Every finding on record at Westhills Village Health Care Facility

Based on observation, interview, record review, and policy review, the provider failed to ensure quality of care for one of one samples resident (27) with hemiplegia (one-sided paralysis) who was not provided a pillow under her arm for support as indicated in her care plan by one of one certified nursing assistant (I).Observation and interview on 3/10/26 at 1:08 p.m. in resident 27's room revealed she was seated in her wheelchair watching television. Her call light was lying on the bed to her left and her left hand was resting in her lap. A sign on the wall behind the resident read, Place a pillow under my left arm when I am up in the wheelchair Due to my Stroke. No pillow was positioned under resident 27's left arm. Resident 27 stated she was unsure when the staff had last placed a pillow under her left arm when she was seated in her wheelchair. 2. Observation on 3/11/26 at 1:30 p.m. revealed resident 27 was sitting in her wheelchair the commons area of the facility. Her left arm was positioned down between her left leg and the left armrest of her wheelchair. There was no pillow observed under her left arm. 3. Review of resident 27's electronic medical record revealed she admitted to the facility on [DATE]. Her 1/8/26 Brief Interview for Mental Status score was 8, which indicated her cognition was moderately impaired. Her diagnoses included hemiplegia following cerebral infarction (paralysis of one side of the body caused by a stroke), and dementia (a group of symptoms affecting memory, thinking, and social abilities). Resident 27's 1/12/26 care plan under the section ADL (activities of daily living) Functional/Rehab Potential dated 1/12/26 indicated: Please support my left arm with a pillow when I am sitting in my wheelchair. 4. Interview on 3/12/26 at 8:07 a.m. with certified nursing assistant (CNA) I in resident 27's room revealed she was aware of the sign posted in resident 27's room. CNA I stated that she believed she had placed the pillow under resident 27's arm on 3/11/26 but later acknowledged she had forgotten to do so. She further stated that the sign was provided by the therapy department and was posted in the room for a couple of months. 5. Interview on 3/12/26 at 8:13 a.m. with director of rehabilitation (DOR) J regarding discharging of a resident from therapy revealed that when a resident was discharged from therapy a Restorative Nursing Referral and Treatment Record form was completed. That form was then to be placed in the restorative binder so that the restorative nursing staff could continue those treatment interventions with the resident. 6. Interview on 3/12/26 at 8:20 a.m. with executive director (ED) A and interim director of nursing (IDON) B revealed minimum data set (MDS) coordinator K initiates the completed Restorative Nursing Referral and Treatment Record form received from the therapy department with the restorative nursing program. After restorative was completed then the MDS Coordinator would add the restorative task to the residents' care plan so the CNAs can begin implementing the new goal. 7. Interview on 3/12/26 at 8:25 a.m. with MDS coordinator K revealed she received resident 27's completed Restorative Nursing Referral and Treatment Record from the therapy department on 12/23/25 and implemented her restorative therapy. She added the restorative task to resident 27's care plan on 1/12/26 for the CNAs to implement. 8. Continued interview on 3/12/26 at 8:29 a.m. with ED A and DON B revealed that the task of placing a pillow under resident 27's left arm while she was in her wheelchair was not added to the resident's medication administration record (MAR) on 1/12/26, would would notify the CNAs to document that they had completed that task. ED A stated that when a new goal was added to a residents' care plan, it was highlighted in yellow to alert the CNAs of a new goal. ED A and DON B both expected the CNAs to follow the residents' care plan.9. Interview on 3/12/26 at 9:45 a.m. with CNA I revealed that she confirmed that a new goal in the residents' care plan was highlighted in yellow to alert the CNAs to a change. 10. Review of the provider's 6/17/25 Care Plan policy revealed: 3. Each resident's comprehensive care plan is designed to: f. As appropriate and applicable, assist in prevention of decline or maintenance of current ability in resident's functional status and/or functional level;

Based on record review, interview, and policy review, the provider failed to ensure that the current advance directives (a document that expresses a person's health care wishes if they become unable to speak for themselves) for five of five sampled residents (7, 13, 26, 27, and 60) were in the residents' medical records according to the provider's policy.Findings include: 1. Review of resident 7's medical record revealed she admitted to the facility on [DATE]. There was no documentation indicating that any advance directive paperwork, which expressed her wishes regarding her code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop), was completed upon admission. 2. Review of resident 13's medical record revealed she admitted to the facility on [DATE]. There was no advance directive or document that indicated her wishes regarding her code status in her medical record. 3. Review of resident 26's medical record revealed she admitted to the facility on [DATE]. A progress note dated 10/30/25 by executive director (ED) A indicated she had completed admission paperwork with resident 26, including the advance directive information. There was no advance directive in her medical record. 4. Review of resident 27's medical record revealed she admitted to the facility on [DATE]. There was no documentation that the resident completed any advance directive paperwork on admission. There was a progress note on 10/2/25 completed by ED A that stated she had completed admission paperwork with resident 27 that which included advance directive information. 5. Review of resident 60's medical record revealed he admitted to the facility on [DATE]. There was a copy of his admission paperwork, including his baseline care plan in his medical record. That paperwork did not include his advance directive. 6. Interview on 3/11/26 at 3:36 p.m. with interim director of nursing (IDON) B revealed that their process for documenting a residents' advance directive wishes was to identify those wishes on the resident's baseline care plan and to keep that care plan in each resident's medical record for the staff to refer to. She acknowledged that resident 60's baseline care plan did not address his advance directives. She acknowledged that the baseline care plans for several residents were not available because she could not find copies of them or they were removed from the resident's medical record and stored at an offsite location and would have to retrieve them, as part of their record thinning process. She acknowledged that without that documentation in their medical records, the code status or those residents could not be confirmed by the staff to honor those wishes. 7. Interview on 3/12/26 at 9:56 a.m. with ED A and IDON B revealed that social service coordinator H would review advance directives with the residents upon their admission to the facility. After social service coordinator H would receive the resident's code status from the interview on admission she would document it in the resident's medical record. Within the first week of the resident's admission, medical director G would conduct an initial assessment of the resident and review the resident's advance directives with the resident Social service coordinator H would review the advance directive with the resident during the resident's care conference and make any changes that were needed. ED A stated that she completed the residents' admission paperwork when social service coordinator H when she was out of the facility. 8. Review of the provider's 12/22/14 Advance Directives policy revealed, The Resident's attending physician will be notified of any Advance Directives and documentation of Advance Directives will be maintained in the Resident's permanent record and reviewed routinely or as needed.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed standard infection prevention practices regarding urinary catheter (flexible tubing placed in the bladder to drain urine) care according to the provider's policy for one of one sampled resident (56) with her catheter supplies stores in a container on a shared bathroom floor, and lack of hand hygiene by two of two certified nursing assistants (D and F) observed assisting two of two sampled residents (15 and 19) with eating. Findings include:1. Observation on 3/10/26 at 10:05 a.m. in resident 56's room revealed resident 56 was asleep in her bed and shared a bathroom with her roommate. The bathroom door was open and there was an unlabeled pink plastic container on the floor under the sink. That container held a bottle of liquid with the label distilled vinegar, an empty 60cc (cubic centimeter) syringe, and an unlabeled urinary catheter (flexible tubing placed in the bladder to drain urine) urine collection bag. The urine collection bag had a colorless liquid in it and there was no cap placed over the opening of the tubing. 2. Review of resident 56's electronic medical record (EHR) revealed she was admitted to the facility on [DATE]. On 3/7/26 a nurse performed a bladder scan (a noninvasive imaging device that can read the amount of fluid that is in a bladder) and determined that resident 56 was retaining urine. A physician's order to place a urinary catheter was obtained and a nurse placed the urinary catheter. The resident was admitted to the hospital on [DATE] for conditions unrelated to that urinary catheter. 3. Observation on 3/11/26 at 11:08 a.m. revealed that the pink plastic container with urinary catheter supplies was still on the floor under the sink in resident 56's shared bathroom. 4. Interview on 3/11/26 at 3:11 p.m. with certified nurse assistant (CNA) E revealed each resident with a urinary catheter used a night urinary catheter bag and a day urinary catheter bag. The night bag was larger and could hang on the resident's bed so the staff could empty it without disturbing the resident while they slept. The day bag was smaller and attached to the resident's leg under their clothes for privacy.The CNAs were expected to change the day urinary catheter bags to the night urinary catheter bags. The CNA would remove one urinary catheter bag, clean the tubing with an alcohol wipe, and attach the other urinary catheter bag.The removed urinary catheter bag would be emptied and flushed with water. The CNA would then use a 60cc syringe to insert vinegar into that bag, place a cap over the tube to prevent vinegar from leaking out, and store the vinegar-filled bag in a pink plastic container in the resident's bathroom cabinet.CNA E acknowledged that resident 56's urinary catheter bag was not stored correctly because it did not have a cap on the tube and the pink plastic container was on a shared bathroom floor. 5. Interview on 3/11/26 at 3:20 with registered nurse (RN) C revealed the night shift was expected to change out all urinary catheter bags on Saturday nights. They would also be expected to obtain a new 60cc syringe and write the date on the syringe with a permanent marker.She agreed with CNA E that the catheter bag that was not in use by the resident was to be filled with distilled vinegar and stored in the resident's bathroom cabinet.She acknowledged that storing resident 56's urinary catheter bag in a pink plastic container on the floor in a bathroom shared between two residents increased the risk of it being contaminated. She then removed resident 56's urinary catheter supplies from the bathroom floor and disposed of them. 6. Observation on 3/10/25 at 11:24 a.m. in the main dining room revealed CNA F was sitting at a dining table between residents 15 and 19 for the noon meal. She assisted resident 19 to take a bite of food from a spoon that was in CNA F's right hand. She put the spoon down, turned to resident 15, grabbed resident 15's spoon with her right hand and fed resident 15 a bite of food.CNA F continued to assist residents 15 and 19 four more times without washing her hands before or after touching their eating utensil. 7. Observation on 3/10/26 at 4:40 p.m. in the main dining room revealed CNA D scooped up a bite of food onto a fork, fed that bite of food to resident 15 and placed the fork onto resident 15's plate.CNA D then turned to resident 19 and scooped up a bite of food onto her spoon, fed that food to resident 19 and placed the spoon down on resident 19's plate. CNA D did not wash or sanitize her hands before assisting residents 15 and 19 to eat. 8. Interview on 3/12/26 at 11:45 a.m. with executive director A and interim director of nursing/infection preventionist B revealed they expected the staff to perform hand hygiene between assisting different residents. That expectation included when the staff assisted residents with eating, and when the staff members used the same hand between those residents.They expected staff members to follow the provider's policy for urinary catheter bag cleaning and storage. The pink plastic container with the urinary catheter cleaning supplies should be stored in the cabinet in the resident's bathroom. They expected the 60cc syringe to be dated, and the urinary catheter tubing to have a cap over the tip to keep the inside clean.They acknowledged that storing the urinary catheter cleaning supplies in the pink plastic container on the floor of a shared bathroom could compromise those supplies and they would no longer be considered clean. 9. Review of the provider's 3/16/16 Catheter Care policy revealed the catheter bags were to be cleaned daily. The procedure for cleaning the bag included instructions for the staff to empty the urine from the bag and then to pour [an] adequate amount of cleaning solution consisting of one part vinegar to four parts water into a graduated cylinder. Using a large syringe, instill the solution into the tubing and allow [it] to flow into the bag. Rinse [the] solution around in [the] bag and tubing and allow to sit for a minimum of one hour. Empty [the] solution and store bag. The syringe will be dated and changed on a weekly basis along with the day bag. The night urinary catheter bag would be changed monthly unless specific [specified] differently by a physician. 10. Review of the provider's 4/13/20 Hand Hygiene policy revealed that hand hygiene was to be completed by the staff before assisting a resident to eat. 11. Review of the provider's 1/22/18 Assisted Dining Program Curriculum revealed that the staff were to perform hand hygiene before and after each resident contact and between different residents when feeding.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, observation, interview, and policy review the provider failed to ensure one of one sampled resident (1) was free from a significant medication error when administered the wrong insulin by licensed practical nurse (LPN) D that resulted in the resident's transfer to the emergency room (ER) evaluation and treatment of low blood sugar levels, and a subsequent overnight hospitalization for observation.Findings include: 1. Review of the provider's 5/4/25 SD DOH FRI regarding resident 1 revealed:*On 5/4/25 at 7:00 a.m. resident 1 was administered by injection 40 units of lispro (a fast-acting insulin) instead of the physician's ordered 40 units of glargine (a long-acting insulin) by LPN D.*At 7:04 a.m. physician G was notified of the medication error.-Resident 1 to receive an injection of glucagon (a medication used to increase the blood sugar in the body).-To continue encouraging resident 1 to eat and drink carbohydrates in an attempt to prevent resident 1's blood sugar from becoming too low.-To call the ambulance to have resident 1 transferred to the emergency department for further evaluation and treatment.*Resident 1 was admitted to the hospital overnight for observation of his blood sugars.*On 5/5/25 at 2:50 p.m. administrator A submitted the initial SD DOH FRI to report the medication error, which resulted in the resident's hospitalization for observation. 2. Review of resident 1's electronic medical record (EMR) revealed he:*Was admitted on [DATE].*Had a diagnosis of diabetes (a group of diseases that effect how the body uses sugar in the blood).*Had a 3/6/25 physician's order for Insulin glargine {U-100} 100 units/ml [units per milliliter] (3 ML) subcutaneous [under the skin] pen [generic] - 40 units Subcutaneous Every Day that was scheduled to be administered at 8:00 a.m.*Had previously been receiving lispro insulin, but that order was discontinued on 3/27/25 by physician G.*In April 2025 resident 1's blood sugars were measured four times daily.-The range of resident 1's blood sugars were 79-257.*Was transferred to the emergency room, after the medication error, on 5/4/25 at 7:27 a.m. and returned to the facility the morning of 5/5/25.*Was discharged from the facility on 6/17/25. 3. Review of resident 1's physician's progress notes from the resident's hospital stay above revealed:*He was evaluated in the emergency department after being administered 40 units of short-acting insulin instead of his prescribed 40 units of long-acting insulin.*Initially his blood sugars were maintained within a normal range by him eating but then dropped to 51 (a diabetic adult's blood sugar should be between 80-130) at around noon on 5/4/25.*An intravenous infusion of dextrose (sugar administered through the vein) was initiated when resident 1's blood sugar decreased to 51 and the intravenous dextrose infusion was maintained for a few hours to increase resident 1's blood sugar to a safe range.*He was admitted to the hospital for observation of his blood sugars and administration of the intravenous dextrose infusion.*Resident 1 was discharged in the morning on 5/5/25 with no changes in his medication orders. 4. Observation and Interview on 7/8/25 at 12:05 p.m. with LPN F at the medication cart revealed:*The residents' insulins were stored in the top drawer of the medication cart once they were removed from the refrigerator for use.*LPN F was working on 5/4/25 at the time resident 1 received the wrong type of insulin.*She stated LPN D had administered 40 units of lispro insulin to resident 1 instead of his physician ordered 40 units of glargine insulin.*LPN F stated that resident 1 had physician ordered lispro insulin but that had been discontinued weeks prior.*The lispro insulin was not removed from the medication cart when it was discontinued but it should have been.*LPN D immediately recognized she had administered resident 1 the wrong insulin and reported the medication error to the on-call physician.*Resident 1's family and physician G were notified of the medication administration error, and resident 1 was transferred to the ER as ordered by physician G. 5. Interview on 7/8/25 at 1:45 p.m. with registered nurse (RN) E revealed: *All residents who had a physician's order for insulin were to have scheduled audits of the insulin on the resident's MAR.*The audits were to be completed and documented weekly by the nursing staff after they had checked all of the insulins in the medication carts. 6. Interview on 7/8/25 at 2:08 p.m. with physician G revealed:*He was the facility's medical director and resident 1's primary physician.*He had been the on-call physician on 5/4/25 and received the phone call from the provider informing him of the medication error.*Due to resident 1 having received 40 units of lispro insulin instead of his prescribed 40 units of glargine insulin, physician G ordered resident 1 to be transferred to the ER by ambulance for evaluation and treatment because he felt resident 1's condition was going to get worse before he returned to his baseline.*While in the emergency department resident 1's blood sugar decreased to 51 and required an intravenous infusion of dextrose to maintain his blood sugar in a safe range.*He stated, if the nurse had not reported her medication error immediately, the result of that medication error could have been critical.*He verified the administration of 40 units of lispro insulin instead of 40 units of glargine insulin was a significant medication error. 7. Interview on 7/8/25 at 2:20 p.m. with LPN D revealed:*She was the nurse who mistakenly administered 40 units of lispro insulin to resident 1 instead of the physician prescribed 40 units of glargine insulin.*There was an insulin pen for both the lispro and glargine insulins in the medication cart at the time of the medication error.*After she made the medication error, she reviewed resident 1's MAR and identified there was no active physician's order for lispro insulin in May 2025.*She knew resident 1 had previously had a physician's order for the lispro insulin, but she was not sure when the order had been discontinued.*She thought the medication error could have been avoided if the lispro insulin had been removed from the cart and destroyed, and she would have completed the rights of medication administration prior to the administration of the insulin.*After the medication error she removed the lispro insulin from the medication cart and destroyed it. 8. Review of the July 2023 manufacturer's instructions for lispro insulin pens revealed:* In-use Pen-Store the Pen you are currently using at room temperature [up to 86 degrees F [Fahrenheit] (30 degrees C [Celsius]). Keep away from heat and light.-Throw away the Insulin Lispro Pen you are using after 28 days, even if it still has insulin left in it. 9. Interview on 7/8/25 at 3:20 p.m. with administrator A and director of nursing (DON) B revealed:*The facility did not have medication that were identified as high-risk medications.*DON B stated she called the facilities pharmacy, and they indicated all medications are high-risk medications.*Administrator A and DON B stated the administration of 40 units of lispro insulin without a physician's order could have resulted in serious adverse effects, including death.*DON B verified resident 1's physician's order for lispro insulin had been discontinued on 3/27/25.*She expected that the nurse who received the order to discontinue the lispro insulin to have removed it from the medication cart and destroyed it at that time.*DON B and administrator A verified the insulin having remained in the medication cart after it was discontinued did not follow the provider's Medication Disposition policy.*DON B and administrator A agreed that a discontinued insulin would be an insulin that should have been identified, removed, and destroyed during the weekly insulin audits according to, Discard any products that are outdated or otherwise not indicated for use.*DON B also verified the lispro insulin would have been taken out of the refrigerator at the latest date of 3/27/25, when the physician's order was received for discontinuation, and in accordance with the manufacturer's instructions it should have been destroyed 28 days after it had been opened, which meant the lispro insulin pen should have been destroyed no later than 4/24/25.*DON B verified there was documentation in resident 1's MAR on 4/28/25 that the insulin audit was completed. That was four days after the lispro insulin should have been removed from the medication cart and destroyed 28 days after it had been opened, per the manufacturer's instructions.DON B and administrator A agreed the administration of 40 units of lispro insulin instead of the physician's ordered 40 units of glargine insulin was a significant medication error. Review of the provider's 11/11/15 Medication Passing Procedure revealed:* Each individual medication must be checked with [the] MAR for:-a. Right Resident name-b. Right medicationc. Right dose-d. Right time-e. Right route-f. Right effect-g. Right form-h. Right documentation. Review of the provider's 3/6/19 Medication Insulin policy revealed Insulin pens and vials will be dated when opened and discarded per the pharmacy guidelines. Review of the provider's December 2018 Medication Disposition policy revealed:* Medications that will not be administered to the resident to whom they were dispensed, such as those that are discontinued, outdated, or are declined by the resident, will be disposed of properly. Medications will not be ‘held for disposal' but will be dispositioned at the time that they were taken out of service pending availability of appropriate staff.* Review for appropriate indication to destroy medications, such as discontinuation of the medication order, etc.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review the provider failed to report to the SD DOH within the required time frame, for one of one sampled resident (1) who was sent to the emergency department, and hospitalized for observation and treatment after being administered the incorrect insulin by licensed practical nurse (LPN) D.Findings include: 1. Review of the provider's 5/4/25 SD DOH FRI regarding resident 1 revealed:*On 5/4/25 at 7:00 a.m. resident 1 was administered by injection 40 units of lispro (a fast-acting insulin) instead of the physician's ordered 40 units of glargine (a long-acting insulin) by LPN D.*At 7:04 a.m. physician G was notified of the medication error.-Resident 1 to receive an injection of glucagon (a medication used to increase the blood sugar in the body).-To continue encouraging resident 1 to eat and drink carbohydrates in an attempt to prevent resident 1's blood sugar from becoming too low.-To call the ambulance to have resident 1 transferred to the emergency department for further evaluation and treatment.*Resident 1 was admitted to the hospital overnight for observation of his blood sugars.*On 5/5/25 at 2:50 p.m. administrator A submitted the initial SD DOH FRI to report the medication error, which resulted in the resident's hospitalization for observation. 2. Review of resident 1's electronic medical record (EMR) revealed he:*Was admitted on [DATE].*Had a diagnosis of diabetes (a group of diseases that effect how the body uses sugar in the blood).*Had a 3/6/25 physician's order for Insulin glargine {U-100} 100 units/ml [units per milliliter] (3 ML) subcutaneous [under the skin] pen [generic] - 40 units Subcutaneous Every Day that was scheduled to be administered at 8:00 a.m.*Had previously been receiving lispro insulin, but that order was discontinued on 3/27/25 by physician G.*In April 2025 resident 1's blood sugars were measured four times daily.-The range of resident 1's blood sugars were 79-257.*Was transferred to the emergency room, after the medication error, on 5/4/25 at 7:27 a.m. and returned to the facility the morning of 5/5/25.*Was discharged from the facility on 6/17/25. 3. Review of resident 1's physician's progress notes from the resident's hospital stay above revealed:*He was evaluated in the emergency department after being administered 40 units of short-acting insulin instead of his prescribed 40 units of long-acting insulin.*Initially his blood sugars were maintained within a normal range by him eating but then dropped to 51 (a diabetic adult's blood sugar should be between 80-130) at around noon on 5/4/25.*An intravenous infusion of dextrose (sugar administered through the vein) was initiated when resident 1's blood sugar decreased to 51 and the intravenous dextrose infusion was maintained for a few hours to increase resident 1's blood sugar to a safe range.*He was admitted to the hospital for observation of his blood sugars and administration of the intravenous dextrose infusion.*Resident 1 was discharged in the morning on 5/5/25 with no changes in his medication orders. 4. Interview on 7/8/25 at 2:08 p.m. with physician G revealed:*He was the facility's medical director and resident 1's primary physician.*He was the on-call physician on 5/4/25 and received the phone call from the provider informing him of the medication error.*He stated, if the nurse had not reported her medication error immediately, the result of that medication error could have been critical.*He verified the administration of 40 units of lispro insulin instead of 40 units of glargine insulin was a significant medication error. 5. Interview on 7/8/25 at 3:20 p.m. with administrator A and director of nursing (DON) B revealed:*It was the provider's process that only the DON or administrator was able to submit a SD DOH FRI.*The administrator submitted the SD DOH FRI on 5/5/24 at 2:50 p.m., after she was notified of the medication error that resulted in resident 1's hospitalization.*The on-call nurse was notified of the incident shortly after the medication error had happened and assisted the staff with the processes of notifications to the physician and family, as well as resident 1's transfer to the emergency department.*Administrator A nor DON B expected the on-call nurse to have notified one of them of resident 1's medication error or his transfer to the emergency department.*They agreed that the transfer to the hospital needed to be reported to the SD DOH and administrator A stated she submitted the report as soon as she was made aware of the incident.*She verified she had not submitted the report to the SD DOH within 24 hours after the medication error, which resulted in resident 1 being transferred to the emergency department and admitted to the hospital. Review of the provider's 6/9/22 Abuse policy revealed:* Reporting / Response-Definitions:--Immediate: Means as soon as possible, the absence of a shorter State time frame requirement, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or serious bodily injury, or no later than 24 hours if the events that cause allegation do not involve abuse and do not result in serious bodily injury.* All alleged violations-Immediately but no later than-1) 2 hours- if the alleged violation involves abuse or results in serious bodily injury.* Serious bodily injury: Injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse.

Based on observation, interview, and policy review, the provider failed to ensure: *Proper glove use by one of one cook (Q) during two of two observed meal services. *Proper temperature probe cleaning by one of one cook (Q) during one of one observed meal service. Findings include: 1. Observation on 11/19/24 at 11:06 a.m. of cook Q preparing for the noon-time meal service revealed: *He put on clean gloves, removed waffles from a plastic bag then placed them in a toaster. *Wearing the same gloves he: -Organized serving plates, paper products, and utensils for the meal. -Retrieved hot dog buns and hot dogs from two separate plastic bags. -Began cutting one of the hot dogs then turned his attention to the waffles that had popped up from inside of the toaster. --Touched the waffles then lowered them back inside of the toaster for additional toasting time. -Resumed cutting the hot dog. 2. Observation on 11/19/24 at 4:15 p.m. of cook Q temping food for the evening meal service and interview with food services manager (FSM) D at that same time revealed: *In between temping the ground beef, mashed potatoes, gravy, and carrots, cook Q had wiped the temperature probe using a rag from a red bucket that contained a mixture of water and sanitizer. -FSM D stated the use of individual alcohol pads was the preferred method of cleaning the temperature probe in between temping each food item. Continued observation at 4:50 p.m. of cook Q plating the evening meal service and interview with FSM D at that same time revealed: *Cook Q used his gloved hands to handle the completed paper menus and individual resident tray cards. He placed both the menus and cards on top of the steam table to refer to as he plated that resident's evening meal. -Wearing the same gloves he grasped a cabinet handle to retrieve individual bags of chips. *He used those now unclean gloves to open up the plastic bag with hamburger buns, remove buns from the bag, and lay them on top of an electric griddle. He handled individually sliced pieces of cheese with the gloves and placed them on top of hamburger patties on the griddle. He removed hamburger patties from the griddle, placed them inside of the warmed buns, then moved them to a cutting board. He used the same gloves to hold the hamburger in place while cutting it in half. *He returned to the steam table to continue plating meals without removing his unclean gloves, performing hand hygiene, and putting on clean gloves. *FSM D stated the failure to remove unclean gloves, perform hand hygiene, and apply clean gloves when handling ready to eat foods increased the risk for cross-contamination. A Dietary Hand Hygiene and Glove Use policy was requested on 11/20/24 at 8:30 a.m. Director of Nursing/Infection Control Nurse C stated the kitchen staff followed the 4/13/20 Hand Hygiene policy which revealed: *Proper hand hygiene will be used within the facility to help reduce the possibility of the spread of infection. -There was no mention of expectations for glove use. A Food Temping policy was also requested on 11/20/24 at 8:30 a.m. A copy of Chapter 3: Food Production and Food Safety (2021 [NAME]) was provided and indicated thermometers used to temp food were expected to be cleaned with an individual alcohol pad, discarded, and a new pad used in between each food that was temped.

Based on observation, interview, and record review, the provider failed to ensure communication and resident care were provided in a dignified manner for five of five sampled residents (19, 24, 31, 33, and 35) by one of one certified nursing assistant (CNA) N. Findings included: 1. Observation and interview on 11/19/24 at 9:30 a.m. in resident 33's room revealed: *She sat in her chair with a bedside table beside her. *She had a wheelchair and a hemi-walker (specialty walker to aid soneone with limitation on one side of their body) in her room. *She said an assistant told her she had not been walking enough. -She had a stroke that affected her left side and walked with a hemi-walker. *In the mornings when she would wake up, she would be unsteady and would not be ready to walk right away but CNA N would make her walk to the bathroom and the resident feared falling due to weakness on the left side of her body. *Resident 33 stated CNA N's tone had not been caring towards her. Review of resident 33's electronic medical record (EMR) revealed her 9/7/24 Brief Interview for Mental Status (BIMS) score was 15 indicated she was cognitively intact. 2. Observation and interview on 11/19/24 at 1:43 p.m. in resident 35's room revealed: *She just finished with restorative therapy and was sitting in her wheelchair. *She stated CNA N had embarrassed her around four months ago when the facility had taken the residents to a local outing. -CNA N had encouraged resident 35 to go to the outing and when it was time to go CNA N loudly and in front of the other residents, had told resident 35 she could not go as she had not signed up. *Resident 35 stated since that time CNA N seemed obsessed with her and has been in her room, The resident had asked CNA N to come into her room anymore unless she had a reason to. -Two weeks ago, CNA N answered resident 35's call light and assisted her to the bathroom, then when resident 35 came out of the bathroom CNA N was sitting in a chair and was asking resident 35 why she did not like her. Resident 35 explained the embarrassment of the outing. Review of resident 35's EMR revealed her 11/1/24 BIMS score of 15 indicated she was cognitively intact. 3. Interview on 11/20/24 at 1:25 with resident 31's spouse revealed: *She stated she was at the facility 85% of the time visiting her husband. *At first, she thought CNA N was doing a good job then two months ago her attitude towards her husband had changed. *She stated CNA N was not professional with her husband, she was harsh with the way she had talked to him. *She stated CNA N's attitude towards her husband was not caring when she took care of him. 4. Interview on 11/19/24 at 10:14 a.m. with resident 19 regarding how staff cared for her revealed: *CNA N was rude to her, and had told her, I don't like your tone, *CNA N in the past had refused to take her to the bathroom and said, You just went 20 minutes ago. *She overheard CNA N tell a new CNA in training, [resident 19's name] doesn't need to go to the bathroom. That's why they have Depends on. Review of resident 19's electronic medical record (EMR) revealed her 8/12/24 BIMS score was 14 which indicated she was cognitively intact. 5. Interview on 11/20/24 at 3:04 p.m. with resident 24 and his spouse revealed: *There is one CNA I'm sure you've already heard about, [CNA N]. She is a problem. She's very aggressive. *CNA N was not very professional and had sat on the counter at the nurse's station and ate food. *The resident had dreaded seeing CNA N assigned to his care because CNA N was aggressive and not very patient when providing care. Review of resident 24's EMR revealed his 10/24/24 BIMS score was 11 which indicated he had moderate cognitive impairment. 6. Interview on 11/22/24 at 8:22 a.m. with administrator A regarding the above findings revealed: *She was not aware of any of these issues. *She did not want any resident to feel scared to ask for help. *Her expectation was that staff provide great care to residents and treat them with respect. *A request to interview administrator A with CNA N was declined by administrator A pending discussion with chief executive officer (CEO) P and director of nursing/infection control nurse B. Interview with CEO P and administrator A on 11/22/24 at 8:36 a.m. and again at 8:47 a.m. revealed: *The incident regarding the outing in resident 35's interview was confirmed. *Professionalism and eating at the nurse's station had been addressed in CNA N's prior performance review. *CNA N was removed from the 11/22/24 schedule pending an internal investigation into the above mentioned allegations. Review of the provider's 11/2008 Resident [NAME] of Rights revealed: *Quality of Life -Our facility must provide care and an environment that contributes to the resident's quality of life including: --Maintenance or enhancement of the resident's ability to preserve individuality, exercise self-determination and control everyday physical needs. --Freedom from verbal, sexual, physical and mental abuse and from involuntary seclusion, neglect or exploitation imposed by anyone and theft of personal property.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control and prevention practices were maintained: -During wound care performed by one of one licensed practical nurse (F) for one of one sampled resident (22). -For nasal cannula care for two of two sampled residents (15 and 40). -For hand hygiene and glove use during one of one sampled resident's (12) personal care by certified nurse aide (CNA) (K). Findings include: 1.Observation on 11/19/24 at 10:40 a.m. of licensed practical nurse (LPN) F performing dressing changes on resident 22 revealed: *She had placed dressing supplies on the resident's bedside table without cleaning the surface or providing a clean barrier. *She washed her hands and put on a pair of gloves and with those gloved hands she: -Removed the resident's blankets and rolled her over to her left side. -Soaked a 4 x 4 gauze pad with normal saline and cleaned the wounds to the resident's right leg. -Used a scissors to cut tape and applied a new gauze dressing to the resident's right leg. -Assisted the resident to roll over more onto her left side. -Used the same normal saline soaked gauze that had been on the resident's bed to clean the left leg wound. -Cut a piece of Hydrafera Blue foam to apply to the resident's left leg wound. -Opened the Kerlix gauze package and cut a piece of the Kerlix gauze. -Applied the Hydrafera Blue foam to the resident's left leg wound. -Wrapped the Kerlix gauze to resident's left leg and cut a piece of tape to apply onto the Kerlix dressing. *Removed her gloves and performed hand hygiene. *Applied a liquid bandage to the resident's left heel. *Washed her hands and put on a pair of gloves. *Applied gentamycin ointment to her gloved finger and applied that ointment to the resident's left great toe. *Removed her gloves, did not perform hygiene, and put on a new pair of gloves. *Applied a piece of Kerlix to the resident's toe and applied a piece of tape to secure the Kerlix. Observation of 11/19/24 at 10:55 a.m. of LPN F revealed the scissor she had used resident 22's dressing changes had not been cleaned or disinfected prior to returning it to the treatment cart. Interview on 11/19/24 11:50 a.m. with LPN F regarding the above dressing changes revealed she: *Had not realized she had used the same pair of gloves during the entire dressing change. *Had not thought to have used a clean cotton tipped applicator to apply the ointment to resident's wound versus her gloves. *Had not cleaned or disinfected the scissor she had used during the dressing change prior to placing it in the treatment cart. *Agreed that she had not cleaned the surface or applied a barrier for the dressing supplies. Interview on 11/20/24 at 3:15 p.m. with director of nursing B and registered nurse (RN)/infection control G regarding the above observed dressing change revealed: *DON B agreed that LPN F had not followed their dressing change policy. Review of the provider's April 2018 Dressing Change (Clean) Guidelines revealed: *Place items on clean field. Arrange items on field in order of use. *Position resident. *Remove gloves, wash hands (or use alcohol based hand rub) and scissors. *Don gloves, removed soiled dressings, note any important clinical characteristics of the soiled dressing and discard appropriately. *Remove gloves, discard appropriately. *Wash hands or use alcohol based hand rub. *Don gloves and utilizing aseptic (clean) technique, moisten gauze pad with wound cleanser or normal saline, if applicable. Clean wound using a circular motion starting from the center towards the outside. *Remove gloves, discard appropriately. *Wash hands or use alcohol based hand rub. *Swab scissors with alcohol wipe if used and wash hands or use alcohol based hand rub. *Don gloves for topical/dressing application utilizing aseptic technique. -If topical is used, apply with clean cotton applicator. *If more than one wound is being treated, gloves should be removed, hands washed and fresh gloves applied for each wound. -Follow same procedure for each wound site. 2. Observation on 11/19/24 at 9:34 a.m. revealed resident 15's nasal cannula was lying on the floor in her room. Observation on 11/19/24 at 4:23 a.m. revealed resident 40's nasal cannula lying on the floor in her room and the portable oxygen nasal cannula wrapped around the oxygen tank on her wheelchair. Interview on 11/19/24 5:14 p.m. with registered (RN) H regarding the storage of resident's nasal cannulas revealed the floor was not a clean area for nasal cannulas to be stored. *Wrapping oxygen tubing around a portable oxygen tank on resident's wheelchair would not be a clean area to store the tubing. Interview on 11/20/24 at 3:40 p.m. with RN/Infection Control G regarding resident's nasal cannulas lying on the floor or wrapped around a portable oxygen tank when not in use revealed that would be an infection control concern. 40788 3. Observation on 11/19/24 at 9:15 a.m. of certified nurse aide (CNA) M assisting resident 40 in her bathroom revealed: *The resident's nasal cannula was pulled out of her nose then dropped to the floor in front of the toilet when she transferred from her wheelchair onto the toilet seat. *After wiping the resident's peri-area with her gloved hands CNA M, without removing her unclean gloves, picked up the nasal cannula from off the floor and handed it to the resident to put back inside her nose. Continued observation and interview with CNA M after resident 40 exited her bathroom revealed: *The resident transferred from her wheelchair to a recliner in her room. She removed the nasal cannula connected to her portable oxygen and hung it over the back of her wheelchair. *CNA M retrieved a second nasal cannula and attached it to the resident's oxygen concentrator. -That cannula was laying underneath a reacher (adaptive grabbing device) and around a wheelchair footrest on the seat of a chair. *Without first cleaning that cannula CNA M handed it to the resident who placed it inside of her nose. *CNA M confirmed she should have cleaned both cannulas with an alcohol pad before she handed them to the resident to place inside of her nose. Review of the provider's 5/29/07 Oxygen Concentrators policy revealed: *Maintenance: -Cannulas will be changed twice per month or more often if necessary for infection control. *There was no instruction regarding how a nasal cannula was expected to have been stored to mitigate the risk for contamination. 51816 4. Observation on 11/21/24 at 9:40 a.m. with CNA K assisting resident 12 in her bathroom revealed: *CNA K assisted the resident onto the toilet and removed and discarded resident 12's wet brief with her bare hands. *CNA K performed hand hygiene, applied gloves, and wiped bowel movement off the resident's buttocks. *CNA K used those same soiled gloves and applied barrier cream to the resident's buttocks area. *After applying the cream, the CNA removed those gloves and did not perform hand hygiene before assisting the resident with pulling up her clean brief and pants, and transferring to her wheelchair. *CNA K did not perform hand hygiene before assisting the resident with her oral cares, or before assisting the resident with transferring from her wheelchair to her recliner. *CNA K did not perform hand hygiene after exiting the resident's room. *CNA K had infection control concerns during the resident's personal care when she failed to: -Use gloves when handling a urine-soaked brief -Perform hand hygiene after handling the soiled brief and before handling a clean brief -Remove gloves, perform hand hygiene, and re-glove after wiping bowel movement off of resident and before applying barrier cream. -Perform hand hygiene after barrier cream application and before assisting with oral cares. -Perform hand hygiene after assisting with oral cares. -Perform hand hygiene after exiting the resident's room. Interview on 11/21/24 at 12:09 with RN G and the IC Nurse regarding the above observations revealed: *She would have expected staff to use standard precautions (the basic level of infection control practices that should always be used when providing patient care) when assisting residents with toileting, personal care, and providing oral care. *She agreed that CNA K did not follow infection control and hand hygiene policies. A review of the provider's 4/13/20 Hand Hygiene policy revealed: *Indications -Hand hygiene should be done by staff: --Before and after physical contact with a Resident, whether or not gloves are worn, and between different site/care activities on the same Resident. --After contact with a Resident or Resident's body fluids, including specimen collection. --After contact with soiled linens, dressings, or equipment. A review of the provider's 04/2024 Infection Control Precautions policy revealed: *Types of Precautions -Standard Precautions are for all residents all the time. They are the basic level of infection control precautions. Standard precautions include: --Hand hygiene --Personal protective equipment (gowns, gloves and eye protection, as appropriate)

Based on observation, interview, and policy review, the provider failed to ensure in-room call lights were accessible for two of two sampled residents (12 and 33). Findings include: 1. Observation and interview on 11/19/24 at 9:30 a.m. in resident 33's room revealed: *She sat in her chair with a bedside table beside her. *There was a gray push call light placed on that bedside table that was to her right side. *She stated around three months ago she did not have her call light when she woke up in the morning, she had to holler to get the attention of a certified nursing assistant (CNA), the CNA came in and told her she had to stop hollering, she was upsetting the other residents. *On the morning of 11/19/24 she did not have her call light and she had to holler to get the attention of the morning CNA. *She stated at times the CNAs put the call light on her left side. -She had a stroke that affected her left side, and she could not use her left hand to push the button on the call light. *The call light that she used was a gray push call light that the CNAs clipped to her shirt or the bed. *She did not have a pendant call light that would have gone around her neck. Review of resident 33's electronic medical record (EMR) revealed her 9/7/24 Brief Interview for Mental Status (BIMS) score was 15 indicated she was cognitively intact. 2. Observation on 11/19/24 at 10:01 a.m. revealed: *During an interview with resident 12's roomate, resident 12 was in her chair in her room. *Resident 12 called out for help. *She said she needed to go to the bathroom but did not have a call light. Her call light was on the floor and out of her reach. *The call light was given to resident 12 and she was able to use it to call for help. 3. Interview on 11/21/24 at 9:45 a.m. with CNA K revealed: *She would have used the gray push call light and clipped it to the residents' shirt or laid it on the residents' tray beside all the residents. *The CNAs also use the gray push call light at night and lay it next to the all the residents in bed. *If the resdients' call lights device had fallen, she would have noticed as she checks on the residents often. 4. Interview on 11/21/24 at 10:27 a.m. with CNA L revealed: *She would have made sure the gray push call lights were within arm's reach of the residents or made sure they were on the residents' bedside table prior to leaving the room. *She [NAME] sure each resident had two call light options. *The gray push call lights had clips that the CNAs could have clipped to the resident to prevent the call lights from falling. *At night the CNAs would have used the gray push call light and placed them next to the resident or under the sheet and when the resident tried to transfer out of bed it would have alerted the staff. *Depending on the resident, she would have placed the call light on the strongest side of the resident. 5. Interview on 11/21/24 at 11:00 a.m. with CNA M revealed: *She used the gray push-call light when the resident was in bed. -She would have placed the gray push call light under the sheet or clipped it to the bed. -The gray push call light was rubber and gripped to the sheet to keep it from falling. *If the resident was in their chair, the gray push call light was placed on the bedside table next to them. *If the call lights had fallen or were not in the resident's reach she would have noticed as she checked on the residents often. 6. Interview on 11/21/24 at 12:33 p.m. with director of nursing (DON)/infection control (IC) nurse B revealed: *Her expectation of staff was to place the call lights within reach for the residents and to make sure the residents knew how to use the call lights. *High fall-risk residents used the gray push call light and staff placed it alongside them. The facility had that identified in each of those residents' care plans. 7. The provider's Call Light policy was requested on 11/21/24 at 10:45 a.m. DON/IC nurse C stated there was no policy that addressed call light accessibility.

Based on observation, interview, record review, and policy review, the provider failed to ensure physician's orders were followed for: *Weight-bearing restrictions for one of one sampled resident (40). *A dressing change for one of one sampled resident (22). Findings include: 1. Observation and interview on 11/19/24 at 9:15 a.m. with certified nurse aide (CNA) M in resident 40's bathroom revealed: *The resident entered the bathroom in her wheelchair wearing a left leg immobilizer. *She twisted her upper extremity to the left and used both of her hands to reach towards the wall-mounted grab bar. She pulled herself up to stand holding those grab bars. -She then pivoted her body holding onto the grab bar and sat down on the toilet seat. *After using the toilet she used the same transferring method to return to her wheelchair. *The resident was pushed out of the bathroom in her wheelchair and positioned in front of her recliner. -She bent forward out of the wheelchair seat to grab the armrest of the recliner, pulled her body towards the chair, pivoted, then sat down in the recliner. *CNA M had not secured a gait belt around the resident's waist prior to either transfer to physically assist her and she had not provided the resident with any verbal cues or instruction during the transfers. -She was unsure if resident 40 had any weight-bearing restrictions. Review of resident 40's electronic medical record (EMR) revealed: *Her admitted was 10/30/24 and her admission diagnoses included a left total knee (TKA) arthroplasty explantation (surgical procedure of removing a previously implanted TKA implant), atrial fibrillation, cellulitis and abcess of the left leg, acute respiratory failure with hypoxia, interstitial lung disease, and weakness. *Her 10/30/24 physician discharge orders included the following weight bearing restriction: left lower extremity (LLE) toe touch weight bearing (TTWB). Interview on 11/19/24 at 4:00 p.m. with registered nurse H regarding resident 40 revealed: *The resident's weight-bearing status was TTWB with contact guard assistance (CGA) from staff whenever she was up. *A type-written Report Sheet dated 11/19/24 was inside of a clear plastic stand at the nurses' station desk. -That sheet was updated daily and identified pertinent resident-specific information for caregivers to refer to such as a resident's transfer status. -On that sheet beneath the Transfer Status column for resident 40: CGA X1 [caregiver] TTWB with hinge brace LLE. On 11/19/24 at 4:10 p.m. director of nursing (DON)/infection control (IC) nurse B was notified of the observation referred to above and CNA M's failure to follow resident 40's physician-ordered weight-bearing restriction. Interview on 11/20/24 at 10:15 a.m. with physical therapist (PT) O regarding resident 40 revealed: *She was the primary PT treating resident 40. *Caregivers had been educated by therapy and nursing staff regarding resident 40's mobility and weight bearing restrictions. *Regarding the observation referred to above, PT O stated: -A gait belt was expected to have been placed around the resident's waist prior to the initiation of any transfer. The caregiver should have had their hand on the gait belt to provide the physical support needed to help the resident maintain TTWB status. -Verbal cues and instruction should have been provided by the caregiver throughout the transfer to help the resident maintain TTWB status. -Failure to follow these recommendations placed the resident at increased risk of re-injuring her left knee. A Quality of Care policy was requested on 11/20/24 at 5:00 p.m. DON/IC nurse C stated the provider had no policy for that. A Physician's Order policy was provided but only addressed the manner in which physician's orders were obtained and not the expectation of staff to have followed physician's orders. 45383 2. Observation on 11/19/24 at 10:40 a.m. of licensed practical nurse (LPN) F performing dressing changes on resident 22 revealed: *She had placed dressing supplies on the resident's bedside table without cleaning the surface or providing a clean barrier. *She washed her hands and put on a pair of gloves and with those gloved hands she: -Removed the resident's blankets and rolled her over to her left side. -Soaked a 4 x 4 gauze pad with normal saline and cleaned the wounds to the resident's right leg. -Used a scissors to cut tape and applied a new gauze dressing to the resident's right leg. -Assisted the resident to roll over more onto her left side. -Used the same normal saline soaked gauze that had been on the resident's bed to clean the left leg wound. -Cut a piece of Hydrafera Blue foam to apply to the resident's left leg wound. -Opened the Kerlix gauze package and cut a piece of the Kerlix gauze. -Applied the Hydrafera Blue foam to the resident's left leg wound. -Wrapped the Kerlix gauze to resident's left leg and cut a piece of tape to apply onto the Kerlix dressing. *Removed her gloves and performed hand hygiene. *Applied a liquid bandage to the resident's left heel. *Washed her hands and put on a pair of gloves. *Applied gentamycin ointment to her gloved finger and applied that ointment to the resident's left great toe. *Removed her gloves, did not perform hygiene, and put on a new pair of gloves. *Applied a piece of Kerlix to the resident's toe and applied a piece of tape to secure the Kerlix. 3. Review of the treatment orders for resident 22 revealed: *On 11/13/24 an order had been placed for wound care to resident's left great toe to include: -Cleanse wound with normal saline, paint with betadine, cover with Hydrafera Blue, cover with 2 x2 and secure with tape. *On 11/13/24 an order had been placed for wound care to resident's right lower extremity to include: -Cleanse with normal saline, apply Santyl (nickel thick), cover with Hydrefera Blue, cover with 4 x 4, wrap with cast padding, secure with stockinette. *On 11/13/24 an order had been placed for wound care to resident's left lower extremity to include: -Cleanse with normal saline, apply Santyl (nickel thick), cover with Hydrefera Blue, cover with 4 x4, wrap with cast padding, secure with stockinette. *There had not been an order for gentamycin ointment to have been used during the dressing changes. 4. Interview on 11/19/24 11:50 a.m. with LPN F regarding the above dressing change revealed: *She had not applied the Santyl cream to the resident's leg wounds, but she did have an order for the gentamycin cream. 5. Interview on 11/20/24 at 3:15 p.m. with director of nursing B and registered nurse (RN)/infection control G regarding the above observed dressing change revealed: *DON B agreed that LPN F had room for improvement. *DON B agreed that the order had not been followed for the dressing changes for resident 22.

Based on observation, interview, and record review, the provider failed to ensure two of two sampled residents (15 and 34) were screened for a history of trauma upon their admission to the facility. Findings include: 1. Observation and interview with resident 15 on 11/19/24 at 2:30 p.m. revealed: *She was in her recliner with her feet elevated. *When asked how she was doing she replied, How do you think I'm doing? -She indicated her right arm and shoulder, and her left leg weren't working. She had arthritis and used either a walker or a wheelchair for mobility. *She was living with her family before she came to the facility. She expected to remain there for long-term care. *She became teary-eyed talking about a flood in 1972 that damaged the family-owned business. In the 2000's, her home was destroyed by a wild fire. One of her sons was developmentally disabled. She voiced regret about having not been more active in things like the PTA (Parent-Teacher Association) when her children were school-aged. Review of resident 15's electronic medical record (EMR) revealed: *Her admitted was 10/17/24 and her diagnoses included rheumatoid arthritis, hypokalemia, obesity, obstructive sleep apnea, and atrial fibrillation. She had a history of surgery to her upper right arm bone that had not properly healed. *Social services designee (SSD) I's progress notes since 10/17/24 included the following: -On 10/18/24 she had completed admission paperwork with resident 15. Resident lives with her daughter and her husband in a private home and goal is to return there. -On 10/30/24 a 5-day assessment note indicated: --A short stay rehabilitation stay was planned for the resident. --The resident's Brief Interview for Mental Status (BIMS) score was a 7 indicating she had severe cognitive impairment. --Her PHQ-2 (a two-question screening tool used to identify depression) score was 0 indicating her mood was not depressed and she never felt lonely or isolated. -On 11/13/24 SSD I met with resident 15's daughter regarding the resident's Medicare-covered services. *Interdisciplinary progress notes between 10/17/24 and 11/20/24 included the following entries: -On 11/15/24 the resident refused her morning care stating she had not wanted to be bothered. -On 11/18/24 an unidentified certified nurse aide (CNA) reported the resident was rude to him and refused care. She called him derogatory names. The CNA stated similar behaviors had been occurring for the past week. An unidentified nurse had spoken with the resident following the incident. The resident acknowledged her behavior but was unapologetic for it. She preferred female staff to care for her and requested not to be disturbed during the night. -On 11/20/24 the resident refused morning cares. *There was no assessment in resident 15's EMR that screened for any historical trauma she may have had. Interviews on 11/20/24 at 10:04 a.m. with administrator A and social services designee (SSD) I and again on 11/21/24 at 10:00 a.m. with SSD I revealed: *SSD I relied on information shared during admission and initial assessment interviews with resident 15 to have known if she had experienced any historical trauma. -There was no assessment tool available to have formally screened for trauma. *She was not aware of resident 15's life events shared during the 11/19/24 interview referred to above. *SSD I had some knowledge of the resident's mood and behavior changes since 11/15/24. *Resident 15's daughter had visited nearly every day but SSD I had not ever discussed with her any past trauma resident 15 may have experienced. 45383 2. Observation and interview with resident 34 while he had been seated in his wheelchair revealed he had been tearful and had a lot of grief and loss in his life. Record review of resident 34's 10/9/24 social services note revealed: *On 10/9/24 a Brief Interview for Mental Status (BIMS) he had scored 5 which indicated he had severe cognitive impairment. *He had received a score of 6 on a PHQ-2 (assessment for depression) which indicated he was mildly depressed. -He had refused counseling services at that time. *There had not been any documentation if the resident had been asked about any traumatic events. Interview on 11/20/24 at 10:50 a.m. with director of nursing/infection control nurse C and administrator A regarding trauma assessments for residents revealed social services would have asked the resident if they had experienced trauma and would have documented the response in the social services note. Interview on 11/20/24 at 2:36 p.m. with social services coordinator I and social services consultant J regarding trauma assessment for residents revealed: *They used the PHQ-2 and the BIMS evaluations of scores to assess for trauma. *Social services consultant J would have asked specifically about trauma and then that usually would start a conversation. *Both agreed that there had not been any documentation in the admission assessment that had indicated if trauma had been screened for resident 34. *Social services consultant J would have expected residents to have been screened upon admission and then quarterly for trauma. A Trauma Assessment policy was requested on 11/20/24 at 10:50 a.m. from administrator A. Administrator A and DON/IC nurse C confirmed there was no Trauma Assessment policy and no expectation or process for screening residents for trauma or cultural preferences.

Based on observation, interview, record review, and policy review, the provider failed to ensure a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *Obtained for one of one sampled resident (22). *Followed for one of one sampled resident (134). Findings include: 1. Observation and interview on 3/29/22 at 9:21 a.m. with resident 22 revealed: *He came to the facility for physical therapy following a hospitalization for a cyst to the back of his left leg. *There was an O2 concentrator near his recliner. *He was wearing O2 with a nasal cannula (NC). *A physical therapist was in his room setting up his portable O2 tank to the back of his wheelchair preparing for his therapy session. Further interview on 3/30/22 at 1:36 p.m. with resident 22 revealed: *He had started on O2 in the hospital and was transferred to the provider with O2. *On 3/9/22 his daytime O2 had been discontinued. -He had been on continuous O2 at night. *The last three to four days he started back on 1 ½ to 2 liters of continuous O2 because of his low O2 level. *The nurse was supposed to check his O2 levels and adjust his O2. Record review of resident 22's electronic medical record revealed: *He was admitted on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *A 2/24/22 Brief Interview for Mental Status (BIMS) the score was 14 indicating he was cognitively intact. *His 2/18/22 care plan stated interventions for O2 related to [CONDITION(S)]. -Please administer O2 at the flow rate prescribed by my MD [medical doctor]. -I am hoping to titrate my O2. *His physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -A 2/18/22 order for a transfer to the facility from the hospital which included O2 3 liters by nasal cannula to maintain SpO2 [oxygen saturation] of 90 - 94% (percent). -On 3/9/22 nursing faxed his physician requesting to discontinue O2 therapy because the resident does not use his O2. --The physician had approved the request and returned the fax to the facility. -On 3/16/22 nursing had faxed his physician a request for PRN [as needed] O2 to keep SAT's [saturation] above 90%? --The physician replied, [MEDICATION(S)] 40 mg BID [twice daily] and BMP [basic metabolic panel] - 1 week. --No O2 order had been received. -On 3/18/22 nursing faxed a request to the physician with a request for O2. --The physician replied Need Evaluation UC [urgent care] or ED [emergency department] on the request. ---On the same above fax, registered nurse (RN) F noted: resident refused. There was no indication the physician was notified. -On 3/30/22 a physician telephone order for Titrate O2 via NC to keep SAT's > [greater than] 90%. *Interdisciplinary notes dated 3/18/22, 3/19/22, 3/22/22, 3/26/22, and 3/29/22 had documentation he was on 2 liters O2 and remained above 90% SpO2. *On 3/20/22 interdisciplinary notes stated: -He was not using O2. -His family had provided him with a pulse oximeter to monitor his O2 saturation. *On 3/19/22 and 3/22/22 staff had documented his O2 level. -There had been no documentation of supplemental O2 being used. Interview on 3/30/22 at 3:55 p.m. with RN F regarding resident 22 revealed: *She was aware resident 22 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *On 3/9/22 the residents' O2 was discontinued by his physician with no order to continue nighttime O2. *When O2 is discontinued, the staff was to remove equipment from the room, sanitize it, and put it in storage. *Requests for O2 had been faxed to his physician on 3/16/22 and 3/18/22 and no order for O2 had been received. *There was no documentation of when his O2 was restarted after 3/9/22. *The flow rate on his O2 after 3/9/22 had not been documented. Interview on 3/31/22 at 11:14 a.m. with administrator A and director of nursing (DON) B regarding resident 22 revealed: *A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *The facility nurses were responsible for obtaining O2 orders and placing the order in the medical administration record. *The facility nurses were responsible for documenting O2 saturation, O2 flow rates, and adjusting O2 flow levels. *When O2 is discontinued, it was expected the equipment to be taken out of the room, sanitized, and placed in storage. *Agreed resident 22 had been using O2 without an order. *They knew resident 22 had his own pulse oximeter in his room and was self-monitoring his ownO2 saturations. -Monitoring his O2 saturation was a rehab goal. 2. Observation and interview on 3/29/22 at 1:07 p.m. with resident 134 revealed: *She was seated in a recliner in her room. *There had been an O2 concentrator in her room set at two liters per minute and a nasal cannula extending from the concentrator was in place in her nostrils. *She thought she had been admitted a couple weeks ago. *She stated she had difficulty breathing. Interview and observation on 3/30/22 at 9:54 a.m. with licensed practical nurse (LPN) D regarding resident 134 revealed: *She had a O2 concentrator in her room. *She was receiving O2 at 2 liters continuously via nasal cannula. -The O2 concentrator was set on 2 liters. *O2 saturation checks had been ordered and were documented in the electronic medication administration record (EMAR) for every shift. -She stated the nurses checked her O2 saturation more frequently, every one to two hours. Review of resident 134's medical record revealed: *She had been admitted on [DATE]. *Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *There had been 3/9/22 hospital discharge information that included: -A history of asthma, shortness of breath, supplemental O2 dependent, diastolic [CONDITION(S)], and obstructive sleep apnea. -Her O2 was to be at 2 liters per minute via nasal cannula. -Asthma exacerbation moderate persistent. -Increasing O2 requirement. Review of resident 134's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *3/10/22 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -Titrate O2 at 2 liters per minute via nasal cannula. -To call physician if oximetry is less than 90% on 3 liters when fully awake. *3/11/22 documented verbal order at 3:30 p.m. that included: -Call physician on call if patient oximetry is below on 3 liters per minute. -An increasing O2 requirement for 3 liters per minute. *3/11/22 order at 9:00 p.m. for 3 liters of O2 via nasal cannula and to call physician if O2 sats fall below 90% when on 3 liters of O2. *There was not a current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *3/11/22 telephone consult with the hospital on call geriatric program that included: -O2 titration had been increased to 4 liters the evening of 3/20/22. --This had then been reduced to 3 liters per minute because her O2 saturations were at 94% while on the 3 liters. *3/12/22 signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident 134's care plan did not include any specific information about O2. Review of resident 134's nurses progress notes revealed: *3/9/22 Resident did have some SOB [shortness of breath] noted and is currently on 3LO2 [3 liters of O2 via nasal cannula and O2 sats staying above 90%. *3/12/22 at 8:27 a.m. her O2 saturations fluctuated between 75% and 85% while on 3 liters of O2 via nasal cannula. -A nebulizer treatment was given, bringing O2 saturations to above 90%. -Her physician was notified, and he said to continue to monitor her and call with worsening conditions. --There had been no documentation of worsening conditions in these notes. *Her O2 had been administered at 2 liters on the following dates: -3/13/22. -3/15/22. -3/17/22. -3/22/22. *There was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident 134's EMAR revealed: *A 3/11/22 order for O2 that included: -3 liters of O2 via nasal cannula, and then 2 liters of O2. -To call the physician if the O2 saturation were below 90% on 3 liters. -There had been no end date for this order. *From 3/12/22 through 3/21/22 the O2 had been administered at: -2 liters on 9 occasions. -4 liters on 2 occasions. -During 3/12/22 through 3/21/22 the EMAR showed the O2 saturations had not fallen below 90%. *There was not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *There was not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 3/30/22 with certified nursing assistant (CNA) E regarding O2 administration revealed: *CNA's were not allowed to adjust O2 settings on concentrators. *They would tell a nurse if the concentrator had been set at the wrong amount of O2. *A nurse tells the CNA's what the liters are to be set at for each resident. *The CNA's received this information from the nurse when the resident is first admitted or during shift reports if there were changes. *She was not sure what resident 134's O2 was to be set at but thought it was 2.5 liters. Interview and record review on 3/30/22 at 9:36 a.m. with registered nurse (RN) C regarding resident 134's O2 usage revealed: *Resident 134 generally used 3 liters and if her O2 saturations were less than 90% the nurse would notify the physician. *There was an Info order on the EMAR that RN C stated was for ease of finding O2 liter requirements easily. *Agreed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *Agreed the transcribed order in the EMAR also showed a column that included 2 liters and that this should have been 3 liters. *The nurse is responsible to change the O2-concentrator dial to the ordered liters and would assess the resident if it needed to be increased. *A CNA would be able to change the dial but would have to be directed by the nurse to do so. *She stated she was not certain how the 2 liters had been missed as it should have been 3 liters. Interview and record review on 3/30/22 at 9:41 a.m. with administrator A regarding resident 134's O2 use revealed: *She was familiar with resident 134's care. *She would have to check the EMAR to know what the number of liters the O2 should be on. -She reviewed the EMAR and found the O2 had been changed to 3 liters and she was not sure why the 2 liters was still showing. -She determined a nurse filled out an unnecessary section when entering the order in the EMAR and had put 2 liters in this section. --She stated the actual orders were for 3 liters and the 2 liters should not have been included in this current order. *She believed that the O2 liters resident 134 had documented in her EMAR, by the nurses, was accurate. Review of the facility's 10/8/12 Oxygen Standing Protocol revealed: *If a Resident's oxygen saturation is not at 90% concentration, oxygen will be started, and the Resident's physician contacted for orders. -There was no further instruction provided in this policy.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure: *One of one unlicensed assistive personnel (UAP) (A) had supervision of a registered nurse (RN) to ensure the prepackaged medication name received from the pharmacy matched the names on the Medication Administration Record [REDACTED]. *The blood glucose meter had been properly sanitized according to policy by one of one observed UAP (A). *There was a documentated rationale and specified duration for a PRN (as needed) [MEDICAL CONDITION] medication for one of four sampled residents (4) whose medical record was reviewed for unnecessary [MEDICAL CONDITION] medications and medication regimen review. Findings include: 1a. Observation on 10/9/19 at 8:04 a.m. of UAP A while she administered medications to resident 10 revealed the resident's packets of medications stated: *Sentry Senior take 1 tablet orally daily in the morning. *[MEDICATION NAME] 500 MG (milligrams) Take (2) tablets orally twice daily for pain. *There had been no matching medications listed on the resident's MAR for either of the above mentioned medications. b. Observation on 10/9/19 at 8:45 a.m. of UAP A while she administered medications to resident 15 revealed the resident's packets of medications stated: *Fiber-Lax Take 1 tablet by mouth twice a day.*Thera M Take 1 tablet by mouth every morning. *There had been no matching medications listed on the resident's MAR for either of the above mentioned medications. c. Interview on 10/9/19 at 8:55 a.m. with UAP A regarding the above for residents 10 and 15 revealed: *UAP A stated she: -Just knew Sentry Senior was the same as [MEDICATION NAME] Silver and [MEDICATION NAME] was the same as [MEDICATION NAME]. -Just knew Thera M was the same as a multivitamin and Fiber-Lax was the same as calcium polycarbophil 625 mg tablet twice a day. -Knew by process of elimination, because she poured all the residents other medications into the cups and these were the medicines remaining. -Just figured them out that way. -Had made the above decisions herself. -Had not asked a licensed nurse to confirm the above medications had been interchangeable. Interview on 10/09/19 at 9:50 a.m. with the consultant pharmacist confirmed the medication names on the packets of medications should match the MARs exactly. Interview on 10/9/19 at 10:00 a.m. with the director of nurses (DON) regarding the above confirmed the medication names on the packages should have matched the medication names on the MARs. Review of the providers 11/11/15 Medication Passing Procedure policy revealed: *Each nurse/med aide (UAP) will be responsible for all medications on their assigned wings. MAR indicated [REDACTED] *Each individual medication was to have been checked with the MAR for the right resident name, right medication, right dose, right time, right route, right effect, right form, and right documentation. Review of the provider's undated Med Aide job description and performance review revealed the medication aide would: Demonstrate proper administration of medication under the supervision of the licensed nurse. 2. Observation and interview on 10/9/19 at 10:21 a.m. with UAP A while she disinfected the blood glucose meter revealed she: *Wiped the blood glucose meter with a Sani-Cloth bleach wipe. *Stated it usually dried between one and one-half minutes to two minutes. *Often waited five minutes to be sure it was dry before she used it for the next resident. *Had been unaware of what the policy for cleaning of the blood glucose meter said to do. Interview on 10/09/19 at 10:40 a.m. with the DON regarding the glucometer disinfecting process confirmed UAP A had not followed their policy. She stated, We just covered about that. Review of the provider's (MONTH) (YEAR) Glucose Meters Cleaning and Disinfecting policy revealed: *The surface of the blood glucose meter was to have been wiped until completely wet. *Let stand for four (4) minutes, ensuring treated surface remains visibly wet. Use additional wipes if needed to assure continuous wet contact time. 3. Observation on 10/8/19 between 8:09 a.m. and 9:48 a.m. revealed resident 4 was in her room in bed asleep. Observation again at 10:06 a.m. revealed: *Nursing staff had changed the resident's [MEDICATION NAME]. -She was calm. *She was taken to the bathroom using a mechanical lift. -The resident voiced no concerns. Observation again at 1:24 p.m. revealed the resident was in a chair in her room watching television, and she voiced no concerns. Review of resident 4's 9/28/19 Minimum Data Set (MDS) assessment revealed: *Her [DIAGNOSES REDACTED]. *Her Brief Interview for Mental Status assessment score was fifteen indicating she was cognitively intact. Review of resident 4's (MONTH) 2019 through (MONTH) 2019 MARs revealed: *There was an order for [REDACTED]. -The start date of that order was 7/17/18. *The resident had used [MEDICATION NAME] three times on three separate days during (MONTH) for a jumpy leg, pain, and anxiety. *The resident had used [MEDICATION NAME] ten times on ten separate days during (MONTH) for anxiety, nervousness, concerns about dying, an appointment, and an inability to urinate. *The resident had used [MEDICATION NAME] six times on six separate days during (MONTH) for nervousness, anxiety, and sharp chest pains. *The resident had used [MEDICATION NAME] four times on four separate days during (MONTH) for anxiety, mild nausea, restlessness, and not feeling right. *The resident had used [MEDICATION NAME] one time during (MONTH) for not feeling good. *The use of PRN [MEDICATION NAME] had been documented as effective. Review of the 5/10/19 physician's visit progress note for resident 4 revealed: *Current resident medications had included [MEDICATION NAME] 0.5 mg. tablet, one tablet PRN orally every six hours. *Chief complaint: -Resident 4 is being seen for her regular recertification exam (examination), management of her chronic illnesses as listed in the past medical history, and for management of her medications. *Notes: -Continue with current care plan. Med list was reviewed with nursing home today. No changes were made. Review of the 7/15/19 physician's visit progress note for resident 4 revealed: *Current medications had included [MEDICATION NAME] 0.5 mg. tablet, one tablet PRN orally every six hours. *Chief Complaint: -Resident 4 is seen for her regular recertification exam, monitoring of her chronic illnesses as listed in the past medical history and for management of her medications. There's been no interval change in her health status. *Notes: -Continue with current care plan. Med list was reviewed with nursing home today. No changes were made. Review of the 9/19/19 physician's visit progress note for resident 4 revealed: *It was not yet completed or signed by the physician. *There was a signed and dated physician's orders [REDACTED]. -By signing below, I acknowledge the following: --Current orders have been reviewed and approved. --Current [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 through (MONTH) 2019 monthly Consultant Pharmacist's Progress Notes regarding resident 4's PRN [MEDICATION NAME] use revealed: *The consultant pharmacist recommendations created between 6/1/19 and 6/13/19 had included a record of the resident's use of PRN [MEDICATION NAME] use from (MONTH) (YEAR) through (MONTH) 2019. *The consultant pharmacist's recommendations between 7/1/19 and 7/12/19 revealed: -Consulted by nursing to evaluate pain and anxiety to develop a pain plan. Given the increase in both PRN [MEDICATION NAME] and [MEDICATION NAME] (pain medication) and that they are frequently given together or within 1 hour of each other they appear to be correlated. -The pharmacist advised the physician: the .last 2 times the [MEDICATION NAME] was increased there was a decrease in pain scores and PRN pain/anxiety medication usage. -There was no subsequent change made to the PRN [MEDICATION NAME] order by the physician. *The consultant pharmacist's recommendations between 8/1/19 and 8/13/19 and recommendation between 9/1/19 and 9/11/19 revealed there was no discussion regarding the resident's use of PRN [MEDICATION NAME]. Interview on 10/9/19 at 1:40 p.m. with the DON regarding resident 4's use of PRN [MEDICATION NAME] revealed: *She would have to review the resident's record to determine if there was physician documentation that had specified a duration of use for the PRN [MEDICATION NAME]. *She would have to review the resident's record to determine if there was physician documentation that had specified a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. Interview on 10/9/19 at 2:23 p.m. with the administrator regarding resident 4's use of PRN [MEDICATION NAME] revealed: *There was no physician's documentation that had specified a duration of use for the PRN [MEDICATION NAME] or a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. *She had referred the matter to the consultant pharmacist. Interview on 10/9/19 at 2:30 p.m. with the consultant pharmacist regarding resident 4's use of PRN [MEDICATION NAME] revealed: *He had no record he had contacted resident 4's physician about specifying a duration of use for the PRN [MEDICATION NAME]. *He had no record he had contacted resident 4's physician about documenting a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. A copy of the provider's policy regarding PRN [MEDICAL CONDITION] Medication Use was requested on 10/9/19 at 3:15 p.m. from the DON. However the facility did not use such a policy, and no comparable policy was provided.

Based on observation, interview, policy review, and quality assurance performance improvement (QAPI) review, the provider failed to: *Create a positive and respectful dining experience for 6 of 14 residents (3, 5, 7, 8, 9 and 16) during two of two observed meals in one of two dining rooms (assisted). *Ensure staff provided assistance with eating in a dignified manner for two of two randomly observed residents (9 and 15). *Ensure one of one randomly sampled resident (17) had not received medication in a public area. *Ensure staff answered call lights in a respectable and and followed up in a timely manner. Findings include: 1a. Observation on 6/13/17 from 10:30 am. through 11:25 a.m. of the assisted dining room (ADR) during brunch revealed: *Residents 15 and 16 had already received their meals and were being assisted by certified nursing assistant (CNA) B. *Resident 9 had been served her meal at 10:30 a.m. and resident 8's meal had been served at 10:45 a.m. *At 11:05 a.m. CNA B left the table with residents 15 and 16 and cued resident 9 to eat her meal. *She then put a bite of food on the fork and cued resident 8 to eat. *She did not sit down with the residents during that time. *She went back and while standing helped resident 15 to take another bite of her food. *She was the only staff member in the assisted dining room until 11:00 a.m. *Three other unidentified CNAs then came into the dining room and assisted residents 3, 5, 7, 8, and 9 with their meal. *Resident 8 and 9's meal had not been reheated. *Resident 14 had received her meal at 10:55 a.m. and her table mate, resident 7, had not received her food until 11:10 a.m. Surveyor: b. Observation on 6/13/17 from 4:40 p.m. to 5:30 p.m. of the main dining room (MDR) and in the ADR revealed: *Five staff consisting of food service and CNAs were available to serve eighteen residents in the MDR. *CNA B was the only available staff to serve and assist fourteen residents in the ADR. She tried to serve, assist, cue, and redirect all fourteen residents during the meal. *Residents 15 and 18 had been brought to the ADR and sat for approximately fifteen minutes before they were served. *Resident 5 sat at a table where resident 13 had been served her food at approximately 4:40 p.m. Resident 5 sat for another twenty-five minutes before he was served. *CNA B tried to assist any and all residents in the ADR. But some residents sat with their food in front of them and were unable to eat without assistance. Surveyor: c. Interview on 6/13/17 at 5:15 p.m. with the certified dietary manager and dietary aide A revealed: *Typically when a resident came into the dining room they were served. *They tried to serve all residents at one table at the same time. *It was more difficult in the main dining room to have served all the residents at one table together. Residents could come into the dining room anytime during the hour the meal had been scheduled. Continental breakfast was served from 7:00 a.m. through 9:00 a.m., brunch was served from 10:30 a.m. through 11:30 a.m., and the evening meal was served from 4:30 p.m. through 5:30 p.m. *Residents in the assisted dining room were served when a CNA was available to assist them. Even if other residents at the table had to wait to have been served their meals. *They had tried to work with nursing staff to not have the CNAs bring the residents into the assisted dining room until they were available to help them. *They had worked with the director of nursing on that Works for a bit and then slides back. Surveyor: Interview on 6/14/17 at 9:00 a.m. with the director of health care and the compliance director regarding the staffs' work flow in the assisted dining room revealed: *They and the director of nursing (DON) had addressed the work flow issue of residents getting their food before staff were available to assist them with eating in the QAPI minutes for January 2017 and February 2017. -Residents were being brought to the assisted dining room and served their food before staff were available to assist them. *In January 2017 they and the DON had performed an audit to ensure residents who needed assistance with eating had not received food items until staff were present to assist them with eating. *The facility had not addressed the work flow issue in the March 2017 QAPI minutes. Staff had felt the work flow in the feeding assistance dining room had improved. *There was no QAPI meeting in April 2017. *The May 2017 QAPI minutes revealed there was still a work flow issue with residents brought to the assisted dining room and served their food before staff were available to assist them with eating. *They agreed the work flow issue needed improvement. *They did not have a policy, procedure, or audits for the work flow in the assisted dining room. Review of the provider's 1/7/15 Meal Service policy revealed: *Residents who could no longer feed themselves would have been provided assistance. *Residents that required assistance with dining would have been assisted to that dining room. *Staff were assigned to the assist dining room at mealtimes. Review of the provider's undated Meal Service and Distribution policy revealed: *A comfortable, attractive atmosphere would be maintained in the dining room area. *Food would have been delivered promptly to ensure quality of food for the residents. *Nursing service was responsible for assisting at meal time following what was appropriate for residents' needs. *Residents' meals were to have been distributed promptly in the dining room by the dietary staff and nursing services. *Nursing staff would have been in the dining room during meal service to assist residents with eating and to handle any emergency that might have arisen. 2. Interview on 6/13/17 from 1:00 p.m. through 2:00 p.m. with a group of seven residents revealed they had not liked it when plastic silverware was used during the continental breakfast. The surface of the silverware was smaller and food easily slid off making it harder to eat. 3. Observation and interview on 6/13/17 at 1:15 p.m. during the resident council meeting revealed: *Resident 17 was provided medication from unlicensed assistive personnel (UAP) C. *He stated he did not like his medication to be given during the meeting. *He felt UAP C could have waited or asked him if it was alright to interrupt him. 4a. Interview on 6/13/17 from 1:00 p.m. through 2:00 p.m. with seven residents during a resident council meeting revealed:*Call lights were usually answered in a timely manner. *The problem was the staff would state to them I'll be right back, OK, or Just a sec. *The staff then did not return to assist them. *Four of the residents in the group felt they needed to learn patience due to waiting. b. Interview on 6/14/17 at 10:00 a.m. with resident 12 revealed there were times when he would wait and wait for his call light to be answered. He stated they would come and turn off the light and state they would be right back. Or they would come and say I'll be right there! but not come back until much later. He understood they had other residents to attend to, but it seemed staff took a lot longer to answer his call light in the morning, evening, and during the night. c. Review of the provider's 1/7/15 Call Lights policy revealed: Purpose: To ensure call lights are answered in a reasonable amount of time. The facility goal is an average response time of 10 minutes. Procedure: 1. When the call light is activated, staff members will answer and assist. 2. When staff members are working with another resident and if possible, they will acknowledge the resident and call light, and give the resident an estimated return time. Should the resident need immediate attention, staff will communicate with the charge nurse for assistance. 3. If the call light rolls over to the charge nurse, they will provide follow-up appropriate to the situation. The Director of Nursing or designee will observe and monitor call light usage and response by staff members. Trending and patterns will be reviewed as needed at facility Quality Assurance meetings.

Based on record review, observation, interview, and policy review, the provider failed to follow professional standards for administration of medications by one of one observed licensed practical nurse (LPN) (D) for one of one sampled resident (6) who received medication per an enteral tube. Findings include: 1. Observation on 6/13/17 at 9:20 a.m. of LPN D while she administered medications to resident 6 revealed she: *Prepared the medications for the resident referring to the medication administration record. *She crushed them and mixed them with water individually. *Took those medications and 150 cubic centimeter (cc) of water to the resident's room. *Instilled the medications through the resident's enteral tube. *Flushed the enteral tube with water between each medication administered. *Flushed the enteral tube with a 150 cc bolus of water after the last medication had been administered. Interview on 6/13/17 at 11:00 a.m. with LPN D regarding resident 6 confirmed she had not verified placement of the enteral tube. She had not used a stethoscope to listen before administering his medications. She stated she confirmed tube placement before administering nourishment but not for medications. Interview on 6/13/17 at 11:45 a.m. with the administrator and the director of nurses confirmed the enteral tube placement should have been verified. It should have been done before the resident's medications and water had been administer into that tube. Review of the provider's June 2015 Enteral Tubes Administration of Formula, Medications, and Liquids policy and procedure revealed placement of the enteral tube was to have been verified With auscultation using 150 cc of air.

Based on observation, interview, procedure review, and manufacturers' website review, the provider failed to ensure: *Insulin administered per injection pens to two of two randomly observed residents (1 and 7) had been done correctly by two of two observed registered nurses (RN) (B and D). *Two of two insulin pens had been dated at the time they were opened. Findings include: 1.a. Observation on 4/19/16 at 8:50 a.m. of RN B revealed: *She administered three units of [MEDICATION NAME]per insulin pen to resident 1. *She injected the insulin into the resident's abdomen. *She immediately withdrew the needle after the insulin had been injected. *RN C had been present through the entire observation. Interview on 4/20/16 at 1:10 p.m. with RNs B and C revealed: *RN C confirmed the correct procedure for the insulin pen administration was to count to ten after the insulin had been injected, and then remove the needle. *RN B agreed with the above confirmation. b. Observation on 4/20/16 at 8:15 a.m. of RN D revealed she: *Administered thirty units of [MEDICATION NAME] per insulin pen to resident 7. *Injected the insulin into the resident's abdomen.*Withdrew the needle three seconds after the insulin had been injected. Interview with RN D at the time of the above observation confirmed she withdrew the insulin needle from the injection site three to five seconds after the insulin had been injected. She stated that was to ensure the resident received all of the insulin. 2.a. Observation on 4/19/16 at 9:00 a.m. with RN B and RN C revealed one [MEDICATION NAME]pen in the back hallway medication cart did not have an open date recorded on it. There had been a yellow sticker that stated Date Opened on the insulin pen. RNs B and C confirmed the above insulin pen had not been dated at the time it was opened. b. Observation on 4/20/16 at 9:10 a.m. with RN D revealed one [MEDICATION NAME]pen in the front hallway medication cart did not have an open date recorded on it. There had been a yellow sticker that stated Date Opened on the insulin pen. RN D confirmed the above insulin pen had not been dated at the time it was opened. 3. Interview on 4/20/16 at 2:00 p.m. with the director of nurses revealed she: *Stated Insulin pens need to be dated. *Expected the nurses to follow their policy and the manufacturers' recommendations for the injection procedure of insulin pens. Review of the provider's revised November 2011 Specific Medication Administration Procedures revealed: *Expiration dates were to have been checked before administration of medications. *When a multi-dose container was opened it was to have been dated. Websites reviewed on 4/20/16 at 3:00 p.m. with the administrator revealed the following: *www.[MEDICATION NAME].com revealed Using your thumb, press the injection button all the way down and slowly count to 10 before removing (Counting to 10 will make sure you get your full insulin dose). Release the button and remove the needle from your skin. *www.[MEDICATION NAME].com revealed After the dose counter returns to zero, wait and count slowly to 6 before removing the needle from the skin.

Based on observation, interview, policy review, and staff proficiency document review, the provider failed to ensure the blood glucose (BG) testing device was disinfected appropriately by one of one observed unlicensed assistive personnel (UAP) A after a BG test had been done for resident (1). Findings include: 1. Observation on 4/19/16 at 8:45 a.m. of UAP A revealed she: *Completed a BG test for resident 1. *Immediately cleaned the BG testing device with an alcohol pad. *Would let the BG device sit for one minute and then put it away. *Confirmed that was her usual process for cleaning the BG device after she had used it. Interview on 4/20/16 at 2:00 p.m. with the director of nurses revealed her expectation was for the UAP to have cleaned the BG device according to their policy. Review of the provider's 2/9/15 dated Glucose Meters (GM) Cleaning and Disinfecting policy revealed: *Glucose meters shared between residents were to have been cleaned and disinfected. *Glucose meters were to have been cleaned and disinfected per manufacturer's guidelines. *Cleaning and disinfection was to have been done with bleach towels. *The GM was to have been wiped with a new bleach towel until completely wet and let stand for one minute to air dry. Review of the provider's 3/19/15 dated Glucometer Testing and Staff Proficiency document revealed the staff were to have demonstrated cleaning of the meter. The method was: *Wear gloves when handling disinfectant bleach towels and remove gross soil, i.e. blood, from meter prior to disinfecting. *Wipe surface of meter with new towel (bleach) until completely wet. *Let stand for approximately one (1) minute. *Wipe dry or allow to air dry.

Based on observation, interview, record review, care plan review, and policy review, the provider failed to: *Ensure four of four sampled residents (5, 6, 7, and 8) who had been admitted to the facility without a pressure ulcer did not develop one. *Accurately use the Braden Scale for Predicting Pressure Ulcer Risk assessment tool (a form to assess the resident's risk for development of pressure ulcers) for two of four sampled residents (6 and 7). *Ensure individualized preventative measures were care planned and implemented for four of four sampled residents (6 and 7). *Ensure pressure ulcer documentation was completed according to the provider's policy for four of four sampled residents (5, 6, 7, and 8). Findings include: 1. Review of resident 6's medical record revealed: *A re-admission from the hospital date of 1/26/15. *[DIAGNOSES REDACTED]. *He had a Brief Interview for Memory Score (BIMS) (memory test) score of three on his 2/1/15 significant change Minimum Data Set (MDS) assessment, that revealed he had severely impaired cognition (memory). *He had required extensive assistance of one staff member for transfers, moving in bed, toileting, and personal hygiene. *He had been at risk for skin breakdown and had a current facility acquired pressure ulcer (an area of injured skin from too much pressure) to his buttocks. *He had a history of [REDACTED]. Review of resident 6's interdisciplinary notes revealed: *A 1/26/15 admission nursing note did not mention any red or open areas to his skin. *A 1/27/15 medicare nursing note mentioned some light redness noted to buttocks/rectal area, [MEDICATION NAME] oint (type of ointment used for skin protection) used BID (twice a day). *A 2/26/15 significant change in status nursing note stated he has required weight bearing assist of 1 staff for bed mobility, transfers, locomotion (moving about) in wheelchair, dressing, toileting, hygiene.He does not routinely alert staff to his needs so his needs are anticipated.He is at risk for pressure ulcers and other skin problems but does not have any areas of pressure. *A 3/9/15 skilled nursing note stated noted unstageable ulcer (type of pressure ulcer covered in slough (yellow, tan, gray, green, or brown drainage) and the depth is unable to be determined) to lower left buttock 0.7 cm (centimeter (unit of measurement)) by 2.0 cm, wound bed covered with yellow slough,.dressing applied per facility protocol except Santyl (type of ointment used to remove the slough) d/t (due to) no supply. *A 4/21/15 skilled nursing note stated stage 3 (type of pressure ulcer that was a full thickness of skin tissue loss) pressure noted to lower right buttock.center is deep red, surrounded by white and yellow slough.treated per facility protocol. *Another 4/21/15 skilled nursing note stated stage 3 pressure ulcer noted to posterior (back) scrotum, wound bed 100% covered with yellow slough,.treated per skin protocol. *A 4/28/15 skilled nursing note stated the left lower buttocks area was healed. *Another 4/28/15 skilled nursing note stated the area to the scrotum was healed. Review of resident 6's following medication and treatment administration records (MAR/TAR) related to skin treatments revealed: *February 2015: -[MEDICATION NAME] ointment to sores on buttocks twice daily; documented on 2/21/15 through 2/25/15. -[MEDICATION NAME] ointment for preventative care to buttocks twice daily; documented on 2/26/15 through 2/28/15. -Dressing to the right crease of the buttocks to be changed PRN (as needed) for soilage; start date 2/25/15. There was no documentation to show it had been completed. *March 2015: -[MEDICATION NAME] ointment for preventative care to buttocks twice daily continued. -Dressing change to unstageable pressure ulcer on lower left buttock every day, apply Santyl to wound bed, cover with hydrogel, apply skin prep to surrounding tissue, and cover the whole area with a bordered foam every day; documented on 3/9/15 through 3/12/15, and 3/14/15 through 3/29/15. Additional notes indicated the Santyl was not available on 3/10/15, 3/12/15, and 3/16/15. *April 2015: -[MEDICATION NAME] ointment for preventative care to buttocks twice daily continued. -Assess unstageable pressure ulcer to lower left buttock and/or dressing to it every shift; documented on 4/1/15 through 4/28/15. -Dressing change to unstageable pressure ulcer on lower left buttock every day, apply Santyl to wound bed, cover with hydrogel, apply skin prep to surrounding tissue, and cover the whole area with a bordered foam every day; documented on 4/1/15 through 4/11/15, 4/13/14, 4/14/15, and 4/16/15 through 4/27/15. Additional notes indicated the treatment was not administered on 4/3/15 since he was up in the chair all day, on 4/4/15 and 4/10/15 he refused to lay down, and on 4/16/15 the nurse used a spot dressing instead. -Assess dressing to stage 3 ulcer on right lower buttock every shift. That had been documented on 4/21/15 through 4/30/15. -Change dressing to stage 3 ulcer on right lower buttock two times a week on bath days per protocol; documented on 4/23/15, 4/26/15, and 4/30/15. -Assess dressing to stage 3 ulcer on posterior scrotum every shift; documented on 4/21/15 through 4/29/15. -Change dressing to stage 3 ulcer on posterior scrotum two times a week on bath days per protocol; documented on 4/23/15 and 4/26/15. *May 2015: -[MEDICATION NAME] ointment for preventative care to buttocks twice daily continued. -Change dressing to stage 3 ulcer on right lower buttock two times a week on bath days per protocol; documented on 5/3/15. -Assess dressing to stage 3 ulcer on right lower buttock every shift; documented on 5/1/15 through 5/5/15. -Change dressing to unstageable ulcer on right lower buttock daily. Cleanse with normal saline, apply nickel thick layer of Santyl to the wound bed, skin prep to the surrounding area and cover with a bordered foam every daily; documented on 5/4/15 through the present time. -Assess dressing to unstageable ulcer on right lower buttock every shift; documented on 5/5/15 through the present time. Review of resident 6's following skin assessment forms that were completed by nursing revealed: *On 2/25/15 the site was the right gluteal fold: -It was not listed as pressure. -Described as a small dime length area of sheared skin at the crease of the right buttocks where the resident's incontinence brief appeared to have rubbed against the area. -The area resolved 2/26/15. *The 3/9/15, 3/15/15, 3/22/15, 4/5/15, 4/19/15, and 4/26/15 forms had been for the left lower buttock. These forms revealed: -Description: unstageable pressure ulcer, with yellow slough, and red edges. -The treatments had been documented inconsistently. -On 3/9/15 it measured 0.7 cm by 2.0 cm. -Measurements were not listed for 3/15/15 and 3/22/15. -On 4/5/15 it measured 0.1 cm by 0.1 cm. -On 4/19/15 it measured 0.06 cm by 0.05 cm. -There had been no form for the week of 3/29/15 through 4/4/15 or 4/12/15 through 4/18/15. -The area healed on 4/28/15. *A 4/21/15 form for the scrotum revealed: -It was a stage 3 pressure ulcer to the posterior scrotum, covered with yellow slough, and red tissue surrounding. -It measured 0.8 cm by 0.2 cm. -The treatment was listed as per skin protocol. -The area healed on 4/29/15. *The 4/21/15, 4/23/15, 4/30/15, 5/1/15, 5/7/15, and 5/14/15 forms had been for the right lower buttock These forms revealed: -On 4/21/14 the area was stage 3, the center was deep red, surrounded by white and yellow slough, and it measured 3.0 cm by 2.9 cm. -On 4/23/15 the area was stage 3, the edges were rough, and it measured 3.9 cm by 3.1 cm. -On 4/30/15 the area was unstageable due to slough, it measured 3.5 cm by 2.4 cm, and the treatment was hydrogel and a bordered foam dressing. -On 5/1/15 the area was unstageable and measured 3.1 cm by 1.9 cm. -On 5/7/15 the area was unstageable and measured 2.8 cm by 2.0 cm. -On 5/14/15 the area was unstageable and measured 2.2 cm by 2.0 cm. *The descriptions and treatments on the forms varied. *On all the above skin assessment forms there was an entire section that was not completed and listed as inapplicable.This area had included items such as: nutrition hydration intervention, ulcer care, preventative protective skin care, date physician notified, time physician notified, type of pressure relieving mattress, responsible party notification date and who was notified, and turning and repositioning program. Interview on 5/20/15 at 10:15 a.m. with the DON and administrator regarding resident 6's skin assessment forms revealed: *The DON was aware the forms were not completely filled out. -She did not want the nurses to fill out that section, because it would not go anywhere. -She felt those items would have been listed in other areas of the documentation. -She agreed there had been differences in documentation by different nurses. *A charting or documentation policy was requested. -The DON stated there was no specific policy. -She further stated they had done ongoing education and audits on the documentation. Review of resident 6's following physician's orders [REDACTED].>*A 2/25/15 fax sent to the physician, resident has small dime lengthed area to crease below right buttocks where top layer of skin appears to have sheared off.area is where attends meets the skin and appears due to attends rubbing against area.will continue to monitor. -Certified nurse practitioner signed and wrote discussed with nurse - healing. *A 3/9/15 fax sent to his physician to update on the unstageable ulcer to his left lower buttocks. -Physician ordered agree with above wound care, aggressively pursue off loading and pressure reduction left buttock, avoid his sitting on this for prolonged periods, shift weight/posture every 30 minutes when sitting up until healed. *A 3/11/15 dietitian recommendation: one packet Juven supplement twice a day, encourage oral fluids and foods, place on red glass program (special program for nutritionally at risk residents), multivitamin with minerals and zinc daily, add calorie booster/protein boosters. Noted by the physician on 3/13/15. -Additional dietitian comments stated has increased needs due to unstageable pressure ulcer to left buttock. *A 5/4/15 fax sent to physician: updated on the unstageable ulcer to his right lower buttock; requested to use Santyl daily. -Physician wrote I agree with wound care plan above, offloading off the area, no prolonged sitting, 1 hour at a time. Interview on 5/20/15 at 10:15 a.m. with the DON and the administrator revealed: *The DON agreed the physician had written the above orders. -She agreed that physician order [REDACTED]. Review of resident 6's 2/1/15 significant change MDS assessment revealed: *He required extensive assistance of two staff for moving in bed, transfers, toileting, and personal hygiene. *He was frequently incontinent (unable to control) of urine. Review of resident 6's 2/23/15 significant change MDS assessment revealed: *He required extensive assistance of one staff for moving in bed, transfers, toileting, and personal hygiene. *He was frequently incontinent of urine and bowel. Review of resident 6's 2/1/15 and 2/23/15 Care Area Assessment (CAA) summary revealed: *He triggered (identified at risk) for pressure ulcer. *The progress note stated he was at risk for pressure ulcers. He did not have any areas of concern. They would continue to care plan to keep the direct care staff aware of his needs. Review of resident 6's Braden Scale assessments from re-admission on 1/26/15 through the present time revealed: *On 2/2/15: -Moisture score two, indicated very moist skin. -Activity score two, indicated was chairfast (unable to bear own weight and/or must be assisted into chair or wheelchair). -Mobility score two, indicated was very limited (made occasional slight changes in position but unable to make frequent or significant changes on own). -Nutrition score three, indicated nutrition was adequate (ate over half of most meals). -Friction and shear (during a move the skin would slide against another surface) score two, indicated a potential problem. -Total score Wada fourteen. *On 2/9/15: -Moisture score three, indicated occasionally moist skin. -Activity score two. -Mobility score four, indicated no limitation (was able to make major and frequent changes in position without assistance). -Nutrition score two, indicated his nutrition was probably inadequate. -Friction and shear score was two. -Total score was seven. *On 2/16/15: -Moisture score one, indicated constantly moist skin. -Activity score two. -Mobility score four. -Nutrition score three. -Friction and shear score two. -Total score was sixteen. *On 2/25/15: -Moisture score two. -Activity score two. -Mobility score four. -Nutrition score three. -Friction and shear score two. -Total score was seventeen. *The bottom of the assessment had a section to give a score of 1 to 4 for a [DIAGNOSES REDACTED]. There was a score of 0 in that area for all the dates listed above. *The form indicated a score total of 12 or less would make them high risk for pressure ulcer development. Interview on 5/21/15 at 8:55 a.m. with LPN A and the MDS nurse revealed: *The MDS nurse agreed the AA were triggered from the MDS assessment on each resident to identify risk areas. -If a CAA was triggered for a resident she would ensure the care plan was updated and write a progress note. *For a pressure ulcer CAA the care plan should have had: kind of mattress, how the skin was monitored, notify the nurse of skin changes, kind of cushion in the wheel chair, and repositioning as appropriate. -She stated there was no specific repositioning program she would put on the care plan. *If the resident had a pressure ulcer the care plan should have had nutrition recommendations, an air overlay on the bed, if the wheel chair cushion needed to be changed, and physical therapy involved. *She stated she felt the Braden score of seventeen for resident 6 on 2/25/15 was correct. -She agreed a score of four for mobility that indicated he had no limitation, when he was coded as extensive assist on his MDS would not have been accurate. -When asked about the score of three for nutrition that indicated he had adequate nutrition she felt that was the correct score. She agreed he had a [DIAGNOSES REDACTED]. *They agreed resident 6 was at high risk for pressure ulcers. *They agreed if a Braden score had been lower and indicated more risk for pressure ulcer development they might have changed the way they treated the resident. *They agreed the MDS, CAA, and Braden assessment would have indicated the specific care the resident needed. Random observations of resident 6 and his room from 5/19/15 at 8:25 a.m. through 5/21/15 at 8:05 a.m. revealed: *He used a wheelchair for getting around. -He was able to propel the wheelchair on his own. -He had a Roho (specialty) cushion in his wheelchair. *He had a pressure relieving mattress on his bed. -No air overlay was noted on his bed, as was indicated that he had on his care plan. *Staff had assisted him with transfers using the sit-to-stand lift (mechanical lift used to move a resident from one place to another). *He was incontinent of urine. *Staff assisted him with personal care including incontinence care. Observation and interview on 5/20/15 at 7:45 a.m. with LPN A and the MDS nurse during a dressing change to his right lower buttock revealed: *He had an unstageable pressure ulcer to the right lower buttock. *There was a scar to his left lower buttocks from a previous pressure ulcer. *There was no designated wound nurse. *The weekly measurements would have been done by the nurse that did the dressing change. *They had a wound consultant that visited once a month for recommendations. *LPN A would have contacted the consultant in between visits if needed. Review of resident 6's current care plan revealed: *A focus area: I have potential for pressure ulcers related to limited mobility, incontinence, fragile skin, start date 2/26/15. -Intervention for that focus area: I have a pressure-reducing mattress and a cushion in my wheelchair. *Focus area: I have a pressure ulcer to my right lower buttock noted on 4/24/15. It is unstageable, start date 5/1/15. -Intervention under that focus area: Please turn and reposition me as appropriate. -No intervention on how often he should have been repositioned. *Intervention under that focus area: I have a pressure-relieving device air overlay, Roho cushion. *There was no mention on resident 6's care plan of his refusal of repositioning *There was no mention of the physician's orders [REDACTED]. Random observations on 5/19/15 from 8:25 a.m. through 3:25 p.m. of resident 6 revealed: *He had been sitting in his wheelchair. *He had been to breakfast, activities, lunch, and wheeling himself throughout the facility during the above timeframe. Interview on 5/19/15 at 3:20 p.m. with certified nursing assistant (CNA) J revealed she had taken resident 6 to the bathroom around 10:00 a.m. He had been in his wheelchair since that time. She further stated that would be normal for his day. She was aware he had a pressure ulcer. Observation and interview with CNA K on 5/19/15 at 3:25 p.m. of resident 6's transfer and personal care revealed: *She had used the sit-to-stand lift to transfer the resident to the toilet and back to his wheelchair. *He had been incontinent of urine, through his brief and his pants. -The cushion in his wheel chair had a wet spot where he had been sitting. *She performed incontinence care. *She usually worked in the evenings. *The evening staff normally toileted him before and after supper. *He liked to roam the hallways in his wheelchair. *Sometimes they assisted him to bed right away after supper and sometimes he stayed up in his wheelchair as late as 9:00 p.m. *He had a dressing in place to the right lower buttocks. *She was aware of the pressure ulcer on his buttocks and was unsure how long it had been there. Interview on 5/20/15 at 8:25 a.m. with CNA B regarding resident 6 revealed: *He normally would have gotten up for the day around this time. *He was active and liked to cruise around the facility in his wheelchair. *Sometimes he refused to lay down in bed. *She stated he should have been repositioned at least every two hours. Observation and further interview on 5/20/15 at 1:30 p.m. with CNA B of resident 6 revealed: *He was lying in bed. *He normally laid down after lunch. *She stated he never argues about that. He likes to lay down at this time of day. Interview on 5/20/15 at 4:25 p.m. with LPN G revealed the staff should have toileted resident 6 every two hours and would normally have laid him down after supper. She stated sometimes he refused to lay down. Interview on 5/20/15 at 10:15 a.m. with the director of nursing (DON) and the administrator revealed: *Staff used the care plans to care for the residents. *Regarding resident 6's care plan and specifically the entry to turn and reposition me as appropriate: -The DON stated it was okay. -She further stated the CNAs knew what was expected related to turning and repositioning the residents through their education. -She did not feel the care plan needed a specific plan or schedule for repositioning since the staff had been educated during inservices and training. *They were asked to provide further documentation that the resident had refused repositioning or laying down. -No further documentation had been received by the end of survey. *When asked about how often a resident with a pressure ulcer on their buttocks should have been repositioned, they gave no direct answer. -The DON stated it depended on the resident, and the staff had been educated on how to care for the residents. -The DON agreed on 5/19/15 the resident had been sitting for longer than one hour as ordered by his physician. *They were asked to provide documentation to support repositioning had been completed by the CNAs. -No further documentation had been received by the end of survey. *The DON was unsure if the mattress the resident had on his bed currently was the one that was on at the time of re-admission to the facility. -She was unsure when or if the air overlay was removed from his bed. -She stated they had an air overlay available to use currently in the store room. *The DON stated when someone developed a pressure ulcer: -They would have immediately looked at what mattress they had and added an air overlay. -She would have gotten the dietary department involved in the nutrition. -She would have involved the pharmacy if needed. -She would have looked at what type of cushion was in the wheel chair. *She had been unsure of what type of cushion the resident had initially had on re-admission or when the Roho cushion had been added by therapy. *She agreed that the resident's Braden score was not accurate. Review of resident 6's 3/27/15 PT (physical therapy) - Therapist Progress notes revealed: *.he does have quite thin skin and there is a wound on his bottom. *We worked with nursing to add a Roho cushion to his w/c (wheel chair) and an air overlay mattress on his bed. Interview on 5/20/15 at 2:40 p.m. with the DON and LPN A revealed: *They agreed resident 6 had acquired his current pressure ulcer to the right lower buttock, the previous one to his left lower buttocks, and scrotum at the facility. *They agreed individualized preventative measures would be appropriate for residents at risk for pressure ulcers. *LPN A indicated the CNAs documented during their shift that they had reviewed the care plans. *They were asked to provide documentation of what prevention measures had been in place prior to resident 6 acquiring his first pressure ulcer on 3/9/15. No further documentation had been received by the end of survey. *They agreed the Braden assessment was a tool used to identify a resident's risk of pressure ulcer. -If the score was low and identified a resident at high risk for pressure ulcer then the management team would be alerted. -If the score was not accurate that would have changed how they would react. 2. Review of resident 7's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had a BIMS score of four indicating his memory recall had been severally impaired. *He had required extensive assistance of one staff member for transfers, moving in bed, and toileting. *He had been working with therapy for strengthening and ambulation. *He had been at risk for skin breakdown with two current facility acquired pressure ulcers to his buttocks. Review of resident 7's 3/27/15 admission head-to-toe physical assessment revealed he had *Bruises in various locations. *No pressure ulcers. *A history of fractures and falls with a recent change in his ability to move around. Review of resident 7's 3/27/15 admission interdisciplinary notes revealed: *He came from (hospital name) with [DIAGNOSES REDACTED]. *He had a large bruise to the top of his right hand and a dry area to the inner part of his right heel. *No documentation to support any pressure ulcers had been identified on admission. *Sit-to-stand lift (device to assist with transfers) and one assist for transfers. *He had used a wheelchair to get around. *He had required staff assistance with personal hygiene and toileting. Review of resident 7's Braden Scale Assessment (a scale of twelve or less indicated at risk for pressure ulcer development) forms revealed: *3/27/15, a score of twenty. *4/3/15, a score of twenty. *4/10/15, a score of twenty. *4/17/15, a score of twenty-two. *For all of the above he had been documented as: -Independent with all body movements and repositioning. He could make major and frequent body changes in positioning without staff support. -Capable of moving in a bed and in a chair independently and had sufficient muscle strength to lift up completely during any change in position. Interview on 5/20/15 at 2:45 p.m. with the DON confirmed the above Braden Scale Assessments had not been accurate. He had required staff assistance with mobility and transfers. Review of resident 7's 4/1/15 admission and 4/10/15 fourteen day MDS assessments revealed he had: *Required extensive assistance with bed mobility, transfers, and toileting. *Been at risk for skin breakdown with no current pressure ulcers. *A pressure reducing mattress and cushion in his chair. *No turning or repositioning program in place. Review of resident 7's 4/3/15 Care Area Assessment documentation by the MDS coordinator revealed: *Pressure ulcer: -(Resident name) is at risk for pressure ulcers. -He does not currently have any areas of pressure. -Continue to care plan to keep direct care staff aware of his risks and how to prevent. Review of resident 7's 4/22/15 fourteen day MDS assessment by the MDS coordinator revealed: *He has required weight bearing assist of 1 staff for bed mobility, transfers, toileting, hygiene, and bathing. *He has started to ambulate short distances with walker, gait belt (device to assist with transferring a resident), and staff assistance of one. Observations on 5/19/15 from 1:00 p.m. through 4:00 p.m. of resident 7 revealed: *He had been laying on his bed sleeping. *There had been no air overlay covering his mattress. *He had been laying on his back during that entire time with his heels and coccyx (tailbone) resting directly on the mattress. No repositioning devices had been observed to relieve pressure from his coccyx or feet while at rest such as pillows or wedges. *No observations of the staff attempting to reposition him off of his back and relieve pressure from his coccyx and heels. Interview on 5/21/15 at 9:20 a.m. with licensed practical nurse (LPN) F revealed all residents should have been repositioned every two hours. She had been unsure if it was acceptable for resident 7 to lay in one position for greater than two hours. She would have to ask the director of nursing (DON) if that was acceptable. Observation on 5/21/15 from 7:30 a.m. through 8:30 a.m. of resident 7 revealed: *He had been laying on his bed sleeping. *There continued to be no air overlay covering his mattress. *He had been laying on his back with both of his legs dangling over the edge of the bed. *His coccyx had been laying directly on the mattress. Review of resident 7's weekly skin assessment form regarding his stage 2 pressure ulcer to his coccyx revealed on: *4/27/15 he had acquired a stage 2 pressure ulcer (outer layer of the skin was missing) to his coccyx. *5/1/15 the stage 2 pressure ulcer on his coccyx had worsened and was now a stage 3 (a small opening underneath of the skin. *5/11/15 he continued to have a stage 3 to his coccyx. *There was no documentation to support the pressure ulcer to his coccyx had been assessed by the nursing staff during the week of 5/3/15 through 5/9/15 for worsening or healing conditions, and was free from signs and symptoms of infection. Review of resident 7's weekly skin assessment form regarding his stage 2 pressure ulcer to the left of his coccyx revealed on: *5/1/15 he had acquired a second pressure ulcer to his bottom. The pressure ulcer had been assessed and documented as a stage 2. *5/11/15 he continued to have a stage 2 to the left of his coccyx. *There was no documentation to support the pressure ulcer to his coccyx had been assessed by the nursing staff during the week of 5/3/15 through 5/9/15 for worsening or healing conditions, and was free from signs and symptoms of infection. All of the above reviewed skin assessments revealed the following areas were documented as inapplicable (did not apply): *Pressure relieving bed. *Pressure relieving chair. *Turing and repositioning program. *Nutritional health drinks and vitamins to promote healing. *Ulcer care. Review of resident 7's current care plan revealed: *A focus area: I have a pressure ulcer to my coccyx noted on 4/27/15. It is a stage II with a start date of 5/1/15. *A goal under that area: I would like to maintain or improve my pressure ulcer through my next review. *Interventions under that area were: -Please turn and reposition me as appropriate. -No documentation for staff to follow on how often they were to have repositioned him. -No instructions for the staff to offload (relieve pressure) at the sight of the wounds. -He was to have a pressure-relieving device air overlay and a w/c cushion. *There had been no documentation to support he had: -A new open area to the left side of his coccyx. -The stage 2 pressure ulcer on his coccyx had worsened and now was a stage 3. Interview on 5/20/15 at 9:00 a.m. with the MDS coordinator, DON, and assistant DON revealed: *They confirmed resident 7 had acquired two pressure ulcers while under their care. *No response or answer had been provided when the surveyor asked for preventative measures that were to be used for residents who had been identified at high risk for skin break down. *They had no futher comment as to what reposition as approrpiate should have meant for the staff who assisted resident 7 with her cares. The provider had not been able to supply this surveyor with any further documentation upon request to support appropriate preventative measures had been put in place to ensure resident 7 had not obtained two facility acquired pressure ulcers. 3. Record review for resident 5 revealed she had been admitted [DATE] following hospitalization for a fractured pelvis. She was identified at risk for potential of developing pressure ulcers related to her limited mobility, fragile skin, and thin body frame. Her BIMS score was three meaning she had severe cognitive (memory) impairment or did not fully understand instructions. Review of resident 5's skin assessment forms revealed inconsistent assessment dates when new skin concerns were identified. Review of resident 5's skin assessment form with body diagram revealed *On 3/20/15 at 12:07a.m.: -category skin condition, other type, described as a small dime size area of sheering was noted to mid back just to the right of her spine. -the diagram showed it just above the buttocks. -wound bed is reddened, and does not blanche (change color when pressed), tender to touch, with no signs or symptoms of infection or drainage noted. -cleansed with normal saline, with hydrogel and a spot dressing applied. -surrounding skin was normal for resident. -resident tolerated treatment well. *On 3/31/15 at 12:55 p.m.: -category skin condition, pressure ulcer type with the above diagram noted. -cleansed with normal saline, dried with guaze and a [MEDICATION NAME] (type of dressing) spot dressing applied. The surrounding skin was reddened. *On 4/7/15 at 12:29 p.m.: -category partial thickness wound, pressure ulcer type described as a small area to lower mid spine a

Based on observation, interview, care plan review, and policy review, the provider failed to review, revise, and individualize care plans for 4 of 11 sampled residents (6, 7, 9, and 11). Findings include: 1. Review of resident 6's medical record revealed: *A re-admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had required extensive assistance of one staff member for transfers and moving in bed. *He had been at risk for skin breakdown with a current facility acquired open area (pressure ulcer) to his buttocks and a history of other open areas. Review of resident 6's current care plan revealed: *A focus area: I have potential for pressure ulcers related to limited mobility, incontinence (lack of bladder control), fragile skin with a start date of 2/26/15. -An intervention for that focus area: I have a pressure-reducing mattress and a cushion in my wheelchair. *A focus area: I have a pressure ulcer to my right lower buttock noted on 4/24/15. It is unstageable (type of pressure ulcer that is covered in slough and the depth is unable to be determined) with a start date of 5/1/15. -An intervention for that focus area: Please turn and reposition me as appropriate. --No intervention on how often he should have been repositioned. -Another intervention for that focus area: I have a pressure-relieving device air overlay, roho cushion. Observation on 5/19/15 from 8:25 a.m. through 3:25 p.m. of resident 6 revealed: *He had been sitting in a wheelchair. *He had been to breakfast, activities, lunch, and wheeling himself throughout the facility during the above timeframe. Interview on 5/19/15 at 3:20 p.m. with certified nursing assistant (CNA) J revealed she had taken resident 6 to the bathroom around 10:00 a.m. He had been in his wheelchair since that time. She further stated that would be normal routine for his day. Observation and interview with CNA K on 5/19/15 at 3:25 p.m. of resident 6's transfer and personal care revealed: *She had used the sit-to-stand lift (a type of mechanical lift used to move a resident from one place to another) to transfer him to the toilet and back to his wheelchair. *He had been incontinent of urine, through his brief and his pants. -The cushion in his wheel chair had a wet spot where he had been sitting. *She performed incontinence care. *She usually worked in the evenings. *The evening staff normally toileted him before and after supper. *He liked to roam the hallways in his wheelchair. *Sometimes they assisted him to bed right away after supper, and sometimes he stayed up in his wheelchair as late as 9:00 p.m. *He had a dressing in place to the right lower buttocks. *She was aware of the pressure ulcer on his buttocks. -She was unsure how long it had been there. Random observations of resident 6 and his room from 5/19/15 at 8:25 a.m. through 5/21/15 at 8:05 a.m. revealed the following: *He used a wheelchair for getting around. -He was able to propel the wheelchair on his own. -He had a ROHO (specialty) cushion in his wheelchair. *He had a pressure relieving mattress on his bed. -No air overlay was noted on his bed, as indicated on the care plan. *Staff had assisted him with transfers using the sit-to-stand lift . *He was incontinent of urine. *Staff assisted him with personal care including incontinence care. Observation and interview on 5/20/15 at 7:45 a.m. with LPN A and the MDS nurse during a dressing change to his right lower buttock revealed: *He had an unstageable pressure ulcer to the right lower buttock. *There was a scar to his left lower buttocks from a previous pressure ulcer. Interview on 5/20/15 at 8:25 a.m. with CNA B revealed resident 6: *He normally would have gotten up for the day around this time. *He was active and liked to cruise around the facility in his wheelchair. *He sometimes refused to lay down in bed. *She stated he should have been repositioned at least every two hours. Interview on 5/20/15 at 4:25 p.m. with licensed practical nurse (LPN) G revealed the staff should have toileted resident 6 every two hours and would normally have laid him down after supper. She stated sometimes he refused to lay down. Further review of resident 6's current care plan revealed: *There was no mention of: -How often he should have been repositioned. -If he had a history of [REDACTED]. *A focus area: I require assistance with my ADL's related to weakness, recurrent UTI. -An intervention for that focus area: For my transfer status, please refer to the transfer status [REDACTED]. -It did not mention that he used the sit-to-stand lift. 2. Review of resident 7's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had required extensive assistance of one staff member for transfers and moving in bed. *He had been at risk for skin breakdown with two facility acquired open areas to his bottom. *One of the open areas had been documented by the staff as healed on 5/19/15. Observations on 5/19/15 from 1:00 p.m. through 4:00 p.m. of resident 7 revealed: *He had been laying on his bed sleeping. *He had been laying on his back during that entire time frame. Interview on 5/21/15 at 9:20 a.m. with licensed practical nurse (LPN) F revealed all residents should have been repositioned every two hours. She would have to ask the director of nursing (DON) if it was acceptable for resident 7 to lay in one position for greater than two hours. Review of resident 7's current care plan revealed: *A focus area: I have potential for pressure ulcers related to DM, limited mobility (moving on my own), incontinence with a start date of 3/27/15. *An intervention for that area: Please turn and reposition me as appropriate. -No intervention or direction for staff on how often he should have been repositioned. Review of resident 7's interdisciplinary notes by LPN A revealed on: *5/1/15 at 3:40 p.m. Stage 2 pressure ulcer (outer layer of skin is missing) noted to left of coccyx (tailbone). *5/1/15 at 3:42 p.m. Stage 2 pressure ulcer to coccyx now a stage 3 (full thickness tissue loss. Subcutaneous fat may be visible). Review of resident 7's current care plan revealed: *A focus area: I have a pressure ulcer to my coccyx noted on 4/27/15. It is a stage II with a start date of 5/1/15. *A goal under that area: I would like to maintain or improve my pressure ulcer through my next review. *There had been no documentation on the care plan to support he had: -A new open area to the left side of his coccyx. -The stage 2 on his coccyx had worsened and now was a stage 3. Surveyor: 3. Interview on 5/20/15 at 10:15 a.m. with the director of nursing (DON) and the administrator revealed: *Staff used the care plans to care for the residents. *The Minimum Data Set (MDS) assessment nurse was in charge of the care plans. *The nurses had been educated, but they would not have added entries or edited the care plans. *Regarding resident 6's care plan and specifically the entry to turn and reposition me as appropriate: -The DON had stated it was okay as written. -She further stated the CNAs knew what was expected related to turning and repositioning the residents. -She did not feel the care plan needed a specific plan or schedule for repositioning since the staff had been educated. *The DON was unsure if the mattress resident 6 had on his bed currently was the one that was on at the time of re-admission to the facility. -She was unsure when or if the air overlay was removed. -She stated they had an air overlay available for use currently in the store room. Surveyor: 4. Review of resident 9's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had been admitted with a gastrostomy tube ([DEVICE]) (tube inserted through the abdomen into the stomach for nutrition and medication administration). Review of resident 9's May 2015 Medication Administration Record [REDACTED] *He had been receiving nutrition through the [DEVICE] from the time of his admission until 5/1/15. *The [DEVICE] was to have been: -Checked for proper placement by the nursing staff once a shift. -Flushed with 30 milliliters of water every shift. Review of resident 9's 5/1/15 care plan revealed no documentation to support he had a [DEVICE]. Interview on 5/20/15 at 3:00 p.m. with the DON confirmed the [DEVICE] should have been documented on his care plan. 5. Review of resident 11's record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. urinary tract infection, and had fallen several times prior to admission. *Family had inquired about hospice care prior to admission; she was considered comfort care. *Fall risk assessment dated [DATE] reflected a total score of thirteen. A total score of ten or greater indicated high risk for potential falls. *Her Brief Interview for Mental Status score was four meaning she had severe cognitive (memory) impairment or did not fully understand instructions. Observation on 5/20/15 at approximately 10:30 a.m. around lunch time of resident 11 revealed she was seated in her room in a side chair. She was attempting to get herself out of the chair with no assistance from staff. Housekeeper H entered her room and attempted to encourage her to remain seated telling this surveyor, She isn't to try to get up or walk by herself. She has fallen before. Resident 11 did not appear to understand what the housekeeper was telling her. Housekeeper H put on the call light, and then asked this surveyor to stay while she sought assistance. Several unidentified staff arrived momentarily as the housekeeper returned. Resident 11 in a joking manner appeared to accept what the assembled group was encouraging. There was a bruised area with swelling still present to right temporal region above the level of the eyebrow. A closed scratch ran through the area. The group of staff stated she fell in her room last night. Review of resident 11's 3/23/15 care plan for falls revealed the following approaches: *Please complete a fall risk assessment on me quarterly. *Please schedule therapy services for me as appropriate. *Please keep my suite (room) clutter free and well-lit during waking hours. *Please ensure my call light is within reach and encourage me to use it. Review of resident 11's 5/19/15 care plan for falls revealed the following approaches: *Please complete a fall risk assessment on me quarterly. *Please encourage me to participate in activities. *I may need assistance to wear non-skid footwear. *Please remind me to lock my wheelchair brakes and call for help when I need to transfer. *Please keep my suite clutter-free and well-lit during waking hours. *Please keep my call light within reach and where it will alert staff to my getting up on my own and encourage me to use it. *Please do not leave me unsupervised during toileting. *Assist me to the bathroom routinely throughout the day. Anticipate my needs. Care plan review and interview on 5/21/15 at 7:45 a.m. LPN F revealed she would not anticipate resident 11 to use her call light and ask for assistance, or remember to lock her wheelchair brakes. She stated it was, The policy to re-educate on the off chance she might remember. Care plan review and interview on 5/21/15 at 9:00 a.m. with LPN I revealed she agreed she would not anticipate resident 11 to activate her call light or lock her wheelchair brakes. It was more realistic to keep an eye on her when going up and down the hall or getting her out to more activities. Interview on 5/21/15 at 9:10 a.m. with certified nurse assistant/medication aide C revealed she agreed resident 11 had no concept of how, or when, and why to use her call light. Review of the fall prevention procedure revealed: Resident care plans will reflect they are a fall risk. Interventions will be documented in the Resident's care plan. A fall assessment will be completed on all Residents at admission, if there is a significant change, and annually. Residents determined to be at high risk for falls will have appropriate preventative measures implemented as determined by the interdisciplianry team and documented in the care plan.

Based on observation, interview, and policy review, the provider failed to ensure external and internal medications had not been stored together in two of two medication carts and in one of one medication room. Findings include: 1. Observation on 5/20/15 at 11:20 a.m. of both medication carts revealed: *A tube of protective barrier ointment, two containers of Vaseline, three containers of triamcinolone cream (used for itching, swelling, and skin irritation), five bottles of various types of medicated shampoo had all been stored with residents' oral medications. *Multiple bottles of Debrox ear drop (medication to remove ear wax) bottles for various unidentified residents had been stored together without individualized storage containers. *Multiple Nystatin bottles (powder to treat antifungal infections) had been stored loosely with residents' eye drop medications. The label on the Nystatin bottle read Not indicated for oral or ophthalmic (eye) use. Interview on 5/20/15 at the time of the above observation with licensed practical nurse (LPN) F confirmed the topical and internal medications should not have been stored together. She agreed there had been the potential for cross-contamination from one resident to another. Interview on 5/20/15 at 11:30 a.m. with the director of nursing (DON) revealed: *She had depended on the pharmacist to check the medication carts for proper storage of all medications. *The pharmacist had just been in the facility and checked both of the medication carts last week. There had been no problem with the storage of the above medications at that time. *She had no concerns regarding the above observations. 2. Observation on 5/20/15 at 11:20 a.m. of the medication room revealed: *A plastic basket in a cupboard contained the following residents' medications without some type of barrier between them: -An inhaler, six bottles of various types of eye drops, one tube of pain relieving gel, one tube of hydrocortisone cream (type of steroid for the skin), one tube of terbinafine cream (type of antifungal) that had a warning on it for external use only. Interview at the same time as the above observation with LPN F revealed those medications typically were stored in the basket that way. 3. Review of the provider's undated General Safety Control Policies revealed External and internal medications must be kept in separate compartments of medicine cabinet. Upon request from the surveyor no other policy had been provided up until the end of the survey.