Every finding on record at West Wind Village

Based on observation, interview, and document review, the facility failed to ensure a standing mechanical lift was maintained in a safe operating condition according to manufacturer's guidelines for 1 of 1 resident (R1) reviewed for accidents. The facility's failure resulted in actual harm when R1 fell from the lift and suffered a femur fracture. The facility implemented corrective measures on 7/24/26 prior to the start of the survey; therefore, the deficient practice was cited as past noncompliance.Findings includeR1's face sheet included diagnoses of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, phantom limb syndrome with pain, morbid obesity, acquired absence of left leg above knee, and muscle weakness.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment and no vision or hearing impairments. R1 was dependent on staff for lower body dressing and required substantial assistance from staff for transfers. R1 had not had any falls since admission.R1's care plan dated 10/23/24, informed staff R1 required a mechanical standing lift with assistance from two staff for transfers in/out of bed with a large/extra-large sling.R1's Nursing Home Incident Report (NHIR) dated 7/24/26, identified on 7/24/26, around 1:25 p.m., R1 was transferred via the mechanical standing lift and two-person assist. During the transfer the sling loop came out of the safety clamp, R1 slid back onto the chair and to the floor.R1's Emergency Department (ED) note dated 7/24/26, indicated R1 was evaluated for significant right lower extremity pain following a fall from the lift. The facility had reported R1 was in a standing lift device, the device failed, and R1 was slowly lowered to the floor, however R1 reported both the left and right straps on the device gave out, causing her to fall to the floor. Both accounts were consistent with mechanical fall involving failure of the assist device. X-ray of right femur obtained and comminuted (broken into multiple fragments) displaced (not aligned in normal position) fracture of the proximal femur just below the greater trochanter (front) and lesser trochanter (back) fragment is displaced. R1 was admitted to the hospital.The facility's Mechanical Lift Inventory dated 7/25/26, identified the EZ Way sit-to-stand mechanical lift with serial number 220807 which was purchased 8/6/2012 and used to transfer R1 was taken out of service.R1's hospital Discharge summary dated [DATE], identified R1 had a right hip fracture surgically repaired on 7/24/26. R1 discharged with weight bearing as tolerated for transfers, bedbound and would need to use the mechanical lift for transfers.During an observation and interview on 8/4/26, at 12:50 p.m., R1 was in bed. R1 recalled the fall incident from the lift, stating, The lift is not safe. That specific one, on one side it has metal and the other rubber to hold the straps in place. R1 explained she was being lifted out of the recliner when the thing let go, the rubber one and I started to fall. When she fell, her hip shattered in three different places.During an interview on 8/4/26, at 1:33 p.m., NA-B stated she could not recall the date of R1's fall incident from the lift but remembered the incident occurred around 2:00 p.m. NA-B stated the commode was placed next to the recliner, and she and NA-C brought the standing mechanical lift into R1's room and placed the harness, butt strap, and leg strap around R1. NA-B described the lift as having two harness connection points, with a black Styrofoam piece serving as the safety piece on the left harness connection point and a metal safety piece on the right harness connection point. NA-B attached the harness to the right side of the lift, while NA-C attached the harness to the left side. NA-B explained, We started to scoot back away from the recliner when R1 asked to be raised higher in the lift. During the transfer, the harness detached from the black Styrofoam piece at the left harness connection point. R1 fell back onto the recliner and then slid from the recliner onto the floor. NA-B recalled, It was so quick.During a follow-up interview on 8/5/26, at 11:05 a.m., NA-B stated she remembered both safety pieces (rubber stopper and metal clip) were in place before she and NA-C began R1's transfer on 7/24/26. However, the rubber safety piece had twisted outward and required adjustment before the transfer so NA-C repositioned the rubber safety piece.During an interview on 8/4/26, at 1:38 p.m., NA-C stated on 7/24/26, around 1:45 p.m., R1 requested to use the commode. NA-C and NA-B hooked up R1 with the harness, butt strap, and leg strap. NA-C operated the standing mechanical lift while NA-B positioned the commode, and both NAs verified the straps were attached and in place. According to NA-C, R1 commonly leans back and sits on the straps and fidgets with the straps and pulls around her arms. NA-C did not raise R1 high in the lift because R1 would complain of leg pain. She raised R1 just above the height of the recliner seat and began moving the lift away from the recliner. At that point, NA-C recalled one side of the harness straps came up weirdly, and R1 fell back onto the recliner and bounced up.During an interview on 8/4/26, at 2:43 p.m., registered nurse (RN)-A stated she went to R1's room immediately after R1 fell from the standing mechanical lift on 7/24/26 and began an investigation. RN-A observed a rubber stopper on the lift that was not holding tightly and estimated there was maybe about one eighth of an inch gap between the rubber stopper and the curlicue. RN-A believed the gap may have allowed the harness strap to slip through. During the investigation, staff reported that when transferring bigger ladies, the straps inside the curlicue could develop some slack. Following the incident, RN-A instructed the maintenance department to remove the rubber stoppers from all standing mechanical lifts and replace them with metal clips. RN-A also initiated audits of the standing mechanical lifts to ensure the metal clips were engaged and functioning according to the manufacturer's instructions. On the lift involved in R1's fall, the rubber stopper was replaced with a metal clip; however, the metal clip did not remain in place as designed, even after the arm of the lift was replaced. RN-A then removed the lift from resident use. RN-A reported maintenance performed monthly inspections of all lifts. The facility also provided annual mechanical-lift training during skills fairs and conducted random audits of staff performing lift transfers.The service history for the standing mechanical lift, serial number 220807, was provided by the maintenance director via email on 8/5/26. The history documented replacement of the Smart board on 1/2/20. The records provided did not document any other repairs, component replacements, or service work performed on the lift. Further, the records did not identify the use of a rubber stopper in place of the metal safety clip or an alternative equipment maintenance program specifically addressing the inspection, maintenance, and replacement of the safety features used to secure the harness straps to the lift, including the pigtails, rubber stoppers, and metal safety clips.During an interview on 8/4/26, at 3:02 p.m., maintenance (M)-A stated she completed maintenance inspections monthly on all lifts. M-A had completed the inspections in July, prior to the incident, which included making sure the stoppers were tight and snapped back in place securely on the machines. Some of the lifts had rubber stoppers and some had metal. After the incident, RN-A had M-A removed all the rubber stoppers and replaced them with metal clip stoppers. M-A reported she had not received any maintenance requests from staff regarding problems with the rubber stoppers or the metal clips.During a phone interview on 8/4/26, at 2:56 p.m., EZ Way lift company representative (REP)-A stated all standing mechanical lifts were required to have the stoppers attached. Staff should verify the harness straps were properly attached and the stoppers were in place before lifting a resident. REP-A indicated both rubber and metal stoppers were acceptable. REP-A stated that when there was tension on the harness straps while attached to the lift, it would be difficult for the harness to come off the machine.During a phone interview on 8/5/26, at 9:25 a.m., EZ Way REP-B stated the standing mechanical lift with serial number 220807 was purchased by the facility on 8/6/2012. REP-B stated the company estimated the lifespan of the lift to be 10 years, depending on how the lift was maintained, and would continue to support and service the lift for 10 years beyond the manufacturer's warranty. REP-B explained that rubber stoppers were an older style used by the company and had been phased out and replaced with metal clips on newer models; however, the company continued to supply rubber stoppers for older lifts. Rubber stoppers should not be cracked or torn and when functioning properly, should not swing or move. REP-B described the lift that require the rubber stopper- the rubber stopper functions like a spring-loaded eraser. The rubber stopper should be secured to the lift with super glue and sit flush with the curl of the pigtail connection point. If the rubber stopper was not secured with glue, it could slide back out. REP-B further explained that when installing a metal safety clip, the clip must be properly threaded and secured through the designated openings; otherwise, the clip could bend. REP-B stated staff training included a 10-second pause before lifting to verify everything was properly connected and positioned.During a follow-up phone interview on 8/5/26, at 2:42 p.m., REP-B reviewed photographs of the standing mechanical lift involved in R1's fall incident, including the lift handle and rubber stopper. REP-B described the rubber stopper currently on the lift (not the one used during R1's fall) as severely disintegrated. REP-B also observed that the opening for the metal clip appeared worn. REP-B stated the manufacturer's instructions for lifts equipped with metal clips directed the use of the metal clips and rubber stoppers should not be applied if lifts came equipped with metal clips. During an interview on 8/5/26, at 3:15 p.m., RN-A stated the facility did not superglue the rubber stopper to the machine as it was tight as it was.During an interview on 8/5/26, at 2:31 p.m., M-A reported she had not replaced any rubber stoppers during the approximately 1.5 years she had been responsible for maintaining the lifts. M-A believed the rubber stopper may have been used instead of a metal clip because the opening was too large for the metal clip to remain in place.During an interview on 8/5/26, at 11:26 a.m., the DON stated the facility used the lift company's competency checklist to train and evaluate staff on the use of mechanical lifts. Staff received training upon hire and annually during skills fairs. The DON also conducted random observations of staff performing mechanical lift transfers to assess competency and adherence to proper lift procedures.The standing mechanical lift Operators Instructions undated, informed staff the lift was designed to transfer weight bearing patients to and from a chair, wheelchair, toilet, or bed, and safely ambulating patients. All equipment must be maintained regularly by competent staff according to the maintenance checklist provided. Limited warranty on equipment included frame of machine for 10 years, components on machine for three years. Instructions on attaching patients to the machine included to stand beside patient with control in-hand. Verify the loops of the harness are hooked inside the pigtail at the end of stand and the safety catch is in place, blocking the strap from exiting through the pigtail.The undated EZ Way lift Operator's Instructions Safety and Maintenance identified that the listed components and operating points were to be inspected at intervals not greater than six months. Any detected deficiency was to be rectified before the stand was put back into service. The instructions further identified that the safety tabs were to be checked to ensure they were in place.The undated EZ Way lift Service Manual identified part 16 as the Safety Hook Spring. The manual directed that the safety tabs be checked to ensure they were installed correctly and were not missing or torn. An illustration accompanying the instructions depicted a metal safety clip. The manual did not identify a rubber safety stopper as an alternative to the metal safety clip.The undated EZ Way Instructions for Installing Wire Safety Clips identified that needle-nose pliers were needed to install the safety clip. The instructions directed the padded arm to be fully raised for access and noted that one hole in the curly queue was lower than the other. One end of the safety clip was to be inserted into the lower hole first. Using needle-nose pliers, the other end of the clip was then to be pulled slightly outward and inserted into the upper hole. When properly installed, the safety clip should snap against the curly queue to prevent the harness loop from coming out.The facility Mechanical Lift policy dated 5/28/25, identified all direct care staff are trained on the use of mechanical lifting devices upon hire. Trained staff will be observed for competency and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Maintenance of lifts will be completed following a monthly maintenance schedule to ensure lifts are working appropriately and no evident repairs are needed. Incidents involving mechanical lift will be immediately investigated to determine if neglect occurred, document the cause for the equipment malfunction, if identifiable, and determine whether preventative maintenance had been completed on the lift and manufacturer's recommendations were being followed.The facility implemented the following actions on 7/24/26 prior to the start of the survey:-Competency checklist for operating the mechanical lift and mechanical standing lift completed by nursing staff-Daily safety clip audit on all lifts implemented.-Removal of the mechanical standing lift from resident use.-Replaced all rubber stoppers on lifts with metal clips.-Re-education and competency testing for NA-B and NA-C immediately and audits on all NA's during transfers.

Based on observation, interview, and document review, the facility failed to implement donning/doffing of personal protective equipment (PPE) practices for 1 of 3 residents (R4) observed for enhanced barrier precautions (EBP) (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).Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R4's quarterly Minimal Data Set (MDS) dated [DATE], identified R4 was cognitively intact. R4 had a diagnosis that included an unhealed pressure ulcer, vascular disease (affects blood flow), and hemiplegia (weakness from stroke). R4 was dependent on staff for dressing and activities of daily living (ADLs). R4's diagnosis reported 5/5/26, identified R4 had acquired absence of right leg below the knee as of 5/9/25. R4's care plan revised on 3/27/25, identified R4 needed assistance with ADLs, transferring, and bed mobility. R4's care plan lacked information regarding EBP. R4's signed physician orders identified on 2/9/26, orders received to gently wash open area on the right stump with warm soapy water and pat dry. Apply PluroGel (dressing to maintain moisture) with Prisma (collagen-based wound dressing) to the wound bed and cover with Mepilex (foam dressing) and gauze dressing two days a week, on Monday and Friday. R4's signed physician orders dated 3/31/26, identified R4 had orders started on 3/3/26 to gently wash open area to the right stump with warm soapy water and pat dry. Apply PluroGel with Prisma to the wound bed. Cover with Allevyn dressing every Monday and Friday. R4's signed physician orders dated 4/30/26, identified R4 had a pressure injury to the right knee and to apply Medi-honey (gel to treat wounds), covered by silver alginate, and cover with boarded gauze dressing. R4's electronic medical records (EMAR) for March 2026, identified R4 had a treatment from 3/6/26 to 4/24/26, to wash the open area to the right stump with warm soapy water and pat dry. Apply PluroGel with Prisma to the wound bed. Cover with Allevyn dressing Monday and Friday. R4's EMAR for April 2026, identified R4 received a new order on 4/24/26, to cleanse the stump wound with wound cleanser and pat dry. Apply Medi-honey, covered by silver alginate (antimicrobial dressing), skin prep peri-wound, and allow to dry, apply bordered foam three times a week. Monitor peri-wound skin daily for increasing redness, warmth, or other signs and symptoms of infection. One time a day every Tuesday, Thursday, and Saturday for the right stump wound, no stop date. R4's Medical Device Related Pressure Ulcer Evaluation History printed 5/5/26, identified on 3/2/26, R4 had a stage two pressure ulcer (shallow red wound bed) on the right rear below knee amputation site measuring 1.48 centimeters (cm) by 1.19 cm and was covered by a dressing with no saturation (wound drainage). On 4/13/26, R4 had a stage two pressure ulcer on the right rear below knee amputation site measuring .42 cm by .36 cm and was covered by a dressing with 25% saturation. R4's skin Issue assessment dated [DATE], identified R4 as having a stage two pressure ulcer, which was improving, and was acquired in the facility. Measurements were 1.48 cm by 1.19 cm. R4 had a limb protector on during a transfer. R4 had bumped his stump on a PAL (mechanical lift), and the new skin had come off the wound. Restarted the order for PluroGel and Prisma to wound bed, the medical provider updated. R4's skin Issue assessment dated [DATE], identified R4 had a right below-knee amputation site. Stage two pressure ulcer with partial thickness skin loss with exposed dermis (middle layer of skin), which had an overall wound characteristics improvement, and was acquired in the facility and had been chronic for more than three months. R4's skin Issue assessment dated [DATE], identified R4 as having a stage two pressure ulcer on the right knee amputation site. R4's wound was stable, acquired in the facility, and has been chronic for greater than three months. Progress note dated 4/14/26, revealed R4 having a stage two pressure ulcer, right rear, below the knee amputation site. The wound is greater than three months. No signs and symptoms of infections. Measurements were 0.42 cm by 0.36 cm. 25% saturation on the dressing. Area continues to improve with the current dressing order. R4 denies pain to the area, no signs or symptoms of infection. Progress note dated 4/23/26, revealed R4's right rear below-knee amputation site was a stage two pressure ulcer with partial thickness skin loss with exposed dermis. Wound acquired in the facility. The wound was greater than three months. No undermining, no tunneling. R4 seen by the provider for wound care. New orders to clean wound with wound cleanser, pat dry, apply Medi-honey, covered by silver alginate, skin prep peri wound, and allow to dry, apply bordered foam three times a week. Monitor peri-wound skin daily for increasing redness, warmth, or other signs and symptoms of infection. R4's progress notes dated 4/30/26, revealed R4 was seen by the wound provider. Wound was stable and appeared to be improving. Continue Medi-honey, covered by silver alginate, and cover with bordered gauze dressing. During an interview/observation on 5/5/26 at 8:51 a.m., license practical nurse (LPN)-A sanitized scissors with an alcohol wipe, gathered alevin dressing, gauze dressings, Med-honey, wound spray cleaner, gloves, skin prep, and brought supplies into the room. LPN -A washed hands and applied gloves. LPN did not apply a gown, and there was no sign on R4's door of being on EBP. There were no gowns outside of R4's room or inside of R4's room. LPN-A indicated the wound was on the top of the right stump. LPN -A removed the old dressing and reported there was a scant amount of drainage on the dressing, which was yellow in color. No signs of infection. LPN-A cleansed the wound with wound wash. LPN-A indicated the wound would be measured with the wound nurse on Thursday and did not have a measuring device, but the wound appears to be approximately 0.5 cm by 0.5 cm and is red around the open wound, and the area appeared to be healing. The LPN-A took off the gloves and sanitized hands. LPN-A applied new gloves, took the Medi-honey and placed on the wound, and covered it with silver alginate. LPN-A used the skin prep around the wound, and the Allevyn dressing was applied. LPN-A indicated the facility received new wound care orders the previous week from the wound nurse. LPN-A indicated R4 had an open area last fall on his right stump but was healed until R4 bumped his stump on something. R4 wound is chronic as R4 has a bone that rubs against the skin and will open up when area is rubbed against something or bumped. LPN-A indicated the wound had been open for over a month. LPN -A indicated that gowns were to be worn if a resident had MRSA or tested positive for an organism that warranted the use of gowns, but did not believe gowns needed to be worn for R4's dressing change. During an interview on 5/5/26 at 12:01 p.m., nursing assistant (NA)-B indicated she did not wear a gown when providing ADLs as R4 did not have Clostridium difficile (c. diff) or a contagious organism and was not on EBP. During an interview on 5/5/26 at 1:53 p.m., infection preventionist (IP) indicated R4 had an open wound on his right stump and had been open for a few months. IP indicated there is a bone under the skin and when R4 rubs the skin on something, the area opens up. IP verified R4 had not been placed on EBP, and staff had not been wearing gowns when doing the dressing changes. During an interview on 5/5/26 at 2:17 p.m., director of nursing (DON) indicated her expectation was for staff to use EBP when working with a resident who has an indwelling medical device or a chronic open wound. DON would expect staff to wear gowns when performing high-contact care such as transfers, dressing, wound changes, and ADLs. DON indicated this is important to prevent multidrug resistant organisms (MDROs). Policy titled Enhanced Barrier Precautions dated 3/10/26, identified EBP should also be used for residents with chronic wounds and/or indwelling medical devices (e.g., urinary catheters, feeding tubes, central line, tracheostomy). Chronic wounds are defined as pressure ulcer, diabetic foot ulcer, unhealed surgical wound, and venous stasis ulcer. Skin breaks or skin tears are not considered a chronic wound. Indwelling medical devices are defined as urinary catheter, feeding tube, central line, and tracheostomy. A peripheral intravenous line is not considered an indwelling medical device. EBP are employed when performing the following high-contact resident care activities: dressing, bathing/showering, changing linen, transferring, hygiene care, toileting/peri care/emptying catheter bag, wound care, indwelling medical device care, therapy treatment. EBP will remain in place for the resident stay or until resolution of the wound or discontinuation of the medical indwelling device. Staff who are not engaging in high-contact resident care activities will not need to employ EBP while interacting with the residents (e.g., answering a call light, verbally conversing, or during medication administration). The facility failed to use EBP for residents with chronic wounds.

Based on observation, interview and document review, the facility failed to assess, implement and evaluate a loss in range of motion for 1 of 1 resident (R7) reviewed for range of motion. This practice resulted in harm when R7 was observed with her right hand contracted, increased pain and difficulty ambulating with a walker. In addition, the facility failed to provide functional maintenance programs as ordered to maintain and/or prevent loss of range of motion (ROM) for 8 of 8 residents (R7, R5, R3, R11,R17,R30,R33, R39) reviewed. Findings include: R7's significant change Minimum Data Set, dated [DATE], identified R7 had moderate cognitive impairment and diagnosis of hypertension (elevated blood pressure), and end stage renal disease (ESRD) and required moderate assist with activities of daily living (ADL's) which include bed mobility toileting and transfers. R7 had impairment on one side of upper extremity. R7's ADL Care Area Assessment (CAA) dated 6/18/25, identified R1 had physical limitations such as, limited range of motion, poor coordination, poor balance, visual impairment, or pain. Identified R7 was at risk for complications of immobility such as contractures. R7's care plan revised 7/18/25, had a self-care deficit related to impaired balance and right (R) sided upper extremity weakness. R7 was independent to walk with a walker. Care plan identified PT/OT (physical/occupational therapies) to treat and evaluate as needed. R7's OT assessment dated [DATE], identified R7 had a functional impairment of the left shoulder and forearm and R7 had no functional impairment of the right shoulder and forearm. R7's OT discharge assessment dated [DATE], identified discharge recommendations to complete a functional maintenance (FMP) program of right shoulder and elbow 7 times per week. Assessment did not indicate any functional impairment of the right hand. R7's medical record lacked evidence the FMP program had been initiated after the 2/4/25 OT recommendations. R7's PT evaluation dated 3/21/25, identified Current Referral Reason R7 referred to PT due to staff wondering about a platform walker for her due to not using her R arm post CVA hx. R7 tends to rest her R hand on her walker vs holding onto it. Reason for Skilled Services: Skilled therapy necessary to assess need for platform walker and trial; however, she declines adamantly. R7 record lacked any further follow up or additional interventions related to her R hand. During two separate observations one on 7/29/25 at 5:48 p.m. and other on 7/30/25 at 8:42 a.m, R7 was pushing a front wheeled walker using her left hand with her right hand down at her side. R7's fingers on her right hand were curled inward. R7 returned to her room and sat down in her recliner using her left hand to touch the recliner as she sat down. During an observation and interview on 7/30/25 at 9:34 a.m., OT opened R7's fingers on the right hand and R7 yelled ouch that hurts. OT did a full assessment of R7's right hand and stated R7 had significant contractures to the thumb and all four fingers on the right hand. OT stated when R7 was admitted to the facility six months ago R7 had mild tightness to her right hand and no contractures. OT stated R7 has had a significant decline in her ROM in her right hand since admission to the facility six months ago. R7's OT evaluation dated 7/30/25, identified R7 was referred to skilled OT due to decreased ROM of her fingers on the right hand, limiting her ability to participate in ADL's and functional mobility. R7 had redness on the tip of her thumb due to it being in between her 3rd and 4th fingers. Area does blanch when pressure is applied. R7 had pain while attempting to assess right hand and ROM. During an interview on 7/30/25 at 10:02 a.m., activities aide (AA)-A stated she had noticed in the past few months R7 was not able to open her right hand and the fingers on her right hand had curled in wards. AA-A stated she had not told anyone because she assumed the facility was aware of R7's decreased ROM and inability to open her right hand. During an interview on 7/30/25 at 10:10 a.m., nursing assistant (NA)-B stated R7's right hand was a little tight when R7 was admitted to the facility six months ago but in the past two months R7's ROM in her right hand has decreased and R7 no longer was able to open her right hand. NA-B did not think R7 had any functional maintenance programs. NA-B stated she did not tell anyone and stated she should have told the nurses about R7's decreased ROM in her right hand. During an interview on 7/30/25 at 10:13 a.m., NA-A stated R7 had some weakness in her right hand when she was admitted to the facility six months ago. NA-A stated up until two months ago R7 was able to fully open her right hand without pain. NA-A stated R7 has been complaining of pain in her right hand for the past 2 months and was no longer able to open her right hand. NA-A stated she had not told anyone about the decline in R7's ROM or complaints of pain because she assumed the nurses were aware. During an interview on 7/30/25 at 10:20 a.m., R7 stated she was having more difficulty walking lately because she was unable to use her right hand to push her walker. During an interview on 7/30/25 at 10:28 a.m., registered nurse (RN)-A stated her expectation was that staff would have let her know when R7's ROM in her right hand began to decrease so she could have let the medical doctor (MD) and therapy know to prevent further decreased ROM and contractures. During an interview on 7/30/25 at 11:05 a.m., family member (FM)-A stated three months ago R7 was able to open her right hand to use the FWW walker. FM-A stated in the past two months R7 had complained of pain in her right hand, was no longer able to open her right hand or able to use her right hand to push her walker. During an interview on 7/31/25 at 12:20 p.m., director of nursing (DON) verified R7 had contractures in her right hand . DON stated she was unaware R7 had decreased ROM or developed the contractures in her right hand in the past few months. DON stated it was her expectation any change in a resident's condition be reported to the nurse and the physician so it could be assessed to prevent a decline in ROM and contractures. During an interview on 7/30/25 at 2:35 p.m., medical doctor (MD) stated he did not recall being notified of R7's decline in ROM or contractures to her right hand. MD stated his expectation was the facility would have let him know about R7's decline in ROM to prevent further decline in ROM and prevent contractures from developing. R3 R3's annual Minimum Data Set (MDS) assessment dated [DATE], identified R3 was cognitively intact and was dependent on staff for all activities of daily living (ADLs). R3 had a diagnosis of hypertension (high blood pressure), diabetes, and hemiplegia (one-side weakness). R3's care area assessment (CAA) dated 5/29/25, indicated R3 was at risk for developing contractures and R3 had restricted mobility. R3's physical therapy (PT) orders signed 5/3/24, R3 was set up with a ROM/orthotic program. On 7/24/25, PT placed orders for R3 to stand one time a shift on day and night shift with platform walker, with the assist of two at the edge of the bed. PT orders lacked documentation on the length of time R3 was to stand with staff. R3's care plan dated 6/27/25, indicated R3 was to receive gentle range of motion (ROM) as tolerated with daily care. R3's care plan lacked information providing what extremity R3 was to have ROM completed on. R3's electronic treatment administration record (eTAR) dated 7/25, lacked documentation R3 was to receive ROM or stand at the edge of the bed with a platform walker and a assist of two. R3's progress notes dated 5/1/25 to 7/30/25, lacked documentation R3 was to receive gentle ROM as tolerated with daily cares. During an interview on 7/30/25 at 1:31 p.m., PT-A confirmed R3 was on a standing program with staff two to three times a day. PT-A indicated the orders were provided to nursing staff to enter the orders on R3's care plan. During an interview on 7/30/25 at 1:47 p.m., NA-E indicated NA-E was unaware R3 had orders to stand one time a shift on day and night shift with platform walker, with the assist of two at the edge of the bed. NA-E further indicated staff do not have time to complete ROM on residents daily. R5 R5's admission Minimum Data Set (MDS) assessment dated [DATE], identified R5 was severely cognitively impaired and needed moderate assistance with all activities of daily living (ADLs). R5 had a diagnosis of dementia, diabetes, and anxiety, R5's care area assessment (CAA) dated 5/26/25, indicated R5 was at risk for developing pressure ulcers. R5's care plan dated 6/14/25, indicated R5 required the assist of one with a walker and gait belt for ambulation. R5's physical therapy (PT) orders signed 5/14/25, R5 was to transfer with the assist of one with walker. R5's eTAR dated 7/25, lacked documentation R5 was being ambulated with the assist of one with walker and gait belt. R5's Kardex Report dated 7/30/25, indicated R5 required the assist of one with a walker and gait belt for ambulation. R5's progress notes dated 5/13/25 to 7/30/25, lacked documentation R5 was receiving the assistance of one with walker and gait belt for ambulation. R11 R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 was severely cognitively impaired and was dependent on staff for all activities of daily living (ADLs). R11 had a diagnosis of dementia, hypertension (high blood pressure), and deep vein thrombosis (DVT) (blood clot). R11's care area assessment (CAA) dated 10/23/24, indicated R11 was at risk for pressure ulcers and pain due to body positioning. R11's care plan dated 3/10/25, indicated R11 was to receive passive range of motion (PROM) to all extremities. R11's care plan lacked information indicating how often staff were to perform PROM for R11. R11's physical therapy (PT) orders signed 9/26/24, identified R11 presented with impaired ROM and position of joints consistent with R11's level of dementia. R11 was a good candidate for set up of ROM program. R11's eTAR dated 7/25, lacked documentation R11 was receiving PROM. R11's Kardex Report dated 7/30/25, lacked documentation R11 was to receive PROM. R11's progress notes dated 5/1/25 to 7/30/25, lacked documentation R11 was receiving PROM. R30 R30's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R30 was cognitively intact and needed minimal assistance with all activities of daily living (ADLs). R30 had a diagnosis of hypertension (high blood pressure), dementia, and a traumatic brain injury (TBI) R30's care area assessment (CAA) dated 1/16/25, indicated R30 was at risk for loss of arm or leg movement and pressure ulcers. R30's care plan dated 1/14/25, indicated R30 was to receive PROM with the assist of one staff to the lower extremity. R30's care plan lacked information on what lower extremity was to receive PROM. R30's physical therapy (PT) orders signed 4/15/24, identified education was provided to nursing on completing ROM program. PT orders lacked information identifying what education was provided to nursing and where R30 was to be receiving ROM. R30's electronic treatment record (eTAR) dated 7/25, lacked documentation R30 was receiving ROM on R30's lower extremity. R30's Kardex Report dated 7/30/25, lacked documentation R30 was to receive ROM on R30's lower extremity. R30's progress notes dated 5/1/25 to 7/30/25, lacked documentation R30 was receiving ROM on R30's lower extremity. R33 R33's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R33 was severely cognitively impaired and dependent on staff with all activities of daily living (ADLs). R33 had Alzheimer's disease and depression. R33's care area assessment (CAA) dated 11/12/24, indicated R33 was at risk for pressure ulcers and pain. R33's care plan dated 4/28/25, indicated R33 was to receive lower extremity, upper extremity, and neck PROM exercises. R33's care plan lacked information identifying what lower and upper extremity was to receive PROM. R33's physical therapy (PT) orders signed 4/15/20, nursing staff ROM program has been implemented and staff educated. R33's electronic treatment record (eTAR) dated 7/25, lacked documentation R33 was receiving lower extremity, upper extremity, and neck PROM exercises. R33's progress notes dated 5/1/25 to 7/30/25, lacked documentation R3 was receiving lower extremity, upper extremity, and neck PROM exercises. During an interview on 7/30/25 at 12:46 p.m., NA -A revealed the facility no longer had a restorative aid. NA-A indicated there were several residents on a restorative program and staff were required to complete restorative therapy when assisting residents up in the morning. NA-A further indicated staff did not have enough time to complete all the needs of the residents which included restorative therapy. During an interview on 7/30/25 at 12:56 p.m., LPN-A stated NAs were responsible for completing restorative therapy on residents. LPN-A further stated the facility had not had a restorative program for about a year and a half. LPN-A indicated staff had never let her know if residents had refused restorative therapy, but she would expect them to let the nurse know. LPN-A further indicated if a resident refused it should have been documented in the residents' notes. During an interview on 7/30/25 at 1:03 p.m., OT-B stated NAs were trained on how to perform restorative therapy on residents with orders from PT/OT (physical/occupational therapy). OT-B further stated if staff did not know how to perform therapy, they would receive additional training and guidance from PT/OT. OT-B indicated all restorative therapy orders were written in the residents' care plans. During an email interview on 7/30/25 at 2:05 p.m., director of nursing (DON) indicated the ROM restorative therapy information is stored on the Kardex however, staff do not sign off that restorative therapy was completed. During an interview on 7/30/25 at 2:35 p.m., LPN-B stated R3s restorative therapy orders would have shown up on the NAs task list to be completed. LPN-B indicated NAs should have been letting nursing staff know if residents were refusing therapy. LPN-B further indicated LPN-B was unaware of any residents refusing therapy. During an interview on 7/30/2025 at 3:30 p.m., PT-B stated orders were put on a sheet and placed in a binder. PT-B further stated the binder used to be in the activities room, but PT-B did not know where the binder went. PT-B indicated the previous process changed when the new system took place and now the sheets are placed in the unit managers bin to be added to the care plans. During an interview on 7/30/25 at 5:15 p.m., DON confirmed the above findings and stated her expectations was staff were to be following the Kardex and care plan to get exercises completed. DON stated she was unaware why the restorative therapy orders were not linking to the tasks so staff could sign them off when they were completed. DON further stated it was important for residents to receive restorative therapy so there is not a decline in the residents or if a decline is noted the resident could be referred to PT/OT. R17 R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R17 as having severe impaired cognition. R17 needed extensive assistance for all activities of daily living (ADLs). R17 had a diagnosis of peripheral vascular disease (narrowing of the blood vessels), arthritis, and hypertension (high blood pressure). No restorative nursing programs was indicated on the MDS. R17's Care Area Assessment (CAA) dated 11/8/24, identified R17 had physical impairments such as weakness, limited range of motion, poor coordination, poor balance, visual impairment, and pain. R17's signed occupational therapy orders dated 12/11/23, revealed occupational therapist (OT) ordered an restorative nursing program to help with carryover and consistency for left upper extremity ROM. Orders included left upper extremity passive range of motion/ active range of motion for elbow flex/extend, shoulder protraction/ retraction/ flex/extension, horizontal abduction/adduction, and wrist flex/extend to help increase flexibility for ADL/s five repetitions with each exercise. R17's care plan dated 10/23/24, indicated R17 was at risk for contractures related to left hemiparesis following a cerebrovascular accident (CVA). The goal was to maintain shoulder range of motion (ROM) by participating in ROM exercises. Nursing was to assist in passive ROM to the left upper extremity shoulder, elbow, and wrist flexion/ extension and abduction/ adduction, all 10 repetitions, two sets. Cue R17 to rest and relax between sets. Three to five times a week, as R17 would allow. R17's medical record under the tasks lacked a restorative program. During an interview on 7/30/25 at 9:13 a.m., licensed practical nurse (LPN)-A indicated that the nursing assistants performed restorative programs, which include ROM. During an observation on 7/30/25 at 9:25 a.m., R17 was sitting in the dining room with left elbow and hand on a padded wheelchair armrest. During an interview on 7/30/25 at 10:42 a.m., occupational therapist (OT)-A indicated that on 12/11/23, OT set up a restorative program for R17. During an interview on 7/30/25 at 1:20 p.m., physical therapist (PT)-B indicated that on 12/11/23, OT set up a ROM program for staff to complete and it was not discontinued. R39 R39's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R39 was severely cognitively impaired and needed extensive assistance with all activities of daily living (ADLs). R39 had a diagnosis of Lewy bodies (affects cognitive and motor functions), Parkinson's (movement disorder), and hypertension (high blood pressure). No restorative nursing programs was indicated on the MDS. R39's CAA dated 12/5/24, identified R39 had assistance with eating, needed assistance with toileting. R39 had cognitive impairment, dementia, and neuromuscular functional risk factors. R39's signed occupational therapy orders dated 6/24/24 indicated R39 would continue to need ROM assistance to help improve ROM. R39 was unable to complete ROM on her own; nursing staff were educated on how to provide ROM for R39. On 6/19/24, the staff received an education sheet on how to complete ROM exercises and indicated ROM was to be done once in the morning and once in the evening. The education sheet provides pictures on how to perform elbow, forearm, shoulder, and wrist ROM. R39's care plan dated 10/24/24, indicated R39 had a passive ROM program to the upper and lower extremities, three times a week as able. R39's medical record under the tasks lacked a restorative program. During an interview on 7/30/25 at 10:42 a.m., occupational therapist OT-A indicated that OT would ask nursing staff quarterly if there were any changes with residents. Nursing staff had not discussed any changes to OT regarding R39. OT-A indicated on 6/24/24, R39 was placed on a ROM program for the elbow and hand for the nursing staff to complete. During an interview on 7/30/25 at 1:08 p.m., physical therapist (PT)-A indicated that on 6/19/24, R39 received orders to continue the restorative program. PT-A confirmed the ROM was not discontinued and would expect staff to continue as R39 tolerated. During an interview on 7/30/25 at 1:44 p.m., NA-A indicated residents participating in a restorative program had a spot in the tasks section on the computer to alert staff of their participation in the restorative program. NA-A viewed the task section for R17 and R39 and indicated that R17 and R39 lacked documentation of a restorative program needed to be performed. During an interview on 7/30/25 at 1:45 p.m., nursing assistant (NA)-B indicated there was no restorative aid in the facility, and the nursing assistants were responsible for performing ROM on residents who had a restorative program. If a resident had a restorative program, the computer would show this in a task section. NA-B indicated R17 and R39 did not have a restorative program, as there was no information in the task section of the computer's Kardex, which the nursing assistants used to identify who had a restorative program. During an interview on 7/30/25 at 3:30 p.m., registered nurse (RN)-A indicated the process was for OT to place restorative orders in a box by the nurse station. RN-A would take the orders and place them in the care plan, then give a copy of the orders to the staff. The facility received a new computer system this past year, and when the restorative program is placed into the care plan, it would populate on the nursing assistant's Kardex tasks on the computer. RN-A indicated that no issues were reported altering staff the Kardex task did not pull from the care plan. The facility policy titled Restorative Nursing Program, dated 4/6/20, identified the facility will have a restorative nursing program that promotes a resident's ability to achieve and/or maintain their optimal function, in accordance with the resident's comprehensive assessment and person-centered plan of care. Procedure: Residents will be evaluated on admission, ongoing and at least quarterly to determine the need for restorative nursing services by the Restorative Coordinator or nursing-designed and/or contracted therapy. The Restorative Coordinator or designee will inquire as to the resident's interest in participating with the recommended restorative nursing services, if applicable. If the resident declines/refuses recommended restorative A nursing services, an Informed Choice Consent form will be completed with the resident and/or resident representative regarding the risks and benefits of the services recommended by the Restorative Coordinator or designee and/or Contracted Therapy. The Restorative Nursing Coordinator or nursing designee will develop the program(s), in collaboration with Therapy if the program is recommended by Therapy, for residents who are identified as having the potential to benefit from the program(s). The Restorative Nursing Coordinator or nursing designee will develop the program(s), in collaboration with Therapy if the program is recommended by Therapy, for residents who are identified as having the potential to benefit from the program(s). A Restorative Assessment will be completed by the RN Restorative Coordinator or by nursing staff under the supervision of the RNC. This will include identifying and care planning the residents' need for restorative nursing services, goal(s), and interventions to meet the goal(s). When a resident is started on a RNP or has a change to their current RNP, the Restorative Coordinator or designee will communicate these changes with the resident, the nursing department and any staff who provide restorative nursing services. Restorative Coordinator or designee will keep the nursing leadership team and providers informed of resident's progress in regard to restorative nursing services, as needed. Restorative Coordinator or designee (must be a registered nurse) and/or Contracted Therapy will train the restorative staff on restorative techniques and individual restorative Nursing program(s). Restorative staff will show competency in restorative nursing programs. Training will be completed on an ongoing basis, as needed. Restorative staff will be responsible for providing the residents with restorative nursing services and will document completion. If a resident is refusing restorative nursing services or has had a change in condition/function, the restorative staff will report to the Restorative Coordinator or designee and the Nurse Supervisor in a timely manner. Documentation of non-compliance will include reason for refusal and any intervention(s) to promote compliance. If resident continues refusal of RNP after implementing interventions and education to promote compliance, the Restorative Coordinator or designee may complete an Informed Choice Consent form with the resident and/or resident representative. The Restorative Coordinator or designee will ensure documentation of the restorative program is complete. Restorative Coordinator or designee will meet with staff performing restorative services routinely to review programs, review documentation, and make recommendations in regard to restorative nursing services. Restorative Coordinator or designee (Registered Nurse) will evaluate the resident's restorative nursing program at least quarterly and document the evaluation in the electronic health record. The evaluation will include the resident's progress toward the goal, any barriers that interfere with the resident's progress, interventions attempted to assist the resident to overcome the barriers, an assessment of frequent refusals to participate in the restorative program and the rationale for the decision to revise, continue or discontinue the restorative nursing program. Restorative Coordinator or designee will update the restorative care plan, as needed. Restorative Coordinator or designee will monitor on an ongoing basis all aspects of the individualized restorative programs being offered. Audits will be completed as needed to review and identify any trends with the restorative nursing program. The Restorative Coordinator or designee will participate and develop a report for Quarterly QAPI meetings. These reports will help identify any variations and gaps to refer for review, improvement and increased monitoring.

Based on interview, and document review, the facility failed to notify the physician and resident representative for 1 of 1 resident (R7) who had a decline in range of motion (ROM) reviewed for limited ROM.R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 had moderate cognitive impairment and diagnosis which included cancer, hypertension (elevated blood pressure), and end stage renal disease (ESRD). R7 required moderate assist with activities of daily living (ADL's) which include bed mobility toileting and transfers and R7 had impairment on one side of upper extremity.R7's ADL Care Area Assessment (CAA) dated 6/18/25, identified R1 had physical limitations such as, limited range of motion , poor coordination, poor balance, visual impairment, or pain. R7 was at risk for complications of immobility such as contractures.R7's care plan revised 7/18/25 had a self-care deficit related to impaired balance and right sided upper extremity weakness. R7 was independent to walk with a walker. Care planned for PT/OT (physical/occupational therapies) to treat and eval as needed. Care plan lacked evidence of decreased ROM to right hand. During an observation on 7/29/25 at 5:48 p.m., R7 was walking from the dining room using a front wheeled walker. R7's right hand was down at her side and R7's fingers on her right hand were curled inward as R7 pushed her walker using only her left hand. R7 returned to her room and sat down in her recliner using only her left hand to touch the recliner as she sat down.During an observation on 7/30/25 at 8:42 a.m., R7 was walking from the dining room using a front wheeled walker. R7's right hand was down at her side and R7's fingers on her right hand were curled inward as R7 pushed her walker using only her left hand. R7 returned to her room and sat down in her recliner using only her left hand to touch the recliner as she sat down.During an observation and interview on 7/30/25 at 9:34 a.m., OT opened R7's fingers on the right hand and R7 yelled ouch that hurts. OT did a full assessment of R7's right hand and stated R7 had significant contractures to the thumb and all four fingers on the right hand. OT stated when R7 was admitted to the facility six months ago there was only a little tightness in R7's right hand and no contractures. OT stated she had not been notified of R7's decline in ROM to the right hand. OT stated her expectation was staff would have notified her and the physician of R7's decline in ROM.During an interview on 7/30/25 at 10:13 a.m., NA-A stated R7 had some weakness in her right hand when she was admitted to the facility six months ago. NA-A stated up until two months ago R7 was able to fully open her right hand without pain. NA-A stated R7 has been complaining of pain in her right hand for the past 2 months. NA-A stated she had not told anyone about the decline in R7's ROM or complaints of pain because she assumed the nurses were aware. NA-A stated she was unaware of any limited ROM of R7's shoulder or forearm and did not think R7 had any functional maintenance programs.During an interview on 7/30/25 at 10:16 a.m., licensed practical nurse (LPN)-A stated R7 had some weakness in her right hand six months ago when she was admitted . LPN-A stated she had noticed R7 had a little more difficulty opening her right hand this past month but it did not appear much worse so she did not notify therapy R7 was having more difficulty opening her right hand. LPN-A stated someone should have let therapy know R7 was having more difficulty opening her right hand to prevent decreased ROM and contractures.During an interview on 7/30/25 at 10:20 a.m., R7 stated She was having more difficulty walking lately because she was unable to use her right hand.During an interview on 7/30/25 at 11:05 a.m., family member (FM)-A stated he has noticed the decreased ROM in R7's right hand in the past few months. FM-A stated he did not recall the facility notifying him of the decreased ROM in R7's right hand. During an interview on 7/31/25 at 12:20 p.m., director of nursing stated she thought R7 had contractures when she was admitted to the facility six months ago. DON stated she was unaware R7 had decreased ROM or developed contractures in her right hand in the past few months or if it had been reported. DON stated it was her expectation that any change in a resident's condition be reported to the nurse so it could be assessed.During an interview on 7/30/25 at 2:35 p.m., MD stated he does not recall being notified of R7's decline in ROM or contractures to her right hand. MD stated his expectation was that the facility would have let him know about R7's decline in ROM to prevent further decline in ROM and contractures from developing.Review of a facility policy titled Notification of Significant Changes revised 5/22/22, identified The Charge Nurse will immediately (as indicated by the change of condition) inform the resident, consult with the physician, and notify the resident representative (consistent with his or her authority), for the following significant change situations: A deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.

Based on observation, interview and document review, the facility failed to re-assess and develop interventions for residents at risk for elopement (leave the facility without staff knowledge) for 1 of 3 residents (R1) reviewed for elopement.Findings include:R7's significant change Minimum Data Set assessment dated [DATE], identified R7 had moderate cognitive impairment and diagnosis which included cancer, hypertension (elevated blood pressure), and end stage renal disease (ESRD). R7 required moderate assist with activities of daily living (ADL's) which include bed mobility toileting and transfers and had impairment on one side of upper extremity.R7's care plan revised 7/28/25, identified R7 was at risk for wandering and had a wander guard on. Interventions included: provide care in a calm and reassuring manner. Care plan lacked further interventions related to wandering. R7's elopement risk assessment dated [DATE], identified R7 had no desire to leave, requests assistance to get into and out of the building due to vision. R7 would be able to sit outside independently with use of a call light for assistance to get back in. R7 was not at risk to wander or elope. R7's progress note dated 7/25/25 at 3:25 p.m., identified R7 went out the back door unattended. A family member of another resident reported R7 was in the parking lot to facility staff. Staff went to the parking lot and escorted R7 back into the building. R7's family was notified and a wander guard was placed on R7. R7 was angry. R7's medical record lacked evidence of any follow-up elopement assessment. During an observation on 7/29/25 at 10:37 a.m., R7 was seated in her room in her recliner with a wander guard on her left wrist. During an interview on 7/29/25 at 12:33 p.m., nursing assistant (NA)-C stated she was very familiar with R7. NA-C stated as far as she knew R7 had no history of wandering and has never gone outside without staff. NA-C further stated did not think R7 had a wander guard and was unaware of any care planned interventions for R7 related to wandering. During an interview on 7/29/25 at 12:36 p.m., NA-D stated R7 went outside a few days ago without staff. NA-D stated R7 talks a lot about wanting to go sit outside. NA-D stated she was unaware how often staff took R7 to sit outside. NA-D stated the only care planned intervention for R7 after going outside without staff was a wander guard. During an interview on 7/29/25 at 12:41 p.m., licensed practical nurse (LPN)-A stated R7 attempted to elope from the facility a few days ago. LPN-A stated a wander guard was placed on R7 after she attempted to elope from the facility. LPN-A stated there were no further care planned interventions for R7 related to wandering. During an interview on 6/30/25 at 10:28 a.m., nurse manager (NM)-A stated she was aware R7 had gone outside the facility a few days ago. NM stated she was unsure why R7 went outside. NM stated a wander guard was placed on R7 and no further elopement assessments had been done for R7. NM further stated she was unaware of any further care planned interventions for R7 related to wandering. NM stated her expectation was a new elopement risk assessment would have been done and more care planned interventions would have been implemented for R7 related to wandering. During an interview on 7/29/25 at 4:38 p.m., director of nursing (DON) verified R7 had eloped over the weekend and was at risk for further elopements. DON stated R7 stated she just wanted to go sit outside. DON verified a new elopement assessment had not been completed for R7 after the elopement and the only care planned intervention was a wander guard had been placed on R7. DON stated her expectation was a new elopement risk assessment would have been done and more care planned interventions would have been implemented for R7 related to wandering.Facility policy titled Elopement dated 8/1/22, identified, If it was unknown by the care center staff that the resident had left the building and is found outside by staff or visitor, this incident would constitute an 'elopement' and would require a report to the state agency. When the resident who eloped is located the facility would have conducted an investigation to determine how the elopement occurred in order to correct any underlying contributing factors.

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 47 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 10/21/23, 11/11/23, 11/19/23, 11/25/23, 12/2/23, 12/10/23, 12/30/23, and 12/31/23 for failure to have licensed nurse coverage 24 hours per day. Review of staffing schedules from 10/15/23 thorough 12/31/23, identified the facility had 14 staff identified to have worked: registered nurse (RN)-C, RN-D, RN-E, RN-F, RN-G, licensed practical nurse (LPN)-A, LPN-B, LPN-C, LPN-D, LPN-E, LPN-F, LPN-G, LPN-H, and LPN-I on each of the above dates listed. In addition, review of staff's time cards on the above-mentioned dates identified licensed nursing staff had worked. Review of the facility's staffing schedules and time cards identified a discrepancy with the PBJ report. During an interview on 5/01/24 at 3:20 p.m. director of nursing (DON) and registered nurse quality consultant (RNQC) verified the above findings and indicated St. [NAME] Health Services, Inc. (SFHS) entered the PBJ reports and they had not been entered correctly. Review of facility policy titled Payroll Based Journal reviewed/amended 4/1/19, SFHS would gather, submit and utilize Payroll Based Journal information as required by regulation. SFHS's Employment System Department (ESD) will review all PBJ data for accuracy and submit prior to the CMS mandated deadline (45 days after quarter end).

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene and donning/doffing of personal protective equipment (PPE) was performed in order to prevent the spread of infection for 2 of 3 residents (R7, R29) observed for enhanced barrier precautions (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). In addition, the facility failed to implement the water management plan for the prevention of Legionella (a bacterium) in the facility water system. This deficient practice had the potential to affect all 47 residents who resided in the facility. Further, the facility failed to ensure water pitchers were delivered in a manner that prevented risk of contamination for 2 of 3 hallways observed for water pitcher pass. In addition, the facility failed to ensure catheter drainage bags and wound vacs were properly placed to prevent the risk for cross contamination for 1 of 1 residents (R25) reviewed for catheter care. Findings include: ENHANCED BARRIER PRECAUTIONS, PPE USE AND HAND HYGIENE Review of CDC guidance dated [DATE], Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R29 R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 had moderate cognitive impairment and diagnoses which included dementia, depression, and diabetes mellitus (DM). Identified R29 required moderate assistance for activities of daily living (ADL's) which included toileting, transfers, and dressing. R29's care plan dated [DATE], indicated R29 indicated R29 required staff assistance to toilet. Care plan indicated R29 was occasionally incontinent of bladder. R29's electronic health record (EMR) banner identified R29 was colonized (being a carrier but not actively infected) with Methicillin - resistant Staphylococcus aureus (MRSA) ( an infection caused by a type of staph bacteria that's become resistant to many antibiotics). During an observation on [DATE] at 12:06 p.m., a plastic storage bin was present on the floor outside of R29's room which contained gowns, gloves and masks. A sign was on R29's door sign that identified Enhanced Barrier Precautions; Everyone Must clean their hands, including before entering and when leaving the room. Wear gloves and gown for the following high contact resident activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. In addition, the sign contained a picture of hand sanitizer a gown and gloves. During an observation on [DATE] at 1:23 p.m., nursing assistant (NA)-A entered R29's room with a standing lift. NA-A had no PPE on, including gloves and gown. NA-A stood within an inch of R29 and proceeded to place a sling around R29, used the standing lift to lift R29 into the air, pulled down R29's pants and placed R29 on the toilet. After toileting, NA-A operated the standing lift to lift R29 into the air, pulled up R29's pants, placed R29 into her wheelchair and brought the standing lift into the hallway. NA-A did not perform hand hygiene at any time during the observation. During an interview on [DATE] at 1:32., NA-A verified he had not worn any PPE while transferring R29 to the bathroom or performed hand hygiene. NA-A stated he should have worn a gown and gloves while assisting R29 to use the bathroom. NA-A indicated he should have performed hand hygiene before and after providing direct care to R29. R7 R7's quarterly MDS dated [DATE], identified R7 had intact cognition and diagnoses which included renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), traumatic brain injury and diabetes mellitus (DM). Identified R7 required limited assistance for (ADL's) which included toileting, transfers, and dressing. R7's care plan dated [DATE], indicated R9 indicated R7 required staff assistance to toilet. Care plan indicated R7 was occasionally incontinent of bowel and bladder. R7's EMR banner identified R7 was colonized with MRSA. During an observation on [DATE] at 1:26 p.m., a plastic storage bin was located outside of R7's room which contained gowns, gloves and masks. A sign was noted on R7's door sign that identified Enhanced Barrier Precautions; Everyone Must clean their hands, including before entering and when leaving the room. Wear gloves and gown for the following high contact resident activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. In addition, the sign contained a picture of hand sanitizer, gown and gloves. During an interview on [DATE] at 1:28 p.m., R7 stated he was unsure why there was a sign on his door and PPE out in the hall because staff did not use any PPE when they provided care for him. During an observation on [DATE] at 2:00 p.m., NA-B entered R7's room and informed R7 she was going to change R7's incontinent product for him. NA-B sanitized hands, applied gloves and did not apply any other PPE. NA-B stood within one inch of R7, asked R7 to stand up and NA-B proceeded to remove R7's soiled brief. NA-B placed the soiled brief into a bag, wiped R7's bottom with a wipe, removed her gloves and placed a clean brief on R7. NA-B walked out of the room, placed the soiled brief in the utility room and sanitized her hands. During an interview on [DATE] at 2:07 p.m., NA-B verified she had not worn a gown while providing incontinent cares for R7. NA-B stated she should have been wearing a gown and gloves while providing incontinent cares for R7. During an interview on [DATE] at 9:18 a.m., infection preventionist (IP) confirmed R7 and R29 were on enhanced barrier precautions for colonization of MRSA. IP stated her expectation was staff would have worn PPE and performed hand hygiene when indicated when caring for residents on EBP. IP indicated staff had been educated on EBP and that she would provide further education to the staff. During an interview on [DATE] at 11:59 a.m., director of nursing (DON) verified R7 and R29 were on enhanced barrier precautions for colonization of MRSA. DON stated her expectation was for staff to perform hand hygiene and wear the correct PPE when caring for residents on enhanced barrier precautions. 48583 WATER MANAGEMENT PROGRAM During an observation on [DATE] at 3:26 p.m., standing water was present in the indoor river located in the middle of the sitting area. The standing water was approximately two to three feet deep nearest rooms ,d+[DATE]. The water in the river continued to become more shallow moving down the river towards rooms ,d+[DATE]. The approximate length of the river was 38 feet long from end to end. [NAME] residue in a line pattern was noted on the inside of the downward flowing rock bed into river. [NAME] residue approximately one inch wide circled the entire perimeter of the rock bed into the river and was present on all edges. Nearest rooms ,d+[DATE], white residue was approximately three to four inches above the water level and approximately one inch wide. Reflective shiny blue/green/purple film swirled throughout the entire standing water in the river from end to end. During an observation on [DATE] at 7:45 p.m., a two feet by one and a half foot section of the river contained a translucent film noted on the top of the water near the end river by the bridge. One fish noted to be moving in the deepest part of the creek nearest rooms ,d+[DATE]. [NAME] slimy substance was noted on the bottom of the river covering the entire bed of the river where the water was standing. A hose was attached to a water spigot on the wall near the top of the river. The hose was coiled up and the end was placed down into a wire grate. No water was running at the time. During an observation on [DATE] at 10:20 a.m., the river continued to be the same as above. During an observation on [DATE] at 11:36 a.m., the river continued to be the same as above. During an interview on [DATE] at 10:20 a.m., during resident council, residents indicated the river had not been running for more than a year. Residents stated there used to be fish in the river however they had all died . During an interview on [DATE] at 9:12 a.m., maintenance director (MD) confirmed the above findings and indicated the river was shut down due to a leak and water was added to the river every week and flushed down the drain. MD stated all that was done as part of the water management plan was to add water to the river. MD stated I flush all the slime and stuff out and let it run down the drain until the river is clear again. MD indicated that water was added weekly not daily as written on the Legionella checklist. MD confirmed there was green slim covering the entire rock bed and revealed the river bed had not been cleaned since it stopped working. MD was unsure what the film on the top of the water was. MD indicated, It grows so quickly. I can already see it coming back from yesterday's flush. I am not sure why it continues to grow or how to get rid of it. MD verified there were two sucker fish (bottom feeders) in the river and they fed off of the bottom of the river and stated they feed off the bottom of the river. MD stated he was aware corporate was working on the river issue however was unsure what corporate's plan was to resolve the water management issue. During a follow- interview on [DATE] at 9:51 a.m., MD indicated the river stopped working in the first part of [DATE] and had not ran since then. CATHETER DRAINAGE BAG/ WOUND VAC During an observation on [DATE] at 3:16 p.m., R25 was laying in bed on her back covered with a blanket and R25's urinary catheter drainage bag was hanging down on the right side of the bed towards the foot end of the bed touching the floor. R25's wound vac was located on the floor near the head of the bed. During an observation on [DATE] at 8:21 a.m., R25 was laying in bed and R25's urinary catheter drainage bag was touching the floor. R25's wound vac was located on the floor near the head of the bed. During an interview on [DATE] at 12:53 p.m., nursing assistant (NA)-C indicated R25 had a foley catheter and required assistance with personal hygiene. NA-C stated the foley catheter bag should not have been touching the floor. NA-C indicated R25's wound vac should have been stationed on her wheelchair or bedside table and off the floor. During an interview on [DATE] at 1:45 p.m., licensed practical nurse (LPN)-A revealed R25 had a foley catheter placed to help reduce the amount of moisture around the sacral area to help heal the ulcer. LPN-A stated R25's urinary catheter drainage should not have been touching the floor. 49620 HAND HYGIENE DURING WATER PITCHER PASS During an observation on [DATE] at 11:01 a.m., dietary aide (DA)-A with developmental achievement center (DAC) job coach pushed a cart down hall with approximately 30 water jugs all with straws uncovered on top shelf of cart going past visitors. DA-A knocked on R24's door, delivered new water jug to R24's room, DA-A exited room with used water jug and placed on bottom shelf of cart. Job coach knocked on R12's door, delivered new water jug to R12's room, job coach exited room with used water jug and placed on bottom shelf of cart. DA-A delivered new water jug to R21 room, DA-A exited room with used water jug and placed on bottom shelf of cart. DA-A knocked on R28's door, delivered new water jug to R28's room, DA-A exited room with used water jug and placed on bottom shelf of cart. Job coach knocked on R200's door, delivered new water jug to R200's room, job coach exited room with used water jug and placed on bottom shelf of cart. DA-A delivered new water jug to R41's room, DA-A exited room with used water jug and placed on bottom shelf of cart. DA-A knocked on R38's door, delivered new water jug to R38's room, DA-A exited room with used water jug and placed on bottom shelf of cart. Job coach knocked on R202's door, delivered new water jug to R202 room, job coach exited room with used water jug and placed on bottom shelf of cart. DA-A knocked on R15's door, delivered new water jug to R15's room, DA-A exited room with used water jug and placed on bottom shelf of cart. DA-A knocked on R23's door, delivered new water jug to R23's room, DA-A exited room with used water jug and placed on bottom shelf of cart. Job coach delivered new water jug to R9's room, job coach exited room with used water jug and placed on bottom shelf of cart. Job coach knocked on R14's door, delivered new water jug to R14's room, job coach exited room with used water jug and placed on bottom shelf of cart. Job coach removed straw from R14's used water jug and threw straw into garbage on dirty dish cart by dining room. DA-A pushed the cart down the hall past visitors and delivered new water jug to R40's room, DA-A exited room with used water jug and placed on bottom shelf of cart. Job coach knocked on R11's door, delivered new water jug to R11's room, job coach exited room with used water jug and placed on bottom shelf of cart. DA-A did not sanitize hands during the entire water pass observation. Job coach did not sanitize hands during the entire water pass observation. During an interview on [DATE] at 12:01 p.m., job coach stated there had not been paper covers on the straws for sometime and was unsure how long. Job coach verified both the DA-A and herself did not sanitize hands between touching clean and dirty water jugs between resident rooms. Job coach stated she had not received any training on infection control practices from the facility and did not see a concern with not sanitizing hands between touching clean and dirty water jugs between resident rooms. During an interview on [DATE] at 2:46 p.m., dietary manager verified the facility trained a job coach from DAC years ago with the expectation that person would train other job coaches. Dietary manager stated she was unaware the straws did not have paper covers on them. Dietary manager indicated the expectation was staff would sanitize hands in between resident rooms when removing dirty water jugs prior to delivering new water jugs to prevent illness from one resident to another. During an interview on [DATE] at 9:18 a.m., infection preventionist (IP) confirmed R7 and R29 were on enhanced barrier precautions for colonization of MRSA. IP stated her expectation was staff would have worn PPE and performed hand hygiene when indicated when caring for residents on EBP. IP indicated staff had been educated on EBP and that she would provide further education to the staff. During an interview on [DATE] at 11:59 a.m., director of nursing (DON) verified R7 and R29 were on enhanced barrier precautions for colonization of MRSA. DON stated her expectation was for staff to perform hand hygiene and wear the correct PPE when caring for residents on enhanced barrier precautions. During an interview on [DATE] at 2:49 p.m., infection preventionist (IP) confirmed the above findings and stated the river has spores or something. The river has been an issue and we have been trying to get it taken out but it has been elevated to a corporate level. I do see a concern with it but I can't do anything with it. At a corporate level it has stalled at this point. During an interview on [DATE] at 2:05 p.m., with director of nursing (DON), a policy on pets was requested. DON stated there was not any fish in the river. Explained MD indicated there were two fish, bottom feeders, that were still living in the river. DON was unaware there were fish still living in the river. During a follow-up interview on [DATE] at 3:29 p.m., DON confirmed the above findings and revealed the river was not running and water remained in the river. DON indicated maintenance was responsible for taking care of the river. DON stated she was aware water was added however was not aware anything else was being done as part of the water management plan for the river. DON said corporate was aware of the river issue and they were working on it. During an interview on [DATE] at 3:24 p.m., director of nursing (DON) and registered nurse quality consultant (RNQC) confirmed the above findings and indicated all urinary catheter drainage bag needed to be off the floor at all times. RNQC indicated if bed was in a low position, urinary catheter drainage bags should have been placed in a wash basin to prevent them from laying directly on the floor to prevent cross contamination. During an interview on [DATE] at 3:25 p.m., IP stated she was unaware straws did not have paper covers on them. IP confirmed straws should have covers and verified her expectation was staff would sanitize hands in between touching dirty and clean water jugs to prevent the spread of infection. IP was unaware of any training that DAC staff had received. During an interview on [DATE] at 3:36 p.m., director of nursing (DON) confirmed the DAC staff had not received any training for infection prevention. A facility policy titled Enhanced Barrier Precaution dated [DATE], identified the facility would apply Enhanced Barrier Precautions to prevent the spread of Multi- Drug Resistant Organisms (MDRO's). identified EBP should have been used when providing high contact care to residents who were colonized or infected with an MDRO when contact or other precautions did not apply. Identified EBP which included wearing a gown and gloves were employed when performing the following high contact resident care activities: Dressing, Bathing, Changing Linen, Transferring, Hygiene care, Toileting, Peri care, Emptying Catheter bags, Wound Care, Indwelling medical devise care, Therapy treatments. A facility policy titles Hand Hygiene revised [DATE], identified staff were to routinely perform hand hygiene to prevent and control the spread of infection. Identified staff were to perform hand hygiene before and after direct contact with a resident. Review of Water Management Program (WMP) Reduce Growth and Spread of Legionella Checklist dated [DATE] to [DATE], revealed the chapel sink was flushed weekly. Review of the river (wells river) indicated reverse osmosis system adds water daily however lacked documentation water was being added. Review of Water Management Program Legionella Prevention reviewed/amended [DATE], indicated the WMP would identify specific potential hazard areas where Legionella could grow and spread. Water features: Fountains, ponds, and [NAME] within the care center would be inspected for biofilm (green slime) buildup on the rocks and the bottom of the water features. This would indicate cleaning of the water feature was needed. Requested a policy on pet fish, however one was not received. Review of the facility policy titled Catheter Care issued [DATE], make sure catheter tubing and drainage bags were kept off the floor. Place in a basin if it could not hang from the bed. Review of the facility policy titled Wound Vac Dressing change undated, did not indicate any information about where the wound vac should be placed at all times. A facility policy titled Fresh Water Pass revised ,d+[DATE], stated the top of a straw would be covered with a wrap. Hands would be cleansed with hand sanitizer before next clean mug/glass was delivered into the next residents room.

Based on observation, interview and document review, the facility failed to ensure urinary catheter drainage bags were covered to maintain dignity for 1 of 1 resident (R25) observed with uncovered urinary catheter drainage bag in view of residents, staff and visitors. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had diagnoses of multidrug-resistant organism (bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and renal failure (kidneys are no longer able to filter and clean blood). Identified R25 was severely cognitively impaired and required extensive assistance for bed mobility, transfers, dressing, and personal hygiene. Indicated R25 had an indwelling catheter. R25's care plan last dated 6/13/22, indicated R25 had an indwelling foley catheter due to an open sacral wound that was affected by incontinence and prevented ulcer healing. Identified various interventions which included change catheter per facility policy, position the catheter bag and tubing below the level of the bladder and away from entrance room door, monitor, and keep the catheter bag in a privacy bag when up in wheelchair or in bed. During an observation on 4/29/24 at 3:16 p.m., R25 was laying in bed on her back covered with a blanket and R25's urinary catheter drainage bag was hanging down down on the right side of the bed towards the foot end of the bed. R25's urinary catheter drainage bag was not covered with a privacy bag. During an observation on 4/29/24 at 5:05 p.m., R25 was seated in her wheelchair in the dining room with two other residents. R25's urinary catheter drainage bag was hanging underneath her wheelchair and was not covered with a privacy bag. Urine was observed in the bottom of the catheter bag. During an observation on 4/30/24 at 8:21 a.m., R25 was laying in bed and R25's urinary catheter drainage bag was touching the floor. R25's urinary catheter drainage bag was not covered with a privacy bag, room door was open, and urinary catheter drainage bag was visible from the hallway. During an observation at 4/30/24 at 11:09 a.m., R25 was seated in her wheelchair in the dining room with the back of her wheelchair facing the doorway to enter the dining room. R25's urinary catheter drainage bag was attached underneath her wheelchair and was not covered with a privacy bag. R25's urinary catheter drainage bag had visible urine in the bottom of the bag. During an interview on 4/30/24 at 3:45 p.m., family member (FM) indicated R25 had an indwelling foley catheter and it would bother R25 to have the urinary catheter drainage bag exposed so other people could see it. FM stated R25 would be embarrassed without the privacy bag covering the urinary catheter drainage bag . During an interview on 5/01/24 at 12:53 p.m., nursing assistant (NA)-C indicated R25 had a foley catheter and required assistance with personal hygiene. NA-C stated a privacy bag should have been placed over the urinary catheter drainage bag when attached under her wheelchair and when R25 was laying in bed. During an interview on 5/01/24 at 1:45 p.m., licensed practical nurse (LPN)-A revealed R25 had a foley catheter placed to help reduce the amount of moisture around the sacral area to help heal the ulcer. LPN-A stated R25 should have had a privacy bag covering her urinary catheter drainage bag when up in her wheelchair or laying in bed. LPN-A's expectations were all urinary catheter drainage bag were covered with a privacy bag. During an interview on 5/01/24 at 3:24 p.m., director of nursing (DON) confirmed the above findings and indicated all urinary catheter drainage bag needed to be covered and staff were expected to place the privacy bag over a urinary catheter drainage bag at all times. Review of the facility policy titled Catheter Care issued 9/11/23, catheter care would be completed to maintain catheter patency, prevent infection, and ensure dignity. Cover drainage bag with a cloth/vinyl bag to protect the dignity of the resident.

Based on interview and document review, the facility failed to ensure procedures were implemented and followed to ensure sufficient medication supplies, timely medication re-ordering, after hours on-call pharmacy use, and appropriate action(s) taken when a medication was not available for administration for 1 of 3 residents (R147) reviewed for medication administration. Findings include: A Vulnerable adult maltreatment report was submitted to the State Agency (SA) on 9/18/23 at 12:55 p.m., and identified R147's ordered Oxycodone (pain medication) was out of supply; thus, R147's Oxycodone was omitted on the morning of 9/18/23 and R147 was sent to the emergency room for out of control cancer pain In addition, the report indicated his medical record lacked evidence staff followed-up with the pharmacy or that his provider was notified timely. R147's significant change Minimum Data Set (MDS), dated [DATE], identified R147 was severely cognitively impaired with diagnoses of cancer, diabetes, arthritis and anxiety. Indicated R147 received scheduled pain medication daily. R147's care plan/service plan identified R147 experienced an alteration in pain related to prostate cancer, osteoarthritis. The care plan directed medication was to be administered as ordered. A nurses note on point click care (PCC) from the facility on 9/18/23, from LPN-B indicated R147's Oxycodone was ordered from pharmacy on 9/15/23, however was not delivered; thus R147 did not receive his Oxycodone the morning of 9/18/23. R147 was hollering out in pain. Every touch and movement R147 was screaming out in pain. R147's September 2023 medication administration record (MAR) directed staff to administer R147 Oxycodone 10mg (milligrams) in the morning related to pain. The MAR identified on 9/18/23, a recorded entry of DNA (drug not available). R147's medical record lacked evidence staff followed-up with pharmacy on the lack of Oxycodone supply, or contacted/updated R147's provider. During an interview on 5/1/24 at 9:01 a.m., licensed practical nurse (LPN-B) confirmed R147 went to the emergency roiagnom on [DATE] related to uncontrolled pain. LPN-B stated she did not recall why his pain medication was not refilled as it was ordered the Friday before. LPN-B verified she was unaware of medications available in the emergency kit or the policy on how and when to use the emergency kit. During an interview on 5/1/24 at 9:22 a.m., registered nurse (RN)-A stated she did not recall why R147 went to the emergency roiagnom on [DATE]. RN-A stated she recalled R147 was admitted to the facility with cancer diagnosis, was to receive therapy and was hopeful to return home. RN-A was unable to provide a process for when the emergency kit would be utilized or a process to update the doctor when a resident's medications were unavailable. During an interview on 5/1/24 at 9:32 a.m., LPN-A verified medications were reordered from the pharmacy when there were eight to nine pills left for a resident. LPN-A stated she would alert the charge nurse and the pharmacy if a medication was not delivered to the facility when needed for a resident. LPN-A stated the facility had a standing order for Tylenol otherwise there were no other pain medications available for a resident if needed. LPN-A confirmed she was unaware of what medications were in the emergency kit or the policy on how and when to use the emergency kit. During an interview on 5/1/24 at 9:40 a.m., RN-B stated the facility would call the pharmacy first if unable to manage a resident's pain and then would sent to the emergency room . RN-B did not indicate the doctor would be updated if a resident was out of pain medications and had pain and verified the facility had an emergency medication kit however was unaware of what medications were in the kit. During an interview on 5/1/24 at 12:12 p.m., emergency room doctor verified the expectation that the facility would contact the on call provider to obtain a refill of a pain medication prior to sending a resident to the emergency room . On 5/1/24 at 10:05 a.m., a message was left for the facility's medical director with no return call received. During an interview on 5/1/24 at 9:46 a.m., the director of nursing (DON) stated her expectation was nurses would update the doctor if a resident was having pain and request pain medications. DON stated the facility had a standing order for Tylenol however no other pain medications were available in the facility for emergency use. DON confirmed the facility has an emergency medication kit however was unaware of what medications were in the emergency kit or when the kit would be utilized. DON stated she was unaware of the process and training for the nurses on the use of the emergency kit and that the facility rarely used the emergency kit as the pharmacy was available seven days a week and the facility was able to obtain medications when needed. During an interview on 4/30/24 at 3:13 p.m., the consulting pharmacist stated the expectation was that the facility would alert the provider if they were out of a medication and that the facility would have a policy on how to use the emergency kit. During an interview on 4/30/24 at 3:26 p.m., the pharmacist from Thrifty [NAME] stated the expectation was the facility would alert the provider when they were out of a medication. The pharmacist stated the pharmacy delivered medications to the facility seven days a week when necessary. When a medication was needed after those hours, she expected the facility staff to utilize their emergency kit and contact the on call doctor. During an interview on 4/30/24 at 2:45 p.m., R147's family member denied concerns with R147's stay; however she was concerned that family was not contacted about R147 having uncontrolled pain and that R147 was sent to the emergency room . During an interview on 4/30/24 at 11:17 a.m., the complainant verified the vulnerable adult report information when reviewed and that R147 came to the emergency room related to uncontrolled pain. He stated the notes sent from the facility stated that R147 was out of pain medication and he did not understand why R147 was sent to the emergency room instead of the facility contacting the doctor for pain medications. A nine month review of pharmacy reorder forms were requested and not provided. Two pharmacy binders were received for review; Thrifty [NAME] pharmacy dated from 2/15/24 through 4/28/24 and the other pharmacy binder from [NAME] Drug lacked any documentation from 9/18/23. A Medication Administration policy, dated 8/7/23, lacked documentation on a procedure if a resident did not have a medication available as ordered. The policy lacked direction(s) related to the pharmacy reordering and/or adequate med supply processes, processes for staff to follow when a med was unfound, and/or the processes for on-call pharmacy utilization. An Emergency Kit policy, undated, stated if the facility had an order for a medication but were out of the resident's medication to follow steps three through five on the emergency kit policy: Write the order in the charge book, write the medication taken in black e-kit binder and take the medication from the e-kit for the resident use. Review of all nurse staff education lacked specific training on use of the emergency kit process and procedures.

Based on interview and document review, the facility failed to ensure a resident was reassessed for continued use of an as needed (PRN) psychotropic medication, Xanax (anti-anxiety), beyond the 14 days for 1 of 5 residents (R202) who was reviewed for unnecessary medications. Findings include: R202's admission Minimum Data Set (MDS) dated [DATE], identified R202 was cognitively intact and had diagnoses which included: cancer, diabetes mellitus and depression. Identified R202 required extensive assistance of one staff with bed mobility, transfers, dressing, personal hygiene and toileting. Indicated R202 had no behaviors and received anti-depressant and anti-anxiety medication. R202's service plan dated 6/11/23, identified R202 had a potential problem related to use of Xanax for anxiety related to her current health condition. R202's service plan identified R202 was very anxious and had interventions which included the following: - Observe for side effects of medications, - Observe for changes in behaviors, make referrals, and update primary provider, - Observe for changes in behavior, - Explain all cares being provided, and - Utilize current support system. Review of R202's progress notes from 6/9/23 to 7/12/23, revealed the following: - On 6/12/23, at 12:04 p.m., the pharmacist recommended a review of R202's Xanax per long term care (LTC) regulations. Review of R202's Consultant Pharmacist Drug Regimen Review Summary (DRR) dated 6/16/23, identified the facility needed to address R202's Xanax as previously noted on 6/12/23, initial pharmacy review. R202 had PRN Xanax 0.25mg to be reviewed by the provider per long term care (LTC) regulations for continued use past 14 days. Review of R202's Physician Progress notes from 6/9/23 to 7/12/23, revealed the following: - On 6/16/23, R202 was seen by her primary provider, and he indicated R202 had squamous cell carcinoma of the right lung with brain metastases and identified R202 had anxiety about her health. R202's daughter had concerns regarding R202's panic attacks and anxiety. R202 previously had an order for Xanax PRN, order changed to scheduled Xanax 0.25 mg twice daily. The plan was to follow-up and adjust dose as needed. -On 6/29/23, R202 was seen by her primary provider and the provider indicated R202's scheduled dose of Xanax twice daily had been helpful for managing her anxiety. Review of R202's Physicians Orders signed and dated on 6/16/23, indicated R202 had received an order from her primary physician for Xanax 0.25 milligrams (mg) two times daily. Review of R202's medication administration record (MAR) summary from 6/1/23 to 7/12/23, identified the following: - on 6/22/23, R202 had received a PRN dose of Xanax 0.25 mg at 8:08 p.m. - on 6/30/23, R202 had received a PRN dose of Xanax 0.25 mg at 4:15 p.m. - on 7/3/23, R202 had received a PRN dose of Xanax 0.25 mg at 11:58 a.m. Review of R202's medical record indicated R202 continued to receive PRN Xanax 0.25 mg along with Xanax 0.25 mg scheduled two times daily following her primary physician discontinued the PRN dose on 6/16/23. During a telephone interview on 7/12/23 at 12:09 p.m., the consulting pharmacist (CP) confirmed he had reviewed R202's admission orders and had made recommendations for the provider to address continued use of PRN Xanax after 14 days. The CP indicated a medication error had occurred when staff continued to administer the PRN Xanax in addition to the regular scheduled doses. The CP indicated he reviewed the residents' medications upon admission and monthly thereafter. He stated he needed to complete a medication safety in-service to ensure errors like this did not re-occur. During a telephone interview on 7/12/23 at 8:50 a.m., the primary physician's nurse (PPN) indicated after confirming with R202's primary physician, R202's primary physician wanted R202's PRN Xanax 0.25 mg discontinued on 6/16/23, and had ordered it to be scheduled two times daily instead. During an interview on 7/11/23 at 3:00 p.m., registered nurse (RN)-A confirmed the above findings and indicated she had not discontinued R202's PRN Xanax 0.25 mg on 6/16/23 as ordered, due to the order being unclear to her. RN-A verified she had not reached out to R202's primary physician for clarification regarding R202's PRN Xanax 0.25 mg. RN-A confirmed R202 continued to receive her PRN Xanax on 6/22/23, 6/30/23, and 7/3/23. In a follow-up interview on 7/12/23 at 12:21 p.m., RN-A indicated she had clarified with R202's PPN R202's PRN Xanax had been ordered to be discontinued back on 6/16/23. During an interview on 7/12/23 at 12:27 p.m., the director of nursing (DON) confirmed the above findings and indicated she would expect nursing staff to call the primary physician for clarification if an order was unclear to them. The DON stated the facility's process was for nursing staff to do rounds with the primary physician and to address any pharmacy recommendations during that time. The DON indicated she would expect nursing staff to process orders as they received them, update the MAR to reflect the updated orders, and to follow the facility policy. Review of the facility policy titled, Physician's Orders undated, indicated nursing staff were expected to obtain an order from the physician, transcribe the order, complete a progress note describing the reason the order was made and notify family. If a medication was discontinued, staff were to remove the medication cassette from the medication cart and the MAR should reflect the changes. Review of the facility policy titled, Psychotropic Medications dated 10/1/15, indicated: -The primary physician would document a rationale and diagnosis for the use of the psychotropic medication. The primary physician would evaluate the effects of the psychotropic within one month and during routine visits thereafter. -Nursing staff would monitor the resident for side effects of the psychotropic medication and review continued use with the primary physician. -The Pharmacist would monitor the resident on psychotropic medications to ensure they were not being used excessively and notify the primary physician or nursing staff if the psychotropic medication was due for review.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R46, and R47) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the current CDC recommendations 3/15/2023, revealed The Center for Disease Control and Prevention (CDC) identified Adults [AGE] years of age or older who had not previously received Pneumococcal 13-valent Conjugate Vaccine (PCV13) and who had previously received one or more doses of Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive a dose of Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Pneumococcal 20-valent Conjugate Vaccine (PVC20). The dose of PCV15 or PCV20 should be administered at least one year after the most recent PPSV23 dose. In addition, the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 was received at age 65 and older, based on shared clinical decision-making, one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Review of R47's facesheet, R47, age 87, was admitted to the facility on [DATE]. Review of R47's Minnesota Immunization Information Connection (MIIC) undated, identified R47 had received the Pneumo-PPSV23 on 11/04/2009, and the Pneumo-PPSV23 on 10/01/2018. R47's medical record lacked documentation R47 had received or been offered the PCV15 or PCV20 vaccines. Review of R46's facesheet, R46, age 80, was admitted to the facility on [DATE]. Review of R46's Minnesota Immunization Information Connection (MIIC) undated, identified R46 had received the Pneumo-PCV13 on 11/04/2015, and received Pneumo-PPSV23 on 1/20/2017. R46's medication record lacked documentation R46 had received or been offered the PVC20 vaccine. During an interview on 7/12/23 at 9:30 a.m., registered nurse (RN)-A stated the facility's usual process was to review the resident's MIIC report upon admission to determine if there was a need for a pneumococcal vaccine. RN-A verified the facility referred to the CDC Pneumococcal Vaccine Timing for Adults dated 4/01/2022, to assist in determining if more vaccines should be offered and was not aware the guidelines had recently been updated. RN-A confirmed R47 and R46 had not been offered or received the pneumococcal vaccinations as recommended by the CDC. During an interview on 7/12/23 at 9:25 a.m., infection preventionist (IP)-A stated the facility's policy was to offer and administer the pneumococcal vaccine according to the CDC recommendations. IP-A indicated her usual practice was to review the resident's MIIC report upon admission and provide the MIIC report information along with the CDC recommendations to the RN unit manager. IP-A indicated she was not aware the CDC recommendations had recently been updated. IP-A confirmed R47 and R46 had not been offered or received the pneumococcal vaccinations as recommended by the CDC. During an interview on 7/12/23 at 1:13 p.m., with director of nursing (DON) confirmed the facility process was for staff to review the MIIC report and to administer pneumococcal vaccinations according to the CDC recommendations. DON stated she was not aware the CDC recommendations had recently been updated. DON confirmed R47 and R46 had not been offered or received the pneumococcal vaccinations as recommended by the CDC. The facility policy titled Resident Immunization dated 12/2/22, identified pneumococcal vaccines would be offered to each resident according to the current recommendations from the CDC on admission to the facility.

Based on interview and document review, the facility failed to follow up on pharmacy recommendations for a dose reduction related to an acid reduction medication for 1 of 5 residents (R12) reviewed for unnecessary medications. Findings include: R12's Resident Face Sheet dated 7/12/23, indicated R12 had diagnosis which included gastro-esophageal reflux disease, anxiety, and depression. R12's Physician Order Review signed and dated 6/23/23, indicated R12 currently had an order for Famotidine (acid reducing medication) 40 milligram (mg) daily at breakfast. Review of R12's progress notes from 5/1/23 to 7/12/23, revealed the following: - On 5/19/23 at 11:21 a.m., the pharmacist recommended to decrease R12's Famotidine from 40 mg to 20 mg daily based on her current renal function and an accumulation of Famotidine in the body could cause an increase in anticholinergic effects in the central nervous system (CNS) placing R12 at an increased risk of confusion. Review of R12's Consultant Pharmacist Drug Regimen Review Summary dated 5/19/23, a recommendation had been made to decrease R12's Famotidine due to her creatinine level. R12's medical record lacked documentation R12's primary physician had reviewed, made recommendations or provided rationale for continued use of R12's current order of Famotidine 40 mg daily. During an interview on 7/12/23 at 1:07 p.m., registered nurse (RN)-A confirmed the above findings and indicated she could not recall if she had communicated the recommendations to R12's primary physician. RN-A stated the facility's usual practice was to print out the pharmacy drug recommendations, communicate the results to the primary physician during rounds and to ask the primary physician to address the recommendations in a timely fashion. During an interview on 7/12/23 at 1:22 p.m., the director of nursing (DON) confirmed the above findings and indicated she would expect nursing staff to follow pharmacy recommendations and the facility policy. The DON indicated the facility's usual practice for pharmacy recommendations included the nursing staff would print the recommendations out, communicate the recommendations to the primary physician and to document the results of the physician's review. Review of facility policy titled, Drug Regimen Review dated 10/8/18, indicated the pharmacy consultant would conduct a drug regimen review (DDR) at least once a month to help manage drug regimens and identify and address suspected or confirmed medication issues. The DDR would include review of each resident's drug regimen to identify and discontinue potentially unnecessary drugs. After the DDR was complete any irregularities noted by the pharmacist would be documented on a separate written report and sent to the DON .

Based on observation, interview, and document review the facility failed to implement appropriate interventions to protect 1 of 3 identified residents (R1) with wandering behaviors from leaving the facility unattended while in the COVID-19 isolation unit. As a result, R1 eloped from the facility on 5/27/22, which resulted in a potential risk of serious harm identified at immediate jeopardy. The immediate jeopardy (IJ) began on 5/26/22, when R1 was transferred from the secure locked memory care unit to the COVID-19 isolation unit. The administrator and director of nursing (DON) were notified of the IJ on 6/2/22 at 9:15 a.m. and the facility implemented corrective action on 5/27/22, prior to the start of the survey and was issued at Past Noncompliance. Findings include: A Nursing Home Incident Report (NHIR) dated 5/27/22, indicted R1 had contracted COVID-19 and had been transferred from the facility's locked secure memory care unit ([NAME] Center) to a COVID-19 unit ([NAME] Lane) which was equipped with a 15 second delay egress exit to the outside. On 5/27/22, at 8:15 a.m. the exterior door alarm sounded, the direct care staff looked outside and did not see any residents. The staff members did a review of the residents residing in the COVID-19 unit and determined R1 was not present. Staff then began searching the facility grounds and found R1 outside with a neighbor. R1's Minimum Data Set (MDS) dated [DATE], identified R1 with severe cognitive impairment and diagnoses including Alzheimer's dementia, major depressive disorder and anxiety. R1's cognition Care Are Assessment (CAA) dated 5/10/22, indicated R1 was oriented to self but not to time or place. R1 was able to ambulate independently and required placement on the secure memory care unit. R1's care plan dated 7/6/20, identified R1 at risk for wandering and exit seeking behaviors. The plan directed the staff to ensure R1 was supervised when off of the secure unit. R1's Elopement Risk assessment dated [DATE], indicated R1 hovered by outside doors, had a history of exit seeking behaviors, anxiety, delusions, searched for people not in the facility and was at risk to wander/elope from the facility. R1's Assessment for Appropriate Placement on Alzheimer's/Dementia Unit dated 5/18/22, indicated R1 was independent with ambulation without assistive devices. R1 did not understand why she was at the facility and searched for ways to leave the facility. R1 had a history of becoming upset and would bang on windows and doors. R1 was appropriate to remain on the secure locked unit. R1's Progress Notes (nurses notes) indicated the following information: -PN dated 5/26/22, at 2:03 p.m. R1 tested positive for [CONDITION(S)] COVID-19 and was transferred to the COVID-19 isolation unit. R1 displayed no signs or symptoms of COVID-19. -PN dated 5/26/22, at 9:00 p.m. (entered on 6/1/22, at 3:38 a.m.) R1 refused dinner and any offered snacks. R1 has been pacing and very upset that she was unable to find her family. Staff spent time with R1 to attempt to cam her and provide reassurances. -PN dated 5/27/22, at 1:30 a.m. (entered on 6/1/22, at 3:36 a.m.) R1 had been upset about the temporary move to the COVID-19 unit. She has been pacing, crying and wondering where her family is and if they know where she is. R1 was offered diversional activities such as having staff members ambulate with her, reading or watching videos. Distractions work for about 15-20 minutes and then she gets back to pacing. -PN dated 5/27/22, at 5:45 a.m. (entered on 6/1/22, at 3:53 a.m.) R1 continued to pace and cry. R1 had periods of quiet time where she would sit with staff or by the window and look outside. R1 had not attempted to leave the facility. -PN dated 5/27/22, at 8:15 a.m. (entered on 6/1/22, at 6:53 a.m.) the [NAME] Unit outside door sound and resident could not be located on the unit. Nursing assistant (NA)-A looked outside and did not see any residents. The DON went outside and saw resident across the street talking to a neighbor and walking towards the facility. R1 was tearful and stated she didn't know where to go. The DON then escorted R1 to the COVID-19 unit and an unidentified activity aide was directed to the COVID-19 unit to monitor R1. -PN dated 5/28/22, at 5:00 a.m. (entered on 6/1/22 at 3:58 a.m.) R1 wandered thought the evening carrying her Bible and reading from it. R1 went to bed around 3:30 a.m. -PN dated 5/29/22, at 9:30 p.m. (entered on 6/1/22 at 4:05 a.m.) R1 had a good evening with the activity staff. R1 walked throughout the unit with her Bible, reading occasionally. R1 did not attempt to leave the COVID-19 unit. -PN dated 5/30/22 at 9:45 p.m. (entered on 6/1/22, at 4:42 a.m.) R1 was noted to pace on the COVID-19 unit. -PN dated 5/31/22 at 9:15 p.m. (entered on 6/1/22, at 4:48 a.m.) R1 had no complaints or behaviors. -PN dated 6/1/22, at 4:51 a.m. R1 remained asymptomatic for COVID-19. R1 was up during the night to use the restroom and returned to bed. On 5/31/22, at 4:46 p.m. R1 was observed on the [NAME] Lane COVID-19 unit. R1 ambulated independently to the State Agency (SA) staff member and stated she did not understand why she was at the facility, and she wanted to go home. R1 was observed to have a wander guard bracelet (a system which triggers an audible alarm when the person wearing the bracelet passes through a door egress equipped a sensor) on her wrist. R1 then turned and ambulated down the hallway. A large (approximately 6 foot by 8 foot) moveable see through red screen ([NAME] screen) was observed to be placed at the end of the hallway at the egress between the resident room hallway and a small sitting room. The [NAME] Lane exterior exit door was located in the small sitting room. On 5/31/22, at 5:00 p.m. NA-B stated the [NAME] Lane COVID-19 unit had been staffed with one NA and a nurse who worked on both COVID-19 units. NA-B stated the unit would occasionally have one staff member present for the 9 residents residing on the unit. However, after R1 left the faciity on [DATE], the facility had assigned two nursing assistants to work on the [NAME] Lane unit to provide additional supervision for the residents with wandering behaviors. On 5/31/22, at 5:08 p.m. NA-C stated the [NAME] Lane unit had increased staffing as of 5/27/22, due to R1 leaving the facility. On 6/1/22, at 8:00 a.m. R1 was observed to be sleeping in a recliner in her room. On 6/1/22, at 9:40 a.m. family member (FM)-A was interviewed via telephone. FM-A stated R1 had been on the secure unit since her admission to the facility in July 2020, due to wandering behaviors and confusion. FM-A stated R1 had not eloped from the facility in the past. In addition, R1 did not have concerns with elopement prior to placement in the facility or during home visits. The incident on 5/27/22, was R1's first elopement. On 6/1/22, at 9:50 a.m. the administrator stated the COVID-19 outbreak began on 5/16/22. This was the first facility COVID-19 outbreak involving the residents since the pandemic began in March 2020. When the residents from the memory care unit began to test positive, the facility focus was to move them into an isolation unit. The facility was in the process of starting a construction project and had two open wings Park Avenue unit and [NAME] Lane unit which were both transformed into COVID-19 isolation units. The Park Avenue unit was not equipped with any type of delayed egresses or wander guard system however, the [NAME] Lane unit was equipped with keypad operated doors to get onto the unit and a delayed egress exterior exit door. The administrator had discussed options of which COVID-19 unit to transfer residents from the memory care onto with the interdisciplinary team and corporate consultant. The [NAME] Lane unit was the better option due to established security. The administrator confirmed the facility did not complete a new comprehensive risk assessment for elopement for R1 upon transferring R1 from the secure memory care unit to the semi secure [NAME] Lane COVID-19 unit. After R1 exited the building new interventions had been implemented, however, a formal written documentation was not completed. On 6/1/22, at 12:09 p.m. R1 was observed walking/pacing on the COVID-19 unit. R1 stated she wanted to go home. - At 12:11 p.m. R1 approached NA-D and informed her she did not like another resident. She stated the resident made her nervous and she wanted to go home. NA-D comforted R1 and offered her lunch. On 6/1/22, at 12:22 p.m. registered nurse (RN)-A stated she was on duty on 5/27/22, when R1 left the building. RN-A heard the alarm sound, initially didn't see any residents outside, but quickly identified R1 was not on the unit. RN-A directed the staff to look outside for R1, they found her and returned her to the unit. R1 was out of the building for approximately 10 minutes and did not sustain any type of injury while out of the building. Since that time, the facility put up the red screen at the end of the hallway, added a wander guard bracelet and they had increased the staff from one NA to two NA per shift on the [NAME] Lane COVID-19 unit. R1 had not left the unit since the staffing was increased. On 6/1/22, at 12:26 p.m. maintenance staff (MS)-A was observed to be working on installing a new mechanical device to the [NAME] Lane interior entrance door. MS-A stated the device was to increase the security of the [NAME] Lane unit by increasing the delayed response for the door to open. MS-A stated the exit door delayed response had been increased on 5/27/22, and the new mechanical parts would further increase the delay time. The parts had been ordered on 5/27/22 and arrived at the facility on 6/1/22. On 6/1/22, at 2:18 p.m. the director of environmental services (DES) stated a delayed egress door was a door which was equipped with a magnetic locking system. Initially when the door knob was turned, the door would not open, however, if the door knob is turned and held for 15 seconds, the door would open. DES stated R1 held the door for 15 seconds on 5/27/22 and was able to elope. Since that time, he had added a wander guard system to the doorway, had placed wander guard alert bracelets on three residents (R1, R2 and R4) who had been in the secure memory care unit and displayed wandering behaviors. In addition, the delayed egress response of the exterior door on [NAME] Lane had been attempted to be increased from 15 seconds to 30 seconds. However, an alarm technician was required to make the change. The alarm technician was called on 5/27/22 and was scheduled to arrive on 6/2/22. In the meantime, DSE had added the [NAME] screen to the unit to add additional diversion from the exterior door and an updated magnetic locking system was added to interior door. On 6/1/22, at 2:30 p.m. the director of nurses (DON) stated the COVID-19 outbreak began on 5/16/22. Since that time 23 residents had been identified as positive with COVID-19. Six of the residents were from the memory care unit and three of them (including R1) displayed wandering behaviors. The DON stated the moment the residents were identified with COVID-19, the facility priority was to transfer the residents into an isolation unit. The DON confirmed the residents from the memory care unit required the security due to wandering behaviors, however, the facility focus was on mitigating the spread of COVID-19. Since R1's elopement, the facility had increased staffing on the [NAME] Lane COVID unit, added wander guards to the residents at risk of wandering, installed the [NAME] screen and improved the locking mechanisms on the doors. The DON confirmed all staff had been notified of the changes during shift report. On 6/1/22, at 3:00 p.m. the DON escorted the State Agency staff to the area in which R1 eloped. The exit door of the [NAME] Lane had a small sidewalk surrounded by a large grassy lawn. The lawn was adjacent to the employee parking lot, a residential street and the neighbor's home. The DON confirmed the distance between the [NAME] Lane door and the neighbor's home was approximately 300-350 feet. The COVID-19 Segregation and Isolation Measures policy dated 9/17/21, directed the staff to relocate the resident to a segregated area to impose a strict isolation to prevent the spread of the disease. The Elopement Policy dated 3/7/22, directed the staff to 1) evaluate any resident who had eloped for potential injury, 2) notify family and physician, 3) conduct an investigation to determine how the elopement occurred in order to correct any underling contributing factor, 4) complete and incident report and 5) report the elopement to the state agency. The immediate jeopardy that was removed on 6/2/22, at 9:15 a.m. after it was verified the facility completed the following actions before the abbreviated survey: -R1's elopement was reported timely in accordance with facility reporting procedures and the regulation. -The facility immediately reassessed R1 and put appropriate interventions in place that included: - Increased supervision on the [NAME] Lane COVID-19 unit. - Wander guard bracelets were applied R1 and all at risk residents who had a history of wandering behaviors. - A [NAME] screen was placed at the end of the [NAME] Lance hallway to deter residents from the exit door without blocking the exit door. - The facility provided education to the facility staff to ensure two staff members were present on the [NAME] Lane unit.

Based on observation, interview and document review the facility failed to provide assistance with routine grooming which included facial removal for 1 of 1 resident (R7) who required assistance with grooming and personal hygiene. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R7 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's) of dressing and personal hygiene. R7's care plan updated 8/26/21, revealed R7 had an ADL self-performance deficit related to [CONDITION(S)] and required assistance with grooming and personal hygiene. R7's care plan lacked identification of R7's preference to be shaved. R7's nursing assistant care guide printed 09/30/21, lacked R7's preference to be shaved. On 10/17/21, at 5:52 p.m. R7 was observed seated in his wheelchair in his room with white and black facial hair two (2) millimeters (mm) length throughout the beard area, and a dozen of white four (4) mm length hair noted under his nose. On 10/18/21, at 9:21 a.m. R7 was observed seated in his wheelchair in his room, he continued to have white and black facial hair 2mm length throughout beard area and with a dozen of white 4mm length hair noted under his nose. On 10/19/21, at 8:40 a.m. R7 was observed seated in his wheelchair in his room, he continued to have white and black facial hair 2-4mm length throughout beard area with a dozen of white 4mm length hair noted under his nose. On 10/20/21, at 9:10 a.m. R7 was observed seated in his wheelchair in his room, he continued to have white and black facial hair 2-4mm length throughout beard area with a dozen of white 4mm length hair noted under his nose. On 10/19/21, at 1:05 p.m. during an interview, nursing assistant (NA)-A identified R7 required extensive assistance with grooming and hygiene and was unable to complete ADLs on his own. NA-A indicated the usual practice would be to assist R7 with shaving daily, however NA-A confirmed R7 had not been shaven that day and likely had a few days of facial hair growth. On 10/20/21, at 9:07 a.m. during an interview, family member (FM)-A identified it would be important to R7 to be clean shaven and not have facial hair growth or stubble. On 10/20/21, at 9:50 a.m. during an interview, licensed practical nurse (LPN)-A identified R7 required extensive assistance with ADLs and that male residents would be checked to be shaved daily. LPN-A confirmed R7 had not been shaven that day and likely had a few days of facial hair growth. On 10/20/21, at 10:45 a.m. during an interview, clinical manager (CM)-A identified R7 required extensive assistance with ADLs and would need to be cued to assist with facial hair removal. CM-A confirmed R7 had not been shaven that day and likely had a few days of growth. On 10/20/21, at 11:27 a.m. during an interview, director of nursing (DON) confirmed it would be her expectation that male residents would be checked and shaved daily if the resident agreed. Reviewed policy titled AM (morning) cares and HS (bedtime) cares last revised in February 2020, which identified the resident was to be shaved with AM cares.

Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was maintained during personal cares for 1 or 3 residents (R4) observed during the provision of personal cares. This deficient practice had the potential to affect all 62 residents. Findings Include: R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had moderately impaired cognition and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R4 required total dependence for personal hygiene, toileting, locomotion, and transfers, and was always incontinent of bowel and bladder. R4's current care plan dated 2/11/19, identified R4 was dependent on two staff to reposition in bed, required repositioning every two hours, was incontinent of bladder, and was totally dependent upon staff for toileting. During an observation on 10/19/21, at 1:35 p.m. nursing assistant (NA)-B and NA-C entered R4's room without sanitizing their hands, and NA-C applied gloves. NA-B and NA-C rolled R4 onto her left side in bed. NA-C removed the soiled (urine and stool) brief from underneath R4. NA-C completed peri-cares and wiped from front to back with visible stool noted on the wipes. NA-C removed her soiled gloves and without washing her hands applied a clean pair of gloves, placed a new brief underneath R4. NA-B and NA-C pulled up R4's pants and repositioned her. NA-C removed gloves, did not sanitize her hands, covered R4 up with a blanket, and placed the soft touch call light next to R4's pillow. Together NA-B and NA-C exited R4's room without completing hand hygiene, and walked down the hallway. NA-B carried a tied plastic bag of garbage to the dirty utility room and NA-C re-entered R4's room without sanitizing her hands. NA-C picked up R4's water mug and a few personal items on the bedside table and moved them around. NA-C informed R4 she would assist R4 to get up. During an interveiw on 10/19/21, at 1:40 p.m. NA-B confirmed she and NA-C had not sanitized their hands prior to exiting R4's room after personal cares were completed. NA-B indicated she completed hand hygiene after disposing the plastic bag of garbage. During an interview on 10/20/21, at 11:32 a.m. registered nurse (RN)-A stated staff were expected to wash their hands before cares, after peri cares were completed, after removal of gloves, when hands were visibly soiled, and prior to the exit of a resident's room. RN-A indicated staff were expected to sanitize their hands prior to exiting a resident room. RN-A stated hand hygiene prevented the transfer of germs from one resident to another and was an important task to complete to prevent infection. During an interveiw on 10/20/21, at 2:28 p.m. clinical manager (CM)-B stated staff were expected to use hand hygiene prior to entering and exiting resident rooms, anytime staff went from clean to dirty, and after removal of gloves. CM-B indicated hand hygiene was used to eliminate and reduce the chance of infection and to helped prevent cross contamination. During an interview on 10/20/21, at 2:44 p.m. director of nursing (DON) stated staff were expected to complete hand hygiene prior to cares, after cares, and prior to contact with a resident. DON indicated hands were expected to be washed with hand sanitizer after removal of gloves and prior to the exit of a resident's room. DON indicated hand hygiene was important in reducing the risk of infections. Review of facility policy titled Hand Hygiene reviewed 5/8/17, identified staff would routinely perform hand hygiene to prevent and control the spread of infection. Hand washing was the single most effective way of preventing and controlling the spread of infection, and would be preformed by staff routinely and thoroughly to protect residents from the spread of infection. Hands were to be washed before and after direct contact with a resident, before and after contact with environment surfaces or equipment in the immediate vicinity of the resident, and between glove changes, and after gloves were removed.

Based on interview and document review, the facility failed to implement care plan interventions with the use of a gait belt to prevent falls for 1 of 3 residents (R5) who required assistance with transfers. This deficient practice caused actual harm for R5, who sustained a 14 centimeter (cm) laceration to her left elbow requiring 27 sutures and the use of [MEDICATION NAME] antibiotic due to intensiveness of the laceration. The facility had implemented corrective action on 7/23/20, therefore the deficient practice is being issued at harm level, past non-compliance. Findings include: R5's quarterly Minimum Data Set ((MDS) dated [DATE], identified R5 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS indicated R5 required extensive assistance of staff for bed mobility and transfers. The MDS identified R5 had impairment on one side of her upper and lower extremities, and utilized a walker and wheelchair. Further, the MDS identified R5 was not steady with moving from a seated to a standing position, walking, turning facing opposite direction while walking, on and off the toilet, surface to surface, and needed staff assistance to stabilize. R5 was not identified as having had any falls from her prior assessment. R5's Fall Risk assessment dated [DATE], indicated R5 was at risk for falls due to cognitive status/behavior indicators, continence, mobility, balance, systolic blood pressure, age, health conditions and medications. R5's care plan revised on 7/22/20, indicated R5 was at risk for falls or injury related to recent cardiovascular accident (stroke) with left sided weakness. The care plan indicated R5 required cueing as completing transfer tasks and assist of one staff and gait belt to pivot transfer. R5's(NAME)Group Sheet undated, utilized by the facility as a nursing assistant care guide, indicated R5 required assist of one with gait belt or mechanical pal lift for transfers. The facility Incident Detail report dated 7/15/20 at 10:15 p.m. indicated R5 had a fall from her chair in her room and received a laceration. The incident report indicated with nursing assistant (NA) present, R5 was transferring from her wheel chair to her recliner when her foot slipped, R5 hit her left arm on the wheel chair causing a laceration with significant amount of blood to her left arm and hit her head on the bed with no sign of laceration or swelling. Pressure was applied immediately, and had two skin flaps present with subcutaneous tissue showing. Charge nurse called hospital at 10:26 p.m., ambulance called at 10:28 pm. and R5 left for hospital via ambulance at 10:50 p.m. R5's Fall Scene Investigation Report dated, 7/16/20, listed the interdisciplinary team (IDT) had reviewed the fall and determined the root cause of R5's fall was foot slipped, and gait belt not used at the time of the fall. R5's care plan had not been followed at the time of the fall. Review of R5's progress notes from 7/15/20 to 7/30/20 revealed the following: On 7/15/20 a progress note indicated R5 had a fall from her chair in her room and received a laceration. The incident report indicated per nursing assistant (NA)-A, R5 was transferring from her wheel chair to her recliner when her foot slipped, R5 hit her left arm on the wheel chair causing a laceration with significant amount of blood and hit her head on the bed with no sign of laceration or swelling. Pressure applied immediately, and two skin flaps present with subcutaneous tissue showing. Charge nurse called hospital and R5 left for hospital via ambulance at 10:50 p.m. to be evaluated. On 7/16/20 at 7:13 a.m., indicated R5 returned to the facility at 4:10 a.m., had received sutures to left elbow laceration, had been started on antibiotics, one of the antibiotics was for left elbow laceration. R5 also had orders to keep wound clean and dry and suture removal in 7 to 10 days. R5's Emergency Department(ED) Notes, dated 7/15/20, indicated R5 extensive laceration of the left upper arm posterior and distally. R5 had 2 large slaps of skin, 1 long and this approximately 10 cm, and 1 broad-based triangular approximately 5 cm long that are open in such ways to leave a large opening of the subcutaneous tissue. Significant debridement of done of fatty tissue as well as some of the skin in order to be able to fit the flaps together. Stitches were placed in approximately 27 interrupted sutures. R5 was given [MEDICATION NAME] (antibiotic) 500 mg intramuscularly, Naproxan 220 mg and Tylenol 650 mg and dressing applied, discharged with following instructions suture removal 7 to 10 days, antibiotics Keflex [MEDICATION NAME] due to extensive laceration, elevate and ice area, keep wound dry and clean and follow up with primary care provider in 2-3 days. The ED report included photographs of the laceration after the sutures were placed. The lacerations were located on her upper arm, above the elbow joint, and had several suture lines, one of which extended approximately 10 cm horizontally across her entire upper arm , adjacent to her elbow on both sides which had 19 to 20 sutures across the entire lacerated area. The area also had a triangular laceration posterior to the other laceration extending down and across which was also covered with approximately 7 sutures. On 8/4/20 at 3:32 p.m. RN-A indicated R5 had fallen in her room, when her foot slipped while NA-A was assisting her to transfer. RN-A indicated NA-A was not following R5's care plan and was not utilizing a transfer belt while transferring R5. RN-A indicated R5's arm was bleeding significantly, had two pieces of skin dangling down and could see adipose tissue and was having pain. RN-A indicated she immediately applied pressure to R5's arm and was taken to the hospital for evaluation and sutures placed. RN-A indicated staff found small amounts of adipose tissue on her wheel chair and small pieces of fatty tissue on the floor. RN-A confirmed R5 was at risk for falls and was very unsteady at times. RN-A indicated she had talked with the DON about following care plans and gait belt use with transfers. On 8/4/20 at 3:35 p.m., NA-A indicated she was doing a pivot transfer from R5's wheelchair back into her recliner when R5 stood up and fell . NA-A indicated when R5 fell she hit her head on the bed and her arm on the wheel chair. NA-A indicated R5 was bleeding from her arm and the skin was coming off. NA-A indicated she was holding the back of R5's pants while she was transferring her and was not using a gait belt. NA-A further indicated she did not see it on the care sheets and indicated she had used a gait belt on R5 in the past when she was weaker, but did not utilize one during the incident because she felt she was stronger that night. NA-A indicated she had received education on following the care plan, proper use of gait belts with transfers and audits had been done on her as well as other staff. On 8/3/20 at 3:05 p.m. RN- C confirmed R5 fell while staff was not following the care plan and utilizing a gait belt with transfers. The RN-C indicated R5 received a laceration to her arm and indicated staff had done some audits to make sure staff were properly using gait belts with transfer and following the resident care plans. On 8/3/20 at 3:20 p.m. NA-B confirmed R5 fell when staff was not using a gait belt to transfer her and she fell and got the cut on her arm. NA-B indicated after R5 fell staff were to transfer R5 with 2 staff using a transfer belt or use a mechanical pal lift. NA-B indicated education was received on utilizing transfer belts with all transfers and to make sure staff was looking at the resident NA care sheet. On 8/3/20 at 3:36 p.m. the director of nursing (DON) confirmed R5 was a fall risk, needed staff assistance with ADL's and required the use of a gait belt with transfers. The DON confirmed staff did not follow the care plan and utilize a gait belt during the transfer when R5 received the laceration. The DON indicated R5 was a big woman and need to be guided with the use of the gait belt with transfers for safety. The DON stated education was provided on proper use of gait belts and following resident care plans for NA-A and other nursing staff. The DON also indicated NA care sheets and care plans were updated per nursing recommendations and audits were performed on NA-A as well as other staff after R5's fall. The DON confirmed she would expect staff to follow the cares plans as written. Review of the facility policy titled, Transfer Belts undated, indicated a transfer belt was to be used when transferring or ambulating any resident who requires staff assistance. unless care planned otherwise. Review of the facility policy titled, Resident Incident/Accident Assessment and Documentation revised on 12/13/20, indicated the intent of this policy was to establish guidelines and procedures that adequately identify, assess, prevent and treat incident and/or accident that put the resident at risk for injury. All incidents will be evaluated and assessed immediately to ensure that treatment and interventions are initial elements of the accident/incident process. The past non-compliance that began on 7/15/20, was verified during the 8/3/20, onsite visit and was corrected by the facility on 7/23/20. The verification of corrective action was confirmed by interview with a variety of nursing staff, residents and observation of residents who utilized transfer belts, in addition to documentation of education provided to the nursing staff. On 7/23/20, the facility had retrained the nursing staff on the following resident care plans, NA sheets and utilizing transfer belts. Nursing staff reviewed care plans and NA sheets and random audits were performed with nursing staff.

Based on interview and document review, the facility failed to immediately report, no later than 2 hours, to the State Agency (SA) an incident of neglect of care for 1 of 1 resident (R5) who sustained an extensive laceration with a fall when staff did not implement the plan of care for use of a gait belt with transfers. Findings include: R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R5 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS indicated R5 required extensive assistance of staff for bed mobility and transfers. The MDS identified R5 was not steady with moving from a seated to a standing position, walking, turning facing opposite direction while walking, on and off the toilet, surface to surface, and needed staff assistance to stabilize. The MDS further identified R5 had impairment on one side of her upper and lower extremities, and utilized a walker and wheelchair. R5 was not identified as having had any falls from her prior assessment. R5's care plan revised on 7/22/20, indicated R5 was at risk for falls or injury related to recent cardiovascular accident (stroke) with left sided weakness. The care plan indicated R5 required cueing as completing transfer tasks and assist of one staff and gait belt to pivot transfer. R5's(NAME)Group Sheet undated, utilized by the facility as a nursing assistant care guide, indicated R5 required assist of one with gait belt or mechanical pal lift for transfers. R5's Incident Detail report dated 7/15/20 at 10:15 p.m. indicated R5 had a fall from her chair in her room and received a laceration. The incident report indicated with nursing assistant (NA) present, R5 was transferring from her wheel chair to her recliner when her foot slipped, R5 hit her left arm on the wheel chair causing a laceration with significant amount of blood to her left arm and hit her head on the bed with no sign of laceration or swelling. Pressure was applied immediately, and had two skin flaps present with subcutaneous tissue showing. Charge nurse called hospital at 10:26 p.m., ambulance called at 10:28 pm. and R5 left for hospital via ambulance at 10:50 p.m. The facility's report to the SA, submitted on 7/16/20 at 11:52 a.m. identified R5 had been assisted with a transfer from her wheelchair to her recliner, when resident's foot slipped and she fell . R5's care plan stated assist of 1 with transfers and se of a gait belt. A gait belt was not being used. R5 received laceration to her left upper arm which required an ET visit for stitches. On 8/4/20 at 3:32 p.m. RN-A indicated NA-A indicated when she entered R5's room, she was sitting on the floor and had a large skin tear to her arm. RN-A indicated R5's arm was bleeding significantly, had two pieces of skin dangling down and could see adipose tissue. RN-A indicated she immediately applied pressure to R5's arm and R5 was sent to the hospital for evaluation. RN-A indicated after R5 had left they found small amounts of adipose tissue on her wheel chair and small pieces of fatty tissue on the floor and knew she had hit her arm on her wheel chair. RN-A indicated R5 had fallen in her room, when her foot slipped while NA-A was assisting her to transfer. RN-A indicated NA-A was not following the care plan and was not utilizing a transfer belt while transferring R5. On 8/4/20 at 3:35 p.m., NA-A indicated she was doing a pivot transfer from R5's wheelchair back into her recliner when R5 stood up and fell . NA-A indicated she was holding the back or R5's pants while she was transferring her and was not using a gait belt. NA-A indicated when R5 fell she hit her head on the bed and her arm on the wheel chair. NA-A indicated R5 was bleeding from her arm and the skin was coming off. On 8/3/20 at 3:05 p.m. RN- C confirmed R5 fell while staff was not following the care plan and utilizing a gait belt with transfers. The RN-C indicated R5 received a laceration to her arm and indicated the incident should of been reported to the SA immediately, within 2 hours, when the care plan was not being followed and neglect of care occurred. On 8/3/20 at 3:36 p.m. the director of nursing (DON) confirmed R5's report had been submitted to the SA the following day and indicated she felt the incident was neglect of care when the NA did not follow R5's care plan to utilize a gait with the transfer. The DON indicated the incident should of been reported within 2 hours of the incident. The DON confirmed the above findings and stated even though it was late, we still wanted to make sure it was reported. Review of facility policy titled, Skilled Nursing Facility Maltreatment Reporting Guidelines amended on 4/1/19, indicated each care center must report to the SA any suspected maltreatment (all alleged violations involving abuse, neglect, exploitation or maltreatment, including injuries of unknown source and misappropriation of resident property) immediately, but no later than 2 hours after the allegation is mad, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and document review, the facility failed to conduct ongoing surveillance for the infection control program to ensure tracking and trending of all infectious illnesses in the facility. This deficient practice had the potential to affect all 64 residents currently residing in the facility. Findings include: A review of the facility's infection control program was conducted on 1/31/20, at 1:41 p.m. with the infection control coordinator (ICC) present. The ICC stated she ran a report every morning which would have indicated if a resident had been started on a new antibiotic. The ICC explained from that point she brought that information to the interdisciplinary team meeting (IDT) every day and it was reviewed with the unit coordinators. The ICC stated she entered the [DIAGNOSES REDACTED]. The ICC verified she had not listed signs and symptoms of the infectious diseases or entered all illnesses caused by viruses. Further, the ICC verified the name and unit the residents resided on had not been entered on the logs. Additionally, the ICC verified the onset, start and stop dates had not been identified. Review of the untitled monthly infection control logs from 4/19, through 12/19, revealed the following: - 4/19, resident in room [ROOM NUMBER] received Keflex (an antibiotic) for history of urinary tract infection [MEDICAL CONDITION], resident in room [ROOM NUMBER] on [MEDICATION NAME] (an [MEDICAL CONDITION] medication) for [MEDICAL CONDITION] prevention and resident in room [ROOM NUMBER] received [MEDICATION NAME](an antibiotic) for history of UTI. The log lacked signs and symptoms, resident names, unit locations, start, stop and onset dates. - 5/19, no new infectious illnesses identified. - 6/19, no new infectious illnesses identified. - 7/19, no new infectious illnesses identified. - 8/19, resident in room [ROOM NUMBER] diagnosed with [REDACTED]. The notation lacked identification of which shoulder the wound had been located, dose and frequency of antibiotic, signs and symptoms associated with the infection, resident name, unit location, start, stop and onset dates. - 9/19, no new infectious illnesses identified. - 10/19, resident in room [ROOM NUMBER] started on an antibiotic for a UTI. The notation lacked the name, dose and strength of the antibiotic. Further, the notation lacked signs, symptoms, culture results, resident name, unit location, start, stop and onset dates. - 11/19, resident in room [ROOM NUMBER] started on Bactrim DS (an antibiotic) for UTI. The notation indicated the resident had displayed disruptive behaviors. The notation lacked culture results,resident name, unit location and onset date. The resident in room [ROOM NUMBER] had been hospitalized for [REDACTED]. The notation lacked culture results, resident name, unit location, start and onset date. The resident in room [ROOM NUMBER] had been started on [MEDICATION NAME] 100 mg. for seven days for pneumonia on 11/29/19. The notation lacked any diagnostic results, resident name, unit location, signs and symptoms. The resident in room [ROOM NUMBER] had been started on Zpak (an antibiotic) on 11/22/19 for [MEDICAL CONDITION]. The notation lacked residnet name, unit location, signs and symptoms. The resident in room [ROOM NUMBER] had been started on [MEDICATION NAME] (an antibiotic) for six days for a UTI. The notation lacked culture results, resident name, unit location, start, stop and onset date. The resident in room [ROOM NUMBER] had been started on [MEDICATION NAME] (an antibiotic) for 11 days for pneumonia. The notation lacked any diagnostic results, resident name, unit location, start, stop and onset dates. There was a notation which stated several residents in the Rossberg unit had a stomach virus over the course of one week. The notation lacked signs and symptoms, number of residents and names, and onset dates associated with [MEDICAL CONDITION]. - 12/19, resident in room [ROOM NUMBER] started on antibiotics for sinusitis. The notation lacked signs and symptoms, the resident name, unit location, start, stop and onset date. Resident in room [ROOM NUMBER] started on [MEDICATION NAME] for sinusitis. The notation lacked signs and symptoms, the resident name, unit location, start, onset date. The resident in room [ROOM NUMBER] started on Zpak and [MEDICATION NAME] (an antibiotic) for pneumonia. The notation lacked any diagnostic results, signs and symptoms, the resident name, unit location, start, stop and onset date. The logs lacked an ongoing surveillance of all infections illnesses by not addressing signs and symptoms, any culture or diagnostic reports, the resident name and unit location. Further, the logs lacked consistent documentation of the onset, start and stop dates of the illnesses and antibiotics. On 1/31/20, at 2:22 p.m. the director of nursing (DON) stated it had been expected the infection control surveillance system should have included monitoring all infectious illnesses, signs and symptoms of each infectious illness, the resident name, unit location and dates of antibiotic use. A facility policy on the infection control surveillance program had been requested and not received.

Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 4 of 4 residents (R7, R53, R51 and R16) who were observed during the supper meal on the Rossberg unit of the facility. Findings include: During observations of the supper meal in the Rossberg unit on 1/28/20 at 5:33 p.m. nursing staff assisted residents to the dining room area for supper. - at 5:48 p.m. R7 was seated in a recliner by the dining room area, with a bed side table in front of her while she ate her food independently. - at 5:56 p.m. R7 remained seated in the recliner next to the dining room area eating independently and sucking on pieces of fruit. Nursing assistant (NA)-D walked over to R7, stood in front of her, grabbed her fork and tried to give R7 a bite of her pancake. R7 turned her head, pushed NA-D's hand away from her face with her right hand and appeared to be upset. NA-D again attempted to give R7 a bite of her pancake, R7 turned her head, again pushed NA-D's hand away from her face with her right hand. NA-D stated she doesn't want to eat and immediately walked away. R7 began to independently eat some of her pancake. - at 6:02 p.m. R53, R51 and R16 were seated at the dining room table, R53 was eating independently, while R51 and R16 were being assisted by a staff member to eat. NA-D walked over to R53, stood on the left side of R53, grabbed her spoon and said here's a bite of soup. NA-D continued to stand over R53 on the left side while she fed her spoonfuls of soup. - at 6:04 p.m. NA-D continued to stand in front of R53 and gave her another spoonful of soup and then proceeded to walk across the dining room to another table and began to pick up dishes. -at 6:05 p.m. R53, R51 and R16 remained seated at the table eating independently. NA-D walked over to the table, and with a rushed manner, began picking up R53's plate, bowl, cups and silverware which caused the dishware to bang against each other loudly and then proceeded to take them to the kitchenette area. NA-D returned to the table and continued in a rushed manner to pick up dirty dishes from another empty place setting at the table, and continued to make loud noises while collecting the dishes from the table. R51 and R16 remained seated at the table, eating the supper meal with assistance from another staff member. - at 6:10 p.m. R51 and R16 remained seated at the table, R51 was eating her supper with staff assistance. NA-D walked over to the table again, removed R16's plate, cup and silverware from in front of R16, and immediately walked to the kitchenette area. R16 remained seated at the table with a glass of juice in front of her, and took small bites from the cookie in her hand. On 1/3/20 at 2:46 p.m. NA-D indicated staff should be talking to the residents, telling the resident what they were feeding them and sitting down with them while they were eating. NA-D verified she stands and assisted the residents with eating at times. NA-D also indicated staff should not be picking up the dishes until everybody was done eating to give other residents time to eat. NA-D indicated this was distracting, rude and not dignified to other residents. On 1/31/20 at 9:41 a.m. director of nursing (DON) indicated she would expect staff to sit down at the residents level, to make eye contact and to assist them as needed. The DON indicated she expected staff to know this and should not be hovering over the resident. The DON also indicated staff should be waiting to clean the dishes off the table when residents were done eating because it could be distracting to other residents. The DON indicated when staff do this the whole thing becomes a dignity issue. Review of facility policy titled, Dignity revised on 10/23/17, indicated the facility will treat each individual residing in our care centers with respect and dignity and care for in a manner and in a environment that promotes maintenance or enhancement of his or her quality of life, recognizing each ones individuality. Review of facility policy titled, Dining undated, indicated the dining experience will enhance the residents quality of life and treat residents with dignity and respect.

Based on interview, and document review, the facility failed to ensure promptly act upon resident council concerns of evening snacks not being offered consistently for 3 of 3 residents (R32, R18, R40) who voiced concerns at resident council. This deficient practice had the potential to affect all 63 residents residing in the facility. Findings include: Review of the Resident Council Minutes from 8/19 to 1/20 revealed the following: -8/20/19, the coffee/snack cart doesn't go around to the rooms in the evening. -9/30/19, the evening snack cart was not brought around and offered to the residents in their rooms. -10/16/19, the documentation lacked follow up on concerns regarding the snack cart being offered in the evening to residents. -11/25/19, the documentation lacked follow up on concerns regarding the snack cart being offered in the evening to residents. -12/10/19, the documentation lacked follow up on concerns regarding the snack cart being offered in the evening to residents. -1/7/20, the documentation lacked follow up on concerns regarding the snack cart being offered in the evening to residents. A resident council group interview was completed on 1/30/20, at 12:26 p.m. and R32, R18 and R40 stated evening snacks were not consistently offered every evening. The residents stated that a snack cart was brought out to the nurses station every evening and the nursing staff was responsible for the snack cart, however, some nursing assistants did not always bring the cart around and ask all the residents if they would enjoy an evening snack. R32, R18 and R40 indicated they have brought the issue of the snack cart on being offered all the time at resident council several times in the past, continued to be an issue and had not been resolved. On 1/30/20 at 12:51 p.m. the activity director (AD) confirmed the above findings and verified residents continued to voice concerns about the snack cart being passed in the evening. The AD indicated her expectation were for nursing staff to pass the snack cart every evening and to offer every resident a snack. The AD indicated she felt the facility should be continue to work on this problem until it's fixed. On 1/30/20 at 1:04 p.m. the director of nursing (DON) indicated she expected all residents to be offered an evening snack by nursing staff and verified it continued to be problem. The DON indicated the facility did not have a system in place to monitor to see if the snack cart was getting passed in the evening and was not sure if nursing staff was passing snacks in the evening for residents. Review of facility policy titled, Nourishments/Snacks undated, indicated the facility would provide and offer evening snack to all residents.

Based on observation, interview, and document review, the facility failed to provide the physicians ordered therapeutic diet for 1 of 3 (R1) residents, who were reviewed for receiving a therapeutic diet. This resulted in actual harm for 1 of 1 (R1) resident who choked, and developed aspiration pneumonia, after staff provided food that was not allowed on a mechanical soft diet. Findings include: R1's medical record was reviewed and the physician orders [REDACTED]. R1's care plan in effect on 8/9/2012 revealed a mechanical soft diet with food cut into small pieces with no hot dogs. An internal investigation dated 8/16/2012 revealed staff did not follow R1's care plan of providing R1 with a mechanical soft diet on 8/9/2012. Although R1 had a physicians order for a mechanical soft diet, R1 received a meal, which included a salad with cucumbers. An undated policy titled "Meal Planning for Mechanical Soft Diet" identified raw vegetables, or vegetables with tough skins or membranes as foods to avoid on a mechanical soft diet. R1 required hospitalization after choking on a cucumber. Hospital documentation confirmed paramedics used forceps to remove a large piece of raw cucumber from R1 throat, after multiple [MEDICATION NAME] attempts were unsuccessful. R1 was diagnosed with [REDACTED]. A policy dated 02/10 titled "Resident Choice Meal Plan Policy" revealed resident diet cards are to be set at the resident's table place setting for dinner and supper. Staff are to write the resident's meal choice on the dietary card. The resident's dietary card will be brought to the buffet area for the cook to review the diet order, and the resident's choice before serving the food to ensure the correct diet is given to the resident. The diet cards will be at the buffet table for the cooks to review at breakfast. Nursing assistant/NA (B) was interviewed at 09:38 a.m. on 08/30/2012 and stated NA (B) brought R1's diet card to dietary staff/Employee (C) on 8/9/2012. Employee (C) provided a meal for R1 that included spaghetti, and a salad with cucumbers. NA (B) asked Employee (C) if R1 could eat cucumbers on a mechanical soft diet, and Employee (C) replied affirmatively. NA (B) served R1 the salad with cucumbers. Employee (C) was interviewed at 2:20 p.m. on 08/30/2012. Employee (C) did not recall NA (B) asking for a mechanical soft diet, or questioning if cucumbers were allowed on a mechanical soft diet. Employee (C) stated cucumbers are not allowed on a mechanical soft diet. Employee (C) went on to say that; staff offers a choice of two meals at lunchtime. Staff frequently requested a meal by verbally indicating number one or number two, not by the resident's diet order. Staff did not always give Employee (C) the resident's diet card when requesting a resident's meal and Employee (C) did not ask for the diet card. Employee (C) did not always verify a resident's diet order prior to providing a resident with a meal that staff requested. Employee (F)/dietary director was interviewed at 10:51 a.m. on 09/24/2012. Employee (D) stated resident's diet cards are located at the buffet table for breakfast. Dietary staff are expected to verify a resident's diet prior serving the residents. Staff offers the residents two meal choices for lunch and dinner. Dietary or Nursing staff are to write the resident's requests on the resident's diet card, and bring the card to the buffet table. The cook then reviews the card and makes alterations to accommodate the resident's prescribed diet. The cooks are expected to verify the residents' diet on the diet cards, prior to serving a resident. Dietary staff has access to what foods are allowed and what foods should be avoided on a mechanical soft diet. Employee (D) confirmed that cucumbers are not on a mechanical soft diet.