [DATE] at 9:12 AM, the Dietary Manager confirmed that the equipment should not have carbon build-up. The Dietary Manager confirmed that there should not be any black discoloration inside the ice machine. The Dietary Manager confirmed there should not be items in the coolers or refrigerator beyond its expiration date. The Dietary manager confirmed that items should be dated when opened. The Dietary manager confirmed that there should not be dirty equipment on the preparation table.

Based on medical record review, observation, and interview, the facility failed to properly store respiratory equipment and failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of medical record, revealed Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 2.5 mg [milligram]/3 ml [milliliter] solution for nebulization .Nebulization Every 6 Hours . Observation in the resident's room on 7/26/2021 at 9:56 AM, 11:29 AM and 3:15 PM, and on 7/27/2021 at 8:05 AM, revealed the Resident #25's nebulizer mask and nebulizer were sitting on the back of the oxygen concentrator with the mask lying against the wall uncovered. Review of medical record, revealed Resident #163 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Continuous Positive Airway Pressure ([CONDITION(S)]) 2 Times Daily .at HS [hour of sleep] .Remove in AM . Observation in in the resident's room on 7/26/2021 at 9:19 AM, and 11:58 AM, and on 7/27/2021 at 9:37 AM, revealed Resident #163's [CONDITION(S)] mask was lying on top of the night stand uncovered. During an interview on 7/27/2021 at 5:39 PM, the Director of Nursing (DON) confirmed that [CONDITION(S)] and nebulizer masks should not be stored uncovered, and the nebulizer mask should not be lying on the oxygen concentrator with the mask touching the wall. Review of the medical record, revealed Resident #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's July 2021 Treatment Administration Record (TAR), revealed the Oxygen tubing and humidifier bottle were signed off as having been changed on 7/23/2021. Observation in the resident's room on 7/26/2021 at 9:20 AM, and 3:14 PM, 7/27/2021 at 5:30 PM, and on 7/28/2021 at 7:48 AM, and 8:09 AM, revealed Resident #35 was in the room receiving Oxygen through a binasal cannula dated 7/18/2021 and a humidifier bottle was dated 7/18/2021. During an interview on 7/28/2021 at 8:09 AM, the DON confirmed the oxygen tubing was dated 7/18/2021, and these should have been changed. The DON confirmed nurses should not sign out tubing and humidifier changes on the TAR unless they have actually been changed.

Based on medical record review, observation, and interview, the facility failed to implement fall interventions for 1 of 1 (Resident #17) sampled residents reviewed for falls. The findings include: Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Interdisciplinary Team Occurrence Investigation Worksheet form documented, .Putting Pants on without Assistanc (Assistance) .Intervention .put in place .Cue Cards in Room to alert staff before Transferring .Date of Incident 10-4-19 .Fall to floor . Observations on 12/9/19 at 9:32 AM and 12/10/19 at 1:22 PM revealed no cue cards in Resident #17's room. Interview with the Director of Nursing (DON) on 12/10/19 at 2:10 PM in the DON Office, the DON was asked what intervention had been put in place after the fall. The DON stated, .cue cards . Interview with the DON on 12/10/19 at 2:19 PM in Resident #17's room, the DON confirmed there were no cue cards present in the room.

Based on review of facility policy, medical record review, review of a facility reported incident, and interview the facility failed to implement a written policy related to suspension of an accused staff member (Certified Nurses Aide (CNA) #1) during an allegation of verbal abuse for 1 (Resident #1) of 3 sampled residents. The findings included: 1. The facility's Abuse, Neglect, Exploitation Policy dated 2/2018 documented, .resident has the right to be free from abuse .Verbal Abuse .use of oral .gestured language .disparaging and derogatory terms to residents .j. Removing the alleged perpetrator from the schedule .e. Suspend the accused employee pending completion of the investigation . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status of 15 which indicated Resident #1 had no impairment for decision making. 3. Review of the facility's investigation dated 7/22/18 revealed on 7/21/18 between the hours of 10:00 PM and 12:00 AM Resident #1 reported to Registered Nurse (RN) #1, CNA #1 had said to him .what do you [***] ing want .I don't have time for your [***] ing ass . The investigation also concluded that RN #1 did not remove CNA #1 from patient care. Interview with the Administrator on 8/2/18 at 2:55 PM, in the conference room, the administrator stated .became aware of this incident after she (CNA #1) contacted me by phone that morning 7/22/18 around 6:30 AM she (CNA #1) asked if she would lose her job . A telephone interview with CNA #2 on 8/2/18 at 4:15 PM, CNA #2 was asked to explain the incident involving Resident #1 CNA #2 stated, .I heard (CNA #1) say to (Resident #1) .What the [***] do you want (with her hands up) .not in the mood for this .don't act [***] ing crazy . A telephone interview with RN #1 on 8/2/18 at 7:30 PM, RN #1 was asked if CNA #1 was removed from resident care. RN #1 stated, .no . Interview with the Director of Nursing (DON) and Administrator on 8/2/18 at 5:00 PM, in the conference room, the Administrator and DON confirmed that CNA #1 should've been removed from patient care immediately.

Based on policy review, medical record review, observation and interview the facility failed to ensure 2 of 5 (Licensed Practical Nurse (LPN) #1 and 2) nurses administered medications free of significant medications errors. LPN #1 and 2 failed to administer insulin within the proper time frame related to food intake for Resident #68 and 109 resulting in significant medication errors. The findings included: 1. The facility's INSULIN ADMINISTRATION IN RELATION TO MEAL SERVICE policy documented, Some insulins have rapid onset times of action, requiring timely meal/food intake to avoid hypoglycemic reactions .The most common insulin .Humalog 15 min (minutes) .[MEDICATION NAME] R (regular) 30 min . 2. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].HumaLOG 100 units/ML (milliters) (SSI) (sliding scale insulin) . Observations in Resident #68's room on 1/10/17 at 11:33 AM, LPN #1 administered Humalog 3 units subcutaneously into Resident's #68 right upper arm. Resident #68 took the first bite of food at 11:55 AM, a total of 20 minutes after the insulin injection had been given. The facility failed to provide a substantial meal within 15 minutes of insulin administration resulted in medication error #1. Interview with LPN #1 on 1/10/17 at 5:57 PM, at the 400 nurse's station, LPN #1 was asked how long after giving the Humalog insulin injection should a resident receive food. LPN #1 stated, .five or ten minutes . LPN #1 was asked who is responsible to make sure residents eat after receiving an insulin injection. LPN #1 stated, .we are . 3. Medical record review revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] R 100 units/ML .SSI .4x(times) a day before meals and at bedtime . Observations in Resident #109's room on 1/10/17 at 5:13 PM, LPN #2 administered [MEDICATION NAME] R 3 units subcutaneously into Resident's #109's left lower abdomen. Resident #109 took the first bite of food at 5:51 PM, a total of 38 minutes after the insulin injection had been given. The facility failed to provide a substantial meal within 30 minutes of insulin administration resulted in medication error #2. Interview with LPN #2 on 1/11/17 at 4:27 PM, on the 100 hall, LPN #2 was asked how long after giving the [MEDICATION NAME] R insulin injection should a resident receive food. LPN #2 stated, .fifteen or thirty minutes . LPN #2 was asked what time did you give the insulin injection. LPN #2 stated, .5:13 PM . Interview with the Director of Nursing (DON) on 1/11/17 at 4:55 PM, in the DON's office, the DON was asked how long after giving a [MEDICATION NAME] R insulin injection should a resident receive food. The DON stated, .10 to 15 minutes . The DON was asked how long after giving the [MEDICATION NAME] R insulin injection should a resident received food. The DON stated, .I think 15 minutes . The DON confirmed a substantial meal should have been given after the insulin injection.

Based on medical record review, the resident council meeting minutes, observation, and interview, the facility failed to ensure the resident's indwelling urinary catheter did not touch the floor for 2 of 3 (#25 and 77) sampled residents reviewed with an indwelling urinary catheter. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident council meeting minutes dated 10/2/16 at 3:00 PM, documented .catheter dragging floor . Observations in Resident #25's room on 1/9/17 at 1:16 PM, revealed the indwelling urinary catheter bag was touching the floor. Interview with Licensed Practical Nurse (LPN) #1 on 1/9/17 at 1:17 PM, in Resident #25's room, LPN #1 was asked if the indwelling urinary catheter bag should be touching the floor. LPN #1 stated, No ma'am. 2. Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #77's room on 1/9/17 at 1:48 PM, revealed the indwelling urinary catheter bag was touching the floor. Observations in Resident #77's room on 1/10/17 at 2:37 PM, revealed the indwelling urinary catheter bag was lying on the floor. Interview with LPN #3 on 1/10/17 at 2:38 PM, in Resident #77's room, LPN #3 was shown the indwelling urinary catheter bag lying on the floor and was asked if it should be lying on the floor. LPN #3 stated, .No ma'am .that could cause infection . Observations in Resident #77's room on 1/11/17 at 8:40 AM, revealed the indwelling urinary catheter bag was lying on the floor on the fall mat. Interview with the Director of Nursing (DON) on 1/11/17 at 8:40 AM, in Resident #77's room, the DON was shown the indwelling urinary catheter bag on the floor on the fall mat and was asked if it was acceptable for the bag to be on the floor. The DON stated, No .

Based on policy review, medical record review, observation and interview the facility failed to ensure 2 of 5 (Licensed Practical Nurse (LPN) #1 and 2) nurses administered medications with a medication error rate greater than 5 percent (%). A total of 2 medication errors were observed out of 25 opportunities, resulting in an error rate of 8%. The findings included: 1. The facility's INSULIN ADMINISTRATION IN RELATION TO MEAL SERVICE policy documented, Some insulins have rapid onset times of action, requiring timely meal/food intake to avoid hypoglycemic reactions .The most common insulin .Humalog 15 min (minutes) .[MEDICATION NAME] R (regular) 30 min . 2. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].HumaLOG 100 units/ML (milliters) (SSI) (sliding scale insulin) . Observations in Resident #68's room on 1/10/17 at 11:33 AM, LPN #1 administered Humalog 3 units subcutaneously into Resident's #68 right upper arm. Resident #68 took the first bite of food at 11:55 AM, a total of 20 minutes after the insulin injection had been given. The facility failed to provide a substantial meal within 15 minutes of insulin administration resulted in medication error #1. Interview with LPN #1 on 1/10/17 at 5:57 PM, at the 400 nurse's station, LPN #1 was asked how long after giving the Humalog insulin injection should a resident receive food. LPN #1 stated, .five or ten minutes . LPN #1 was asked who is responsible to make sure residents eat after receiving an insulin injection. LPN #1 stated, .we are . 3. Medical record review revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] R 100 units/ML .SSI .4x(times) a day before meals and at bedtime . Observations in Resident #109's room on 1/10/17 at 5:13 PM, LPN #2 administered [MEDICATION NAME] R 3 units subcutaneously into Resident's #109's left lower abdomen. Resident #109 took the first bite of food at 5:51 PM, a total of 38 minutes after the insulin injection had been given. The facility failed to provide a substantial meal within 30 minutes of insulin administration resulted in medication error #2. Interview with LPN #2 on 1/11/17 at 4:27 PM, on the 100 hall, LPN #2 was asked how long after giving the [MEDICATION NAME] R insulin injection should a resident receive food. LPN #2 stated, .fifteen or thirty minutes . LPN #2 was asked what time did you give the insulin injection. LPN #2 stated, .5:13 PM . Interview with the Director of Nursing (DON) on 1/11/17 at 4:55 PM, in the DON's office, the DON was asked how long after giving a [MEDICATION NAME] R insulin injection should a resident receive food. The DON stated, .10 to 15 minutes . The DON was asked how long after giving the [MEDICATION NAME] R insulin injection should a resident received food. The DON stated, .I think 15 minutes . The DON confirmed a substantial meal should have been given after the insulin injection.

Based on policy review, observation, and interview, 2 of 5 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2) medication nurses failed to prevent the potential spread of infection during medication administration pass. The findings included: 1. The facility's HANDWASHING policy documented, HANDWASHING Employees are inserviced at a minimum quarterly on infection control to include proper handwashing technique . 2. Observations in Resident #113's room, on 1/9/17 at 3:00 PM, revealed RN #1 failed to wash her hands prior to connecting the antibiotic to the Intravenous (IV)tubing. Interview with RN #1 on 1/11/17 at 4:39 PM, in the north med room, RN #1 was asked if she had washed her hands prior to hanging the IV antibiotic. RN #1 stated, .I did not . 3. Observations in Resident #112's room, on 1/10/17 at 8:23 AM, revealed LPN #2 administered an inhaler to the resident. LPN #2 did not wash hands before medication administration. Interview with LPN #2 on 1/11/17 at 4:27 PM, in the 100 hall, LPN #2 was asked if she had washed her hands before administering the inhaler. LPN #2 stated, .I didn't wash my hands . Interview with the Director of Nursing (DON) on 1/11/17 at 4:55 PM, in the DON's office, the DON was asked what do you expect nurses to do prior to giving medications. The DON stated, .wash hands .before and after .

Based on review of the POCKET GUIDE TO PRESSURE ULCERS and National Pressure Ulcer Advisory Panel, medical record review and interview the facility failed to ensure accurate wound assessments related to staging of the pressure wounds were completed for 1 of 3 (Resident #89) sampled residents reviewed of the 5 residents with a pressure ulcer. The finding included: 1. Review of the POCKET GUIDE TO PRESSURE ULCERS THIRD edition, page 48 documented, .reverse staging is prohibited. Therefore, once an ulcer reaches a high numeric stage, it remains that stage even as it heals . Review of the National Pressure Ulcer Advisory Panel .updates the stages of pressure injury .Date: April 13, 2016 . retrieved from www.npuap.org <http://www.npuap.org> documented .if slough or eschar is removed, a Stage 3 or 4 pressure injury will be revealed . 2. Medical record review revealed Resident # 89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Wound and Pressure Ulcer Information revealed on 9/9/16 the wound was documented as an unstageable wound with an increase in slough to the left buttock. On 9/23/16, the wound to the left buttock was documented as a Stage 2 with granulation tissue. Review of the facility's Wound and Pressure Ulcer Information revealed on 9/16/16 the sacrum wound was documented as an unstageable wound. On 9/23/16, the sacrum wound was documented as a Stage 2 pressure ulcer with granulation tissue. Interview with the Assistant Director of Nursing (ADON) on 1/11/17 at 10:33 AM, in the conference room, the ADON stated .left buttock prior to admission on 9/9/16 the date of onset was 9/2/16 due to Stage 2 declined to unstageable in the wound .became an unstageable on 9/9/16 .looks like it improved to me. It should've been staged at a 3 or 4 .she staged it incorrectly . Interview with the Director of Nursing (DON) on 1/11/17 at 4:20 PM, outside the Dining room, the DON was asked if a wound is unstageable, can it ever be a stage 2. The DON stated, .I believe it can be .

Based on policy review, medical record review, observation and interview, it was determined the facility failed to complete neuro checks and follow up monitoring each shift for 72 hours after 1 of 3 (Resident #38) sampled residents of the 24 residents included in the stage 2 review had an unwitnessed fall. The findings included: Review of the facility's "Fall Risk/Fall Prevention Guidelines" policy documented, "...Licensed nursing will complete follow-up/monitoring documentation on each shift after each fall for 72 hours..." Medical record review for Resident #38 documented an admitted [DATE] and re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/4/14 documented, "...Functional Status... Extensive Assistance... One Man Assist for ADL's (Activites of Daily Living)... G0300. Balance During Transitions and Walking... 2. Not steady, only able to stabilize with staff assistance..." Review of nurse's event note dated 9/4/14 at 2:50 AM documented, "...Res. (resident) call light went off, this nurse went to answer light and found res on floor beside the bed. Res had woke up earlier not being able to sleep and wanted to go ahead and wash up for dialysis, she said she wanted to sit up in her wheelchair for awhile before going back to bed. When this nurse entered the room, res was beside bed sitting on her buttocks, res was alert and stated she was trying to transfer from her chair to the bed and slid to the floor. When asked she did not hit her head, she just slid to the floor... IMMEDIATE STEPS IMPLEMENTED TO PREVENT RECURRENCE: Instructed res to use call light for assistance before trying to transfer. Apply skid socks..." The facility was unable to provide documentation the nurses had completed neuro checks and follow-up/monitoring on each shift for 72 hours after Resident #38's fall on 9/4/14. During an interview at the north nurses' station on 9/24/14 at 11:35 AM, the Assistant Director of Nursing (ADON) was asked if she could find nurses' note for follow-up on Resident #38's 9/4/14 fall. The ADON stated, "I don't see one." During an interview in the Director of Nursing's (DON) office on 9/24/14 at 1:45 PM, the DON was asked what her expectations were for her staff after a fall took place. The DON stated, "I expect the nurses to complete an assessment, neuro checks if a fall is unwitnessed, complete an occurrence investigation and apply an appropriate intervention and document follow up monitoring every shift for 72 hours. The DON was asked if her staff completed fall monitoring documentation for Resident #38. The DON stated, "No, I can't find any." The DON was asked if there was documentation that neuro checks were completed. The DON stated, "No, I don't see any."

Based on policy review, observation, and interview it was determined the facility failed to ensure hot foods were served at 135 degrees Fahrenheit (F) or above. The findings included: Review of the facility's "ORGANIZATION FOR FOOD PREPARATION" policy documented, "...Hold prepared foods at proper temperature...(hot food at 135 (symbol for degree) F. or above)..." Observations in the kitchen on 11/15/11 at 11:20 AM revealed the first meal cart left the kitchen. The hot food temperatures taken at 11:22 AM revealed chopped meat at 110 degrees F, pureed peas at 118 degrees F, and pureed meat at 118 degrees F. During an interview on 11/14/11 at 3:40 PM at the South Wall nurses' station Dietary Staff #1 confirmed that hot foods should be served at 135 degrees or higher.

Based on "The Long Term Pocket Guide for Infection Control", observation and interview, it was determined the facility failed to ensure that pericare (perineal care) was performed according to the policy for 1 of 2 (Resident #5) sampled residents observed during pericare. The findings included: Review of the "Long-Term Pocket Guide for Infection Control...Section 2...page 50..." documented, "...Decontaminate hands if moving from a contaminated-body site to a clean body site during resident care...Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident..." Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #5's room on 11/15/11 at 9:40 AM revealed Certified Nurse Assistant (CNA) #1 donned gloves and placed a barrier across Resident #5. CNA #1 repositioned the residents right leg. CNA #1 proceeded to perform perineal care without changing her gloves. During an interview in Resident #5's room on 11/15/11 at 9:45 AM CNA #1 stated, "...should have changed gloves..." During an interview in room [ROOM NUMBER] on 11/16/11 at 8:35 AM the Director of Nursing confirmed staff should not go from a dirty to a clean area without changing gloves.

Based on observation and interview, it was determined the facility failed to maintain a clean environment in two of twenty-five resident's bathrooms on the facility's North Wing as evidenced by the over the commode chair with yellow dried spots in 1 of 25 (Room 224) bathrooms and brown substance on grout around the commode in 2 of 25 (Room 224 and 230) bathrooms. The findings included: Observations during the initial tour on 11/14/11 at 9:10 AM revealed two bathrooms located in resident rooms 224 and 230 had a brown debris at the base of the commode. Observation on 11/14/11 at 9:10 AM revealed the bathroom located in room 224 had dried yellow spots on the lid of the over the commode chair and brown greasy debris on the arm rests. Observations on 11/15/11 at 3:00 PM in the bathroom of room 224 and 230 revealed the grout around the two commodes was still soiled. The lid and arm rest of the over the commode chair were still soiled. During an interview on 11/16/11 at 4:00 PM in the bathroom of room 224 the Housekeeping Supervisor, Maintenance Supervisor and the Assistant Director of Nursing verified that the base of the commodes and the over the commode chair were dirty and should be cleaned.