Every finding on record at Victorian Village HLTH & Well

Based on observation, interview, and record review, the facility failed to ensure staff appropriately perform hand hygiene during g-tube care and during dining, failed to ensure staff donned PPE (personal protective equipment) outside of the resident's room for a resident on EBP (enhanced barrier precaution), and failed to ensure staff appropriately transporting soiled linens from a resident room to the soiled utility room in an effort to prevent the spread of infectious microorganism. These failures affected 3 of 8 residents (R9, R79 and R82) reviewed for infection control and had the potential to impact 16 residents in the 2 affected units. The findings include The resident census dated August 3, 2026, showed the combined census on the 2 affected units was 16. 1. On August 3, 2026, at 4:10 p.m., a sign on R9's door stated, Enhanced Barrier Precautions (EBP) and directed everyone to clean their hands before entering and when leaving the room. It also instructed providers and staff to wear gloves and gowns during high-contact resident-care activities, including care or use of a central line, urinary catheter, feeding tube, tracheostomy, or any skin opening requiring a dressing. A personal protective equipment (PPE) bin was located by R9's door. V18 (Nurse) took PPE from the bin and entered R9's room without performing hand hygiene, then donned the PPE inside the room. V18 removed R9's gastrostomy-tube (G-tube) dressing, cleansed the site, removed her gloves, and placed the soiled gloves on R9's dressing table. She did not perform hand hygiene before donning a clean pair of gloves and completing the dressing change. R9 is an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses include multiple rib fractures, pulmonary fibrosis, gastrostomy, anxiety disorder, parotid-gland cancer, repeated falls, and dysphagia. R9's BIMS score, dated July 8, 2026, was 13, indicating intact cognition. R9's care plan, initiated on July 2, 2026, documented EBP related to his gastrostomy tube. 2. On August 3, 2026, at 4:25 p.m., a sign on R82's door stated, Enhanced Barrier Precautions (EBP) and directed everyone to clean their hands before entering and when leaving the room. It also instructed providers and staff to wear gloves and gowns during high-contact resident-care activities, including care or use of a central line, urinary catheter, feeding tube, tracheostomy, or any skin opening requiring a dressing. A PPE bin was located by R82's door. V18 (Nurse) took PPE from the bin and entered R82's room without performing hand hygiene, then donned the PPE inside the room. V18 removed R82's gastrostomy-tube (G-tube) dressing, cleansed the site, and removed her gloves. She did not perform hand hygiene before donning a clean pair of gloves and completing the dressing change. R82 is a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses include muscle disorders, chronic respiratory failure with hypoxia, laryngeal edema, dysphagia, gastrostomy, hypertension, diabetes, and dementia. R82's BIMS score, dated August 1, 2026, was 03, indicating cognitive impairment. His care plan, initiated July 29, 2026, documented Enhanced Barrier Precautions related to his PEG tube. On August 4, 2026, at 1:19 p.m., V2 (Director of Nursing) stated that staff are expected to perform hand hygiene and don PPE before entering a room under EBP. V2 added that soiled gloves should be discarded and that staff must perform hand hygiene after removing gloves and before putting on a new pair. The facility's Enhanced Barrier Precautions SNF policy, effective March 1, 2023, stated that Providence Life Services uses Enhanced Barrier Precautions to reduce transmission of novel or targeted multidrug-resistant organisms (MDROs) and infection risk among residents with open wounds or indwelling medical devices. The policy further indicated that EBP applies to residents with a chronic wound or indwelling medical device, even when the resident is not known to be infected or colonized with an MDRO. The facility's Isolation Precautions policy instructed staff to remove gloves promptly after use and discard them before touching noncontaminated items or environmental surfaces. The facility's Handwashing policy identified hand hygiene as one of the most effective infection-control measures and required it before and after glove use, including during food handling and resident care. 3. On August 4, 2026, at 11:45 AM, during meal service in one unit dining room, V17 (Certified Nursing Assistant), while wearing gloves, removed used cups and napkins from the dining room tables and put them in the trash. V17 did not change gloves or perform hand hygiene after throwing away the used cups and napkins. V17 then passed out clean silverware to the residents in the dining room. On August 4, 2026, at 11:59 AM, V17 picked up a piece of bread that had fallen to the floor and threw it in the trash. V17 did not change gloves or perform hand hygiene. V17 continued to prepare lunch trays for the residents. On August 6, 2026, at 8:42 AM, V2 (Director of Nursing), verbalized that during meal service, staff are expected to discard gloves and perform hand hygiene when they are discarding trash or if something falls to the floor and they need to pick it up. The facility's policy titled, Infection Control Nursing Procedures.Handwashing last reviewed February 2026 states that, Purpose: Handwashing is considered one of the most effective infection control measures. Frequency: .5. After handling any contaminated items. Also, after contact with inanimate objects in the immediate vicinity of the client .9. Before and after using gloves (i.e., handling food, client care) . 4. On August 03, 2026, at 11:04 am in another unit, this surveyor and V12 (MDS Coordinator) entered R79's room. Inside the room, V9 (Certified Nursing Assistant) put soiled linens in yellow laundry bag, removed her gloves, and then held the top of the yellow bag and dragged the bag outside of R79's room and walked towards the soiled utility room. This was pointed out to V12. V12 stated she (V9) was dragging the soiled linen bag on the hallway floor; she should not have done that for infection control. V9 was then observed opening the soiled utility room and put the yellow laundry bag inside. On August 5, 2026, at 9:27am, V9 (Certified Nursing Assistant) stated she just completed changing her (R79)'s bed linens and sheets and completed assisting her with shower; and she forgot to use the laundry cart when she transported the laundry bag. V9 stated she dragged the laundry bag on the hallway floor towards the soiled utility room. V9 stated she was supposed to use a cart to transport the soiled linens because it was not hygienic dragging the soiled linen on the floor. On August 03, 2026, at 11:20 AM, V3 (Assistant Director of Nursing) stated the expectation is to put the laundry bag in the laundry cart or carry it, if not heavy away from their uniform, for infection control. V3 stated everyone in the Rehab 2 unit uses a walker or a wheelchair when they go to therapy room located on Rehab 2 unit adjacent to the soiled utility room. On August 04, 2026, at 11:23am, V2 (Director of Nursing) stated the expectation is to put all soiled linens in the yellow laundry bag and to transport the soiled linens to the soiled utility room using a linen cart. Staff should not be dragging the laundry bag onto the hallway floor because this creates a risk of contaminating the floor and cross contaminating the shoes of the residents, staff, and visitors walking on hallway. R79's admission Record documented that this resident is a [AGE] year-old female Caucasian with diagnoses including but are not limited to disorder of muscle, acute kidney failure, and hypertension. R79's (8/3/2026) Bath and Skin Check sheet documented that V9 assisted R79 with shower. The (August 5, 2026) email correspondence with V2 (Director of Nursing) documented, in part This is our policy on transporting linen. For the CNAs, the expectation is that when they are transporting soiled linens from the room to the soiled utility room that it is in a yellow linen bag and that they use the cart to transport the linen through the hallway. It is important for them to use the cart to transport the linen for infection control and to prevent cross contamination.

Based on observation, interview, and record review, the facility failed to ensure resident's dignity during meals for residents, who are dependent on staff for feeding. This applies to 2 of 2 residents (R20 and R54) reviewed for activities of daily living (ADL) care in the sample of 17.The findings include 1. On August 3, 2026, at 12:35 p.m., R54 was observed in the dining area with five other residents. R54 is an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses include dementia, hyperlipidemia, depression, Alzheimer's disease, cardiomyopathy, prostate cancer, and a cardiac pacemaker. Two staff members were present on the unit. V4 (Nurse) served lunch trays to the six residents seated at the table, while V5 (Certified Nursing Assistant, CNA) delivered trays to residents in their rooms. V4 sat with another resident, and four residents fed themselves. R54 stared at his food but was unable to feed himself. He did not receive feeding assistance until 12:58 p.m., by which time four other residents at the table had finished their meals. V4 was also observed standing while feeding R54.R54's BIMS score, dated June 10, 2026, was 00, indicating severe cognitive impairment. He was unable to express himself.The functional-ability section of R54's MDS, dated [DATE], indicated that he made no effort to eat independently and was dependent on staff for eating.R54's care plan, initiated September 23, 2024, documented an ADL self-care deficit related to deconditioning, metabolic encephalopathy due to hyponatremia, acute or chronic CHF, and respiratory failure. The plan indicated that R54 depended on one staff member for meals. 2. On August 4, 2026, at 8:20 a.m., R20 was observed in the dining area with five other residents. R20 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses include palliative care, major depression, protein-calorie malnutrition, nutritional deficiency, anxiety disorder, psychosis, and hypertension. At 8:24 a.m., V4 (Nurse) served breakfast trays to all six residents at the table, including R20. Three residents required feeding assistance. The other two residents received assistance, but R20 was not helped with breakfast until 8:50 a.m., after everyone else at the table had finished eating. There was no cueing on the part of the staff to encourage R20 to eat. R20's care plan, initiated January 18, 2022, documented: substantial/maximal assist x 1; see if R20 is feeding herself, if not then assist with eating. On August 4, 2026, at 1:19 p.m., V2 (Director of Nursing) stated that the residents should have received meal assistance because the unit was adequately staffed. Review of facility's policy titled, 'Activities of Daily Living (ADL) Care' with effective date of December 2019, showed ADL care is provided to prepare the client for daily activities, promote good health, hygiene and well-being. 1. Follow all appropriate client's rights and infection control practices. 2. Based on the needs of resident, ADL care may be comprised of any of the following: e. Meal attendance and assistance.

Based on observation, interview, and record review, the facility failed to follow the transfer method recommended by physical therapy and indicated in the resident's plan of care. This failure resulted in R1 sustaining a 12cm (centimeter) left lower leg laceration, transfer to the hospital, and laceration repair with 21 sutures.This applies to 1 resident (R1) reviewed for safe transfers in a sample of 4.The findings include:On 3/24/2026 at 1:24 PM, R1 was in bed with a gauze wrap on her left leg.On 3/24/26 at 4:07 PM, V5 (CNA/Certified Nurse Assistant) said on 3/4/26 V12 (CNA) asked her to assist with transferring R1. V5 said prior to the transfer, R1's wheelchair was next to her bed, facing the head of the bed, with R1's left leg next to the bed. V5 said she was standing behind R1's wheelchair, and did not touch R1 during the transfer. V5 said V12 told R1 to hold onto the bed rail with her left hand while V12 put her arms under R1's armpits while she stood up. V5 said V12 did not use a gait belt or sit to stand mechanical lift. V5 said R1 stood up, pivoted to her left and sat down on the bed and then said my leg. V5 said she and V12 then looked down and saw R1's leg was bleeding and V5 thought R1 must have scraped her leg on the wheelchair during the transfer. V5 said she never took care of R1 before and she did not know R1's transfer status, she trusted V12 knew how to transfer R1 safely. V5 said the CNAs have to follow the transfer status recommended by therapy, because they are the ones who evaluate the resident for safe transfer and that is their expertise.On 3/24/26 at 10:48 AM V2 (DON/Director of Nursing) said on 3/4/26 as V5 and V12 (CNAs) were transferring R1 from her wheelchair to her bed, R1's leg got caught on the wheelchair and once she was in bed, the CNAs noticed the laceration on her left leg. V2 said at the time of the transfer, R1 was a sit to stand mechanical lift transfer as per physical therapy assessment and recommendation. V2 said as a result of R1's injury during transfer, V12 no longer worked at the facility and had been let go due to improper transfer and not following the facility culture of safety.On 3/25/26 at 9:27 AM, V13 (PTA/Physical Therapy Assistant) said as of 3/4/26, the nursing staff was expected to transfer R1 with the sit to stand mechanical lift with 2 staff assistance. V13 said there were times in the therapy gym that R1 was able to transfer with max assist x1 therapist with gait belt, but therapy delegated to the nursing staff to use the sit to stand mechanical lift with 2 staff for transfers. V13 said therapy would have to observe R1 perform repeated max assist stand and pivots in the therapy gym before they would upgrade R1's transfer status to a one-person max assist. V13 said therapy always encourages gait belts to be used for max assist transfers so there is a place for staff to hold other than the resident's appendage. V13 said lifting from under a resident's armpit puts them at greater risk for injury.R1's Face Sheet shows she was admitted to the facility on [DATE] with primary diagnosis of disorder of muscle and R1's POS (Physician Order Sheet) shows an order dated 2/26/26 may have physical therapy evaluate and treat as indicated.R1's Transfer to Hospital Summary dated 3/4/26 at 23:35 stats RN (registered nurse) was notified by CNA that assistance was needed in the resident's room. Upon entering, resident was observed sitting on the edge of the bed with an open laceration noted to the left lower leg with active bleeding present. When asked about the incident, CNA reported resident obtained skin injury during transfer. Assessment revealed a laceration measuring approximately 13cm in length and 3cm in width to the left lower leg. Due to the size and depth of the wound, RN activated EMS (911) for transfer to the hospital for further evaluation and treatment. Resident transported via EMS for further evaluationR1's ED (Emergency Department) Provider Notes dated 3/4/26-3/5/26 shows: Laceration Repair on 3/5/26 at 4:46 AM of left lower leg 12cm length and 5mm (millimeter) depth laceration with 21 simple interrupted sutures.R1's Care Plan initiated 2/26/26 states resident has an ADL self-care performance deficit related to deconditioning and interventions include transfer resident with sit to stand machine.The facility's policy titled, Lifts and Safe Client Movement Program last revised 1/26 states, Policy:.committed to providing safe care that maximizes clients' quality of life while maintaining a safe work environment for employees. The Safe Client Movement Program includes client movement equipment, employee training, client plan of care and a culture of safety approach to safety in the work environment. Definitions:. Client Movement Equipment: Equipment used to assist in the lift, transfer or repositioning process. Examples include gait belts, sit to stand lift, total mechanical lift, sliding boards, repositioning sheets, etc. Employee Responsibilities:.It is the responsibility of the employee to follow the transfer method indicated in the plan of care.

Based on observations, interviews and record review, the facility failed to follow the planned menu plan for residents on diabetic diets. This applies to 4 of 4 residents (R10, R198, R202, R248) reviewed for dining in the sample of 13. The findings include: Daily menu spreadsheet for Monday June 30, 2025 lunch meal showed that dessert choice for all diets except for CCHO (Carbohydrate Controlled diet) was #8 scoop or 1/2 cup Cherry Cobbler. The dessert choice for the same meal for CCHO diets for diabetics included #8 scoop of spiced peaches. On June 30, 2025 at 12:30 PM, the lunch meal service was observed in the facility 2nd floor dining room with V8 CNA (Certified Nursing Assistant) and V9 (CNA) serving the meals from the server. V9 was noted slicing Cherry Cobbler in the server and passing it out to the residents seated in the dining room for dessert. 1.R10's face sheet had multiple diagnoses including Type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. R10's 5 day MDS (minimum data set) dated May 31, 2025 showed that R10 was cognitively intact. R10's diet order on POS (Physician Order Summary) dated May 28, 2025 included CCHO, NAS [No added salt] diet, Regular texture, Thin Liquids consistency. On June 30, 2025 at 11:18 AM, R10 stated Food here is not diabetic friendly. My sugar goes up as I have to eat what they serve me. I don't want any night time snacks. I try to pick things on the menu that is for diabetics. On June 30, 2025 at 12:45 PM, R10 was served cherry cobbler with her meal. R10 was seen eating the cherry cobbler after she finished her meal. When asked R10 stated They gave it to me. They need to be more careful. R10's nutritional care plan revised May 28, 2025 showed to provide, serve CCHO NAS diet as ordered. 2. R202's face sheet had multiple diagnoses including Type 2 diabetes mellitus with hyperglycemia, other specified noninfective gastroenteritis and colitis. R202's diet order on POS dated June 24, 2025 included CCHO/NAS diet, Regular texture, Thin Liquids consistency. On June 30, 2025 at 12:46 PM, R202 was seated at the dining room and eating her lunch which included cherry cobbler. R202's nutritional care plan initiated June 25, 2025 showed to provide, serve diet (CCHO, NAS) as ordered. 3. R248's face sheet had multiple diagnoses including type 2 diabetes mellitus without complications, unspecified atrial fibrillation, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R248's diet order on POS dated June 20, 2025 included CCHO/Heart Healthy diet, Regular texture, Thin Liquids consistency. On June 30, 2025 at 12:46 PM, was seated at the dining room and eating his lunch which included cherry cobbler. R248's care plan initiated June 23, 2026 showed provide, serve diet (CCHO Heart Healthy) as ordered. 4. R198's face sheet had multiple diagnoses including including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. R198's 5 day MDS dated [DATE] showed that R198 was moderately impaired in cognition. R198's diet order on POS dated June 23, 2025 included CCHO diet for management of Diabetes Mellitus. On June 30, 2025 at 1:10 PM, R198 was eating from a room tray in his room. R198 received cherry cobbler in his room which R198 ate 100%. When asked whether he ordered the cherry cobbler, R198 stated that he was served the same. R198's care plan revised June 23, 2025 showed to provide CCHO Heart Healthy, Mechanical Soft as ordered. On June 30, 2025 at 12:59 PM when V5 (Director of Dining) was asked what dessert the Diabetics were supposed to receive, V5 stated that the residents were supposed to have received peaches as it was on the meal tickets. V5 then brought forward a container of peaches that was covered in a plastic wrap and kept at the corner of the counter in the 2nd floor dining room server. On June 30, 2025 at 1:18 PM, V4 (Dietitian) stated that it was an error on the staffs part and the residents on CCHO diets should have received spiced peaches instead of cherry cobbler. Facility 'Resident Diet Information' dated June 30, 2025 included that R10, R198, R202 and R248 were on CCHO diets.

2. Face sheet showed R21 is 73 years-old who has multiple medical diagnoses including aftercare following joint replacement surgery and infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter. Care plan dated June 9, 2025, shows R21 is receiving intravenous (IV) antibiotic therapy for 35 days related to prosthetic joint infection after a total knee arthroplasty (TKA). R21 was in his room on June 30, 2025, from 12:14PM until 12:40PM receiving care from V13 (Nurse). R21's room was noted with a sign showing, Enhanced Barrier Precautions and a set-up was noted outside R21's room door. During this time, V12 provided care to R21 (flushing an IV line, applying compression socks and changing dressing to the wound) without wearing an isolation gown. 3. R2 is 76 years-old who has multiple medical diagnoses including displace comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing. On July 1, 2025, at 11:12 AM, V16 (Certified Nursing Assistant/CNA) provided personal care and hygiene to R2. V16 cleaned R2's perineum from front to back, she put a pair of shorts on to R2 and a pair of sneakers on his feet. V16 helped R2 to reposition and placed new sheet on the bed. V16 changed her gloves in between tasks, however, she did not perform hand hygiene throughout the provision of care. 4. Face sheet showed R149 is 73 years-old who has multiple medical diagnoses including enterocolitis due to clostridium difficile, not specified as recurrent. Active care plan shows R149 is on isolation for Clostridium Difficile (C. diff). On July 1, 2025, at 1:41 PM, V12 (CNA) and V17 (Nurse) rendered peri-care to R149. V12 cleaned R149 from front to back, she changed the incontinence brief, opened R149's vanity drawer multiple times and help reposition R149. V12 changed her gloves in between tasks, however, she did not perform hand hygiene all throughout the provision of care. On July 2, 2025, at 1:50 PM, V2 (Assistant Director of Nursing/ADON) stated that every time a staff provide patient direct contact care to a resident on EBP, the staff must put on gloves and gown as protection between staff and resident. When the staff provide incontinence or peri-care, the staff must change gloves and perform hand hygiene from dirty to clean tasks, or in between tasks to prevent cross contamination and the spread of infection. The Facility's Enhance Barrier Precautions (EBP) Policy and Procedure dated March 21, 2024, shows: Policy: Facility employs Enhanced Barrier Precautions in effort to reduce the transmission of novel or targeted multi drug resistant organisms (MDRO) and infection risk for residents with open wounds or indwelling medical devices. Enhance Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employs targeted gown and glove use during high contact resident care activities. Procedure: 1. Enhance Barrier Precautions (EBP) are used in conjunction with standard precautions and require the use of gown and glove during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Based on observation, interview and record review, the facility failed to ensure that hand hygiene was performed during perineal care and failed to ensure that a gown was donned during wound care for a resident identified on (EBP) Enhanced Barrier Precaution. This applies to 4 of 4 residents (R2, R20, R21, and R149) reviewed for infection control in the sample of 13. 1. R20's face sheet showed multiple diagnoses including, dementia, Alzheimer's disease and failure to thrive. R20's (MDS) Minimum Data Set, dated [DATE] showed the resident had severe cognitive impairment, urinary and bowel incontinence, and was dependent on staff for toileting. On July 1, 2025 at 11:22 am, V14 (CNA/Certified Nurse Assistant) provided incontinence care to the R20. R20's incontinence brief was soiled with urine and bowel movement. After provision of incontinence care, V14 touched R20's thigh and right hand to assist the resident to grab the bed rail, adjusted the pillow and the lift pad under the resident while using the same soiled gloves. V14 then took off the soiled gloves, pulled out two gloves from her pocket, wore the gloves and then applied a clean incontinence brief to the resident without performing hand hygiene (hand washing or use of hand sanitizer). On July 2, 2025 at 11:18 am, V2 (ADON/ Assistant Director of Nursing) stated while performing incontinence care, the CNA should remove gloves after cleaning the resident's urine and stool, and perform hand hygiene using hand sanitizer or soap and water. She also stated that the CNA should re-apply clean gloves before touching the resident or touching clean surfaces. V2 stated that hand hygiene and application of clean gloves should be performed in between dirty and clean tasks to prevent cross-contamination and ensure infection control. The facility's nursing policy and procedure regarding infection control last reviewed by the facility on April 2024 showed under types of precautions . 3. employees must wash their hands for twenty (20) seconds using soap and water under the following conditions: .d. after removing gloves. 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all of the following situations: a. before and after direct contact with residents; b. before donning gloves; . f. before moving from a contaminated body site to a clean body site during resident care; g. after contact with a resident's intact skin; . j. after removing gloves.

Based on observation, interview, and record review, the facility failed to provide supervision during meals. This applies to 1 of 1 resident (R201) reviewed for eating supervision in the sample of 13 The findings include: R201's face sheet showed diagnoses including heart failure, asthma, chronic kidney disease, stage 2 (mild), diaphragmatic hernia without obstruction or gangrene, encounter for screening for respiratory tuberculosis, complete rotator cuff tear or rupture of right shoulder, not specified as traumatic. R201's MDS (minimum data set) dated June 20, 2025 showed that R201 needs substantial maximal assistance with eating. R201's POS (Physician Order Summary) June 13, 2025, showed diet order of CCHO [Carbohydrate Controlled diet] Heart Healthy diet, Regular texture, Thin Liquids consistency. Fluid Restriction and Maximum Supervision at meals. On July 01, 2025, at 09:09 AM, R201 was lying in bed with the head of bed raised at about 30-45-degree angle and eating breakfast from an over the bed table. R201's right arm was in a sling. R201 continued to cough in between mouthfuls of food. Staff was not present in R201's room or in the immediate area. On July 01, 2025, at 09:22 AM, V6 (Speech Therapist) was seen evaluating R201 while eating breakfast. On July 01, 2025 at 1:17 PM, V6 stated that R201 should be eating with the head of bed at 90 degree angle and should sit upright for 30 minutes after the meal. V6 added that R201 should have staff supervision at meals. V6's treatment encounter progress notes dated July 01, 2025, included the following information: Patient is seen by skilled Speech Therapy to address dysphagia deficits. Educated patient verbally and followed up with staff via email regarding recommendations from swallow evaluations, including Diet CCHO Heart Healthy diet, Regular texture, Thin Liquids. Tray set up with assist. Meat /vegetables cut up into approximately quarter sized pieces. Upright 90 degrees for all po [oral] intake. Supervision at meals. Cue R201 to eat slowly, alternate one sip for every 3-4 bites of food. Small bites/small sips. Upright 90 degrees and 30 minutes post po intake. Ensure oral cavity is clear following po intake On July 2, 2025 at 10:48 AM, V2 (Assistant Director of Nursing) stated that R201 needs maximum assistance with feeding. V2 stated that maximal assistance means that the resident needs more than 50% assistance from staff with eating including supervision.

Based on interview and record review, the facility failed to follow their policy and procedure regarding privacy and confidentiality of health information. This applies to 2 of the 3 residents (R2, R3) reviewed for privacy/confidentiality in the sample of 5. The findings include: 1. The electronic medical record (EMR) shows R2 is 77 years-old who was admitted to the facility for a short-term rehab and was discharge from the facility on May 23, 2025. R1 was discharge with multiple medications including the Fluticasone furoate-vilanterol (Breo Ellipta) inhaler. However, on May 22, 2025 (the day prior to R2's discharge), R2's (inhaler) was sent with R1 when R1 was discharge that day. On June 2, 2025, at 8:58 AM, V15 (R1's Daughter) stated that she picked up R1 from the facility and brought him home with her. V15 found R2's Breo Ellipta inhaler when she started sorting through R1's medications that was provided by the facility. V15 called the facility to inform them about it. 2. The EMR shows R3 is 77 years-old who was admitted to the facility on [DATE], for a short-term rehab. Physician ordered multiple treatment including occupational therapy. R3 remained in the facility at the time of this survey. On June 2, 2025, at 8:58 AM, V15 said that V12 (Home Health Physical Therapist/PT) went to their house to evaluate R1. During evaluation, V12 asked a question that was not related to R1's condition. Upon review of R1's electronic medical records, V12 found a page of R3's therapy notes. V15 also verbalized concern, that information of other residents (R2's medication and R3's therapy note) was sent to them. On June 2, 2025, at 2:58 PM, V12 (Physical Therapist/PT) stated that she saw R1 for initial physical therapy (PT) assessment. V12 obtained R1's information from the electronic medical records (EMR) of their agency which was provided by the nursing facility where R1 came from. There was multiple information in the EMR including laboratory results, medications and therapy notes. However, V12 did not notice the discrepancy until she assessed R1 and interviewed V15 (R1's daughter). V12 inquired about R1's arm sling. V12 was informed that R1 does not wear a sling. V12 reviewed R1's EMR again and realized that the page of the medical record that she was reading belonged to R3. Facility presented a copy of R1's discharge medical record that was sent to the home health agency. The discharge documents show multiple information including therapy notes. There was a page in R1's therapy notes that belongs to R3. It was an occupational therapy note dated May 21, 2025, which showed R3's name, birthday, and plan of care. On June 2, 2025, at 2:34 PM, V1 (Administrator) stated V15 called the facility and reported that R1 did not received the Metoprolol medication prescribed to him. When V1 delivered the Metoprolol, V15 informed her that R3's inhaler was sent with R1. V15 returned the inhaler to V1. On June 3, 2025, at 1:29 PM, V1 also stated that part of the discharge referral for home health care is to send information or medical records of the resident to the home health provider. The expectation is to release accurate documentations/documents to the provider; the documents should only pertain about the concerned resident. The facility's Confidentiality of Health Information/HIPAA policy and procedure with the most recent review date of December 2023, shows: Policy: The facility will uphold the client's right to have their health information kept confidential. Procedure: The medical records department will establish systems that ensure that client information is maintained in an orderly and secure manner. Establish systems will cover areas including but not limited to record storage, records maintenance, and record release. Facility's Notice of Privacy Practices (undated) shows: Facility is required by law to maintain the privacy of your protected health information (PHI) and to provide you with a notice of its legal duties and privacy practices. State and federal laws require this facility to maintain the privacy of your health information .

Based on interview, and record review, the facility failed to ensure that all prescribed medication was provided to the resident upon discharge. This applies to 1 of 3 residents (R1) reviewed for discharge process in the sample of 5. The findings include: The electronic medical record showed that R1 is 93 years-old who was admitted to the facility for a short-term rehab, and was discharged from the facility on May 22, 2025, to his daughter's (V15's) home. R1's discharge order summary report showed multiple prescribed medications, including Metoprolol Succinate ER 12.5 milligrams (mg) twice a day. On June 2, 2025, at 8:58 AM, V15 (R1's Daughter) said she sorted through R1's medications when they got home, and observed that the prescribed medication, Metoprolol, was missing. However, V15 found a Breo Ellipta medication that belongs to R2, that was mixed among R1's discharge medications. On June 3, 2024, at 12:53 PM, V9 (Nurse) stated that part of their discharge process is to ensure that prescribed medications were reviewed, and dispensed medications were provided to the resident either for 15 days or 30 days, depending on the request of the resident or resident representative. They also review and itemize each medication with the resident or resident representative prior to discharge to ensure that they are going home with the right medications and prescriptions. On June 2, 2025, at 2:34 PM, V1 (Administrator) stated V15 called the facility and reported that R1 did not received the Metoprolol medication prescribed to him. V1 delivered the Metoprolol to R1 on May 23, 2025. On June 4, 2025, at 12:11 PM, V2 (Director of Nursing/DON) stated that it is their expectation upon the resident's discharge that the nurse will give discharge instructions, including medication review to the resident and family; ensuring that resident will be discharged with the medications that were prescribed to them. Facility's policy and procedure for Discharge of a Client with the review date of May 2024, shows multiple procedures including: - Complete client/family education about treatments, procedures, and supply use and document in the medical record. - Review medications and use with responsible party. - Arrange for medication needs at home.

Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to all 46 residents in the facility receiving dietary services. Findings include: On [DATE] at 3:42 PM V2 DON (Director of Nursing) confirmed on [DATE] all 46 residents of the facility received dietary services. On [DATE] at 10:08 AM, the facility main kitchen was toured with V9 Director of Dining Services. Dust was covering the vents over the stove. Open pots of food were cooking on the stove. Large Refrigerator- Zipped bag of 3 hot dogs dated [DATE]. Ham loosely wrapped with plastic wrap open and exposed dated [DATE]. Raw ground beef 10lb chub open end covered by plastic wrap meat gray. No opened on or use by date. Shredded Mozzarella cheese 5lb (pound) dated ,d+[DATE] bag open to air no use by date. Grated parmesan cheese 5lb opened dated [DATE]. Yellow sliced cheese no labels no open on or use by dated. Corner of cheese hard. Grated parmesan 5lb bag open dated ,d+[DATE] and ,d+[DATE]. V9 stated it has too many dates and not sure when it expires. Vanilla icing 12lb opened with brown specs in it no opened on or use by dates. Blue bucket with no product label delivery date or use by date contained sliced brown mushrooms with dark spots on them. Pantry- V9 Director of Dining Services stated we throw dented cans out we don't send them back anymore. Dented cans: Two cans of pinto beans 6lb (pounds) 15oz (ounces). Diced tomatoes 6lb 5oz Two cans of water chestnuts 3lb 14 oz Pumpkin pie mix 30 oz. Two cans chunk tuna White flakes identified by V9 as coconut [NAME] wrapped in plastic writing not legible. Freezer 1- items identified by V9 that were in a clear plastic bag and did not have a manufacture label or facility label with contents, dates: chicken cordon blue, omelets with frost in the bag, sweet potato fries, two bags of hash browns. Zipped bag dated ,d+[DATE] identified by V9 as lamb meat. Box of sliced beef 42 oz manufactures expiration date of [DATE] Cookie dough pieces 20lb box plastic bag open with frost and freezer burn. V9 stated everything should have a label and dates written on it so we know what it is when it came in, when it is opened and when it expires. Cabinets 7.5L (Liter) storage containers with cereals bran with raisins, oat o's, flakes of corn, crisped rice all with expiration date of [DATE]. White powder in 6L container identified by V9 as flour no label or date. Dried pasta 2lb box opened with contents exposed. Freezer 2- Items identified by V9. Two clear plastic bags with French fries - no label or dates. Seasoned curly fries bag opened no label or dates. Stuffed shells dated ,d+[DATE] with freezer burn and frost in the bag. Cookie dough in bag exposed to air with no label or dates. Bagged Waffles no labels or dates. Bagged French toast sticks no labels or dates. Kitchen Drawers- Drawer with kitchen utensils crusty with dried spills and crumbs. Drawer with jelly roll pans crusty Drawer with skillets - skillets were coated with grease. Drawer with hand grater was dirty with fingerprints and smeared with a dried substance. On [DATE] at 1:42 PM the second-floor kitchenette was toured with V11 CNA (Certified Nursing Assistant) Cabinets- Items stored under the kitchen sink two red buckets, plastic bags, dishwasher powdered detergent 75 oz box, liquid cleanser 2lb 8oz and pan cleanser 2.5L. Upper cabinet- bag of 1lb potato chips opened exposed to air dated ,d+[DATE]. Bag of potato chips no opened on or use by date. Refrigerator- Clear bowl of peaches in juice loosely covered with plastic wrap no label or dates. Clear bowl of cantaloupe and watermelon loosely covered with plastic wrap no dates or label. Sliced yellow cheese poorly wrapped in plastic corner of cheese dried out no label or use by date. Freezer- Chocolate shakes from three different fast-food restaurants with open tops no labels to identify who they belong to. Only one shake had a sticker from the restaurant dated [DATE]. On [DATE] at 10:19 AM, Faith house kitchen was observed with V13 CNA. Refrigerator- A clear bowl with mixed fruit did not have a label or date. Drawers- Drawer with muffing tin and jelly roll pans had dark splattered substance and crumbs in it. All the potholders in the drawer were dirty and crusty with food stains and particles. Two food warmers had dirty water in them and were caked with grease and dried drips of food. Lower cabinet with ketchup had a large dried dark orange spill. On [DATE] at 1:09 PM, V9 Director of Dining Services stated it is important to label foods with delivery date, open date and expiration date to make sure we aren't serving expired foods. If we use food from dented cans, it can develop bacteria. If someone eats it, they could get sick. The kitchen should be cleaned daily. in the houses the CNAs are responsible for the kitchen cleaning. Nursing should be overseeing the little house but it all falls under me so I should be doing rounds and reporting it to the appropriate manager if it is not being done. The kitchen should be cleaned and sanitized daily and after each use. The water in the steamer stray / warmer should not be left in there. The CNAs should be cleaning the refrigerators out completing the logs. They should be labeling food with open on and use by dates as well. foods should be sealed to avoid bacteria and contamination. Nothing should be stored under the kitchen sink. Open food in the freezer will get freezer burn, contaminated and it affects the taste. If food is removed from the original container, it should be labeled with the name of the product, open on and use by dates. On [DATE] at 1:44 PM, V2 (DON) Director of Nursing, stated the CNAs are responsible to make sure the kitchenettes are clean and completing the logs. The nurses are responsible for making sure the CNAs are completing their tasks and keeping the kitchen is in order. V2 stated he is responsible for making sure the nurses are monitoring the CNAs. The facility did not provide the requested kitchen logs for the two small house or 2nd floor for the dishwasher, refrigerator/freezer. Sanitization bucket or breakfast holding temperatures. The facility policy Food Storage Expiration Dates dated [DATE] states all opened food that is placed into storage shall be labeled with the product name, date opened and or expiration or use by date. leftover food and leftover deli meats expire three days after opening. Dairy products not in the original container expires 3 days after opening. Thawed, uncooked frozen foods and raw meats expires seven days after opening. The facility policy Storage dated [DATE] states all food, chemicals and supplies should be stored in a manner that ensures quality and maximizes safety of the food served. Personal items are not to be store in food supply storage areas. Store food in its original container if it is clean, dry and intact. If necessary, repackage food in clean, well labeled containers using food storage label. The facility policy Machine Ware Washing- High Temperature dated [DATE] states the dish machine will be checked prior to each meal period to ensue that it is functioning properly. Employees who use the dish machine will be responsible for knowing how to use the machine, document its use and properly maintain it after use. Record the date/ temperature and initial the entry on the dish machine record form. This should be done one time per meal period. The dining services manager / designee will check the temperature monitoring form to ensure that temperatures and thermal sticks meet standards and are recorded daily.

Based on interview and record review, the facility failed to offer COVID-19 vaccines to the facility's staff members and failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. This has the potential to affect all residents at the facility. Findings include: On 09/11/24 at 01:06 PM, V2 DON (Director of Nursing) said that he did not have any documentation to provide that the facility is offering the staff the COVID-19 vaccine or offering education about it. V2 said that the facility doesn't offer it anymore because it is too expensive. On 09/12/24 at 02:54 PM, V2 said that the facility has not offered any COVID-19 vaccine education to the staff in the last year. On 09/12/24 at 12:00 PM, V1 (Administrator) said that she has been at the facility since November 2023 and the facility has not offered COVID-19 vaccines to the staff or has had a COVID clinic since she has been here. V1 said that the facility should be offering the COVID-19 vaccine to staff. On 09/12/24 at 10:39 AM, V5 (Nurse) said that the facility has not offered the COVID-19 vaccine to him this year. On 09/12/24 at 10:41 AM, V6 (Housekeeping) said that the facility has not offered her the COVID-19 vaccine since 2020. On 09/12/24 at 10:57 AM, V4 (Wound Nurse) said that the facility has not offered her the COVID-19 vaccine. On 09/12/24 at 10:51 AM a sign on the wall in the entrance to the facility was observed, the sign showed, this establishment makes available opportunities for staff to be fully vaccinated against COVID-19. Please see your administrator for further information. The facility's COVID-19 Interim Measures policy (6/2/23) showed, for employees who have not received their COVID-19 vaccination but desire to receive one, the facility will discuss avenues for future vaccinations. At the time of this survey, the facility's CMS 671 form (Long-Term Care Facility Application for Medicare and Medicaid) showed a census of 46 residents.

Based on observation, interview, & record review, the facility failed to provide ADL care (activities of daily living) to dependent residents. This applies to 3 of 4 residents (R24, R27, & R30) reviewed for ADL care in a sample of 19. Findings include: 1. On 09/10/24 at 11:28 AM, R24 was observed in the dining room during activities, and she was observed scratching her head. At 12:26 PM, R24 was observed again but while she was being toileted and receiving incontinence care and R24 was still scratching her head and white flakes were observed on her shirt. At 01:09 PM, R24 was observed scratching her head and her nails were observed jagged with brown substance under the nails. R24's hair was observed dry with no oil present. R24 said that her head itches. R24's electronic health records showed that R24 is an [AGE] year old female admitted to the facility on [DATE] with diagnoses including encounter for palliative care, major depressive disorder, anxiety disorder & hypertension. R24's 8/19/24 MDS (Minimum Data Set) showed that R24 is dependent for personal hygiene. R24's 8/29/24 care plan showed that R24 has an ADL self-care performance deficit related to diagnoses including dementia with interventions including personal hygiene needing dependent assistance. 2. On 09/10/24 at 12:02 PM, R27 was in her room with V15 (R27's daughter) present. V15 said that she has a problem with the staff not taking care of her mother's dry skin. R27 was observed with dry skin on her arms and legs. R27's electronic health records showed that R27 is an [AGE] year old female admitted to the facility on [DATE] with diagnoses including unspecified dementia, hypertension, anxiety disorder & depression. R27's MDS showed that R27 needs dependent care for personal hygiene. R27's 9/13/22 care plan showed that she has an ADL self-care performance deficit related to deconditioning, and diagnoses including dementia with interventions including personal hygiene needing substantial/maximal assistance. 3. On 09/10/24 at 02:06 PM, R30 was observed in her bed with her fingernails on her right hand polished red and no polish on her fingernails on her left hand. On R30's left thumb a reddish brown colored substance was observed on the thumb and under the thumbnail. R30's right and left hands fingernails were also observed with long jagged nails with brown substances under the nails. At 02:12 PM V5 (Nurse) was told about the reddish brown substance on R30's thumb and came to examine R30. After examining R30 V5 left the room and then returned to clean R30's thumb and told the state surveyor that the staff informed him that the reddish substance on R30's thumb was strawberry jelly. At 02:17 PM, V8 CNA (Certified Nurse's Assistant) said that R30 had strawberry jelly and toast for breakfast and watermelon for lunch and that R30 eats with her hands and that was probably what was on her thumb. At 02:21 PM, V5 came out of R30's room after washing her hands and said that the reddish brown substance was the strawberry jelly and probably the watermelon too. R30's electronic health records showed that R30 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including hemiplegia & hemiparesis, spastic hemiplegia affecting right dominant side, dementia adjustment disorder, osteoporosis, depression and anxiety disorder. R30's 12/26/23 care plan showed that R30 has an ADL self-care performance deficit related to deconditioning, and diagnoses including right hemiparesis from previous CVA (cerebral vascular accident). The interventions included personal hygiene - dependent, shower bathe - substantial/maximal assist, check nail length and trim and clean on bath day and as necessary. R30 7/6/24 MDS showed - eating supervision or touch assistance, personal hygiene - dependent and R30's 7/7/24 mental cognition is moderately impaired. On 09/12/24 at 11:53 AM, V1 (Administrator) said that nails should be short and non-jagged, and they should be clean for hygiene, infection control, and dignity. V1 said that the resident's skin should be moisturized because the residents have poor skin elasticity, and to prevent skin tears. The facility's Activities of Daily Living (ADL) Care policy (2/5/24) showed ADL care is provided to prepare the client for daily activities, promote good health, hygiene and well-being. Based on the needs of resident, ADL care may be comprised of skin care, nail care, toilet assist-incontinence care and personal hygiene.

Based on observation, interview and record review the facility failed to follow manufacturer guidelines for blood glucose monitoring. This applies to one resident (R35) reviewed for quality of care in a sample of 19. Findings include: R35's Face sheet shows a diagnosis of type 2 Diabetes Mellitus. R35's POS (Physician Order Sheet) shows an order dated 8/27/24 to check blood glucose twice a day. R35's Weights and Vitals Summary shows his blood glucose result on 9/10/24 at 9:34 AM was 72, and his blood glucose result on 9/12/24 at 8:00 AM was 88. On 9/11/24 at 8:11 AM, V18 (RN/Registered Nurse) was observed checking the blood glucose of R35. V18 first cleaned R35's finger with an alcohol wipe, then waved his gloved hand at the finger to dry the alcohol. V18 then poked R35's finger with lancet, squeezed out a drop of blood, wiped it with alcohol wipe, squeezed out a second drop of blood, and then placed that drop on testing strip to obtain blood glucose. The alcohol had not had enough time to dry from resident's finger after V18 wiped the first drop of blood off and placed the second drop on test strip. V18 told R35 that his blood glucose result was 153 and R35 replied, Oh, that is high for me, I am usually low 100s. On 9/12/24 at 2:51 PM, V2 (DON) said the nurse is supposed to allow the alcohol time to dry on the resident's finger before placing blood sample on testing strip, because the alcohol on the skin can affect the blood sugar reading and give an inaccurate blood glucose result. R35's Care Plan initiated on 9/10/24 shows the resident has Diabetes Mellitus and interventions include obtain fasting serum blood glucose as ordered by the doctor. The facility's policy titled, Blood Glucose Monitoring last reviewed 1/24 states, Procedures: .6. Obtain sampling of blood. Follow manufacturer's instruction for use of glucometer .*MANUFACTURER GUIDELINES: 1. Allow finger to dry after swabbing with alcohol .

Based on observation, interview, & record review, the facility failed to provide proper hand hygiene during incontinence care & while providing a physical exam. This applies to 3 of 4 residents (R24, R96, & R16) reviewed for bowel and bladder incontinence, and 1 of 4 residents (R30) reviewed for ADL care (Activities of Daily Living) in a sample of 19. The findings include: 1. On 09/10/24 at 12:48 PM, V3 CNA (Certified Nurse's Assistant) was observed toileting and providing incontinence care for R24. R24 was observed standing over the toilet and V3 was observed with gloved hands removing R24's soiled brief and then setting R24 on the toilet. V3 then was observed getting a tissue and cleaned R24's nose. V3 then removed her gloves and put on clean gloves but did not clean her hands. V3 then moved R24's (reclining high back) chair in her room, then returned to the bathroom, and removed her gloves and put on new gloves but did not clean her hands. V3 then grabbed a box of tissue and wiped R24's perineal area then wiped R24's buttocks cleaning stool from R24. V3 then removed her gloves and again did not clean her hands before putting on clean gloves and then applied barrier cream to R24's buttocks. V3 then touched R24's walker, put a clean brief on R24 and pulled up R24's pants with her dirty gloved hands. V3 then removed the dirty gloves but did not clean her hands and then touched R24's back and assisted R24 out of the bathroom, walked R24 to the recliner in her bedroom, removed the gait belt from around R24's waist, put a pillow behind R24's head, put R24's call light within reach, took a throw blanket off of R24's bed and placed it on R24, picked up the TV control and turn the TV on, and then pushed R24's reclining high back) Chair into R24's bathroom. V3 did all of this with her uncleaned hands. R24's 8/23/24 care plan showed that R24 has an ADL self-care performance deficit related to diagnoses including dementia, and impaired balance, with intervention including personal hygiene - dependent assistance, bowel incontinence - provide peri care after each incontinent episode. R24's 8/13/24 MDS (Minimum Data Set) showed that R24 has long and short term memory problems. R24's 8/19/24 MDS section GG showed that R24 is dependent on toileting and personal hygiene. 2. On 09/11/24 at 09:58 AM, V4 (Wound Nurse) was providing incontinence care for R96 while R96 was in bed. V4 with gloved hands cleaned R96's perineal area, then picked up a clean brief with the same dirty gloved hands, rolled R96 to her right side, wiped R96's buttocks, removed the soiled brief, put the clean brief under R96, rolled R96 back on her back, and attached the clean brief on R96. V4 then put the wipes back in R96's drawer, adjusted the sheets on R96 and then V4 removed her gloves. Then V4, after removing her gloves, began touching personal items on R96's dresser and touching items used for R96's wound care treatment including the scissors. V4 did this with ungloved and uncleaned hands. On 09/11/24 at 10:12 AM, V4 said that she should have removed her gloves and cleaned her hands and then put on clean gloves after providing perineal care and going from a dirty area to clean area for infection control and to prevent cross contamination. R96's 7/23/24 care plan showed that R96 has occasional bladder incontinence with diagnoses including OAB (overactive bladder). 3. On 09/10/24 at 02:06 PM, R30 was observed in her bed with her right hand fingernails polished red and no polish on her left hand fingernails. On R30's left thumb a reddish brown colored substance was observed on the thumb and under the thumbnail. At 02:12 PM, V5 (Nurse) was observed at the nurses' station typing at the computer when he was informed of R30's reddish colored thumb. V5 was observed getting up from the computer, coming into R30's room, and putting on gloves, but V5 did not clean his hands before putting on the gloves. V5 then began examining R30, touching her hands and other parts of her body including her face to determine the source of the reddish brown color on her thumb. V5 said that it was dry blood on R30's thumb but was unable to locate were R30 was bleeding from. R30's electronic health records showed that R30 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including hemiplegia & hemiparesis, spastic hemiplegia affecting right dominant side, dementia adjustment disorder, osteoporosis, depression and anxiety disorder. R30's 12/26/23 care plan showed that R30 has an ADL self-care performance deficit related to deconditioning, and diagnoses including right hemiparesis from previous CVA (cerebral vascular accident). The care plan interventions include personal hygiene - dependent, shower bathe - substantial/maximal assist, check nail length and trim and clean on bath day and as necessary. R30 7/6/24 MDS section GG personal hygiene - dependent. R30's 7/7/24 MDS section C showed that R30's mental cognition is moderately impaired. On 09/12/24 at 11:58 AM, V1 (Administrator) said that the staff should remove their gloves, clean their hands and put on new gloves after leaving a contaminated area or touching a contaminated item, and before going to a clean area or touching a clean item for infection control. The facility's Infection Control Nursing Procedures policy dated 1/4/2023 showed, Subject: Handwashing - handwashing is considered one of the most effective infection control measures. The policy showed under Frequency: After handling any contaminated items. Before and after having contact with a client's intact skin during client care. If hands will be moving from a contaminated body site to a clean body site during client care. Before and after using gloves. 45906 4. On 9/11/24 at 10:10 AM, V17 (CNA/Certified Nurse Assistant) provided incontinence care for R16. First, V17 put gloves on, then she touched the bedside table, R16's nightstand drawer handle to remove wipes out of the drawer, then she touched the blinds to close them. With the same gloves on, V17 removed R16's sheet and blanket and put her heel boots back on. Next, with the same gloves on, V17 placed a new incontinence pad inside a new incontinence brief, touching the area that would be against R16's perineum. V17 then removed wipes and unfastened R16's incontinence brief and used the wipes to clean under R16's abdomen fold and her right and left groin. R16 then rolled to her left side and V17 wiped R16's buttocks. V17 then rolled the soiled incontinence brief under R16's left side and placed the clean brief under her buttocks. V17 then had R16 roll onto her right side and V17 removed the soiled incontinence brief from R16's left side and pulled the clean brief through. R16 then turned onto her back and V17 pulled the clean brief up through/between R16's legs and V17 fastened the brief. V17 did not change her gloves or perform hand hygiene once throughout this process while she touched possibly contaminated surfaces, then touched the resident and her soiled incontinent brief, and then touched the new/clean brief. V17 went from dirty/contaminated areas to clean areas while wearing the same gloves. On 9/12/24 at 11:31 AM, V2 (DON/Director of Nursing) said staff should perform hand hygiene before incontinence care, during incontinence care after cleaning the resident, and again after finishing incontinence care before going to the next resident's room. V2 said after cleaning the resident, the staff member's gloves would be dirty so they have to change them and perform hand hygiene. V2 said it is an infection control issue to go from a dirty area to a clean area with the same gloves on and the harm in this practice is contamination. R16's MDS (Minimum Data Set) dated 8/14/24 shows she is dependent on staff for personal hygiene and she is frequently incontinent of urine and always incontinent of stool. R16's Care Plan last revised on 9/22/22 shows she has an ADL (Activities of Daily Living) self-care performance deficit related to osteoarthritis and lymphedema. Interventions include that she is dependent assist x1 staff member for toilet hygiene The facility's policy titled, Resident Perineal Care last reviewed 6/24 states, Purpose: Protection of skin integrity, cleansing of perineum and prevention of infection and odor. Procedures: .6. Dry perineal and anal area. 7. Remove gloves, perform hand hygiene and apply new gloves. 8. Apply appropriate product: brief, pad, or other .

Based on observation, interview, and record review, the facility failed to follow physician medication orders. This applies to one resident (R146) reviewed for quality of care in a sample of 19. Findings include: On 9/10/24 at 11:47 AM, R146 said her pain was getting up to an 8 (on a scale of 0-10) and she was just about to call the nurse to ask for a hydrocodone/acetaminophen pain pill. R146 said it had been about 4 hours since she last took pain medication and every 4 hours the pain starts to creep up again. R146's Face sheet shows diagnoses of history of falling and contusion of left lower leg. R146's POS (Physician Order Sheet) shows two orders for hydrocodone-acetaminophen PRN (as needed) pain medication. The first order shows hydrocodone-acetaminophen oral tablet 5-325mg (milligram) give 1 tablet by mouth every 4 hours as needed for moderate to severe pain *DO NOT EXCEED 3 GM (gram)/DAY ACETAMINOPHEN FROM ALL SOURCES*. The second order shows hydrocodone-acetaminophen oral tablet 5-325mg give 2 tablets by mouth every 4 hours as needed for moderate to severe pain *DO NOT EXCEED 3 GM/DAY ACETAMINOPHEN FROM ALL SOURCES*. R146's eMAR (electronic medication administration record) shows R146 received a total of 11 tablets of hydrocodone-acetaminophen 5-325 mgs on 9/11/24. This equals a total of 3,575 milligrams of acetaminophen or 3.575 grams of acetaminophen, which exceeds the maximum 3 gram 24 hour limit written in the physician's order. On 9/12/24 at 11:31 AM, V2 (DON/Director of Nursing) verified that R146 was administered 11 tabs of hydrocodone/acetaminophen 5-325 mgs on 9/11/24. V2 said 11 tabs equates to 3.575 grams of acetaminophen which exceeds the physician's order of 3 grams maximum in a day. V2 said the harm in administering more than 3 grams of acetaminophen in a day is kidney and liver toxicity and/or damage for the resident. On 9/12/24 at 2:51 PM, V2 said the facility did not have a policy that pertains to following physician orders. R146's Care Plan initiated on 9/9/24 states the resident has a risk for pain and interventions include: administer as needed hydrocodone/acetaminophen as per the physician's orders.

Based on observation, interview, and record review, the facility failed to maintain indwelling urinary catheter according to best practice to prevent complications. This applies to 1 resident (R151) reviewed for urinary catheter in a sample of 19. The findings include: R151's Face sheet shows a diagnosis of chronic kidney disease. R151's MDS (Minimum Data Set) dated 8/21/24 shows her cognition is intact. R151's Care Plan revised on 9/10/24 shows the indwelling urinary catheter is to be reinserted due to urinary retention. Interventions include position the catheter bag and tubing below the level of the bladder and away from entrance room door. On 9/10/24 at 12:16 PM, R151 said my bladder is not working again, they are going to put a catheter in again. On 9/11/24 at 2:11 PM, R151 said they put my catheter back in again late yesterday afternoon. Surveyor then noticed while R151 was lying in bed, the urinary catheter drainage bag was not hooked to the bed frame or seen on either side of R151's bed. On 9/11/24 at 2:16 PM, surveyor noted that R151 was lying in bed and was wearing a urinary catheter leg bag on her left leg. R151 was wearing pants and the urinary catheter tubing and leg bag was on her leg, even with her bladder. The urine in R151's leg bag was minimal. R151 said the nurse had not emptied the urine in the leg bag in a long while and she was having some lower abdomen discomfort. On 9/11/24 at 2:20 PM, V16 (RN/Registered Nurse) said R151 had an indwelling urinary catheter placed yesterday because she was retaining urine. V16 said R151 should not have a leg bag on while she is lying in bed because the urine can back flow into the bladder and cause a urinary tract infection (UTI). On 9/12/24 at 11:31 PM, V2 (DON/Director of Nursing) said a resident should not be lying in bed with an indwelling catheter leg bag on. V2 said the CNA (Certified Nurse Assistant) should have communicated to R151's nurse when R151 was assisted back into bed so the nurse could have switched the leg bag to a regular catheter drainage bag. V2 said the leg bag while in bed can cause urinary reflux from the tubing back into the bladder which can cause a urinary tract infection. V2 said the tubing and drainage bag of the urinary catheter should be lower than the bladder at all times to prevent UTI. On 9/12/24 at 1:44 PM, V2 said the facility does not have a policy regarding indwelling catheter maintenance. The facility's policy titled, Catheter Insertion, Removal, and Changing last reviewed 12/23 states, Policy: Catheters are utilized and maintained according to best practice. Indwelling catheters are utilized for the following purposes: 1. Urinary retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible .14. Secure urinary drainage bag below the level of the bladder .

Based on observation, interview and record review, the facility failed to store pots and pans in a sanitary manner and failed to discard dented cans. This applies to all 49 residents that reside in the facility. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated August 28, 2023, showed that the facility census was 49. Facility gave verbal confirmation that 48 residents received oral diets and one resident was on dual (oral and tube) feedings. On August 28,2023 at 9:41 AM, during the initial tour of kitchen, the dish room had multiple cleaned pots and pans inverted on trays that were placed on a free-standing rack. These trays were noted to have marked miscellaneous debris, dust and unknown dried stains or spills. This was brought to the attention of V15 (Director of Dining Services) who acknowledged the findings and stated that she will ensure that the holding trays be cleaned and the pots and pans rewashed. In the dry storage cabinet, there were two cans of Country Style Sausage Gravy (6 lbs/pounds and 8 oz/ounce each can) and one can of Peach Pie Filling (7 lb) which had the top edges of cans dented in several areas. V15 remarked They should be checking it immediately on delivery and it should not go in. I will do an in-service. On 08/30/23 at 11:57 AM, V26 (Dietitian) stated that cans that have their rims and (side) seals dented in, should be discarded. Facility provided delivery dates for above dented cans as August 1, 2023, and August 8, 2023. Facility Policy titled Storage of Pots/Pans/Dishes and Utensils (reviewed August 29, 2023) included: All cooking equipment should be stored in a manner that maximizes safety of foods served. Facility Policy titled Receiving (last revised and reviewed September 11, 2022) included: Policy: All food should be checked for proper condition as it is received in the facility. Procedure: Receiving Dry Goods 1) Inspect cans for leaks, incomplete labels, dents, bulges, and other visible signs of damage. Reject flawed cans and put in a designated area for credit. 3) Notify the unit supervisor or designee to call the vendor when damaged items are found so the product can be picked up and returned and a credit issued.

Based on observation and interview; the facility failed to maintain an effective pest control program. This applies to 5 of 5 (R9, R14, R15, R20, R31) residents reviewed for environment in a sample of 13. The findings include: 1. R14's admission record, showed R14 was admitted to the facility on [DATE]. R14 had multiple diagnoses including disorder of the muscle, malignant neoplasm of the prostrate, malignant melanoma of the skin, chronic pulmonary embolism, history of falling, and major depressive disorder. R14's MDS (Minimum Data Set) dated July 26, 2023, showed R14 was cognitively intact, and required limited assistance from staff with ADLs (Activities of Daily Living), including bed mobility, transfer, toilet use and personal hygiene. On August 28, 2023, at 11:20 AM, R14 stated he had too many flies in his room, while he spoke there were three flies observed on his pillow next to his head and two observed on his bedside table. On August 29, 2023, at 10:12 AM, R14 stated he still had flies in his room he said he swatted at three flies earlier in the morning. On August 30, 2023, at 10:20 AM, R14 stated he saw three flies in his room earlier, but he can't find his fly swatter. V3 (Assistant Administrator) was in the hall outside of R14's room and made aware of R14's concern. 2. R9's admission record showed R9 was admitted to the facility on [DATE]. R9's multiple diagnoses included cardiac arrhythmia, unspecified, idiopathic peripheral autonomic neuropathy, benign prostatic hyperplasia with lower urinary tract symptoms requiring the use of indwelling urinary catheter, pressure ulcers of both left and right buttocks and essential hypertension. R9's MDS showed R9 is cognitively intact, and required extensive assistance from staff with ADLs, including bed mobility, transfer, toileting, and personal hygiene. On August 28, 29, and 30, 2023, during multiple observations, R9's room door had a sign on pink paper that read, keep door closed at all times due to flies. On August 29, 2023, at 4:57 PM, R9 was observed in the room swatting at a fly away from his face while sitting in his room. V29 (LPN) was present and stated we have had a fly problem here for a while. 3. R31's admission record showed R31 was admitted to the facility on [DATE], with multiple diagnoses including disorder of the muscle, hemiplegia, dementia, urinary tract infection, and osteoarthritis of the left shoulder. R31's MDS dated [DATE], showed R31 was cognitively intact and requires extensive assistance from staff with ADLs including bed mobility, transfer, toileting, dressing and personal hygiene. On August 28, 2023, at 11:31 AM, R31 stated the flies around here are terrible, I wish I had a fly swatter. On August 29, 2023, at 10:20 AM, R31 stated she still had a bothersome fly in her room earlier that morning. 4. R15's admission record showed R15 was admitted to the facility on [DATE], with multiple diagnoses including orthopedic care after surgical amputation, chronic obstructive pulmonary disease, chronic diastolic congestive heart failure, chronic peripheral venous insufficiency, and age-related osteoporosis. R15's MDS dated [DATE], showed R15 was cognitively intact and required extensive assistance from staff with ADL's including bed mobility, transfer, toileting, dressing, and personal hygiene. On August 28, 2023, at 1:28 PM, R15 was seated at the dining table in the main dining room, eating lunch and asked this surveyor, Is there anything you can do about the flies around here? There were two flies observed in the dining area, flying around the table, at the time. 5. R20's admission record showed R20 was admitted to the facility on [DATE]. R20 had multiple diagnoses including Heart failure, diabetes, atrial fibrillation, generalized osteoarthritis, lymphedema, and pressure ulcer. R20's MDS, dated [DATE], showed R20 was cognitively intact, and required extensive assistance from staff for bed mobility, dressing, toileting, and personal hygiene and was dependent on staff for transfer. On August 28, 2023, at 11:39 AM R20 stated she had a concern because there are flies in her room, including tiny baby flies and the flies are also seen in the dining room. On August 28, 2023, at 1:15 PM, V7 (RN) stated the flies have been a problem for about a week now, there's nothing we can do about them they are coming through the entrance doors. On August 29, 2023, at 10:05 AM, V19 (CNA) stated the flies started in a garbage can in the soiled utility room and the garbage was left for a long-time flies had babies and the fly population grew. The flies were so bad on Sunday (August 27, 2023) that the nurse took the garbage can outside. On August 29, 2023, at 10:30 AM, during the soiled utility room observation with V17 (CNA) there was no regular garbage can in the soiled utility room only red bag waste container and soiled clothing bin. On August 29, 2023, at 11:21 AM, V8 (Maintenance Director) stated he became aware of the fly situation in the small house during the morning meeting on August 28, 2023. V8 also stated normally the staff tell the receptionist so a work order can be put in or tell V8 directly. The facility policy titled Pest Control dated October 12, 2022, showed staff is to Dispose of garbage quickly and correctly. Keep garbage containers clean, in good condition, and tightly covered in all areas (indoor and outdoor), Clean up spills around garbage containers immediately. Wash, rinse and sanitize containers regularly.

Based on observation, interview and record review, the facility failed to provide diet as ordered by the Physician. This applies to 5 of 5 residents (R1, R2, R11, R27, R30) reviewed for diet orders in the sample of 13. The findings include: 1. On August 28, 2023 at 12:49 PM, during lunch meal service in the dining room, R30 received small portions (per request) of meat loaf, mashed potatoes and vegetables. Facility diet order listing showed magic cup (fortified ice cream) twice a day and R30 did not receive the same. On August 29, 2023 at 12:28 PM, during the lunch meal service, R30 received small portion of braised turkey, green beans and noodles. R30 did not again receive magic cup. R30 stated that she receives ice cream only when she asks for it and that she likes the same. R30 added that nursing gives her nutritional supplement (Ensure) routinely but she doesn't care for it. On August 29, 2023 at 12:36 PM, V16 (CNA/Certified Nursing Assistant) stated that the meal service is completed. V16 added They got everything they should get. V16 added that there is no magic cup available in the unit refrigerator and that the nurses also give supplements at medication pass. R30's diet order on POS (Physician Order Sheet) included magic cup two times a day related to nutritional deficiency (start date September 6, 2022). R30's care plan intervention updated on August 25, 2023 showed to provide and serve (General) diet as ordered, supplements & magic cups as ordered. 2. On August 29, 2023 at 12:20 PM, during the lunch meal, R1 received braised turkey cut up into large pieces (about 1-2 inches/piece) along with a side of vegetables and noodles served by V16. R1 had earlier stated that she has her upper teeth missing. When V16 was asked how she knows what diet to serve, V16 stated that she reviews the diet order listing that was on the service counter. When this diet order listing was reviewed, it showed Mechanical Soft diet for R1. V16 was notified of the same and V16 stated that she made a mistake and that R1 should have received ground turkey. R1's diet order on POS showed General diet, Mechanical Soft texture, Thin Liquids consistency (start date on March 8, 2023). 3. On August 29, 2023 at 02:31 PM, R2 received his lunch meal with a glass of regular consistency milk in the dining room. There was also a can of ginger ale soda pop close to his plate. This was verified with V17 (CNA). Facility diet order listing showed nectar thick liquids. V17 stated that she was only aware that R2 was on regular consistency liquids and added that R2 usually receives milk and ginger ale as he likes the same. R2's diet order on POS showed NAS (No Added Salt) diet, Regular texture, Nectar Thick Liquids consistency (start date April 28, 2023). R2's care plan interventions updated on April 28, 2023, included to serve NAS diet with Nectar Thick Liquids). 4. On August 29, 2023 at 12:45 PM, R27 received a pureed meal and 8 fluid ounces of Ensure Plus high protein (nutrition supplement) in the dining room. Facility diet order listing included magic cup and R27 did not receive the same. V17 (CNA) was not aware of magic cup listed on diet order listing. R27's diet order on POS included magic cup two times a day related to Nutritional Deficiency (start date October 19, 2023). On August 30, 2023 at 11:47 AM, V15 (Director of Dining Services) stated that the Dietary Department does not distribute magic cups and that the nutritional supplements are managed by the nursing department. On August 30, 2023 at 11:57 AM, V26 (Dietitian) stated that R1 should get diet of mechanical soft consistency as ordered by the Physician. V26 stated that magic cup is given by nursing. V26 stated that she was told that R2's family had earlier signed a waiver for nectar thick liquids. V26 was not able to verify this information. On August 30, 2023 at 01:05 PM, V7 (Registered Nurse) who had worked as the floor nurse on August 28, 2023 and August 29, 2023, stated that he did not give magic cup to R30 and R27. V7 stated that either the dietary or nursing gives the magic cup to the residents. 16746 5. R11 had multiple diagnoses which included dysphagia, oropharyngeal phase, based on the face sheet. R11's admission MDS (minimum data set) dated July 5, 2023 showed that the resident was severely impaired with cognition and required limited assistance from the staff during eating. On August 28, 2023 at 1:05 PM, R11 was served her lunch meal in three separate bowls consisting of pureed rice, pureed fish and pureed vegetables. R11 was eating independently with V18 (SLP/Speech Language Pathologist) present. On August 29, 2023 at 12:54 PM, R11 was served her lunch meal in five separate bowls consisting of pureed turkey, pureed noodles, pureed green beans with mushrooms, pureed bread roll and pureed cake. R11 was eating independently with occasional encouragement from the staff. R11's active order summary report showed an order dated August 17, 2023 for full liquid diet, full liquid texture, nectar thick liquid consistency. R11's active care plan initiated on June 29, 2023 addresses the resident's poor nutritional intake. The same care plan showed an added intervention dated August 17, 2023 to provide full liquid diet, nectar thick consistency. On August 30, 2023 at 12:36 PM, V18 (SLP) stated that on August 28, 2023 during lunch meal, R11 was received pureed diet because she was doing the trial feeding. V18 stated that on August 29, 2023 during the lunch meal, R11 should have received the ordered diet of nectar thick full liquid because she (V18) had not made the recommendation to upgrade the diet to pureed and there was no physician order to change the diet to pureed. According to V18, the facility should follow the physician's order to give the nectar thick full liquid diet to R11 and not the pureed diet, until the diet is changed and/or upgraded. V18 stated that R11 had a video swallow at the hospital prior to admission to the facility, and the video swallow showed that the resident had pharyngeal esophageal weakness which was unclear, because pharyngeal esophageal weakness could mean possible esophageal stricture, possible difficulty with food transport from the esophagus to the stomach or possible esophageal weakness which could cause regurgitation or vomiting. V18 stated that during the trial on August 28, 2023 with the pureed diet, R11 tolerated the food, but she does not want to recommend the diet consistency upgrade until the diagnostic imaging (video swallow) confirms that the resident could safely swallow. On August 30, 2023 at 1:33 PM, V2 (Director of Nursing) stated that the diet orders of the residents should be followed at all times for safety, especially for those resident's with swallowing problems.

Based on observation and interview the facility failed to provide privacy during a blood draw. This applies to 1 of 1 resident (R248) observed for blood draws in the sample of 13. Findings include: On August 28, 2023 at 11:23 AM V20 (Phlebotomist) was drawing R248's blood from his right arm while R248 was sitting at a table in the common area dining room on the second floor. R29 was also sitting in the same dining room at the same time. V20 finished drawing R248's blood and placed the vials of blood on the dining room table on top of a magazine in front of R248. The vials of blood rolled off the magazine and onto the table. V20 stated she was told by the company she works for that she could draw blood in the dining room if no one else was around. V6 (Registered Nurse) stated V20 should not be drawing blood in the dining room and then went over to tell V20 about it. V30 (Assistant Director of Nursing, ADON) then came over and introduced herself as the ADON to V20 (Phlebotomist). V30 told V20 that blood draws should not be done in the dining room and should be done in resident's room. On August 30, 2023 at 10:00 AM, V28 (V20's Manager) stated that it was not their policy to have their phlebotomist draw blood in the dining room. V28 stated that V20 (Phlebotomist) knows better and has had eight hours training, and 6 weeks of on the job training. On August 30, 2023 at 2:49 PM, V2 (Director of Nursing) stated the facility does not allow blood draws to be done in the dining room because it is an infection control, dignity, and privacy issue.

Based on observation and interview the facility failed to ensure call lights were within reach of residents and operational. This applies to 3 of 3 residents (R17, R247, R250) reviewed for call lights in the sample of 13. Findings include: On August 28, 2023 at 10:35 AM, R250 stated she waited for 45 minutes for someone to answer her call light yesterday. R250 was asked to hit the call light to see if it worked. It did not work. The light did not illuminate inside the room on the call light panel, or illuminate outside of the room, or beep. On August 28, 2023 at 11:17 AM, R17 was sitting in her room in a wheelchair on the side of her bed. R17's call light was behind her and about 4 feet away, tied to the bed rail and not within R17's reach. On August 28, 2023 at 11:48 AM, R247 was sitting in her wheelchair and seems very lethargic. R247's eyes were mostly closed while she was talking. R247 stated she was very weak. R247's call light was in front of her about 4-5 feet away and not within her reach. The call light was wrapped around the bed railing. V6 (RN) was informed that R247 was feeling weak and was also notified about where R247 call light was. V6 stated R247's call light should be within reach of the resident. On August 29, 2023 at 10:45 AM, R250 was sitting in a wheelchair and stated that she has problems with moving both her arms, V6 was present in R250's room. R250's call light was not within her reach. R250's call light was on her left side, behind her about 4 feet away, and wrapped around the bed rail. While V6 was unraveling R250's call light to place it closer to the resident, V6 stated R250's call light was not within R250 reach. R250 also stated her call light was not within her reach. On August 30, 2023 at 02:49 PM, V2 (Director of Nursing) stated call lights should be within easy reach of the resident.

Based on observation, interview and record review, the facility failed to assess for pressure relief a resident who was wearing a foot enclosed in an orthotic boot. This failure resulted to the resident sustaining unstageable pressure ulcer in the left heel. This applies to 1 of 3 residents (R42) reviewed for pressure ulcer in the sample of 12. The findings include: Face sheet indicate that R42 is [AGE] years-old, she has multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission note showed that R42 was admitted to the facility on [DATE] wearing an orthotic boot on the left foot. MDS (minimum data set) dated 6/12/21 indicated that R42 is alert and oriented and requires extensive assistance for bed mobility, locomotion, dressing toileting and personal hygiene. R42's Braden Scale Risk Assessment (Skin Assessment) dated 6/5/21 showed that R42 is very high risk for skin breakdown. On 6/21/21 at 3:00 PM, R42 was resting in bed, she was awake, alert, and oriented. R42 has a wound dressing to her left foot. R42 stated, she had multiple surgeries in her left lower extremities in the past month related to a fall incident at home resulting into a fracture. She was admitted to the facility a few weeks ago (6/5/21), with an orthotic boot on her left foot. R42 said that the boot was placed on her from the hospital. Since then, the boot has been on her, without anyone visually assessing her left foot that was enclosed in the orthotic device. R42 has been complaining on and off pain/burning sensation to her left foot. The pain was more intense at nighttime. R42 would tell staff about the pain and they would loosen up the boot which gave her a feeling of relief. However, no one had ever removed the boot to assess her foot. One day (6/16/21), one of the staffs was assisting her for hygiene care (R42 was unable to re-call who it was) suggested to clean her feet. The staff removed her boot and found the pressure ulcer. On 6/22/21 at 8:52 AM, V3 (Wound Care Nurse) stated that R42 had a surgery on her left hip, she was wearing a PRAFO (Pressure Relief Ankle Foot Orthosis) boot on her left foot upon admission to the facility. It was reported that R42 was complaining of pain on her left foot, and upon assessment (on 6/16/21) she had an open skin in the left heel which was unstageable due to slough formation in the wound bed. V3 also stated that she was not sure if the staff who admitted R42 did a full body assessment. However, the facility's policy requires staff to do a full body assessment which include a head to toe skin assessment upon admission. The PRAFO boot was placed on R42 for her foot drop and not for offloading. This device was lined with sheep skin (fur) for comfort, but with R42's boot, the lining in the heel area had worn off and her left heel was resting directly on the frame of the boot which put pressure on it. On 6/22/21 at 11:39 AM, V3 rendered wound care to R42's unstageable pressure ulcer in the left heel. R42 repeated what she said from the day before that no one had assessed or seen her left foot until 6/16/21. R42's orthotic boot was shown to surveyor. The boot had a soft inner lining, however, the lining of the heel area had flattened and hardened from the secretions of her wound. On 6/22/21 at 10:15 AM, V7 (Nurse), stated that on 6/16/21 V10 (Occupational Therapist/OT) notified V7 about R42's wound. V10 was assisting R42 and took off the boot. V10 found the wound and immediately notified V7. V7 stated R42 told me that she has been complaining of pain to the nurse. Everyday each shift has a group of residents who are responsible for a full body assessment of each residents for Medicare charting. R42 is assigned to night shift staff and I believed that the orthotic boot order indicates to keep it on while in bed. I should have also check but I didn't. She is high risk for pressure ulcer and has history of pressure sore in the left and right buttocks and upper posterior left thigh. Had she (R42) said anything to me I could have assess it right away and take care of the problem. On 6/22/21 at 12:18 PM, V8 (Wound Care Physician) gave the following statement: If a resident has some sort of removable device and the resident started to complain of pain related to it, the staff must remove the device and do an assessment. If the staff is not sure whether to remove the device, they should call the physician. If V8 was notified about this type of concern, V8 would have instructed the staff to remove the boot and do a skin assessment. This situation could have been prevented. If the staff had done it right away, it could have been caught as stage 1 or DTI. Loosening the boot does not relieve the pressure from the foot. On 6/22/21 at 3:35 PM, V11 (Nurse), stated that when R42 first came in, they (staff) did a full body assessment. V11 took R42's boot off when she complained of burning sensation to her foot. When V11 assessed R42's heel, she (V11) noted that it was a little boggy (extra soft which was unusual). V11 put barrier cream to the left heel for comfort and removed the boot temporarily and placed R42's foot on top of a pillow to relieve the foot. V11 also said she could not recall calling the doctor about it. On 6/23/21 at 12:12 PM, V2 (Director of Nursing/DON) stated that when a resident is admitted with splints or supporting device the staff must take off the device and completely assess what is underneath. The staff should also remove the device during shower days to assess the skin, and if the staff is not familiar with the resident, they should remove device and assess the skin. R42's progress notes was reviewed, and it showed documentation from 6/5/21 through 6/15/21 of R42's left boot in place due to foot drop, able to wiggle toes and was noted to have [CONDITION(S)] to both lower extremities. A physician note dated 6/9/21 showed that R42 has high risk for developing contractures, pressure ulcers, poor healing or fall if not receiving adequate therapy and pain control. The 6/16/21 progress note showed that a wound was found on the left heel which extended up to the Achilles tendon with the circular portion measuring Length (L) 5.0 centimeter (cm) x Width (W) 5.0 cm x Depth (D) 0.2 cm. The wound bed was covered 40% with slough and partial scabbing in the remaining 60%. The wound appears to be pressure related. There was no evidence of documentation that R42's left foot was fully assessed, and the boot was ever removed for foot relief prior to the discovery of her pressure ulcer. Facility was unable to present documentation actual skin assessment done during shower or bathing time. Facility's Pressure Injury Reduction Policy and Procedure showed: Policy: Skin assessments and risk assessments for pressure injury are performed, individualized care plans are formulated to address identified needs, and interventions are implemented, monitored, as needed to reduce the incidence of pressure injuries, and promote healing of existing injuries. Procedures: 1. All clients receive a skin assessment to identify the status of the skin and note areas of skin compromise such as pressure injury, wound bruise, skin tear, surgical site, other. The skin assessment is performed beginning on admission/re-admission. Skin integrity is monitored routinely in the course of care, and skin compromises that may be noted are reported to the nurse.

Based on observation, record review and interview, the facility failed to implement fall prevention / safety measures including the use of chair alarms, locking wheel chair wheels for residents that were high risk for falls. This applies to 2 of 2 residents (R2 and R7) reviewed for falls with fracture in a sample of 12. As the result of this failure, R2 sustained impacted acute fracture of the distal radius. The Findings include: On June 20, 2017 at 11:00 AM, R2 was in the wheel chair seated at a table, stationed in the dining room. R2 was quiet, had R2's right hand over R2's left shoulder with grimace on face, R2 was unable to express verbally of any pain. R2's admission (September 16, 2016) nursing fall assessment showed a score of '18' meaning R2 is at high risk for falling due to the history of recent fall with a left shoulder fracture, confusion, require one to two staff members and is chair bound. R2's subsequent quarterly fall assessment also showed a score of '18' and R2 continued to be at high risk for falls. R2's October 5, 2016 high fall risk care plan interventions included: keep bed in the lowest appropriate position and to use chair alarm. The Facility's Nurses notes for April 2017 and facility's incident reports showed on April 10, 2017 at 7:30 AM E13 (Resident Care Partner / Certified Nurse Aide - CNA) noted R2 had discoloration to left upper inner arm while performing activities of daily living and reported to E8 (Day Nurse). E8 along with E14 (Night Nurse) conducted assessment of the injuries and noted 3.0 cm x 5.5 cm hematoma to left upper inner arm, mild hematoma and 1+ swelling to left wrist and 3.0 cm / 0.75 cm abrasion to the left elbow and the range of motion to left wrist was guarded. R2's April 10, 2017 X-Ray report showed R2 sustained impacted acute fracture of the distal radius. R2's April 10, 2017 Emergency Department physician notes read 'patient presents following fall and was sent from the nursing home for fracture of the left distal radius.' The facility incident investigation report did not determine how R2 sustained the injuries on April 10, 2017. No changes in the plan of care interventions were made. The staff interviews conducted during the investigation, none of the staff was able to state how R2 sustained fractured left wrist. According to staff schedule pattern, there is only one CNA for each independent house at night shift. Based on the lay out of the House, it is not practical for one staff to have a full visual view of the residents' movements, answer call lights and attend to residents' nursing needs. There is only one Nurse between two independent houses. R2 after sustained injuries including left wrist fracture on April 10, 2017, R2 had three accidents / incidents: On April 18, 2017 at 8:00 PM, R2 was found on the dining room floor on R2's back. One of the residents who witnessed the incident 'R2 tried to reach out and pass candy to the other resident, as R2 keeps moving the wheel chair moved and R2 slid out of the wheel chair and landed on R2's buttocks on the floor.' On April 20, 2017 at Noon noted increased swelling of left hand where cast is in place for previous fracture. R2 was sent to Emergency Department. No specifics available to determine cause and effect of the injury. When R2 returned to the facility at 7:30 PM, R2 came with steristrips on the right shin. No details available to determine how R2 sustained the skin tear on the right shin. During the survey from June 20, 2017 through June 23, 2017 R2 had no wheel chair alarm on, the wheel chair wheels were not locked when R2 was seated in her wheel chair. On June 22, 2017 at 2:30 PM an agency staff stated she was not aware R2 uses a chair alarm. R2's wheel chair was sliding away from the table as R2 attempted to turn self in the chair. On June 23, 2017 at 10:30 AM, one of the consultant staff verified R2's wheel chair was not locked while was seated in the wheel chair. 2. R7's medical record documents R7 was admitted with the following Diagnoses: [REDACTED]. The facility incident report documents the following falls for R7: Original admit: January 16, 2017. Fall on January 28, 2017-CNA (Certified Nursing Assistant) entered the room and observed resident on floor. Prevention measures at time of fall, Alarm (none); Resident reassessment prior to fall: Fall risk assessment (N/A); Plan of care for falls completed (N/A). Conclusion written by E2 (Director of Nursing) entered on March 22, 2017. Root cause- due to resident action or internal risk factor. Recommendation - none noted. Readmit: March 15, 2017. Fall on March 16, 2017 0345 am, Observed lying on floor, with legs out in front, wrapped in a blanket. Alert and oriented X 2 which is resident's baseline. Stated I was getting up to go to the bathroom. Alarm (none), Fall risk reassessment completed (N/A), Plan of care for falls completed (N/A). Staff interviews (No staff interviews available). Root cause-due to resident action or internal risk factors. Recommendations- none noted. There were no fall risk assessments in R7's medical record prior to the fall on March 16, 2017. On June 21, 2017 at 2:31 PM, R7 was alone in R7's room. R7's call light was not in reach. R7 was sitting in the wheelchair wearing a cervical collar. There was an alarm on R7's chair. The activation switch was in the off position. The indicator lights were not flashing. E9 (Certified Nursing Assistant) stated she was R7's care giver. When asked about the alarm, E9 turned the alarm on. The lights were now active. E9 stated I'm not sure with the new alarms if the switch activates them or not. On June 21, 2017 at 2:47 PM, E10 (Certified Nursing Assistant) stated she was R7's care giver when R7 fell on [DATE]. E10 stated R7 was confused. E10 stated she did not know if R7 had falls prior to March 16th and R7 was not a fall risk. E10 added R7 received an alarm after the fall on March 16, 2017. On June 21, 2017 at 3:00 PM, E2 (Director of Nursing) stated R7 was initially admitted to the facility with a cervical collar related to a C2 fracture. E2 stated on March 16, 2017, R7 was attempting to go to the bathroom when R7 fell . E2 stated residents deemed high risk for falls are given a bed / chair alarm. E2 stated R7 was provided an alarm after the March 16th fall. When asked to provide R7's care plan prior to the fall, E2 looked in the computerized charting and stated I don't see it. E2 stated R7 was totally confused and had been taking muscle relaxers prior to the fall. E2 stated R7 should have been high fall risk and given alarm prior to the fall. E2 added that the facility does not have a Quality Assurance Committee. E2 stated there has been no individual review of R7's fall / interventions. E2 stated when staff hear alarms they go there to try to prevent falls. E2 stated alarms should be on whenever residents are up and in their chairs. The Care Plan documents: at high risk for falls - March 16, On floor, initiate bed alarm. June 13, 2017- did have a fall and may need surgery on the C2 fracture. The radiology report for R7 dated March 16, 2017 documents: In comparison to report March 5, 2017 - Redemonstrated is a C2 fracture with 2.5 mm posterior displacement of the cephalic fragment. The physician progress notes [REDACTED]. I suspect we are now looking at a surgical option rather than hoping this fracture is going to heal. The policy for Falls Reduction documents: The facility's clinical team reviews falls at least weekly to attempt to discern a root cause. This process includes the evaluation of factors such as medications, toileting patterns, infection, etc to recommend new prevention strategies. Results of the fall committee review are communicated to staff through written updates to the client care plan and verbal communication during shift to shift report.