Every finding on record at Westchester Gardens Health & Rehabilitation

Based on interviews and record reviews, the facility failed to implement the ordered interventions to alleviate pressure to the heels for one resident (#1) out of three reviewed for following wound care provider orders.Findings included: Review of admission Record showed Resident #1 was admitted to the facility on [DATE], with diagnoses to include left hip fracture, emphysema, respiratory failure, dementia and moderate protein calorie malnutrition. Review of Resident #1's Wound and Healing progress notes, dated 9/24/2025, showed wound orders for wound #2 on the left heel and wound #3 right heel to off load wound, and float heels in bed. Resident #1's plan of care was discussed with nursing.A review of Resident #1's order summary report, as of 9/29/2025, revealed that the orders to off-load the wound and float heels in bed, as directed by the wound care provider, were not entered.Review of Resident #1's care plans showed focus areas for alteration in skin integrity and potential for alteration in skin integrity, both initiated on 8/27/2025. The interventions for these focus areas did not include off-load the wound and/or float heels in bed, as ordered by the wound care provider.Review of Resident #1's Kardex, dated as of 9/29/2025, did not show tasks to off-load wound and/or float heels in bed.During an interview and record review on 12/3/2025 at 1:17 P.M. with the Wound Care Nurse regarding Resident #1's wound care provider orders to off-load the wound and float the heels while in bed, she acknowledged these orders were not transcribed into the electronic health record (EHR), where such orders should be listed. The Wound Care Nurse reviewed the resident's care plans and was unable to show the interventions were included. When asked how the Certified Nursing Assistants (CNAs) were made aware of the wound care provider's orders, she stated that the CNAs know what to do because the information is listed in the resident's Kardex. She reviewed Resident #1's Kardex and was unable to show instructions to off-load the wound or float the heels while in bed.During an interview on 12/3/2025 at 2:29 P.M., the Director of Nursing (DON) stated that her expectation is for all wound care provider orders to be entered into the resident's electronic health record (EHR) and incorporated into the resident's care plans.Review of the policy titled, Comprehensive Care Plans, revised 10/27/2025, showed the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the policy titled, Transcribing Physician Orders, revised 10/27/2025, showed the following: Policy: Licensed Nursing staff will transcribe physician/medical provider's orders according to clinical standards of practice.

Based on interview and record review, the facility failed to maintain an accurate medical record for medication and transmission-based precautions for one resident (#451) of 36 sampled residents on five of five days reviewed involving five nurses on three different shifts. Findings included: Review of Resident #451's medical record revealed Resident #451 was admitted to the facility on [DATE] for short-term rehabilitation. On 5/29/25 the resident was placed on empiric contact transmission-based precautions for a rash identified on the resident's skin. The resident received treatment on 5/31/25 for Ivermectin three milligrams, give three tablets by mouth one time only for one day. Review of the progress note documentation for 06/02/25 at 3:29 PM indicated the contact precautions were removed after the nurse practitioner examined the resident and treated her for folliculitis and ordered doxycycline antibiotic for seven days. Documentation by nurses for the ALERT antibiotic/infection note revealed the following: On 6/01/25 at 1:22 AM Staff Y, licensed practical nurse (LPN) inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25. On 6/02/25 at 9:39 PM and 6/03/25 at 3:17 AM Staff X, Registered Nurse (RN) inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued at 3:29 PM on 6/02/25. Doxycycline was not documented in the antibiotic note. On 6/03/25 at 10:03 PM Staff W, RN inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued the previous day at 3:29 PM. Doxycycline was not documented in the antibiotic note. On 6/04/25 at 1:16 AM Staff Y, LPN inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued two days earlier. Doxycycline was not documented in the antibiotic note. On 6/04/25 at 2:50 PM Staff Z, RN inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued two days earlier. Doxycycline was not documented in the antibiotic note. On 6/04/25 at 8:43 PM Staff X, RN inaccurately documented the current treatment was Ivermectin that was already given on 5/31/25 and inaccurately documented the resident was on contact transmission-based precautions that were discontinued two days earlier. Doxycycline was not documented in the antibiotic note. In an interview with the infection preventionist on 6/05/25 at 10:00 AM, he stated the night shift nurse must have copied the note inaccurately from the previous shift. An interview with Staff Z, RN on 6/05/25 at 11:35 AM was conducted. She stated the electronic medical record system must have defaulted to the previous treatment. She said she did not notice it or make the correction to the accurate antibiotic/treatment and that the resident was no longer on contact transmission-based precautions. On 6/05/25 at 11:45 AM the Director of Nursing (DON) was asked about the facility expectations for accurate documentation and he said his expectation is for the nurses to document accurately for each resident and avoid copying previous documentation.

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during meal service in four halls (200, 300, 400 and 500 hall of six halls observed, and for nine residents (#3, #60, #452, #448, #96, #76, #1, #58 and #43) of 36 residents sampled. 2) The facility failed to implement their infection prevention and control plan by failing to provide evidence of process surveillance of staff practices directly related to resident care. 3) The facility failed to properly use enhanced barrier precautions (EBP) for one resident (#19) of two residents observed for EBP with indwelling medical devices. 4) The facility failed to properly disinfect a multi-use blood glucometer for two staff members observed during medication administration (Staff members O, Licensed Practical Nurse (LPN) and P, Registered Nurse (RN)) of five staff observed. The current census was 113 residents. Findings included: 1. During a dining observation on the 500 wing on 6/02/25 at 11:32 AM, two staff members assisted Resident #3 to sit on the edge of the bed to eat lunch. Hand hygiene was not offered to the resident prior to eating. On 6/02/25 at 11:40 AM Resident #60 and Resident #452 were observed in their rooms eating lunch as they were seated in their wheelchairs. Both residents stated staff did not offer hand hygiene to them prior to their meal. On 6/02/25 at 11:45 AM family members were visiting Resident #448 and Resident #96. Both residents were seated in wheelchairs. The family members stated when the residents were in the hospital, staff offered a hand wipe to clean their hands before meals. They stated since they have been in this facility, hand hygiene was not offered prior to meals. On 6/02/25 at 12:18 PM Resident #76 was eating lunch in her room while seated in a wheelchair. She stated staff did not offer hand hygiene before they brought her meal. During an interview with the Infection Preventionist (IP) and the Director of Nursing (DON) on 6/04/25 at 11:30 AM, they stated the current IP is also the Unit Manager and Assistant Director of Nursing. He has been in the IP position since December of 2024. The DON stated he was the IP prior to November and has been training the ADON for the IP role. They were asked about offering or assisting with hand hygiene to residents before meals. They were not aware that residents who dine in their rooms and need assistance with hand hygiene were not offered or assisted with hand hygiene. The IP and the DON were asked to provide any process surveillance for hand hygiene for staff. The IP indicated he did not think he had any documentation of any process surveillance, but he would look for it. On 6/05/25 at 11:00 AM, the IP stated he did not have documentation of hand hygiene surveillance. When asked about any policy for staff fingernails, he stated they take a liberal stance on fingernails, and he acknowledged several direct care staff have long artificial fingernails that extend past the fingertips. 43453 2. During a dining observation of Halls 200 and 300 on 06/02/25 at 12:04 PM observations were made of staff members delivering trays to residents in their rooms as follows: Staff T, CNA was observed going into rooms 301, 305 and 307 without performing hand hygiene on herself nor the residents. Staff U, CNA was observed going into rooms 202, 209 and 311 without performing hand hygiene on herself nor the residents. Staff A, CNA, was observed going into rooms [ROOM NUMBERS]. Staff A,CNA did not apply hand hygiene and did not offer the residents hand hygiene prior to meal service. Staff T, Certified Nursing Assistant (CNA) and Staff W, CNA were observed going into Rooms 200, 209, 202 and 205 to provide lunch trays to the residents without performing hand hygiene on themselves nor the residents. On 06/02/25 at 12:14 PM an interview was conducted with four CNA's, Staff T, Staff W, Staff B and Staff A. They confirmed they did not offer the residents hand hygiene prior to meal service. Staff B, CNA stated the expectation was for them to perform hand hygiene when going from room to room. The four CNAs did not answer regarding offering the residents hand hygiene. During dining observations on Hall 200 on 06/04/25 at 11:50 a.m. observations were made of staff members Staff A, CNA, Staff X, CNA and Staff T, CNA delivering trays to residents in their rooms. The staff members did not offer the residents hand hygiene prior to meal service. An interview was conducted on 06/04/25 at 11:56 a.m. with Staff A, CNA, Staff X, CNA and Staff T, CNA. They confirmed they did not offer the residents hand hygiene prior to meal service. Staff X, CNA stated she offers the residents hand hygiene when they are done with the meal but not prior. On 06/04/25 at 12:24 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the staff should apply hand hygiene prior to passing trays or when moving from resident to resident. He stated expected staff to wash hands or use hand sanitizer. He stated they had not thought about hand hygiene for the residents prior to meal. The DON stated it was a good learning opportunity. 14762 3. On 6/2/25 at approximately 9:30 AM, Resident #19 was observed seated in a wheelchair in his room and noted to have a urinary catheter drainage bag hanging from his wheelchair frame. The resident's room was noted to have a magnetic sign which read Enhanced Barrier Precautions and instructed staff to use gowns and gloves when providing direct care. Staff M, Certified Nursing Assistant (CNA) was observed at this time to enter the resident's room and touch the resident's urinary catheter tubing and bag several times to find a location to hang the bag. The CNA did not have gloves or a gown on. An interview was conducted with Staff M, CNA at this time, and she confirmed she should have put on a gown and gloves before handling the urinary catheter tubing and bag. 37965 4. On 06/03/25 at 4:21 PM, an observation was made of Staff O, Licensed Practical Nurse (LPN) as she was preparing to administer evening medications to the patient in room [ROOM NUMBER]. She was standing at the cart outside the resident's room having just checked the residents' blood sugar. She was holding the glucometer (portable device used to measure the amount of glucose (sugar) in a person's blood) in her gloved hand. She stated that she had just checked the resident's blood sugar. At this time, she opened the top drawer of the medication cart and placed the glucometer into the cart. At no point was she observed to disinfect the glucometer prior to placing it into the cart. At this time, she was asked if she cleaned the glucometer and she said, I guess I should have She then retrieved the glucometer from the drawer and wiped with bleach wipes and immediately placed it back into the cart. On 06/03/25 at 4:44 PM, Staff P, Registered Nurse (RN), was observed checking the blood sugar of the patient in room [ROOM NUMBER]. After checking the patient's blood sugar, she returned to the medication cart she placed the glucometer into the top drawer. At this time, she was asked if she had disinfected the glucometer prior to placing it into the cart and she stated, I must have missed it but I should have done it. She then cleaned the glucometer with a small alcohol wipe stating, We can use alcohol wipes or the cleaning wipes if they are available. On 06/04/25 at 8:48 AM, during an observation of medication administration an interview was conducted with Staff Q, LPN. He reported that staff clean glucometers after use using big bleach wipes but if they are not available staff can use an alcohol wipe. He clarified that he was referring to a small alcohol wipe used to clean fingers when checking blood sugar. On 6/04/25 at 4:01 PM, an interview was conducted with the Infection Control (IC) nurse and the Director of Nursing (DON), during which they were asked how staff should clean a glucometer after checking a resident's blood sugar. The IC nurse stated that staff are expected to wipe the glucometer with a bleach wipe, if the bleach wipe container has a blue top the dwell time (the period a disinfectant must remain on a surface to effectively kill germs, bacteria and viruses) is 3 minutes or if it has a purple top the dwell time is 1 minute. He reported that this information is written on top of the bleach wipe containers, so staff do not have to look it up. The DON stated that it is Never appropriate to clean with an alcohol wipe to disinfect a glucometer after use. He also stated that it is never appropriate to return a glucometer to a cart without disinfecting it. Review of a corporate facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes, dated 10/14/24 showed It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights or each resident. The Policy Explanation and Compliance Guidelines showed: (2.) Assist resident with washing hands before and after meal, if applicable. Review of the facility policy Glucometer Disinfection, created on 10/3/22 and reviewed 10/14/24 revealed Glucometers should be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (Human immunodeficiency viruses), Hep C (Hepatitis C virus) and Hep B virus (Hepatitis B virus). Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Review of the manufacturers' recommendations for cleaning the glucometer used by facility staff revealed Cleaning and Disinfecting Procedures for the Meter (The glucometer brand name) should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the (glucometer brand name): The list includes a list of 4 disinfectant cleaners that contain bleach. Step 5 for Materials needed states To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA registered wipes may be used for disinfecting the (glucometer brand name) however, these wipes have not been validated and could affect the performance of the meter. Allow the surface of the meter to remain wet at room temperature for the contract time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. NOTE: Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. The facility policy and compliance guidelines for the Infection Control Program Overview reviewed 10/22/23 and 1/04/25 indicated surveillance activities with be monitored facility-wide and a combination of process and outcome measures will be utilized. The section for surveillance revealed separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. A review of the Risk Assessment report for Infection Surveillance, Prevention and Control Program completed on 11/13/24 indicated the risk assessment is used to provide information about where an organization should focus its surveillance. Treatment and care practices is one category included in the assessment tool. Hand hygiene, Glucometer cleaning/disinfecting were two areas the facility identified as high priority. On 6/05/25 at 11:20 AM the DON confirmed the facility had not documented any process surveillance, including but not limited to hand hygiene and glucometer cleaning/disinfecting. A review of the Hand Hygiene policy provided by the DON revealed a review date of 10/14/24. The top of the policy indicated it was applicable for Minnesota, Arizona, California, Florida, Montana, Oregon, South Dakota. Printed copies are for reference only. Please refer to electronic copy. On 6/04/25 the Administrator stated they did not have any electronic versions of the policies and procedures that are specific to his facility based on the Facility Assessment. He stated they are corporate policies for all the facilities in the states listed in the policy. The policy indicated: The health care community will take every precaution to prevent spread of infections by using proper hand hygiene techniques at all times. The procedure included: Facility will follow current Centers for Disease Control and Prevention (CDC) recommendations for hand hygiene techniques and recommended hand hygiene protocols. The current CDC Hand Hygiene for Healthcare Workers as of February 27, 2024, key points includes: Protect yourself and your patients from deadly germs by cleaning your hands. All healthcare personnel should understand how to care for and clean their hands. Hand hygiene protects both healthcare personnel and patients. Recommendations included but are not limited to: Know how to wash hands with soap and water, Know how to use alcohol-based hand sanitizer, and maintain fingernail and jewelry safety. (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) The current CDC Hand Hygiene for Patients in Healthcare Settings as of February 27, 2024 includes: Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients. When patients should clean their hands: Before preparing or eating food. Review of the policy and procedure for enhanced barrier precautions (EBP) reviewed 10/14/24 indicated EBP employs targeted gown and glove use during high-contact resident care activities. EBP will be initiated for residents with indwelling medical devices ( .urinary catheters .). Personal protective equipment for EBP is only necessary when performing high-contact care activities. The policy compliance guidelines listed device care or use: urinary catheters as a high-contact care activity.

Based on observations, interviews, and record review, the facility failed to ensure residents received a dignified dining experience in two halls (200 and 300) of six halls toured and for three residents (#1, #58 and #43) of 36 residents sampled. Findings included: 1. An observation was conducted on 06/02/25 at 12:26 p.m. of Resident #1 in her room during her lunch meal. The resident was receiving meal assistance from Staff R, Clinical Student. Staff R was observed standing over the resident. An observation was conducted on 06/02/25 at 12:16 p.m. of Resident #58 in her room during her lunch meal, being assisted by Staff V, Clinical Student. Staff V was observed standing over the resident. A dining observation of Hall 200 was conducted on 06/02/25 at 12:04 p.m., observations were made of staff delivering trays to residents in their rooms. The staff members did not knock or announce themselves prior to entering the resident's rooms as follows: Staff T, Certified Nursing Assistant (CNA) and Staff W, CNA, were observed going into rooms 200, 209, 202 and 205 without knocking or announcing self. Staff T, CNA was observed going into rooms 301, 305 and 307 without knocking or announcing self. Staff U, CNA was observed going into rooms 202, 209 and 311 without knocking or announcing self. Staff A, CNA, was observed going into rooms [ROOM NUMBERS] without knocking or announcing self. On 06/02/25 at 12:14 PM an interview was conducted with four CNA's, Staff T, Staff W, Staff B and Staff A. They all confirmed they did not knock when entering the resident's room during meal service. They confirmed they did not announce themselves. The CNAs confirmed the expectation was to knock prior to entering the residents' rooms. They stated they should sit when assisting residents with meals. On 06/04/25 at 11:56 a.m. an observation was made of Resident #1 in her room during her lunch meal being assisted by Staff S, Clinical Student. Staff S was observed standing over Resident #1. Staff X, CNA took over the meal assistance halfway through the feeding. Staff X, CNA was observed standing over the resident during the meal assistance. A follow-up interview was conducted with Staff S, Clinical Student. Staff S stated she did not know there was a facility policy or expectation regarding meal assistance. On 06/04/25 at 12:07 p.m., Resident #37 was observed with her meal tray in front of her. The resident was not eating. An interview was conducted with Staff Y, CNA at 12:15 p.m. She stated the resident needed assistance with her meal. Staff Y said, I'm helping other residents. At some point someone will assist her, she needs to be fed. Resident #37 waited 20 minutes to be assisted with her meal. On 06/04/25 at 12:24 p.m. an interview was conducted with the Director of Nursing (DON). He stated the expectation was for staff to knock and announce themselves prior to entering the resident's room. He stated they should not stand over the residents during meal. He stated they should be at eye- level. The DON said dependent residents should not wait with their tray in front of them. He said, the food will get cold. The DON stated the clinical student's role was dependent on where they are in their course study. He said, We have given our policies to the school to review with students. They should follow appropriate health care procedures, yes, hand washing, knocking and not standing over the residents. 52791 2. On 06/02/25 at 11:44 a.m. an observation was made of Staff T, CNA entering Resident #43's room without knocking. She was observed standing and assisting the resident with eating. Staff T offered the resident more food, while the resident was still chewing food. Resident #43 was admitted to the facility on [DATE], with a primary diagnosis of, nondisclosed fracture of lateral malleolus of right fibula, subsequent encounter for closed fracture with routine healing. A care plan for Resident #43 was initiated on 03/15/2025 and revealed Resident #43 has potential for alteration in nutrition needs related to: Dementia. Interventions showed the resident required assistance with meals as needed. On 06/04/2025 at 11:48 a.m. an interview was conducted with Staff T, CNA. She stated the resident's right hand was limited. She stated the resident required assistance with eating. She stated that the resident can eat certain foods on her own. On 06/02/25 at 12:14 P.M., an interview was conducted with Staff T, CNA. She confirmed she did not knock on the door when entering the resident's room and did not announce herself either. Review of the facility's policy titled Promoting/Maintaining Resident Dignity During Mealtimes, dated 10/14/24 showed It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights or each resident. Policy Explanation and Compliance Guidelines showed: 1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. 2. Assist resident with washing hands before and after meal, if applicable. 3. Assist resident with eating per state training and allowance. 4. Focus on the resident while talking to him/her and addressing him/her individually. 5. All staff will be seated, if possible, while feeding a resident. 6. Resident requests will be honored during meals to the extent possible. 7. All catheter bags will be covered during meals if applicable. 8. Ensure the resident receives the proper tray and diet. 9. Assist resident with opening items, cutting necessary food items, etc. 10. Offer substitutes if applicable. 11. Allow adequate time for resident to complete as much as desired of the meal. Do not rush. 12. If resident is in the dining room, assist back to room as needed. If resident is in his /her room, position as resident desires or as directed.

Based on observations, staff interviews, and facility policy review, it was determined that the facility failed to ensure five resident room bathrooms out of ten resident room bathrooms toured on the 400 hallway of the facility's Queen's Way resident unit were maintained in a clean, homelike environment. (Photographic evidence obtained.) The findings include: On 06/02/25 at 10:38 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:11am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:15 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:18 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:30 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:32 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/04/25 at10:41am, during an interview with the Maintenance and Housekeeping Manager, He stated, Daily cleaning by housekeeping. They have a list on their cart for a 10-step cleaning. The list is kept on each housekeeping cart He provided a copy of this list for review. The list revealed: Occupied room: 3. High Dust. The Housekeeping and Maintence Manager said high dust would include the bathroom vents. He was asked who cleans the vents above the toilets in the resident's rooms. He stated, They should be checked and dusted daily but monthly they are vacuumed by one of my guys on staff. But housekeeping should be checking those daily and they should let me know if they need to be vacuumed in between the monthly schedule. The Housekeeping and Maintence Manager reviewed the pictures of the bathroom vents from rooms 400, 401, 403, 405, and 407 taken on 06/02/25 and 06/3/25. He stated, Yes the housekeepers should have let us know about the dust that accumulated. A review of the facility policy titled Homelike Environment (created 11/3/15, reviewed 3/15/25) revealed: Policy: The facility will provide a safe, clean, comfortable, and homelike environment. Policy explanation and compliance guidelines: 2. The facility will maintain a clean environment.

Based on observations, interviews, and record review, the facility failed to provide necessary services to maintain grooming and personal hygiene for one resident (#49) out of four residents sampled for grooming and personal hygiene services. The findings include: On 06/02/25 at 11:16 a.m., Resident #49 was observed in a wheelchair in the 400 hallway. His right-hand fingernails were observed elongated with brown debris under each nail. His left-hand fingernails were observed elongated. On 06/02/25 at 11:39 a.m., Resident #49 was observed in his room. His right-hand fingernails were observed elongated with brown debris under each nail. His left-hand fingernails were observed elongated. Resident #49 was interviewed at the time of the observation, and he said he likes his nails short, and he doesn't think staff clean and trim his fingernails. Photographs of Resident #49's fingernails were obtained with his verbal permission. On 06/03/25 at 9:35 a.m., Resident #49 was observed lying in bed, awake and dressed for the day. His right-hand fingernails were observed elongated with brown debris observed under each fingernail. His left-hand fingernails were observed elongated. On 06/04/25 at 8:57 a.m., Resident #49 was observed with his right-hand fingernails trimmed, not filed, with brown debris under the fingernails. His left-hand nails were observed trim, not filed. (Photograph taken with resident's verbal permission.) A review of the medical record for Resident #49 revealed a Minimum Data Set (MDS) evaluation dated 05/20/25, referred to as his admission evaluation. The evaluation revealed section C for Cognitive Patterns with a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 indicates intact cognitive function. Review of Resident #49's MDS evaluation dated 05/20/25 revealed section E for Behaviors showed the resident did not display any behavior. This assessment included an assessment for rejection of care, which also revealed the resident did not display any behaviors of rejection of care. A review of the personalized Care Plan for Resident #49 revealed: Focus: (Created 05/15/25) Self care deficit: requires assist with Activities of Daily Living (ADLs) due to safety management; multifactorial comorbidities; generalized weakness; active infectious process. Goal: Resident will be able to participate in ADLs as able on a daily basis through next review date. Interventions: Allow resident to complete as much of the task as possible. Assist as needed. Explain procedures and process prior to starting. Further care plan review revealed Resident #49 did not have a personalized care plan for behaviors/refusal of care. A review of Certified Nurse's Assistant (CNA) tasks documented from 05/14/25 through 06/4/25 revealed: What behaviors were observed? (Choices included: neglecting self-care; refusing care). Each day from 5/14/25 through 6/4/25 for 3 shifts per day was charted as no behaviors observed. During an interview on 06/03/25 at 2:22 p.m. with Employee N, CNA, she said the CNA's provide fingernail care. She said there is no set schedule to provide fingernail care It depends on when it's needed, if I see nails are long, I ask them. She was asked what is involved in performing the fingernail care. She stated, I put my gloves on, use nail clippers, and file. She was asked about cleaning under nails if there is any debris observed. She stated, Yes, I use a brush to clean under the nails. She was asked what is the process if a resident declines or refuses fingernail care. She stated, I talk to the nurse, and the nurse will talk to them. They might still say no; I'll ask the next day. She was asked if a resident declines or refuses fingernail care, does she chart or record the refusal anywhere. She stated, No, I just tell the nurse. She was asked if she was caring for Resident #49 today. She stated yes. She was asked if she could explain the current state of his fingernails. She stated, I did clean and trim them one time, when he first came here. He has refused since then. She was asked if she had let the nurse know the times he had refused fingernail care. She stated yes. During an interview on 06/03/25 at 2:35 p.m. with Employee D, Licensed Practical Nurse (LPN). She was asked who provides fingernail care for the residents. She stated, It depends, typically the aides will offer it to them. If they refuse, then they will let me know and I'll try to change their mind. If not, we report it to the unit manager. She was asked how often fingernail care is provided. She stated, It depends on the patient and their nail growth. There is no schedule, no, it's not with shower days. She was asked what is involved in fingernail care for residents. She stated, I've never had to do fingernail care here. She was asked what is the process if a resident declines fingernail care. She stated, We chart it, the nurse has to chart it and report it to the manager. It could be a behavior issue. She was asked if she was caring for Resident #49 today. She stated yes. She was asked if any CNAs had let her know that Resident #49 has declined fingernail care. She stated yes. She was asked when that was. She stated, I'm not sure. I did not chart it. She was asked if she let the Unit Manager know. She stated, No, I didn't let the Unit Manager know. On 06/03/25 at 3:46 p.m., an interview with the Director of Nursing (DON) was conducted, he was asked if the facility had a policy specific to fingernail care. He stated no. He was asked what the facility process or expectations are for fingernail care are. He stated, To follow the plan of care, depending on the resident wishes, to keep the fingernails trim, clean and dry, safe length. He was asked who provides fingernail care for the residents. He stated, Multiple disciplines, the nurses, the CNAs and activity staff does nails as an activity for some residents. He was asked how often fingernail care is provided. He stated, As needed. He was asked if there was a schedule. He stated, No. I think standard practice is to trim and clean nails if the care is observed as needed. If I was a CNA and saw they needed the care, I would provide it. A review of the facility's policy titled Activities of Daily Living, created 3/11/15 and reviewed on 10/7/24 revealed: Policy: The facility ensures that the resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Definitions: ADLs include the resident's ability to: 1. bathe, dress, and groom Procedure: 3. Provide necessary services for residents who are unable to carry out activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations interview and record review, the facility failed to ensure continuous oxygen therapy was provided per physician orders, and failed to ensure respiratory equipment was stored appropriately for one resident (#76) of one resident sampled. Findings included: During facility tours conducted on 06/02/25 at 09:43 a.m. and 06/03/25 at 09:24 a.m. Resident #76 was observed in her room lying on her bed. The resident was observed with continuous oxygen (O2) on. The oxygen concentrator revealed her oxygen was set at 3.2 liters. During these observations, Resident #76's nebulizer mask was observed on her bedside table uncovered. (Photographic Evidence Obtained). Review of Resident #76's admission record revealed an admitted [DATE] with diagnoses to include respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of physician orders for Resident #76 revealed the following: O2 at 2L/min (liters per minute) via N/C (nasal cannula) PRN (as needed) for O2 sats (saturation) lesser than 92% DX (diagnosis): Hypoxia - Start date 08/23/2024. Ipratropium Albuterol Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) 1 vial inhale orally three times a day for sob (shortness of breath) - Start Date 08/26/2024. Review of the MAR/TAR (Medication Administration Record / Treatment Administration Record) for May and June 2025 showed documentation Resident #76 was receiving oxygen at 2L. Review of a care plan for Resident #76 initiated on 10/14/24 showed the resident had oxygen therapy r/t (related to) hypoxia, COPD. The goal showed the resident will have no s/sx. (signs/symptoms) of poor oxygen absorption through the review date. Interventions included to monitor for s/sx of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color, Promote lung expansion and improve air exchange by positioning with proper body alignment. An interview was conducted on 06/04/25 at 09:31a.m. with Staff Q, Licensed Practical Nurse (LPN). Staff Q, LPN reviewed Resident #76's orders and said the oxygen should be set at two liters. He reviewed the photographic evidence and confirmed the oxygen concentrator was set at 3.2 liters and stated the nurses were responsible for monitoring three times a day. Staff Q, LPN said, It should be two liters per orders. He stated he would adjust the oxygen concentrator. Staff Q, LPN stated for nebulizers the nurse should clean the mask and put it in the bag after use. On 06/04/25 at 09:42 a.m. an interview was conducted with Staff K, LPN/UM (Unit Manager). Staff K, LPN/UM stated no one should be touching the oxygen except the nurses and Respiratory Therapist. He stated the nurses should make sure the order is correct, and if there is need to increase, they should contact the Medical Doctor for orders to increase. He stated Resident #76's oxygen should be administered at two liters per her current physician orders. An interview with the Director of Nursing (DON) on 06/04/25 at 12:35 p.m. was conduncted. He said the expectation is for the nurses to follow the physician orders. He stated the nurses should be checking the oxygen during administration, at least three times daily for Resident #76. The DON stated the mask should be bagged when not in use. Review of the facility policy titled Oxygen Concentrators, dated 10/14/24 showed the purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Under Policy Explanation and Compliance Guidelines it showed 1. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device 2. Oxygen is administered under orders of the attending physician, except in the case of an emergency. 4. (a.) The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.). (l.) Keep delivery devices covered in plastic bag when not in use. Review of the facility policy titled, Nebulizer Treatments, dated 10/14/24 showed the policy expectation is to provide residents with appropriate nebulizer treatments administered in a safe, effective manner in accordance with physician orders and current clinical standards.

Based on observation, interview and record review the facility failed to ensure one resident (#59) of three sampled residents who require wound care were provided with pain management services and staff accurately assessed for the presence of pain. Findings included: On 6/2/25 at approximately 10:48 AM, Resident #59 was observed in his room and Staff I, Licensed Practical Nurse (LPN) was observed to be preparing supplies for wound care treatments. Staff I, LPN requested a Certified Nursing Assistant (CNA) to assist her with turning the resident onto his right side. The CNA held the resident on his right side and Staff I, LPN proceeded to remove a sacral dressing and a dressing to the left ischial (buttock) area. Resident #59 was observed to attempt and reach back behind him with his left hand toward the CNA and the CNA was observed to hold the resident's hand down. Staff I, LPN proceeded to use a gauze pad soaked with normal saline to clean the resident's wounds. Resident #59 began to make noises indicating he was uncomfortable and attempted to move away from Staff I, LPN. Staff I, LPN continued with the cleaning and the resident was heard saying ow in a loud voice. The CNA was observed to attempt to hold the resident on his right side as the resident attempted to take his left hand and try to reach backwards toward his buttock area. Staff I, LPN was asked if Resident #59 had received any premedication for pain prior to the wound care treatment and she indicated that she did not know whether the resident was pre-medicated or not but would check. Staff I, LPN reviewed the resident's medication orders and indicated Resident #59 received Tylenol earlier in the morning. Staff I, LPN then met with the Assistant Director of Nursing (ADON), and he indicated he would contact the resident's physician to see if pain medications were indicated during wound care. A review of Resident #59's medical record revealed he is a [AGE] year-old male with a recent hospitalization for a respiratory infection and returned to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The wound care weekly assessment dated [DATE] from the Advanced Practice Registered Nurse (APRN) revealed the resident had a history of sepsis, renal failure, adult failure to thrive, dysphagia, congestive heart failure, senile dementia, muscle weakness, and acute respiratory failure with hypoxia (low oxygen levels). The APRN documented the resident had several wounds and described the left posterior thigh wound as a chronic shear with a status of not healed measuring 2.4cm (centimeter) length x 1.2cm width x 0.3cm depth with moderate amount of serous drainage (type of wound drainage). The APRN documented the resident's sacral wound as an acute shear not healed measuring 4.2cm length x 2.2cm width x 0.2 cm depth and moderate amount of serous draining. The clinical record revealed current physician orders for wound care for the left ischial open skin chronic shear wound were to clean with normal saline, pat dry, apply Santyl (wound care medication to promote healing), calcium alginate (material to promote wound healing) and cover with a foam dressing daily. The current physician orders for the sacral wound were to clean with normal saline, pat dry, apply calcium alginate, Santyl, and cover with a large optifoam dressing daily. A review of the daily nursing vital signs flow record from 3/5/25 through 6/3/25 revealed the resident was coded as 0 as not experiencing any pain, however the CNA task record from 5/22/25 through 6/4/25 revealed the resident had experienced pain 9 times during the 14-day period. On 6/3/25 at approximately 7:50 AM Staff K, LPN was observed preparing medications for Resident #59 and Staff K, LPN explained that he would be giving Resident #59 Tramadol 50 milligrams (medication to treat moderate to severe pain) prior to the wound care treatment this morning. At 8:10 AM Resident #59's physician was observed checking on him. The physician was interviewed at that time, and he confirmed his expectation is staff ensure the resident is comfortable during wound care. At 8:41 AM Staff L, Registered Nurse (RN) was observed performing wound care treatments for Resident #59. Staff L, RN asked Staff K, LPN, to assist, and he turned the resident. Staff L, RN was observed to ask Resident #59 if he was having any pain and he replied no. The RN proceeded with the wound care and the resident appeared more comfortable, did not try to pull away from the RN, and did not make a verbal expression of discomfort. On 6/4/25 at approximately 8:30 AM an interview was conducted with the wound care APRN. She indicated she was conducting her weekly rounds and had provided wound care treatment for Resident #59 earlier. She indicated the resident appeared comfortable when she had seen him. The APRN said pain is avoidable and residents should be premedicated to avoid that as much as possible. She indicated she also used lidocaine topical spray to help with any discomfort during wound treatments.

Based on observations interviews and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for three residents (#37 #86, and #76) of 36 sampled residents. Findings included: 1. During a facility tour on 06/02/25 at 10:01 a.m. an observation was made of Resident #37 sitting in her wheelchair with her bedside table positioned in front of her. An observation was made of a white capsule medication on the bedside table. Another observation was made of an unidentified white powder in a medication measuring cup placed on top of the resident's dresser next to four bottles of a beverage. The resident could not answer questions related to the capsule medication or the unidentified powder. On 06/03/25 at 09:25 a.m. an observation was made of an unknown white powder in a plastic medicine cup on Resident #37's dresser next to bottles of beverages, similar to what as previously observed. Review of Resident #37's Admission Record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, Dementia and peripheral vascular disease. On 06/02/25 at 11:06 a.m. an interview with the Director of Nursing (DON) was conducted. He said the capsule medication found on Resident #37's bedside table was a probiotic. He stated the nurses should supervise the residents during medication administration. Review of physician orders for Resident #37 confirmed the order for Probiotic Capsule 250 MG (Saccharomyces boulardii), Give two capsule by mouth two times a day for probiotic/ family to provide. Review of a care plan for Resident #37 initiated 05/18/22 revealed the resident did not have a self-administration medication care plan. On 06/03/25 at 12:48 p.m. an interview was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B, CNA stated the white unidentified powder was an antifungal treatment powder. Staff B, CNA stated she applied it to the resident as needed. Staff B, CNA stated all the medications are supposed to be locked up. She stated the antifungal was in a medicine cup because she had to get some from Resident #76's drawer a couple days ago, because Resident #37's bottle was empty. Staff B, CNA said the antifungal should have been secured. Staff B. CNA looked in both residents' drawers and pulled out bottles of antifungal powder. 2. During an interview on 06/03/25 at 12:48 p.m., Staff B, CNA stated Resident #76 was receiving an antifungal powder. Staff B, CNA walked into the resident's room and pulled an antifungal powder stored in the resident's drawer. Staff B, CNA stated she applied it to the resident's groin areas and under her breasts. Staff B, CNA did not know if there was a physician order for the antifungal powder. Review of the Admission Record for Resident #76 revealed an admitted [DATE] with a primary diagnosis of unspecified fracture of right acetabulum. Review of physician orders for Resident #76 showed the resident did not have orders for the antifungal powder. An interview was conducted on 06/03/25 at 01:01 p.m. with Staff K, LPN. Staff K, LPN stated all resident's medications to include antifungal powders /creams should be secured and administered by nurses. Staff K, LPN stated the CNAs should keep the antifungal powder in its original container and secured in the treatment cart. He stated the residents should have physician orders for powders and creams. 3. On 06/02/25 at 10:17 a.m. an observation was made or Resident #86 sleeping. A round, yellow-colored medication was observed on the floor next to his bed. An immediate interview was conducted with Staff D, Licensed Practical Nurse (LPN) assigned to the resident. Staff D, LPN stated this resident did not take any yellow - colored tablets. Staff D, LPN looked at the medication and noted it had an imprint of number 36. Staff D, LPN further stated the medication did not belong to Resident #86's roommate. She stated she would notify the Director of Nursing (DON). A follow-up interview was conducted on 06/02/25 at 10:50 a.m. with the DON. The DON stated the medication was a blood pressure medication. He said, It probably belongs to a staff member. No resident at this facility is taking it. On 06/03/25 at 01:10 p.m. an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated medications of all kinds should be secured. An interview was conducted on 06/03/25 at 03:44 p.m. with the DON. The DON stated all biologicals, and all medications should be secured. The DON confirmed Resident #37 and #76 did not have orders for antifungal powder. He stated the residents should have active orders and the medications should be secured. Review of the facility policy titled Medication Storage (Medication Cart/Narcotics) dated 07/22/24 showed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure temperature and security. The General Guidelines showed: A. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. B. Only authorized personnel will have access to the keys to locked compartments. C. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and medical record review and policy review, the facility failed to report an allegation of neglect for one (Resident #1) of two residents sampled for abuse and neglect. Resident #1 was served a peanut butter brownie by facility staff and had a documented peanut allergy. The resident required medication to treat the allergy and was transferred to the hospital for further evaluation. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia. Upon admission, the resident reported she had an allergy to peanuts and peanut butter. The resident's allergy was documented and reported to the dietary department along with the resident's diet order. A review of the resident's medical record revealed a nurse's note written on 06/15/2023 at 14:12 (2:12 p.m.) documenting the resident's report that she had eaten part of a brownie before realizing there was peanut butter in it. The note explained that the resident had a documented allergy to peanuts. The note documented the resident 's complaint of feeling short of breath. A call to the resident's physician resulted in an order for a dose from the epi-pen and Benadryl 25 mg. The resident reported feeling like her throat was closing. The resident was taken to the hospital approximately one hour after the resident had eaten some of the brownie. She returned within 4 hours from the hospital. An interview was conducted with the Director of Nurses (DON) on 07/17/2023 beginning at 12:25 p.m. The DON reported that she was not in the building on 06/15/2023 when the incident occurred and when she returned on 06/18/2023, she learned of the incident. She did not think it met the criteria of a Federal report, requiring submission of a report within 24 hours due to the resident not sustaining serious bodily injury. A review of the facility's policy entitled Abuse, Neglect and Exploitation revealed guidance under section V11, Response and Reporting of Abuse, Neglect, Exploitation and Misappropriation: Anyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility Administrator, abuse agency hotline or file a complaint with the state survey agency and adult protective services immediately or not later than 24 hours if the events that lead to the allegation do not involved abuse and do not result in serious bodily injury. Reporting and investigation should be in accordance with state law/regulation. The facility's policy defined Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. An interview was conducted with the Dietary Manager (DM) on 07/17/2023 beginning at 9:00 a.m. The DM confirmed there had been a new dessert item - a peanut butter brownie - on the menu on 06/15/2023. She reported her staff were to review the menu for the meal they were getting ready to serve, so everyone was aware of the different foods available. She reported the resident's diet slips list allergies and likes and dislikes and both the cook and the aide at the end of line were to check the diet slip against the foods on the resident's tray to ensure they matched. She confirmed she had not reviewed the new dessert item with the staff and the possibility that there might be a resident with a peanut allergy that should not receive the peanut butter brownie. She confirmed neither the cook nor the aide assigned to check the diet slip one last time before the trays were sent out noticed Resident #1's documented allergy to peanuts and how that might indicate that Resident #1 should not receive the peanut butter brownie. On 07/17/2023 at 12:00 p.m. , the process of passing trays to the nursing aides who then serve the meal to the residents was observed. A nurse was observed to compare the meal items with the diet slip and then hand the tray to the nursing aides. Both the nurse and the aide, when asked if this was the process used during tray passing, answered, Usually.

Based on record review and interview the facility failed to follow their process of following resident diet slips to ensure residents did not receive and consume foods to which they were allergic for one (Resident #1) of two residents reviewed for food allergies. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia. Upon admission, the resident reported she had an allergy to peanuts and peanut butter. The resident's allergy was documented and reported to the dietary department along with the resident's diet order. A review of the resident's medical record revealed a nurse's note written on 06/15/2023 at 14:12 (2:12 p.m.) documenting the resident's report she had eaten part of a brownie before realizing there was peanut butter in it. The note explained the resident had a documented allergy to peanuts. The note documented the resident's complaint of feeling short of breath and feeling like her throat was closing. A call to the resident's physician resulted in an order for a dose from the epi-pen and Benadryl 25 mg. The resident was taken to the hospital approximately one hour after she had eaten some of the brownie. She returned within 4 hours from the hospital. The Registered Nurse's Initial Assessment of the resident, dated 06/13/2023, did not include the resident's food allergy to peanuts. The assessment documented the resident's degree of confusion as mildly impaired with forgetfulness. The Registered Dietitian's Initial Assessment of the resident, dated 06/14/2023, documented the resident's food allergy to peanuts, her ability to safely feed herself after set up as well as requiring supervision and or cueing for eating. This assessment did not include any reference to the resident's cognition. A review of the care plan for Resident #1, developed initially at admission, revealed the allergy to peanuts was included with the Focus area of having the potential for alteration in nutrition needs related to Diabetes, Hypertension, and Gastro-intestinal reflux. The planned intervention was to exclude foods and beverages containing nuts, peanuts, and peanut butter. An interview was conducted with the Dietary Manager (DM) on 07/17/2023 beginning at 9:00 a.m. The DM confirmed there had been a new dessert item - a peanut butter brownie - on the menu on 06/15/2023. She reported her staff were to review the menu for the meal they were getting ready to serve, so everyone was aware of the different foods available. She reported the resident's diet slips list allergies and likes and dislikes and both the cook and the aide at the end of line were to check the diet slip against the foods on the resident's tray to ensure they matched. She confirmed she had not reviewed the new dessert item with the staff and the possibility that there might have been a resident with a peanut allergy that should not receive the peanut butter brownie. She confirmed neither the cook nor the aide assigned to check the diet slip one last time before the trays were sent out noticed Resident #1's documented allergy to peanuts and how that might indicate Resident #1 should not receive the peanut butter brownie. A review of Resident #1's diet slip revealed the resident's allergy to peanut butter and peanuts was listed. The Dietary Manager indicated staff were inserviced on the protocol to check the food items on the trays against the diet slips in the afternoon of 06/15/2023 after Resident #1 had been sent out to the hospital after eating the peanut butter brownie. She reported a new process of using a different color highlighter for allergies, dislikes and preferences was in place to ensure her staff noted resident allergies and preferences. On 07/17/2023 at 12:00 p.m. , the process of passing trays to the nursing aides who then served the meal to the residents was observed. A nurse was observed to compare the meal items with the diet slip and then hand the tray to the nursing aides. Both the nurse and the aide, when asked if this was the process used during tray passing, answered, Usually. An interview was conducted by phone on 07/24/2023 beginning at 3:25 p.m., with Staff A, Certified Nursing Assistant (CNA) who responded to the resident's call light during lunch on 06/15/2023. Staff A reported the nurses did not usually get involved with looking at the diet slips prior to handing the meal tray off to the aides to pass to the residents. Staff A said it was the aides who got the trays off the cart and took them to the residents. She said the diet slip did not list the meal items so she could not answer the resident when the resident asked if the brownie contained peanut butter. She said the resident said she had taken a bite of the brownie and could taste peanut butter and she was allergic to peanut butter - it made her throat close up. Staff A said the nurse came into the room, didn't know about the peanut butter either, so took the diet slip to the kitchen to ask them if the brownie contained peanut butter. She said when the nurse came back she gave the resident the epi pen injection and emergency services arrived shortly after that to take the resident to the hospital. A review of the staff training conducted on 06/15/2023 related to food allergies revealed learning objectives included the dietary department's responsibility to check meal trays for food items the resident was allergic to and the nursing department's responsibility to check meal trays for food allergies before giving the meal tray to the resident.

Based on observation, interview, and record review, the facility failed to follow care plan interventions related to fall mat placement for two of four observations made during a four-day survey, for one (Resident #12) of three residents reviewed for falls. Findings included: Review of Resident #12's admission record revealed the resident was admitted to the facility on [DATE], with medical diagnoses that included but were not limited to multiple sclerosis, repeated Falls, muscle weakness, abnormalities of gait and mobility, cognitive communication disorder, insomnia, and overactive bladder. During an observation on 04/03/23 at 09:16 p.m., Resident #12 was observed in his bed with one fall mat to the right side of his bed, in-between his bed and the wall. The resident was interviewed at this time, and he stated, They just left the mat there, they said I fell out of bed, but I got out of bed. It didn't turn out too good. I didn't use the call light. I didn't have injuries, just my pride was damaged because I fell . Another fall mat was observed on the comforter in bed B which was unoccupied and not assigned to any residents. During an observation on 04/04/23 at 9:06 a.m., Resident #12 was observed in his bed with one fall mat on the floor in between the resident's bed and the wall. Another fall mat was observed leaning against the wall. (Picture evidence taken). An observation and interview were conducted on 4/4/23 at 1:45 p.m. Resident #12 was observed to be in bed eating chicken wings with his family. He was observed to have a floor mat on both sides of his bed. Staff A, CNA stated she was not the resident's CNA today but yesterday she was, and she was familiar with the resident. She confirmed the resident should have both floor mats on both sides of his bed. She stated they would move the floor mats when they used the lift to get him out of bed, but when he was in bed, he should have the floor mats on both sides of his bed for fall protection. Further observation and interview was conducted on 4/05/23 at 9:45 a.m. with Staff B, CNA (Agency). she stated she had worked with [Resident #12] many times before . It was observed that the resident was in bed, eyes closed, and had floor mats on both sides of his bed. Staff B, CNA stated, he is supposed to have both floor mats on the floor when he is in bed for falls. An interview was conducted on 04/05/23 at 10:00 a.m. with Staff C, Unit Manager. She stated, [Resident #12] is very lazy, very, very confused he thinks he is in New York sometimes. A couple weeks ago he had a fall early in the morning and we found him eating his sunflower seeds off the ground. So now he is supposed to have floor mats on both sides of his bed while he is in bed. Review of Resident #12's progress notes revealed an incident note on 3/31/23 at 1:43 a.m. Patient was found on the floor sitting against the bed facing his roommates bed eating sunflower seeds. Stated he was trying to walk and that he was walking all day. Patient found soiled. Bed not in lowest position. Skin intact but with red marks on the back in the cervical thoracic region. Son notified and left message with APRN [Advanced Practical Registered Nurse]. Floor mats placed at bedside for immediate intervention. Further progress note review revealed a clinical note dated 4/4/23 at 6:36 a.m. After investigating and IDT [interdisciplinary team] review/discussion, it was determined that the root cause of the fall that occurred on 3/31/23 was related to the resident attempting to get out of bed to ambulate without asking for assistance. Per the resident's statement, he walks every day and he doesn't understand why he can't ambulate again. The resident is confused more than usual due to the increased ammonia level and recent bacteriuria. The resident did not sustain any injuries at this time. The resident is at risk for falls due to a diagnosis of frequent falls, multiple sclerosis, HTN, muscle weakness, gait abnormality, and insomnia. Interventions related to falls include verbal education to residents to ask for assistance, staff to provide frequent incontinence checks before bedtime and staff verbal education to place the bed in the lowest position when a resident is in bed. The resident's son [family member name] and the resident himself stated an understanding of risk factors for falls and interventions in place. IDT recommendations have been implemented and the resident CP/POC has been updated to reflect interventions. Review of Resident #12's care plan revised on 1/20/23, revealed a focus of The resident is at risk for falls r/t [related to] Deconditioning, Gait/balance problems, Unaware at times of safety needs, impaired physicals mobility, weakness, h/o [history of] falls, medication in use, advancing disease process. The goal included: The resident will not sustain serious injury due to falls through the review date. Interventions included but are not limited to, Bilateral floor mats in place while in bed. initiated on 3/31/2023. Review of Resident #12's Certified Nursing Assistant (CNA) care sheet revealed Safety . Bilateral Floor mats in place while in bed.Resident Care Floor Mats An interview was conducted on 04/05/23 at 10:54 a.m. with the Director of Nursing (DON). She confirmed Resident #12 should have bilateral floor mats around his bed when the resident was in bed. Review of the facility's Comprehensive Care Plans policy date reviewed: 10/4/22 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observations, interviews, and record review the facility failed to appropriately secure medications in four medication carts (100,200,400 and 500 Halls) of five medication carts sampled. Findings included: On 6/24/2021 at 02:51 p.m., an observation was conducted of the Medication Cart located on 100 Hall, which included in the sixth draw from the top of the medication cart, loose tablets. Staff A, Registered Nurse (RN) confirmed the presence of the one (1) white tablet, two (2) one- half (1/2) pieces of a white tablet and one quarter (1/4) of a white tablet observed to be in the third draw from the top of the medication cart. On 6/24/2021 at 3:03 p.m., an observation of medication cart located on the 400 Hall included four (4) loose tablets. Staff B, Licensed Practical Nurse (LPN), confirmed the presence of unsecured medications of one (1) white round tablet and one yellow tablet seen in the 4th draw from the top of the medication cart. Staff B (LPN) also confirmed the presence of a white tablet located in the fifth draw and a pink unsecured tablet in the 6th draw. On 06/24/21 at 03:23 p.m., an observation of the medication cart located on the 500 Hall included two (2) loose tablets. Staff C (Agency LPN) confirmed the presence of the unsecured medications. On 6/24/2021 at 03:58 p.m., an observation of the medication cart on 200 Hall included two loose tablets in the third (3rd) draw from the top of the medication cart. Staff D (RN)confirmed the presence of the round white and oval white unsecured tablets. On 06/24/2021 at 4:00 p.m., an interview with the Director of Nursing (DON) was conducted. The DON was informed of the observations made, and she stated, There should be no loose or unsecured medications in the carts, it is unacceptable and it's the nurses responsibility to check their medication carts for loose pills. On 06/25/2021 at 11:04 a.m., a telephone interview was conducted with the facility's Consultant Pharmacist. During the telephone interview he stated, unsecured tablets and or loose tablets in the medication carts are improper storage of medications. A review of the facility's policy and procedure titled, Medication Storage (Medication Cart/Narcotics), Reviewed 07/25/2020, Page 01 of Page 02, was reviewed and read under Policy Heading, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure temperature and security.

Based on record reviews and interviews the facility failed to provide the Office of the State Long-Term Care Ombudsman with a written notice of the hospital transfers for two (#63 and #105) out of two residents reviewed for hospitalization s. Findings included: 1. Review of the Electronic Medical Record (EMR) census revealed Resident #63 was admitted on [DATE]. Further review of the EMR indicated that an unplanned transfer occurred for the resident to an acute care facility on 4/29/21 and was returned to this facility on 5/3/21. An additional review of the EMR did not include information that the Ombudsman was notified of Resident #63's transfer that occurred on 4/29/21. 2. Review of the Electronic Medical Record (EMR) census and the physical hard copy of the clinical record for Resident #105 that indicated the resident was admitted on [DATE]. Further review of the EMR and the hard copies indicated that the resident had an unplanned transfer on 4/28/21. An additional review of the EMR and hard copy of Resident #105's clinical record did not indicate that the Ombudsman was notified of the residents transfer on 4/28/21. An interview was conducted on 6/24/21 at 12:15 p.m. with the Social Service Director (SSD). The SSD stated she tries to notify the State Office of the Ombudsman quarterly but could not locate documentation that the Ombudsman office was notified of transfers and/or discharges that occurred after January 2021. An email, sent on 6/22/21 at approximately 9:00 a.m., to the local office of the State Long-Term Care Ombudsman was unanswered. The policy, Transfer and Discharge, created 2/5/15 and reviewed 10/24/20, did not address the necessity that the Office of the State Long-Term Care Ombudsman be notified of Emergency Transfers/Discharges.

Based on observations, record review and staff interview the facility failed to ensure care plan interventions were properly implemented for two (#65 and #305) of six residents sampled for care planning Findings included: 1. A review of the facility's fall log revealed that Resident #65 had documented falls on 6/7/21, 6/10/21, and 6/15/21. A review of Resident #65's clinical progress notes for the identified events on the facility's fall log revealed: -6/8/21 at 12:35 AM: Patient found on floor in kneeling position at bedside. Patient alert and confused. Unable to answer questions appropriately. Limited [Range of Motion (ROM)] to lower extremities. Patient PERRLA [pupils equal and reactive to light], strong hand grasps bilaterally, no complaints of H/A [headache], nausea or vomiting. Skin intact with slight redness to bilateral knees. Family and [Primary Care Physician (PCP)] notified by supervisor. Assisted patient back into bed via hoyer lift with assist of 2. Will monitor for any changes. Post fall evaluation reviewed with no issues. -6/10/21 @ 11:35 PM: [Nurse] heard someone calling for help, [nurse] asked the aide to check on [room], and the aide found the resident on the floor lying on the left hip. The resident was unable to explain how she fell . The resident was able to do a full ROM without complaint. [Nurse] called and talked to [PCP]'s on-call provider, [On-call provider], with orders to obtain and x-ray of hips and put resident on neuro checks, will continue to monitor. Will put the resident on 15 min [minute] check, and matts to floor and bed in lowest position. Post fall evaluation reviewed with no issues. -6/15/21 @ 10:45 PM: Patient was seen kneeling on the floor mat beside her bed. Bed at lowest position. Nonskid socks on. Call bell within reach but was not activated [by resident]. Alert and oriented x1 with baseline confusion. Patient is incoherent when asked what she was doing before she fell . [Vital signs] within normal limits ([Blood Pressure (BP)]: 140/80mmHg [milligrams mercury], HR [heartrate]: 70[beats per minute (bpm)], RR [respiratory rate]: 15pm, Temp [temperature] 97.0, O2sat [oxygen saturation] 96% in room air). Pupils reactive to light (2mm [millimeters] brisk round). No bruising/open wound noted +ROM/mobility on all 4 extremities with no complaints of pain/discomfort. Positioned safely back to bed. Neuro checks initiated. Assisted with ADLs. Safety precautions reinforced. Daughter informed. PCP notified with no new orders given. Will continue to monitor. On 6/24/21 at 9:00 AM, Resident #65 was observed asleep in bed. The resident's floor mat was visible between the bed and wall but not on both sides of bed. There was a second floor mat leaning against the window's wall. On 6/24/21 at 12:40 PM, resident's second floor mat remained on its side leaned against the wall on top of the other floor mat against the window's wall; the resident was in bed. A review of the resident's face sheet revealed that Resident #65 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was a DNR (do not resuscitate). A review of the resident's most recent Minimum Data Sheet (MDS) dated [DATE] revealed: Sections C (Cognitive Patterns), Brief Interview for Mental Status (BIMS) of 04 out of 15, indicating severe cognitive impairment; E (Behavior), the resident had not displayed any behavior symptoms; G (Functional Status), total dependence for all ADLs (activities of daily living); and Q (Participation in Assessment and Goal Setting), The resident participated in their assessment. The resident wishes to remain in long term care. A review of Resident #65's Care Plan dated 4/30/21 showed a focus of [Resident #65] will be free from fall related injury through next review. Interventions included: assist resident with completing tasks, encourage resident to do as much for self as possible, monitor for increased fatigue and encourage rest periods, set resident up with proper equipment within reach, low bed, bilateral floor mats, and widened bed. On 6/25/21 at 8:37 AM, Resident#65's floor mat was again observed leaned against the window wall, and the resident was in bed. Photographic evidence obtained. On 6/25/21 at 9:07 AM, Staff B, Licensed Practical Nurse (LPN), stated the Certified Nursing Assistants (CNA) tend to move the fall mat so it is not a fall risk for the staff during care and mealtimes. Stated both fall mats were in place when she came in this morning. On 6/25/21 at 9:17 AM, the Director of Nursing (DON) stated the facility's expectation for fall mats was that when the patient is in bed then both mats need to be on the floor. If it did need to be moved to provide care, then it would be expected to be placed back before leaving the resident in bed. After seeing photographic evidence obtained by surveyor, the DON stated, It seems pretty cut and dry. 2. During initial observation and an interview with Resident #305 on 6/22/2021 at 09:55 a.m., he was seen to have a left-hand contracture. The resident stated, I had a stroke, I wear a splint, and they have not put it on me yet for some reason this morning. An observation was conducted on 06/22/2021 at 10:25 a.m. of Resident #305. During the observation, the resident was observed to not be wearing the left-hand brace. Resident # 305 was asked if they came in to apply the splint and he stated No, they do it usually first thing in the morning. An observation was conducted of Resident #305 self-propelling outside the main dining room on 06/23/2021 at 08:56 a.m. The resident was observed to not have the brace on his left-hand contracture. Resident #305 stated they have not put it on yet. During an observation conducted of Resident #305 on 6/23/2021 at 10:52 a.m., the resident was observed to be sitting in his room in a wheelchair and did not have the left-hand splint on. Resident #305's left hand was hanging down by the wheelchair and the splint was observed to be on the mechanical wheelchair. (Photographic Evidence Obtained.) An observation was conducted on 06/23/2021 at 02:59 p.m. of Resident #305 not wearing the left-hand brace. The resident stated, No I saw her around, but she did not come in, it's still on my chair over there. On 06/24/2021 at 02:27 p.m. a subsequent observation was made on Resident #305 in the main dining room. The resident was observed to not have the splint on his left-hand contracture. On 06/25/2021 at 08:35 a.m. Resident #305 was observed not wearing the splint. The resident revealed that staff had not put it on him, and that he had not refused having the device applied to his left-hand contracture. Record review of active physician orders dated 5/10/2021 for Resident #305 read Splint by shift Left hand RNP [restorative nursing program] follows for placement and ROM [range of motion], may remove for skin checks. Facility Profile review for Resident #305 indicated he was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review of Resident #305's care-plan with Goal date of 7/29/2021 revealed under active interventions RNP for Left Hand splint remove for skin checks and hygiene. A continued record review of quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident #305's Brief Interview for Mental Status (BIMS) score was 12, (on a 0-15 scoring scale) indicating moderate cognitive impairment. During an interview conducted with both the DON and Staff F, Restorative Aide, on 6/25/2021 at 9:06 a.m., Staff F Indicated what her job duties were related to Resident #305's left hand contracture. She stated we do range of motion with his left hand; we wash and dry and lotion his hand and put the splint on. Staff F was asked about Resident #305, she stated I have not made it down there this week, and it is my responsibility to put it on, and sometimes the direct care put it on too. The DON, who was listening to the interview, then asked Staff F to immediately put the splint device on Resident #305. On 06/25/21 at 09:32 a.m. an interview was conducted with the Director of Rehabilitation. During the interview, she indicated she went down to ask Resident #305 if he can move his hand up, when it falls, and to assess the resident. She further revealed that she told the resident to let someone know when it falls or is in a bad position or his hand is hanging off the wheelchair because he cannot move it. A review of the facility policy titled Comprehensive Care-Plans, with review date of 10/28/2020, C.1, Pages 01- 03 reads as follows: POLICY: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-seven medications were observed administered and two errors were identified for one (1) (Resident #103) of three (3) residents observed. These errors constituted a medication error rate of 7.41 percent. Findings included: An observation of 500 Hall medication administration on 06/24/2021 at 11 a.m., resulted in Staff E, Licensed Practical Nurse (LPN), giving Resident #103 two (2) medications for Hypertension ([CONDITION(S)]) of [MEDICATION(S)] 100mg (milligrams)and [MEDICATION(S)] 25 mg. Observation of the medication on the Electronic Medical Record (EMAR) computer screen that Staff E, (LPN) was looking at was noted to contain parameters for both medications read Hold if SBP [systolic blood pressure] is less than 110 or HR (pulse) less than 60. An immediate interview was conducted at 11:11 a.m. with Staff E, (LPN) related to administration of the two Blood Pressure (BP) medications and noted parameters seen for each medication's SBP for each one. During the interview Staff E, (LPN) indicated she did not give the medications and stated she threw the medications in the garbage. An observation was conducted of Staff E, (LPN) dumping the medication cart garbage on the top of the 500 Hall medication cart. Staff E (LPN) indicated again that she threw the two medications in the garbage and will find them to show the surveyor. In an interview with the Director of Nursing (DON) on 06/24/2021 at 11:20 a.m. she stated My expectation is that they (nurses) follow parameters for Blood Pressure (BP) medications prior to administering the medication. If the BP indicates the medication should be held, then they (nurses) should hold it. An interview was conducted with the Staff G, (LPN) Unit Manager (UM) on 06/24/21 at 12:37 p.m. During the interview Staff G, (UM) stated The nurse went off on me too, and then on the DON, and said that we are all lying. She did not find the pills in the garbage, and we knew she was not going to find the pills in the garbage. During a subsequent interview conducted with Staff G, (UM) at 02:07 p.m., Resident #103 was seen sitting in a wheelchair next to the nurse's station near the staff member. Staff G, (UM) stated I called to report the two medical errors to the Nurse Practitioner, and family. I will be personally monitoring the resident for six (6) hours, and taking his BP during the monitoring process. Record review of active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if SBP less than 110 or HR less than 60. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #103's care plan problem area dated 3/26/2021 revealed Alteration in cardiac status r/t [related to] high blood pressure. The goal indicated cardiac stability will be maintained as evidenced by vital signs within (Resident #103's) baseline through next review. A further record review for Resident #103 indicated he was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of quarterly Minimum Data Set (MDS) dated [DATE] identified in Section C, Cognitive Patterns, Resident #9's Brief Interview for Mental Status (BIMS) Score to be 09 (on a 0-15 scoring scale), indicating moderate cognitive impairment. On 06/25/2021 at 11:04 a.m., a telephone interview was conducted with the facility's Consultant Pharmacist. He confirmed, both items were medication errors, because it goes against the doctors' orders. A facility provided policy titled, Medication Administration-SNF, with revision date 10/28/2020 Page 01 of 02 reads under Policy, Medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner. Procedure: 3. Medications. are administered in accordance with the written orders of the attending physician. 9. The person administering the medication will document on the electronic medical record.

Based on observation, interview and medical record review the facility failed to provide services for device management for three (#11, 8 & 5) out of eleven sampled residents for an indwelling Foley Catheter by not following Standard Precautions and standard practice and by not ensuring the bag and the tubing was positioned up off the floor to prevent possible cross contamination out of total eleven residents with indwelling Foley catheters. Findings Included: 1. On 1/25/2021 at 10:35 a.m. staff member A, occupational therapist assistant was noted pushing resident #11 in his wheelchair from the end of the 400 hall way. As staff A passed the nursing station dragging sound was overheard. Resident #11's indwelling Foley catheter bag and tubing were observed dragging on the floor under the wheel chair. Staff A transported the resident the length of the 400 hall and stopped at the end of the 500 hall were the therapy room located. Approximately eighty feet. Resident #11 was observed in therapy department and appeared comfortable. His hair was damp and indicated he just had a shower. His catheter bag was observed on the floor. Staff A was present and indicated she was unaware the catheter bag was on the floor. She stated he usually has a leg bag on. I didn't see it. He just had a shower. 2. At 10:55 a.m. resident #8 was observed lying in bed with her eyes closed and appeared comfortable. On the right side of the residents bed an indwelling Foley catheter bag was attached to the frame. The bag was observed sitting on the floor. The catheter tubing contained a dark amber colored urine. The bed appeared to be in its lowest position at the time. Physician orders [REDACTED].# 8 that were dated on 8/1/2020 Foley catheter may inset indwelling Foley catheter to facilitate wound healing. Review of the Minimum Data Set that was dated 8/10/2020 Significant change assessment The Care Area Assessment summary (CAA) section indicated a fall history. 3. At 11:10 a.m. resident # 5 was observed from the hallway sleeping in her bed. The bed frame had an indwelling Foley catheter bag attached to it. The bag was touching the floor. The floor underneath the bag contained a black colored debris (photographic evidence obtained). Medical record was reviewed for resident #5 that revealed care plan report for Problem: alteration in urinary elimination r/t (related to) [MEDICAL CONDITION] bladder-Foley in place. The interventions: maintain drainage bag below urinary bladder, observed position of bag and tubing. At 11:15 a.m. Staff Member C, registered nurse was asked about resident #8 catheter bag. Staff C went into resident #8 bedroom at that time and stated it not supposed to be on the floor Staff C went to the bedside and adjusted the catheter bag location toward the foot of the bed. She then picked up the beds handheld remote control. She used the remote and raised the bed up from the floor. Appeared as a foot height. Staff C stated the bed needs to be raised. So, the bag is not on the floor. On 1/25/2021 at 11:30 a.m. an interview was conducted with the Assistant Director of Nursing (ADON) about the observation of resident #11 catheter bag and tubing. She stated he usually has a leg bag on. She confirmed that the bag should not touch the floor. At 5:00 p.m. an interview was conducted with the Assistant Director of Nursing (ADON) on the observations that were conducted with resident # 5 and #8. That revealed both of their Foley catheters on the floor. She was informed that staff C had raised both of the beds from its lowest position. She confirmed that their beds need to be in the lowest position related to possible fall interventions being in place. The facility provided a copy of their policy titled Urinary Catheters that was dated on 10/24/2020. Policy: Use of urinary catheters may affect the resident sense of dignity, psychosocial well-being and could lead to other medical complications. Policy Explanation and Compliance Guidelines: Urinary Catheters: 5. Staff will follow current standards of practice when handling catheters Urinary collection bag is kept below the level of the bladder and off the floor. Review of Advanced Infection Prevention and Control Training May 2018 version 1, Prevention of catheter-associated urinary tract infection (CAUTI). Drainage bag: To help prevent trauma to the urethra, the urinary drainage tubing should be secured to the patent's thigh with straps and adjusted to a comfortable ft. The catheter drainage bag must always be placed below the level of the bladder to promote good drainage. If a catheter stand is used, the drainage bag and drainage tap must not come in contact with the floor. https://www.who.int/infection-prevention/tools/core-components/CAUTI_student-handbook.pdf

Based on observation, interview and record review, the facility failed to monitor and provide intervention for a supra pubic catheter for one (#87)'s out of 30 sampled residents. Findings included: Review of Resident #87's face sheet revealed she was admitted to the facility on [DATE] from home with [DIAGNOSES REDACTED]. An observation was conducted on 9/24/19 at 10:15 a.m. Resident #87 was observed to be in bed with her eyes closed. The resident did awake to knocking on her door. Resident #87 was interviewed at this time and she was unable to use words but was able to use hand gestures and nod yes or no. The resident's catheter was observed to have blood and dark yellow colored urine where the catheter bag and the catheter tubing connected. The blood was located at the connection of the tubing and the bag and up into the catheter tubing. The resident was asked if she was in any pain in her groin area and she nodded her head yes. Resident #87 was asked if the nurses knew about the pain and she shook her head no. she shook her head no when she was asked if she had urinary tract infection and she shook her head no when she was asked if she was on antibiotics. Review of Resident #87's physicians orders were conducted and did not reveal an antibiotic order for a urinary tract infection. The resident did have a physician's orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the resident's nursing notes for the month of (MONTH) did not reveal any evidence Resident #87 had bloody urine. On 09/24/19 at 12:34 p.m., the resident was observed to have her catheter bag hanging on the bed frame of the bed with dark red blood at the connection of the catheter bag and the catheter tubing. The dark red blood lead up into the tubing with dark yellow urine the same as what was observed on 9/24/19 at 10:15 a.m. (picture evidence obtained). Further observation was conducted on 9/25/19 at 12:21 p.m. the resident was observed to be in bed eyes closed. Her catheter bag was observed to be hanging on the bed frame off of the ground. The catheter still had the thick dark red blood at the connection of the catheter bag and up the catheter tubing with dark yellow urine in the tubing. Another observation was conducted on 9/26/19 at 11:35 a.m. the resident was observed to be in bed, eyes open receiving care from Staff B, Certified Nursing Assistant (CNA). The resident's catheter was observed to still have the thick dark red blood at the connection of the catheter bag and up the catheter tubing with dark yellow urine in the tubing that had cloudy sediment in it. Staff B, CNA was asked who empties the catheters? She stated the CNAs empty the catheter and we only tell the nurse how much was in there if they ask us too. If there was anything wrong then we would tell the nurse. Right now Resident #87's urine is bloody I'm going to tell the nurse about that. I have not gotten a chance to tell her yet because I just saw it. I have not worked with this resident in a while. Further review of the resident's nursing notes did not reveal a note indicating the resident had bloody in her catheter. Review of the treatment administration record revealed the catheter had not been irrigated from 9/1/19 to 9/26/19. An interview was conducted with Staff C, Licensed Practical Nurse (Resident # 87's Nurse) on 9/26/19 at 11:43 a.m. she stated, in report this morning I was told she had tinged red drainage. I have to give the doctor a call and let him know after I review her history and do my homework. that was the first time I've heard of it was this morning in report. They asked me to call the doctor about it. An interview with the resident's spouse was conducted on 09/26/19 at 1:00 p.m. He said his wife has always had frequent UTI's even before she came to the facility. He stated she also has had kidney stones with lipotripsy about 3 or 4 times. They thought the kidney stones were causing her frequent UTI's. I was changing her at home about 6-8 times a day so we got her the suprapubic catheter. I know she had blood in her urine she gets that sometimes. Staff C, the nurse just came in here and irrigated it. I saw her urine was bloody for the past couple days but I wasn't worried about it. The care here is great and everyone is great here. The resident was asked at this time if she was in any pain in her groin area and she shook her head no. On 09/26/19 at 12:19 p.m. Staff C, LPN said resident #87 has a history UTI's. I called the doctor and we have an irrigation order so I irrigated it. She tolerated that well, the urine was yellow with scant amount of red sediment in it. The doctor told me to use the as needed irrigation and that she has a history of UTI's. Her husband is there now and he used to take care of her at home and he said she has had a history of [REDACTED]. During an interview on 9/26/19 at 3:29 p.m. with the Director of Nursing (DON) she stated I was made aware Resident #87 had a small amount of blood in her urine as of this morning and the family and physician was made aware. I know she has an extensive history of urinary issues. The DON was shown the picture of resident #87's catheter taken on 9/24/19 and stated, I was not under the impression that this had been going on for a few days so I will be following up on this. Further interview was conducted with the DON on a 9/27/19 at 10:00 a.m. The DON stated she spoke to nursing, Staff A, Unit Manager and the physician. The physician said he was aware she had dark yellow urine and blood in her urine, the resident had an extensive urinary history from stents to a dilated ureter and UTI's. He stated he did not wish to be called every time she has blood in her urine. He would want to be called if there are signs of UTI such as temperature or abdominal pain. The DON also agreed to there was a concern with the monitoring and lack of intervention related to Resident #87's catheter. Review of Resident #87's care plan, effective 5/17/19, revealed the resident had alteration in urinary elimination related to suprapubic catheter for [MEDICAL CONDITION] bladder. The goal is for urinary appliance will remain patent and resident will have no signs and symptoms of infection through next review date. Interventions included maintain urinary appliance per physician's orders [REDACTED]. Review of the facility's urinary catheters policy, date of approval 10/17/18, revealed, POLICY: use of urinary catheters may affect the resident's sense of dignity, psychosocial well-being and could lead to other medical complications. Review of the facility's Notification of Changes policy date reviewed: 10/11/18 revealed POLICY: The facility will immediately inform the resident; consult with the resident's physician; and if known. Notify the residents legal representative or appropriate family members of the following .2. A significant change in the physical, mental or psychosocial status of the resident.

Based on interview and record reviews, the facility failed to ensure that two (# 165 and # 415) of five sampled residents for medication review received their prescribed medication. Resident #165 did not receive her anti-anxiety medication at bedtime, as ordered, and Resident #415 did not receive an antibiotic of five sampled residents for medication review. Findings included: 1. During an interview held with Resident#165 on 09/24/19 at 10:26 AM, the resident reported that she was newly admitted to the facility as of yesterday afternoon 9/23/19. She stated that she did not like it here because, I wasn't able to get my anxiety medication last night, I had a terrible night and as of now, I still have not received my medication. On 09/26/19 at 11:46 AM an interview with staff member (A) in regards to the resident not receiving her [MEDICATION NAME] on the evening that she was admitted . Staff member (A) confirmed that the resident did not receive her medication on the evening of admission. Staff member (A) confirms that the resident should have received her medication. She will have an education for the nursing staff. Staff member (A) stated, Not having the script should not interfere with us providing this medication. Staff could have called the medical director, or MD. On 09/27/19 at 9:29 AM, an additional interview was conducted with the Director of Nursing (DON) in the conference room in regards to Resident#165 not receiving her 9:00 PM anti-anxiety medication on 9/23/19 date of admission. Resident # 165 was admitted to the facility on [DATE] at 4:30 PM. The medication discharge summary from the hospital was provided by the DON and reviewed which revealed that the resident was to receive [MEDICATION NAME] 0.5 mg 2 tablets by mouth once a day (at bedtime) Next dose: tonight at 9:00 P.M. The DON confirmed resident should have received her anxiety medication. 2. Review of Resident #415's admission record revealed she was admitted to the facility on [DATE] at 5:10 p.m. with a [DIAGNOSES REDACTED]. Further record review revealed the resident has a history of diabetes, [MEDICAL CONDITION] and thrush. During an interview with Resident #415 on 09/24/19 at 09:50 a.m. she stated when she first came to the facility she had an infection and the facility didn't give her antibiotics the first night she was there. Review of the resident's hospital discharge instructions, dated 9/14/19, under physicians' instructions, new medications, revealed [MEDICATION NAME] 300mg every 12 hours for 5 days next dose tonight. Review of the resident's physicians orders revealed an order, dated 9/15/19, for [MEDICATION NAME] 300mg every twelve hours for five days starting 9/15/19 for Urinary Tract Infection. Review of Resident #415's Medication Administration Record [REDACTED]. Further review of Resident #415's hospital discharge instructions, dated 9/14/19, revealed [MEDICATION NAME] 100 mg oral capsule 2 capsules by mouth once a day at bedtime next dose tonight. [MEDICATION NAME] 500,000 units swish and swallow every 6 hours next dose tonight 6 p.m. and [MEDICATION NAME] 5mg by mouth twice a day next dose tonight. Further review of the physician's orders [REDACTED]. Review of the MAR indicated [REDACTED] Review of a nurses' note with an effective date of 9/14/19 at 6:30 p.m. and a entered date of 9/15/19 1:45 a.m. revealed order verified with Advanced Practice Registered Nurse and faxed to pharmacy. Review of the pharmacy admission/readmission cover sheet showed it was dated for 9/15/19 at 12:56 a.m. During an interview on 09/26/19 at 01:07 p.m. with Staff A, Unit Manager she looked up [MEDICATION NAME] 100mg capsules, [MEDICATION NAME] 5mg tablets, [MEDICATION NAME] 300mg capsules and [MEDICATION NAME] 500,000 units swish and swallow. She confirmed that all of those medications were in the emergency drug kit located in the medication storage room on Resident #415's unit except the [MEDICATION NAME] swish and swallow. Staff A also stated upon admission we call the doctor and go over each medication and the doctors can adjust or discontinue the medications at that time. Then, we fax over the orders and medication list to the pharmacy. The pharmacy tells us that if we get the orders in by 9:00 p.m. the medication will deliver on the first delivery in the morning. I think it is around 5 a.m. The UM reviewed Resident #415's hospital medication list and said those medications are available to give so they should have been given. An interview was conducted with the facility's DON on 09/27/19 at 9:30 a.m. and she stated, We don't go by the hospital orders. We verify those orders with the physician and then enter the orders into the computer and send it to the pharmacy. Sometimes, it's just not realistic, depending on what time the residents are admitted or how many admissions we have that night, to get their medications the night they come in. Review of the facility's admission orders [REDACTED] POLICY: The facility will obtain and verify physician orders [REDACTED]. Physician orders [REDACTED].

Based on resident council meeting, interviews and facility policy the facility failed to offer residents a bedtime snack. Findings included: A resident council meeting was held on 09/26/19 at 1:30 P.M., The President of the resident council was present as well as six additional council members. The residents were asked about their bedtime snacks, all in attendance reported that they are not offered bedtime snacks and would enjoy having them offered. On 09/26/19 at 2:48 PM, an interview conducted with the Nursing Home Administrator in regards to voiced concerns during the resident council meeting. The Nursing Home Administrator stated that he would provide documentation in regards to bedtime snacks. An interview conducted with the Director of Nursing (DON) on 09/27/19 at 9:09 AM in regards to offering bedtime snacks to the residents. The DON reported the following information: We went around the entire building last night and asked all of our residents if they wanted a snack, many said that they did, others were unaware that this was available. We have updated care plans to reflect that this is something that the resident wants and, also, we will offer the residents that are non- verbal bedtime snacks. We were not offering bedtime snacks and only providing them to residents with a physician's orders [REDACTED]. The Director of Nursing provided the following facility policy titled: Nourishment and Supplements with an effective date of 7/26/18 and revision date of 8/12/19. The policy reads: The Director of culinary services will assure a supply of nourishments such as snacks between meals or supplements that have been ordered and available. Nursing staff will deliver the nourishments and /or supplements and assist residents with set-up and/or consumption as needed.

Based on observation, interview, and record review, the facility failed to assure that one (#1) of three residents reviewed, who was totally dependent on staff for safe care and unable to communicate her needs, had a care plan that accurately reflected the resident's mobility needs based on Fall and Minimum Data Set assessments. Findings include: Review of the Annual Minimum Data Set (MDS) for resident #1 with assessment reference date of 7/7/10, revealed the resident was assessed with [REDACTED]., and [MEDICAL CONDITIONS] with [MEDICAL CONDITION] (stroke with left sided paralysis), and was receiving no physical or occupational therapy. The Resident Assessment Protocols (RAPs) dated 7/8/10 stated all of the resident's needs were anticipated and met by staff, that she had a communication problem and was unable to make needs known, was frequently repositioned with assist of two persons, had significant immobility and required total assist of two persons for bed mobility, received all nutrition via tube feeding, [MEDICAL CONDITION] left [MEDICAL CONDITION] and bilateral foot drop which contributed to her immobility. Review of a quarterly MDS with assessment reference date of 2/13/11, assessed the resident scoring 13 out of 15 on a cognitive test, required extensive assist of two for bed mobility, non ambulatory, totally incontinent, and with [MEDICAL CONDITION]. Review of the "Falls/Safety Risk/Positioning/ Assistive Device Evaluation for Fall Safety Management Plan" dated 11/15/10 revealed that the resident was assessed as non ambulatory and used enabler bars for positioning. The bars were considered a "therapeutic intervention to achieve proper body alignment and/or positioning". The question related to the resident's ability to proper use the device read as follows: "The resident is able to demonstrate the ability to properly use the device?". The facility documented, "No". A comprehensive nursing evaluation dated 11/15/10 revealed the resident was assessed as requiring two person assist for bed mobility. The "Falls/Safety Risk/Positioning/ Assistive Device Evaluation for Fall Safety Management Plan" assessment dated [DATE] stated resident required total care for all activities of daily living and was non ambulatory using a mechanical lift, made no attempts to stand alone or transfer without assist, continued to used enabler bars for positioning. A comprehensive nursing evaluation dated 2/14/11 stated resident was dependent for bed mobility. The resident's falls care plan updated 11/19/10 stated the resident required the assist of one or two for bed mobility, was able to adjust right side at times but had no significant amount of movement. The goal was that the resident would be free of falls. The fall care plan was review during the quarterly assessment dated [DATE] and no changes were made. The residents fall care plan did not reflect the accurate information related assistance needed based on the MDS assessments dated 07/07/2010 and 02/13/2011, Resident Assessment Protocols (RAP)s dated 07/08/2010, or the "Falls/Safety Risk/Positioning/ Assistive Device Evaluation for Fall Safety Management Plan" assessment dated [DATE] and 2/14/11. The DON stated after the resident returned from the hospital, she was made a two person assist for bed mobility, but review of the printouts of care provided by the CNAs, revealed the CNAs still used one assist at 11:32 p.m. on 3/8, at 9:35 a.m. and 11:54 p.m. on 3/9/11 and at 11:04 a.m. and 11:34 p.m., on 03/11/2011 at 10:40 a.m. and 11:41 p.m. The MDS coordinators and the DON both stated the CNAs did not know how to document accurately. The DON stated in the same interview that one and 15 day reports were filed and that they felt it was not an adverse incident. She further stated that since the incident she had a plan to assess all of the residents who use mechanical lifts and put half rails on their beds and that the current specialty beds would be replaced with beds with larger bolsters at the sides. This plan was in process and not completed and would be taken to Quality Assurance team, but had not been yet. In an interview with the same CNA on 3/14/11 at 11:00 a.m., he stated that on 3/2/11 the resident was on a regular mattress and had no side rails on the bed. The resident had small grab bars on either side of the bed about four inches wide and six inches high which the CNA showed to the surveyor on another resident's bed. The CNA stated that on 3/2/11 at 1:35 p.m., he was providing care to the resident without assistance from anyone else and turned the resident onto her right side, she was hanging on to the grab bar device with her right hand, her left leg which was paralyzed slipped over the right leg and toward the floor. The weight of her left leg caused her to slip off of the bed. The CNA stated he had raised the level of the bed as he did when observed 3/14/11 at 10:30 a.m. so the height of the bed was approximately three feet from the floor. Review of X-rays done on 3/2/11 revealed the resident had a left [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to assure that one (#1) of three residents reviewed who was totally dependent on staff for safe care and unable to communicate her needs was adequately assessed for safe bed mobility when being turned on her side. The facility failed to provide adequate care to prevent accidents resulting in the resident falling out of bed to the floor and fracturing her hip. Findings include: During care for resident #1 on 3/14/11 at 10:30 a.m. with the Certified Nursing Assistant (CNA) (who was caring for the resident when she fell out of bed on 3/2/11), it was observed that the resident's body was at the same level as the height of the top of the 1/2 rails on both sides of the bed. The resident was lying on a specialty mattress which was slightly scooped on both sides at a 45 degree angle up about four inches. The Director of Nurses (DON) entered the room at this time, per the request of the surveyor, and stated she had not seen that the level of the top of the mattress was at the same level as the top of the side rails which presented a risk when the resident was turned on her side. The CNA raised the bed level to to about three feet from the floor and began the resident's bath. The CNA turned the resident on her right side to bath her back and the DON assisted him at this time on the opposite side of the bed to prevent the resident from rolling out of bed. The resident was not able to control her lower extremities and her left leg was paralyzed. In an interview with the same CNA on 3/14/11 at 11:00 a.m., he stated that on 3/2/11 the resident was on a regular mattress and had no side rails on the bed. The resident had small grab bars on either side of the bed about four inches wide and six inches high which the CNA showed to the surveyor on another resident's bed. The CNA stated that on 3/2/11 at 1:35 p.m., he was providing care to the resident without assistance from anyone else and turned the resident onto her right side, she was hanging on to the grab bar device with her right hand, her left leg which was paralyzed slipped over the right leg and toward the floor. The weight of her left leg caused her to slip off of the bed. The CNA stated he had raised the level of the bed as he did when observed 3/14/11 at 10:30 a.m. so the height of the bed was approximately three feet from the floor. Review of X-rays done on 3/2/11 revealed the resident had a left hip fracture. The CNA stated he provided care with a two person assist now for protection. When asked how he knew what care to provide for his residents, the CNA demonstrated the computer and showed the surveyor the care plan which currently called for a two person assist for bed mobility. When asked what was different now about her and why they had not used two before, he did not know. In an interview with the unit manager on 3/14/11 at 11:30 a.m., she stated the resident should be a two person assist for bed mobility. When asked why the resident was not a two person assist or had no side rails for protection prior to her fall, she stated they were trying to keep residents free of restraints, but admitted the resident did not move anyway so it would not have been a restraint. Review of the Annual Minimum Data Set (MDS) for resident #1 with assessment reference date of 7/7/10, revealed the resident was assessed with [REDACTED]., and cerebral vascular accident (CVA) with [DIAGNOSES REDACTED] (stroke with left sided paralysis), and was receiving no physical or occupational therapy. The Resident Assessment Protocols (RAPs) dated 7/8/10 stated all of the resident's needs were anticipated and met by staff, that she had a communication problem and was unable to make needs known, was frequently repositioned with assist of two persons, had significant immobility and required total assist of two persons for bed mobility, received all nutrition via tube feeding, had CVA with left hemiparesis and bilateral foot drop which contributed to her immobility. Review of a quarterly MDS with assessment reference date of 2/13/11, assessed the resident scoring 13 out of 15 on a cognitive test, required extensive assist of two for bed mobility, non ambulatory, totally incontinent, and with [DIAGNOSES REDACTED]. Review of the "Falls/Safety Risk/Positioning/ Assistive Device Evaluation for Fall Safety Management Plan" dated 11/15/10 revealed that the resident was assessed as non ambulatory and used enabler bars for positioning. The bars were considered a "therapeutic intervention to achieve proper body alignment and/or positioning". The question related to the resident's ability to proper use the device read as follows: "The resident is able to demonstrate the ability tp properly use the device?". The facility documented, "No". A comprehensive nursing evaluation dated 11/15/10 revealed the resident was assessed as requiring two person assist for bed mobility. The "Falls/Safety Risk/Positioning/ Assistive Device Evaluation for Fall Safety Management Plan" assessment dated [DATE] stated resident required total care for all activities of daily living and was non ambulatory using a mechanical lift, made no attempts to stand alone or transfer without assist, continued to used enabler bars for positioning. A comprehensive nursing evaluation dated 2/14/11 stated resident was dependent for bed mobility. The resident's falls care plan updated 11/19/10 stated the resident required the assist of one or two for bed mobility, was able to adjust right side at times but had no significant amount of movement. The goal was that the resident would be free of falls. The fall care plan was review during the quarterly assessment dated [DATE] and no changes were made. The residents fall care plan did not reflect the accurate information related assistance needed based on the MDS assessments dated 07/07/2010 and 02/13/2011, Resident Assessment Protocols (RAP)s dated 07/08/2010, or the "Falls/Safety Risk/Positioning/ Assistive Device Evaluation for Fall Safety Management Plan" assessment dated [DATE] and 2/14/11. In an interview with the DON on 3/14/11 at 1:30 p.m., she stated the resident had not had a prior fall and they had tried to keep her restraint free. She stated the admission nurse evaluated the residents and the 11:00 a.m.-7:00 p.m. nurse developed the care information for the CNAs and put it in the computer. The CNAs used computer to input information and to see the care required for the residents. Review of printouts of care dated 12/10/10 received from the facility revealed that the resident was assist of one for positioning and Activities of Daily Living (ADL) before the accident and assist of two after the accident. This was observed by the surveyor on the computer. Printouts of the care recorded as provided by the CNAs dated 2/28/11 showed that the CNAs used one assist for bed mobility on 3/4/11 (after the resident had fractured her hip and had not been treated). The DON stated after the resident returned from the hospital, she was made a two person assist for bed mobility, but review of the printouts of care provided by the CNAs, revealed the CNAs still used one assist at 11:32 p.m. on 3/8, at 9:35 a.m. and 11:54 p.m. on 3/9/11 and at 11:04 a.m. and 11:34 p.m., on 03/11/2011 at 10:40 a.m. and 11:41 p.m. The MDS coordinators and the DON both stated the CNAS did not know how to document accurately. The DON stated in the same interview that one and 15 day reports were filed and that they felt it was not an adverse incident. She further stated that since the incident she had a plan to assess all of the residents who use mechanical lifts and put half rails on their beds and that the current specialty beds would be replaced with beds with larger bolsters at the sides. This plan was in process and not completed and would be taken to Quality Assurance team, but had not been yet.