Every finding on record at Wynscape Health & Rehab

Based on observation, interview, and record review, the facility failed to remove expired medications. This applies to 6 of 6 residents (R5, R6, R14, R24, R25, R43) reviewed for medication storage in a sample of 18.The findings include:On 8/21/25 at 9:18 AM, the medication storage room had the following items: R25's Metoprolol Tartrate 50 MG (Milligrams) expired 12/31/24 with 30 pills remaining in the box., and R25's Flecainide Acetate 50 MG expired 3/11/25 with 30 pills remaining in the box. R25's face sheet showed she was admitted to the facility with diagnoses including cerebral infarction, paroxysmal atrial fibrillation, and cerebrovascular disease. R24's Phenazopyridine 100 MG expired 2/4/25 with 15 pills remaining in the box. R24's face sheet showed she was admitted to the facility with diagnoses including pain in left leg and generalized pain. R24's POS (Physician Order Sheet) showed an order for phenazopyridine 100 mg starting 2/3/24 as needed three times daily. On 8/21/25 at 9:23 AM, V3 (ADON/Assistant Director of Nursing) said the drawers in the medication room are for extra medications and they were checked once a week. V3 said the expired medication should be returned to the pharmacy to be destroyed. On 8/21/25 at 9:50 AM, a medication cart was checked and had the following items: R6's Novolog Insulin pen without a clear opened on date or expired on date. R6's face sheet showed she was admitted to the facility with diagnoses including type 2 diabetes mellitus. R43's Benzonatate 200 MG expired 1/4/25 with 10 pills remaining in the box. R43's face sheet showed he was admitted to the facility with diagnoses including congestive heart failure, hypothyroidism, and dementia. R14's Ondansetron HCl (hydrochloride) 4 MG with four tablets expired on 3/1/25 mixed in the same box with three tablets expired 2/2024. R14's face sheet showed she was admitted to the facility with diagnoses including congestive heart failure, dizziness and giddiness, and gastroesophageal reflux disease. R5's Hydralazine 50 MG expired on 4/11/24 with 33 pills remaining in the box, and R5's Gabapentin 100 MG with 42 pills dated 10/19/24 and three pills dated 2/23/24. R5's face sheet showed she was admitted to the facility with diagnoses including hypertensive heart disease, heart failure, low back pain, osteoarthritis, and hypertension. On 8/20/25 at 1:18 PM, V5 (RN/Registered Nurse) said she was unable to tell what the date was on R6's Novolog Insulin pen. V5 said they need to know the correct date because the pen was only valid for 28 days. On 8/21/25 at 10:04 AM, V2 (DON/Director of Nursing) showed Novolog insulin pens should be labeled with the initials of the staff who opened it, the opened-on date, and the expires-on date. On 8/21/25 at 1:55 PM, V8 (LPN/Licensed Practical Nurse) said there should not be expired medication in the cart. V8 said the medications with various expiration dates should not be mixed within the same box as they have different lot numbers, and it would be difficult to track if there was a recall. V8 said the staff should not be storing expired medication in the medication cart or the storage room. V8 said the pharmacy comes to the facility every afternoon and the expired medication should be returned to the pharmacy. V8 said there was a potential to give expired medication to residents if it was stored in the medication cart. The facility's Medication Labeling and Storage policy dated 2/2023 showed If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 35 opportunities with 3 errors resulting in an 8.57% error rate. This applies to 2 of 3 residents (R38 and R6) observed in medication pass. The findings include: 1. On 8/20/25 at 8:22 AM, V6 (RN/Registered Nurse) was observed for medication pass for R38. At 8:37 AM, V6 took R38 his Breyna inhaler to him. V6 put the inhaler in R38's mouth and administered one puff of the inhaler and held it there for 10 seconds prior to removing the inhaler. V6 did not instruct R38 to take water, swish, and spit the water after administration of the inhaler. V6 also did not administer R38's Metformin 850 MG (Milligrams). R38's face sheet showed he was admitted to the facility with diagnoses including Type 2 diabetes mellitus and wheezing. R38's POS (Physician Order Sheet) showed an order for Symbicort 160-mcg-4.5 mcg/actuation aerosol (Breyna inhaler) dated 8/12/25. R38's Breyna medication packaging showed to rinse and spit after administration of Breyna inhaler. R38's POS also showed an order for pioglitazone 15 MG/Metformin 850 MG two times daily starting 7/31/25. On 8/20/25 at 2:44 PM, R38's medication cart was reviewed and showed a box for pioglitazone with a highlighted section showing to Take along with Metformin 850 MG. R38's medication cart did not have a box of Metformin HCL (Hydrochloride) 850 MG tablets. On 8/20/25 at 3:22 PM, V6 said she thought the pioglitazone was combined with the metformin and thought she had administered the combination medication. On 8/20/25 at 3:18 PM, V3 (ADON/Assistant Director of Nursing) said she found R38's Metformin 850 MG tablets in the medication room. At 3:23 PM, V3 said the staff probably put the medication in the medication storage room because they thought it was two boxes of the same medication. The FDA (Food and Drug Administration) label for Breyna showed it should be administered as 2 inhalations twice daily (morning and evening, approximately 12 hours apart), every day by the orally inhaled route only. After inhalation, the patient should rinse the mouth with water without swallowing. 2. On 8/20/25 at 8:51 AM, V6 prepared R6's Novolin insulin pen. V6 cleaned the tip of the pen, attached the needle, and primed the pen with one unit of insulin. V6 then clicked the pen to 5 units of insulin and administered it to the resident. R6's face sheet showed she was admitted to the facility with diagnoses including Type 2 diabetes mellitus. R6's POS showed an order for Novolog flexpen U (Unit)-100 insulin aspart 100 unit/mL (Milliliter) subcutaneous (5 units) insulin Pen starting 8/16/25. On 8/20/25 at 1:18 PM, V5 (RN) said when administering medications, you had to follow the order in the computer. V5 said for insulin pens, it needed to be primed with two units prior to administering the dose. V5 also said after administering Breyna, the nurse should offer water to the resident to have them rinse their mouth and spit out the water. On 8/21/25 at 1:55 PM, V8 (LPN/Licensed Practical Nurse) said insulin pens needed to be primed with at least two units of insulin and to make sure to see the insulin shoot out. V8 said this was done to make sure there were no bubbles in the needle to ensure the resident received the correct dose. V8 also said after administration of the Breyna inhaler, the resident should rinse the mouth and spit the water out to prevent thrush. V8 said the order for pioglitazone with metformin were two separate pills and not a combination drug. On 8/21/25 at 9:42 AM, V2 (DON/Director of Nursing) said the insulin pens needed to be primed with five to 10 units of insulin to ensure removal of the bubbles. V2 said one unit of insulin was not sufficient to remove any bubbles. V2 also said after the use of the Breyna inhaler, the nurse had to offer the resident water to swish and spit as it could cause candida in the mouth. The facility's Administering Medications policy revised 4/2019 showed Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent the spread of infection.This applies to 2 of 2 residents (R35, R27) reviewed for infection control in a sample of 18.The findings include:1. On 8/19/25 at 11:56 AM, V4 (Scheduler) was passing lunch trays. R35's room was on contact isolation with signage on the door frame and an isolation cart with PPE (Personal Protective Equipment) including gowns, gloves, and face masks outside the room door. At 11:56 AM, V4 pulled the tray cart in front of R35's room, pulled R35's meal tray out of the cart, and entered R35's room without performing hand hygiene or wearing any PPE. V4 set R35's tray on the bedside table, moved her belongings around, and rolled the tray table in front of R35. R35 requested creamer from V4 and V4 left the room without performing hand hygiene and went to find creamer. Upon return at 11:59 AM, V4 entered R35's room again without performing hand hygiene or applying any of the appropriate PPE prior to re-entering R35's room. V4 handed R35 the creamer and removed the lid of her tray. On 8/21/25 at 1:51 PM, V4 said for contact isolation rooms, the staff need to wear gowns and gloves. V4 said prior to entering the room, the staff need to use gel to clean hands and apply PPE, and before exiting the room, to remove the PPE and wash hands. On 8/21/25 at 1:55 PM, V8 (LPN/Licensed Practical Nurse) said for contact isolation residents, you have to wash hands, wear gown, gloves before entering the room. V8 said even just to pass the meal trays, all the PPE should be worn. V8 said the PPE was worn to protect the staff and to prevent the spreading of whatever disease the resident had. On 8/21/25 at 9:42 AM, V2 (DON/Director of Nursing) said for residents with contact isolation, the signage needs to be placed outside the room door with an isolation bin. V2 said prior to entering the room, the staff need to wear gowns and gloves as it was strict isolation, and everything needed to be worn. R35's face sheet showed she was admitted to the facility with diagnoses including congestive heart failure, cognitive communication, and urinary tract infection. R35's POS (Physician Order Sheet) dated August 21, 2025 shows an order for Isolation- Contact Precautions Notes: For ESBL (Extended-spectrum beta-lactamase) in urine. R35's care plan dated August 21, 2025 showed Problem: [R35] has an infection- UTI (Urinary Tract Infection) (ESBL in urine) with interventions including Infection precautions per physician order. Use PPE, gown, and gloves at all times. Maintain contact isolation precautions at all times. Placed isolation signage outside [resident] door. Educated resident and family regarding contact isolation precautions and use of PPE. The facility's Contact Precautions policy revised 3/12/25 showed In addition to wearing gloves as outlined under Standard Precautions, clean, nonsterile gloves will be worn when providing direct care (changing clothing, toileting, bathing, dressing changes, etc.) to residents with MDROs (Multi Drug Resistant Organisms). Gloves should also be worn when handling items potentially contaminated by MDROs. This may include items such as bedside tables, over-bed tables, bed rails, bathroom fixtures, television and bed controls, suction, and oxygen tubing. Wearing gloves is not a substitute for hand washing. Gloves will be removed and discarded before leaving the resident's room, hands will immediately be washed with soap and water or an alcohol based hand rub will be used. Gowns should also be worn when body contact with environmental surfaces and items in the room that may be contaminated is anticipated.The gown will be removed and appropriately discarded before leaving the room. After gown removal, staff should ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other residents or environments. 2. On 08/20/2025 at 11:51 AM, V10 CNA (Certified Nursing Assistant) put on PPE of face shield, gown and gloves in addition to the surgical mask he was already wearing. V10 CNA went into R35's contact isolation room, assisted her to reposition items on her over bed table, and delivered her meal tray. V10 removed all the PPE he was wearing and stepped out of R35's room without performing hand hygiene. V10 removed a new surgical mask from the PPE cart, re-entered R35's room and applied the surgical mask, exited R35's room, and used hand sanitizer. V10 CNA then moved the meal cart down the hall to deliver R27's meal tray. V10 put on a gown, face shield and gloves. V10 did not perform any hand hygiene. V10 assisted R27 in positioning the overbed table and delivered the meal tray. V10 removed his PPE except for the surgical mask and did not perform any hand hygiene. V10 moved the meal cart further down the hall. V10 stated he is required to perform hand hygiene before and after removing PPE. V10 stated he had missed opportunities for hand hygiene during the meal delivery. V10 did not say why it was important to do hand hygiene before and after removing PPE. On 08/21/2025 at 1:15 PM, V2 DON (Director of Nursing) stated R35 is on Contact isolation for ESBL (Extended Spectrum Beta Lactamases) in her Urine. V2 stated R27 is on Enhanced Barrier Precautions related to a wound she has. V2 DON stated staff entering and exiting resident's room should perform hand hygiene before and after care and before and after applying and removing PPE. Touching the clean PPE cart with soiled hands is an infection control issue and contaminates the clean PPE and increases the spread of infections.

Based on observation, interview and record review, the facility failed to provide safe transfer to a resident (R1) while using a mechanical transfer total lift device. This applies to 1 of 3 (R1) residents reviewed for transfer using a mechanical transfer total lift device. The findings include: The EMR (Electronic Medical Record) showed that R1, an [AGE] year-old, with diagnosis that included dementia, with moderate psychotic behavioral disturbance, chronic obstructive pulmonary disease, seizure, depressive disorder, abnormalities of gait and mobility, lack of coordination, Lewy Body Disease, aphasia, anxiety and paranoia. R1 was admitted into the facility on [DATE]. The MDS (Minimum Data Set) dated November 8, 2024 and January 5, 2025 showed that R1's cognition was moderately impaired. R1 also required maximum/dependent with staff ADLs (Activities of Daily Living). The care plan dated October 21, 2024 showed that R1 requires mechanical transfer total lift device with two-person assist for transfer for bed to wheelchair and vice versa. The facilities' incident report dated October 27, 2024 showed that during early morning care, R1 was noted with a cut and discoloration around his right eye. Further review of the facilities' incident report showed that R1 sustained this injury due to unsafe transfer while using a mechanical transfer total lift device on October 26, 2024 at approximately 7:30 PM. This transfer was done by V3 (CNA/Certified Nursing Assistant). On January 21, 2025 at 11:30 AM, V1 (Administrator) said that V3 had improperly transferred R1 on October 26, 2024 at 7:30 PM by not following the facilities' policy. V1 further explained that two-person assist is required when mechanical transfer total lift device is utilized. However, with this case, it was only V3 that transferred R1. V1 also added that due to the unsafe transfer R1 sustained a small cut and bruise around right eye. V1 also said that V3 had said he was the only one who transferred R1 to bed on October 26, 2024 around 7:30 PM. V1 further said that V3 was terminated for not following facilities' policy. On January 21, 2025 at 12:20 PM, V7 (CNA) mentioned he took care of R1 during day shift on October 27, 2024. V7 also said that prior to getting up R1 from bed, she noted R1's small cut and bruising around the right eye. V7 said there was no fall that was noted to R1. On January 21, 2025 at 12:25 PM, V6 (RN/Registered Nurse) said that he took care of R1 on October 26, 2024. V6 said that R1 slept throughout the night and there were no unusual occurrences or falls. On January 21, 2025 at 12:30 PM, V4 (Nurse) who attended R1 on October 26, 2024 (evening shift) and October 27, 2024 (day shift) stated there was no bruise or cut around R1's right eye during the evening of October 26, 2024. However, V7 notified her that R1 was with a cut and bruise on the right eye during early morning of October 27, 2024 prior to R1 being transferred out of bed. The facility policy (Lifting Machine, Using a Mechanical) dated March 2024 reflected the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .at least two (2) nursing assistants or nurses are needed to safely move a resident with a mechanical lift.

Based on observation, interview, and record review, the facility failed to discard expired food items and failed to store food items in the freezer safely by having ice built up on food packages, the ceiling, and the floor. This affects all 47 residents consuming food from the kitchen. The findings Include: On [DATE], at 9:25 AM, V3 (Dietary Manager) stated that 47 out of 48 residents consume food from dietary services. On [DATE] at 9:20 AM, during an initial kitchen tour, the kitchen dry storage contained five-pounds of grits which expired on [DATE]. On [DATE] at 9:30 AM, the freezer had ice formed on food-containing boxes, including a box of Canadian bacon and a 9-pound box of pita pockets and the boxes were soiled. Ice was built up on the freezer ceiling and floor. At 9:35 AM, a full-sized aluminum tray with a sherbet dessert that expired on [DATE] was present. On [DATE] at 9:35 AM, V4 (Assistant Cook) stated, The aluminum tray has sherbet dessert and is expired. It shouldn't be there. [DATE] 9:35 AM V3 stated, Everyone is responsible for checking for expired labels. Ice shouldn't be built on food packets to prevent cross-contamination. We have somebody coming out today to address the condensation. We don't have any specific policy regarding condensation with freezers. On [DATE] at 12:05 PM, V3 added that the dietary staff should have threw out the expired food items. The facility presented the Dietary Department policy on Sanitation and Food Safety document: Food products are used by their expiration date. Food products not used by the expiration date are discarded.

Based on interviews and record reviews, the facility failed to ensure R1 was free of physical restraints during a behavioral episode. This applies to 1 out of 1 resident (R1) reviewed for Physical Restraints in a sample of 17. R1's Admission Records shows he was admitted to the facility on [DATE]. Diagnoses includes anxiety, delusional disorder, and paranoid personality disorder. R1's MDS (Minimum Data Sheet) dated 2/1/2024 documents R1 has moderately impaired cognitive functions. On 2/28/2024 at 1:12 PM, V18 (CNA- Certified Nurse Assistant) said on 2/14/2024, R1 was having a behavior episode and was trying to hit V19 (CNA). V18 said she saw V19 holding R1 by the shoulder to stop him from falling. V18 said she was not sure of how long V19 held R1. On 2/28/2024 at 1:23 PM, V1 (Administrator) said R1's incident on 2/14/2024 was a bit different from his previous behaviors so she started to investigate what triggered R1's behavior. V1 said during staff interviews, it was determined that V19 was with R1 when his behavior escalated. V1 said V19 said she repositioned and grabbed R1's arm and was trying to keep him from falling from his wheelchair. V1 said V19 mentioned that R1 was pulling on R1's collar. V1 found the statement odd and investigated further. V1 said V19 demonstrated how R1 was held down. V1 said V19 held R1 by his left shoulder and held the collar of his shirt when R1 attempted to stand. The Conclusion of Facility's Final Report on the Facility Reported Incident of 2/14/2024 documented it was determined V19 (CNA) inappropriately held R1 while he was agitated which escalated R1's agitation and behavior. It was concluded the actions of V19 included unreasonable methods to confine the resident to prevent him from falling. Facility's undated Restraint Policy states the following: .1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restrict freedom of movement or restricts normal access to one's body.4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted .

Based on interview and record review, the facility failed to have precautions in place to ensure a resident was free from serious injury after being served hot liquids. This failure resulted in R1 spilling hot coffee onto his lap and sustaining second-degree burns on his right and left inner thighs. This applies to 1 of 3 residents (R1) reviewed for accidents in the sample of 3. The findings include: On November 13, 2023, at 10:15 AM, R1 was sitting in the dining room in his wheelchair. R1's black pants had dried food and a dried white dripped substance over much of R1's bilateral thigh area. R1 was drinking water from a small, uncovered drinking glass. No other food items were present. R1 was not interviewable due to his cognitive status. R1 was not able to recall the incident where he spilled hot coffee on himself on October 31, 2023. V5 (OT-Occupational Therapist) was standing near R1 and explaining to the resident it was time to receive occupational therapy. R1 required redirection by V5 to go to therapy. R1 kept getting off track while talking, and frequently asked about his newspaper. V5 (OT) said, [R1's] tremor is minor, but his coordination is worse, especially when bringing items from the table to himself. V5 was not aware of R1's recent burn incident. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with multiple diagnoses including, spinal stenosis, Parkinson's Disease, polyneuropathy, heart disease, generalized anxiety disorder, unsteadiness on feet, dysphagia, muscle wasting and atrophy, lack of coordination, cognitive communication disorder, bladder cancer, and left femur fracture. R1's MDS (Minimum Data Set) dated November 1, 2023, shows R1 has severe cognitive impairment. The MDS continues to show, upon admission to the facility, R1 was able to eat with supervision or touching assistance. The facility's Event Report dated October 31, 2023, at 7:20 AM shows: Resident Statement: I spilled hot coffee on my thigh. I tried to drink and hold the cup, but I accidentally spilled it. The report shows the incident occurred in the facility's dining room. The report continues to show there were no witnesses to the event. The report shows R1 sustained an approximately 4 x 4 cm. (Centimeter) deflated blister to his left inner thigh and an approximately 2 x 3 cm. deflated blister to his right inner thigh. The facility's Wound Assessment, completed by V2 (DON-Director of Nursing) on October 31, 2023, at 12:49 PM, shows R1 had a facility-acquired, second-degree burn on his right anterior thigh. The wound assessment continues to show the wound size measurement was 1.50 cm. long by 1.10 cm. wide by 0 cm. deep, with 30 percent intact skin, and 70 percent bright red (beefy) skin. The facility's Wound Assessment, completed by V2 (DON) on November 6, 2023, at 12:24 PM, shows R1's right thigh burn wound size was 11.0 cm. long by 3 cm. wide by 0 cm. deep, with 20 percent intact skin, and 80 percent of the wound bright beefy red. The Wound Assessment continues to show Wound Note: 3 patches all next to each other. Wound Status: Active. Probable Outcome: Probable decline. The facility's Wound Assessment, completed by V2 ((DON) on October 31, 2023, at 12:58 PM, shows R1 had a facility-acquired, second-degree burn on his left anterior thigh. The wound assessment continues to show the wound size measurement was 3.70 cm. long by 2.50 cm. wide by 0 cm. deep, with 30 percent intact skin, and 70 percent bright red (beefy) skin. The facility's Wound Assessment, completed by V2 (DON) on November 6, 2023, at 12:26 PM, shows R1's left thigh burn wound size was 8.50 cm. long by 2.50 cm. wide by 0 cm. deep, with 35 percent intact skin, and 65 percent of the wound bright beefy red. On November 13, 2023, at 12:59 PM, R1 was lying in bed. V7 (Spouse of R1) was also present in the room. V7 said, Once in a while, when we are at home, [R1] drops things while eating. We use a covered mug for all drinks at home. V2 (DON) uncovered R1's legs and showed two large dressings, covering R1's right and left inner thighs. The dressings were dated 11/12/23. V2 removed the dressings and showed the bilateral burn wounds on the inside of R1's right and left thighs. V2 did not measure the wounds or apply treatment. R1 requested the wounds be left open to air and he be allowed to take pain medication prior to V2 administering treatment. The burn wounds were red around the outside of the wounds, with pale, yellow skin towards the center of each wound. There were multiple wounds on R1's right and left inner thighs, all varying shapes and sizes. The largest burn area appeared approximately four inches long by approximately one inch wide. On November 13, 2023, at 2:00 PM, V8 (Son of R1) said, he was upset R1 sustained burns on his legs from spilling coffee on himself. V8 said, Who gives a confused man with Parkinson's disease a cup of hot coffee without a lid on it? On November 15, 2023, at 9:11 AM, V12 (Dietary Aide) said, On October 31, 2023, [R1] was sitting in his wheelchair at a table in the dining room. It was early in the morning, before breakfast was even served. He was sitting closer to the area we call the pantry which has a large window between the dining room and the kitchen. He was not near the nurse's station. It is hard to see the nurse's station from where [R1] was sitting. [V14] (Cook Helper) was in the pantry. No other staff were present in the dining room with me. I believe there were two other residents in the dining room at the time. They both asked for coffee, so I served them coffee also. That day was the first time I met [R1]. I did not know him. He asked me for a cup of coffee. I used the coffee dispenser in the dining room. The dispenser makes one cup of coffee at a time, and we serve the coffee in a coffee mug. I served the coffee to [R1] black. I did not add cream or sugar. I did not put the coffee in a covered mug. After I served the coffee to the resident, I left the dining room. No other staff took over for me or stayed in the dining room with the residents. When I came back to the dining room, [R1] had already spilled the coffee on his lap and two nurses were taking care of him. On November 13, 2023, at 2:16 PM, V4 (ADON-Assistant Director of Nursing) said, I was the nurse working when [R1] spilled the coffee on himself on October 31, 2023. I was sitting in the nurse's station waiting for the nurse from the next shift to take over for me. I had worked the night shift. [R1] was up around 6:30 AM. I was the night nurse, and I know I gave him his medication around that time. The dietary staff served the coffee to [R1]. The dietary staff was there to prepare the food and serve the liquids to residents. Dietary staff do not supervise the residents. No staff was in the dining room supervising the residents when [R1] spilled the hot coffee. I saw him flinch and I ran to him right away. He had spilled hot coffee in his lap. I got a towel and put it inside his pants. We took him to his room and changed him right away. When we removed his pants there were already blisters on his thighs and some open skin areas. On November 13, 2023, at 11:07 AM, V2 (DON) said, [R1] is new to us. The morning that he spilled the coffee (October 31, 2023), [V4] (ADON) was here. He asked for a cup of coffee. He was given the coffee by a dietary aide. He spilled the coffee on his lap. [V4] removed his pants and saw he had blistering on his thighs right away. I want to say they applied cool cloths to his skin. Maybe an hour or two later I came, and I assessed him. The blisters were red and opened at that point. I applied a treatment. His physician came the next day and saw him. His wife comes here every day after breakfast. She was not here when he spilled the coffee because it was before breakfast. He was in the dining room when it happened. On November 13, 2023, at 3:13 PM, V11 (Therapy Director) said, I am familiar with [R1]. He usually lives in our independent living area, and I have been to his apartment in the past to provide therapy. He is very confused at times. At times he needs cues and supervision that everything is safe. He needs to have eyes on him and make sure he is doing well. He has some coordination deficits. For instance, when we give him a cone during therapy, and ask him to place it on the table in front of him, sometimes he cannot do that due to his lack of coordination. He isn't really a person with tremors. There are just times where there is inattention and a coordination thing. Sometimes he misjudges something, and he loses his coordination a bit. Because of the variance in his cognition, he needs supervision and cues at times. He needs more supervision, and that is why he cannot eat alone in his room. His motor impairment has become more pronounced. He has decreased motor control of his left leg. He cannot move his left leg out of the way, if, for instance, he was spilling something and trying to avoid the spill. On November 14, 2023, at 1:13 PM, V1 (Administrator) said, We do not have a policy on hot liquids handling. On November 14, 2023, at 1:43 PM, V9 (Physician) said he knows R1 well and has known him for a few years. V9 said he has seen R1 at his independent living apartment prior to coming to the facility. V9 continued to say R1 spilled coffee on himself in the dining room and sustained second-degree burns on his inner thighs from the coffee. On November 15, 2023, at 11:25 AM, V15 (Territory Sales Manager) said, it is up to the facility to have their own safety system in place to ensure no one gets burned from hot coffee. I think it is a known thing that hot coffee is coming from the coffee machine. Usually nursing homes have a CNA (Certified Nursing Assistant) working or someone watching to keep residents safe from burns. Other options are to set the coffee cups off to the side and let them cool five minutes or so and the coffee temperature will drop ten to twenty degrees before it is served. Sometimes facilities point fingers at us or blame the machine. It is a hot beverage, and the facilities need to have precautions in place, and train and educate their staff when serving to nursing home residents.

Based on observation, interview and record review the facility failed to properly store cleaning supplies and implement fall intervention to ensure residents safety. This applies to 5 of 24 residents (R2, R206, R44, R52, and R22) reviewed for safety. On 7/25/23 at 10:35 AM, in R2 and R206's shared bathroom there was a clear plastic bag tied to a water shut off valve. The unlabeled bag was filled with clear yellow liquid and a toilet brush. On 7/25/23 at 10:50 AM, R44's bathroom had a clear plastic bag tied to a water shut off valve. The unlabeled bag was filled with clear yellow liquid and a toilet brush. On 7/25/23 at 11:02 AM, R52's bathroom had a clear plastic bag tied to a water shut off valve. The unlabeled bag was filled with clear yellow liquid and a toilet brush. On 7/25/23 at 11:11 AM, V7 EVS (Environmental Services) was stopped while cleaning a resident's room and asked what the clear yellow liquid was in the bags tied under residents' sinks. V7 stated the brush was for cleaning the toilet, but she did not know what the yellow liquid was and would have to ask her boss. On 7/25/23 at 11:18 AM, V8 (Housekeeping Supervisor), stated the clear yellow fluid in the bags stored in resident's bathrooms is a disinfectant. Toilet brushes are stored with the disinfectant in all of the residents bathrooms. They keep it stored in residents' bathrooms so the CNAs (Certified Nursing Assistants) can clean the toilets if residents make a mess using the toilet. V8 provided the Safety Data Sheet for Peroxide Multi Surface Cleaner stored in the residents' bathrooms. On 7/27/23 at 9:44 AM, V9 (Director of Facilities Services) stated he does HazCom (Hazard Communication) training with all the staff including, housekeeping, clinical and maintenance. The training he does is a general umbrella, and each manager is responsible for providing specific training to their staff as it relates to their department. The training includes proper labeling of products. V9 said everything except water needs to be labeled. V9 said he reviews how to treat spills, product dilution and how to store and label products. V9 said storing cleaning products in a plastic bag is not a safe storage container and all products should be labeled. On 7/27/23 at 1:38 PM, V1 (Administrator) stated she was not aware that toilet brushes were being stored in cleaning solution in residents' rooms. V1 stated there is a possibility for residents to inadvertently ingest the product. On 7/28/23 at 8:45 AM, V12 (Health Information Specialist) stated the peroxide multi-surface cleaner should be stored in a suitable labeled container. V12 said the product even diluted is an irritant to skin and eyes and it should be washed off immediately. V12 said the product should not be accessible to individuals that are not cognitively aware. V12 said someone would need to know if they came in contact with the product wash the area and monitor for symptoms and the product should be stored in a suitable labeled container. V12 said a plastic bag is not a suitable container for the product. The Hazardous Communication Standard dated February 2023 states labels must provide the identity of the chemical and appropriate hazard warning. Labels require: Pictogram (symbols) - to convey specific information about the hazards of a chemical. Signal Words - to indicate the level of severity of hazard and alert the reader to potential hazard on the label Danger and Warning are signal words. Hazard Statement - a statement assigned to a hazard class and category that describes the nature f the hazard of a chemical, including the degree of hazard. Precautionary Statement - Phrase that describes recommended measures to be taken to minimize or prevent adverse effects resulting from exposure, improper storage, or handling. Supplier Information - name address and phone number. Staff should educate themselves about the chemicals. Before working with any chemical read the SDS (Safety Data Sheet). Check for leaking containers. Remove only the amount of chemical that will be used. Return the sealed container to the proper storage location. Never leave containers open. Never use a container that is not labeled. The facility policy Cleaning Supply Storage dated 2/3/2023 states all carts must have a lockable compartment for containers of cleaning and disinfectant solutions. While in use never leave them unattended or out of sight. The products Safety Data Sheet dated 06/27/2019 states product can cause serious eye irritation. Avoid contact with skin and eyes. In case of eye and skin contact rinse with plenty of water. If swallowed rinse mouth and get medical attention if symptoms occur. If inhaled get medical attention if symptoms occur. Wash hands thoroughly after handling. In case of mechanical malfunction or if in contact with unknow dilution of product wear full personal protective equipment. Keep out of children. Store in suitable labeled containers. Good general ventilation should be sufficient to control worker exposure to airborne contaminants 44387 5. On 7/25/23 at 11:01 AM, R22 was observed in bed in her room. R22's bed was positioned against the wall. R22's bed was in high position, not low in low bed position and had two floor mattresses across the room, stacked against the wall by the door. Surveyor asked R22 where the call light was, R22 picked up her bed control and adjusted the bed; R22 was unable to locate the call light. R22's face sheet (7/26/23) showed R22 had the following diagnoses fracture of left femur, pain in left hip, dementia, need for assistance with personal care, fall, and lack of coordination. R22's current MDS showed that R22's cognition is severely impaired; is total dependence with two or more physical assist with transfers, total dependence with one person physical assist with toilet use and personal hygiene. R22's current care plan shows that R22 has high risk for fall due to poor balance and limited mobility. R22's care plan shows that R22 had eased off the bed and off floor mattress. R22 is alert and oriented and is able to use call light; has interventions to have call light system within reach, keep bed in low position, and bed remote control to be at the foot of the bed. On 7/27/23 at 1:45 PM, V3 (ADON-Assistant Director of Nursing) said after R22's last fall incident, interventions put in place was to have her bed in low position, floor mattress on floor next to bed, bed control to be at the foot of the bed and call light to be within reach; these were placed to prevent fall related injuries.

Based on observation, interview and record review, the facility failed to have call lights accessible and in good working condition to dependent residents. This applies to 2 of 2 residents (R8 and R22) reviewed for accommodation of needs in a sample of 22. The findings include: 1. On 7/25/23 at 10:26 AM during initial tour rounds, R8 was in bed, bed was in low position and had 2 floor mattresses on the floor next to his bed. Surveyor asked R8 where his call light was, R8 pointed to his nightstand and said over there; the floor mattress was between R8's bed and the nightstand. The call light was not within R8's reach. Surveyor asked how R8 notifies staff if he need assistance, R8 stated he calls out for help, or he knocks on the wall; R8 proceeded to knock on the wall. At 11:25 AM, R8's call light still on the nightstand, not within R8's reach. R8's face sheet (7/26/23), showed R8 had following diagnoses hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle wasting and atrophy, lack of coordination, dementia and need for assistance with personal care. R8's current Minimum Data Set (MDS) shows R8's cognition is moderately impaired; needs extensive assistance with two or more-person physical assist with transfers and toilet use, and extensive assistance with one-person physical assist with personal hygiene. R8's care plan (revised 1/1/8/23) shows R8 is high risk for falls, has poor safety awareness, cognitive deficit, and is impulsive; intervention is for staff to place call system within R8's reach. 2. On 7/25/23 at 11:01 AM, R22 was observed in bed in her room; R22 said she was hungry and wanted some black coffee. Surveyor asked R22 where the call light was, R22 picked up her bed control and adjusted the bed; R22 was unable to locate the call light. Surveyor left R22's room to locate facility staff. At 11:13 AM, V5 (CNA- Certified Nurse Aide) came to R22's room said R22 does not use her call light and staff checks on her regularly. On 7/25/23 at 12:04 PM, R22 was observed eating lunch in bed in her room, call light was next to her. Surveyor asked if R22 was able to use the call light. R22 pushed the call light button and the light did not flash. At 12:13 PM, V6 CNA came in R22's room: V6 said R22 can use the call light. Surveyor informed V6 that the call light was not working, V6 said if the call light was working, it should flash when pushed; V6 pushed the call light and it did not flash, the call light was not working. R22's face sheet (7/26/23) showed R22 had the following diagnoses fracture of left femur, pain in left hip, dementia, need for assistance with personal care, fall, and lack of coordination. R22's current MDS showed that R22's cognition is severely impaired; is total dependence with two or more physical assist with transfers, total dependence with one person physical assist with toilet use and personal hygiene. R22's current care plan shows that R22 has high risk for fall due to poor balance and limited mobility. R22 is alert and oriented and can use call light and to have call light system within reach. On 7/27/23 at 10:56 AM, V2 DON said call lights should be working and should be within reach for residents to use, if they need help. The facility's Call light Response policy (reviewed 3/30/23) states to have call light within reach.

Based on observation, interview, and record review, the facility failed to follow accurate procedure to obtain blood glucose measurements and did not administer insulin using correct technique to ensure administration into subcutaneous tissue. This applies to 3 of 3 residents (R9, R18, R306) reviewed for quality of care in the sample of 24. The findings include: 1. On 07/26/2023 at 11:20 AM, V2 (DON/Director of Nursing) took the blood glucose measurement for R9. V2 put the test strip into the blood glucose monitor, wiped R9's finger with an alcohol pad, wiped the first drop of blood away with the same alcohol pad, and measured the blood glucose levels with the second drop of blood. At 11:33 AM, V2 administered insulin using an insulin pen to R9. R9 was sitting in her wheelchair with a sweatshirt and t-shirt on. V2 stood in front of R9, lowered her left sweatshirt sleeve and lifted her t-shirt sleeve, exposing the deltoid muscle, which is a thick, triangular shoulder muscle, causing the skin to stretch flat. V2 wiped the deltoid muscle with an alcohol pad and did not pinch R9's subcutaneous fat prior to administering insulin through the insulin pen. V2 administered one unit of insulin. On 07/27/2023 at 8:26 AM, V10 (LPN/Licensed Practical Nurse) entered R9's room to check R9's blood glucose level. R9 was eating her breakfast tray when V10 explained he was going to take her blood glucose level. R9 said I beat ya to it, I already ate. V10 continued to take R9's blood glucose level. R9's face sheet showed R9 was admitted to the facility with diagnoses including Alzheimer's disease, heart failure, cognitive communication disorder, and type 2 diabetes mellitus. R9's current MDS (Minimum Data Set) showed R9 had moderate cognitive impairment and required extensive assistance for bed mobility, eating and personal hygiene, and was totally dependent on staff for transfers, dressing, and toileting. 2. On 07/26/2023 at 12 PM, V2 took the blood glucose measurement for R18. V2 entered R18's room and R18 was sitting in his chair eating his lunch. V2 asked to take R18's blood glucose measurement. V2 opened the alcohol swab and wiped R18's finger, pierced the finger with the lancet, and wiped the first drop of blood away using the same alcohol swab. V2 used the second drop of blood to obtain the blood glucose level. At 12:06 PM, V2 returned to R18's room to administer insulin using the insulin pen. V2 lifted R18's t-shirt to expose the stomach and wiped the left middle quadrant of R18's stomach with an alcohol pad, held his skin flat, and administered two units of insulin using the pen. R18's face sheet showed R18 was admitted to the facility with diagnoses including heart failure, type 2 diabetes mellitus, and hyperlipidemia. R18's current MDS shows R18 had moderate cognitive impairment and required limited assistance for eating, and extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. 3. On 07/26/2023 at 11:45 AM, V2 administered insulin through an insulin pen for R306. V2 cleaned the right middle quadrant on R306's stomach, did not pinch to get the subcutaneous fat, and administered 19 units of insulin. R306's face sheet shows R306 was admitted to the facility with diagnoses including hyperlipidemia, type 2 diabetes mellitus with diabetic nephropathy, and heart failure. R306's MDS was not due to be completed. On 07/27/2023 at 11:50 AM, V2 said the facility's policy shows using alcohol can alter the results of the blood glucose measurement. V2 also said the blood glucose level should be checked prior to the resident eating as it can alter the blood glucose level and could result in a higher reading. V2 said a higher result would mean more insulin would be given, which could cause the blood glucose levels to become too low, potentially leading to a coma. V2 said the nurse and the CNA (Certified Nurse Assistant) should have communicated that the blood glucose measurement needed to be completed and to hold the meal tray. V2 said she did not communicate to the CNA that she needed to check the blood glucose level. The facility's Obtaining a Fingerstick Glucose Level policy reviewed on 05/02/2022 shows If alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the reading. Obtain a blood sample by using a sterile lancet. Discard the first drop of blood if alcohol is used to clean the fingertip because alcohol may alter the results. The facility's Insulin Administration policy dated 02/09/2020 shows Lightly grasp a fold of skin and insert the needle into the skin at a 90-degree angle.

Based on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times or in ordered dosage). There were 35 opportunities with 2 errors resulting in a 5.71% error rate. This applies to 2 of 6 residents (R9, R18) observed in the medication pass. The findings include: 1. On 07/26/2023 at 11:33 AM, V2 (DON/Director of Nursing) prepared R9's insulin pen for administration. V2 explained to R9 she was about to receive insulin and stood in front of R9. R9 was sitting in her wheelchair wearing a t-shirt with a sweatshirt over it. V2 lifted R9's t-shirt sleeve and lowered R9's sweatshirt sleeve to expose an area of skin to administer the insulin. The exposed area of skin was the deltoid muscle, which is the thick, triangular muscle of the shoulder. V2 used her left-hand fingers to hold the articles of clothing apart to prevent the clothes from touching the area after wiping it clean with an alcohol swab. V2 did not pinch for subcutaneous fat to ensure proper administration. V2 then injected the insulin pen into the area of exposed skin and administered R9's insulin. R9's face sheet showed R9 was admitted to the facility with diagnoses including Alzheimer's disease, heart failure, cognitive communication disorder, and type 2 diabetes mellitus. R9's current MDS (Minimum Data Set) showed R9 had moderate cognitive impairment and required extensive assistance for bed mobility, eating and personal hygiene, and was totally dependent on staff for transfers, dressing, and toileting. 2. On 07/27/2023 at 11:33 AM, V10 (LPN/Licensed Practical Nurse) prepared R18's insulin pen for administration. V10 cleaned the top of the insulin pen with an alcohol pad and attached the needle to the top. V10 did not prime the insulin pen. V10 turned the insulin pen to two units. V10 went to R18's room and administered the insulin. R18's face sheet showed R18 was admitted to the facility with diagnoses including heart failure, type 2 diabetes mellitus, and hyperlipidemia. R18's current MDS shows R18 had moderate cognitive impairment and required limited assistance for eating, and extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. On 07/27/2023 at 11:46 AM, V10 said he did not prime the insulin pen prior to administering it. V10 said the insulin pen should be primed first and then administer the dose of insulin. On 07/27/2023 at 11:50 AM, V2 said the subcutaneous injections should be administer in the fat. V2 also said insulin pens should be primed with two units of insulin prior to administering the insulin to the resident. The facility's Insulin Administration policy dated 02/09/2020 shows Insulin may be injected into the subcutaneous tissue of the upper arm. Lightly grasp a fold of skin and insert the needle into the skin at a 90-degree angle. For very thin residents, insert at a 45-degree angle to avoid intramuscular injection.

Based on observation, interview and record review, the facility failed to label and secure resident's medication in a locked compartment. This applies to 1 out of 7 residents (R31) reviewed for medication labeling and storage in a sample of 24. The findings include: R31's Admission Record shows R31 was admitted on [DATE]. Diagnoses includes gout, muscle spasm and pain in left knee. On 07/25/23 at 10:50 AM, 07/26/23 at 09:11 AM and 07/27/23 at 09:23 AM, R31 had five topical painkillers (Aleve, Salonpas, Arthritis Pain, Calmoseptine, and Joint Flex) in a pink bin on the floor on the right side of R31's recliner. All topical painkillers were not labeled. On 07/26/23 at 09:11 AM, R31 said he had just applied Joint Flex Cream on his knees and shoulders. R31 said he used the Aleve Cream and Joint Flex Cream for pain in his knees, Salonpas Cream for pain in his toes, and Arthritis Pain Cream and Calmoseptine Cream for pain in his legs. R31 said he brought the topical painkillers from home when he was admitted on [DATE]. On 07/27/23 at 09:38 AM, V2 (DON-Director of Nursing) said all medications are kept in the medication cart or the medication room. V2 (DON) said all medications should be labeled. V2 (DON) said there is no resident in the facility with an order to keep medication by the bedside. V2 (DON) said there was no resident in the Facility with an order for Self-Administration of medication. V2 (DON) said the facility does not allow medication from home. She said if medication from home is found, staff takes it from the resident. On 7/26/2023 at 1:30 PM, R31's POS (Physician Order Sheet) showed there is no order for Aleve Cream, Salonpas Cream, Joint Flex Cream and Calmoseptine Cream. R31's POS did not have an order for medication to be kept at bedside or to self-administer medication. Facility's Policy on Labeling of Drugs and Biologicals dated April 2019 stated the following: . All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations.6. Labels for over-the-counter drugs include all necessary information, such as: a. the original label indicating the name, strength, and quantity of the medication; b. the expiration date when applicable; and c. directions for use and appropriate accessory/cautionary statements. Facility's Policy on Storage of Medications dated April 2019 stated: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, interview, and record review, the facility failed to follow R1's care plan and facility policy while conducting a transfer using a mechanical lift. This resulted in R1 falling from a mechanical lift and sustaining a subdural hemorrhage and lacerations that required emergency room services and hospital services. This applies to 1 of 3 (R1) reviewed for safety during transfers. The findings include: The EHR (Electronic Health Record) shows that R1, a [AGE] year-old with diagnoses of Alzheimer's Disease, AHSD ([CONDITION(S)] heart disease), [CONDITION(S)] (hypertension), [CONDITION(S)], history of falling, [CONDITION(S)], major depressive disorder, [CONDITION(S)] and collapse, [CONDITION(S)], dementia, [CONDITION(S)] and mood disorder. The MDS (Minimum Data Set) dated 4/11/2022 shows that R1 was assessed for total assist of all aspects of ADLs (Activities of Daily Living). The MDS also shows that R1 scored 4/3 for transfers (total assistance with 2-3 person assist). The current care plan dated 4/14/2022 shows that R1 uses the total transfer lift device for transfers from bed to wheelchair and vice versa. The care plan shows that 2-person assist is required for transferring R1 with the use of the transfer lift device. The fall risk assessment dated [DATE] shows that R1 scored 75, a high risk for fall. The fall assessment legend shows that a score of 0-24 is not a risk; 25-50 is low risk; and 51 and above is a high risk for fall. The incident report dated 7/5/2022 at 4:30 P.M., shows that R1 had a fall during transfer from bed to wheelchair using the total lift mechanical device. The report shows that V3 (CNA/Certified Nurse Assistant) was the only staff who assisted R1 during this transfer that had caused R1's fall. The report shows that the total lift transfer device tilted while R1 was hoisted up for transfer by V3. The report also shows that R1 landed on the floor, on her right side and a moderate amount of blood was noted under right side of her head. The transfer lift device also tilted and ended on the floor next to R1's feet. R1 was sent via 911 at 4:38 P.M. on 7/5/2022. The clinical notes entered 7/6/2022 at 12:41 A.M. show that a nurse was alerted by CNA that R1 had fallen on the floor during transfer and that the total lift mechanical transfer device had tilted forward. The notes also show that when the nurse checked R1, R1 was found lying on the floor with the sling of transfer device underneath R1 and the transfer lift device was by R1's feet. The recliner chair was also next to R1. R1 was moaning, /groaning and mumbling. Blood was noted coming from R1's left nostril, and a small cut on right eyebrow. The notes show that R1 was sent out via 911 and was admitted with subdural hemorrhage. On 7/19/2022, staff who had knowledge regarding R1's care and fall incidents were interviewed: - At 10:30 A.M., V1 (Administrator) stated V3 should have not transferred R1 alone by herself. V1 said R1 was transferred by V3 using the total lift transfer device on 7/5/2022 at around 4:30 P.M. V1 said during the transfer, the transfer lift device had tilted and R1 ended on the floor with the transfer lift device. V1 said when she interviewed V3 regarding the fall incident, V3 admitted that she was by herself and no other staff assistance. V1 said it is always 2-person assistance that is required when transferring a resident using the total lift transfer device. V1 said V3 did not follow proper transfer policy regarding using the total transfer lift device. - At 11:00 A.M., V2 (Interim DON/Director of Nursing) said R1 uses the total lift mechanical transfer device for transfers from bed to wheelchair and vice versa. V2 said that 2-person assistance is always required when R1 is being transferred. V2 said she immediately went to R1's room when R1 fell while being transferred from bed to wheelchair by V3 on 7/5/2022 around 4:30 P.M. V2 said she found R1 lying on the floor on her right side. R1 was bleeding on her right side of head and face. R1 was also lying on the floor with the sling of the transfer device still attached on R1's back. V2 said that the transfer lift device was on the floor on tilted position next to R1. - At 11:56 A.M., V4 (LPN/License Practical Nurse, on duty when R1 fell on [DATE]) said that V3 was from staffing agency. V4 said she informed V3 that R1 requires a mechanical total transfer lift device when transfer from bed to wheelchair and vice versa. V4 said she also informed V3 to ask for help when R1 is to be transferred since requirement of 2 person is needed. V4 said she immediately checked R1 when V3 informed her that R1 fell to the floor when she transferred R1, and the transfer device had tilted. V4 said R1 was noted with blood coming from the right side of face and head. V4 said R1 was sent out via 911 and was admitted with subdural hemorrhage. - At 12:10 P.M., V6(CNA) said R1 fell on [DATE] around 4:30 P.M. when V3 transferred R1 from bed to wheelchair. V6 said the transfer lift device tilted and R1 went down with the transfer device. V6 said V3 did not ask for help during R1's transfer. - At 5:00 P.M., V5 (CNA) said V3 did not ask for help when V3 transferred R1 by herself using the total lift transfer device. V5 said that 2-person assist is required using the total lift deice when transferring R1. - At 12:10 P.M., V3 (CNA) said on 7/5/2022 at around 4:30 P.M., V3 looked in the hallway and saw no other staff, so she decided to transfer R1 by herself. V3 said during the transfer, the total lift device tilted to the right side, and R1 went down with the device. V3 said she immediately informed V4 regarding R1's fall. The hospital record dated 7/5/2022 at 5:30 P.M. shows R1 had sustained an acute subdural hematoma and acute subdural right temporal subarachnoid hemorrhage, a punctuate wound laceration to the right side of face, small laceration to right side of cheek, and right eyebrow, ecchymosis on the right orbital area, right hand, and right knee due to R1's fall from the total lift device. R1 was admitted to the hospital and was transferred back to the facility on [DATE]. On 7/19/2022 at 11:30 A.M., R1 was observed being transferred with a total transfer lift device being assisted by V6 and V7 (CNAs) with V2's supervision. R1 was non-responsive both verbal and tactile stimuli. R1 was observed with dried scabs on her right forehead and right eyebrow. V2 said, those were the lacerations sustained from the fall that were stitched, and the stitches were removed already. The facility's policy with revision date of December 2013 regarding Safe Lifting and Movement of Residents shows In order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices lift to lift and move residents.7 .All lifts will be used with 2 persons assist.

Based on observation, interview, and record review, the facility failed to assess and manage pain for residents during pressure ulcer dressing change for 2 of 3 residents (R13 and R299) reviewed for pain in sample of 14. The findings include: 1. On 6/15/22 at 9:52 AM, V3 (Wound Nurse) informed R13 of her pressure ulcer dressing change to her coccyx. V4 CNA (Certified Nurse Aide) assisted V3 with R13's dressing change by repositioning her to her right side. V3 gathered supplies, performed hand hygiene and donned gloves and proceeded remove old dressing. While V3 was doing R13's pressure ulcer dressing change, R13 was groaning, moaning, had facial grimacing and said I can't do it several times. V3 continued with R13's dressing change while V4 told R13, you're ok and V3 said to R13, you're almost done. V3 finished R13's dressing change, gathered her supplies and garbage, and washed her hands. V4 repositioned R13 in bed. V3 did not assess R13's pain and did not offer pain medication before and during the dressing change. 2. On 6/15/22 at 10:29 AM, V3 informed R299 of his pressure ulcer dressing change to his coccyx. V3 gathered supplies and performed hand hygiene and donned gloves. R299 was already on his left side. Prior to V3 starting the treatment, R299 told V3 it's painful when you touch the sore. While V3 was applying the treatment to R299's coccyx area, R299 said ouch twice and had facial grimacing. V3 said to R299, the wound doctor will check it later, and finished applying the treatment. V3 gathered supplies and garbage, and washed her hands. V3 did not assess R299's pain and did not offer pain medications before or during the pressure wound treatment. On 6/15/22 at 10:43 AM, V3 said she asks residents if they are in pain after the pressure ulcer dressing change. V3 said she should have asked the residents' nurse if they administered pain medication prior to dressing change, and if the resident complains of pain during dressing change, she should have stopped and informed the nurse to give pain medications. On 6/15/22 at 11:04 AM V2 DON (Director of Nursing) said the wound nurse should ask the resident about pain before doing the dressing change. V2 said if the resident complains of pain during dressing change, the nurse should stop, assess the resident for pain and give pain medication. The Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR documents that R299 was given Acetaminophen 500mg on 6/15/22 at 10:53 AM. The facility's policy titled Pain Management (undated) documents under Program Objectives 5. Pain will be based in the resident's verbal and non-verbal expression of pain.

Based on observation, interview and record review, the facility failed to serve pureed entrees in serving sizes specified by the facility menu. This applies to 10 of 10 residents (R6, R9, R19, R27, R31, R37, R39, R40, R50 and R51) receiving pureed diets. The findings include: Meal Service Report, dated 5/17/21, shows R6, R9, R19, R27, R31, R39, R40, R50 and R51 had physician orders for pureed diets. Facility diet extensions for Monday Week 3 spring/summer 2021, shows the pureed scalloped turkey was to be served with a #6 (2/3 cup) scoop. On 05/17/21 at 12:00 PM during lunch service, V6 (Food Service Server) was serving pureed scalloped turkey using a #8 (1/2 cup) scoop. V6 served the pureed scalloped turkey using the #8 (1/2 cup) scoop to R6 and R37. V6 continued to serve the pureed scalloped turkey to residents using the #8 (1/2 cup) scoop. On 05/17/21 at 12:08 PM, V4 (Food Service Manager) stated the pureed scalloped turkey should have been served using a #6 (2/3 cup) scoop because the #8 (1/2 cup) scoop serving was too small. Facility document Serving Portions, dated 2016, states Food will be served in portions indicated on the cycle menu and on the standardized recipes Prior to serving the meal, the director of food and nutrition services or person in charge will check the serving utensils to ensure that the correct ones will be used.

Based on interview and record review, the facility failed to offer the PPSV23 (PPSV or Pneumococcal [MEDICATION(S)] Vaccine) injection to residents who previously received the PCV13 (PCV or Pneumococcal Conjugate Vaccine) injection. This applies to 4 of 5 residents (R14, R36, R47 and R48) reviewed for pneumococcal vaccines. The findings include: Face sheets, dated 5/19/21, showed R14, R36, R47, and R48 were all greater than [AGE] years old. Facility document Immunizations, dated 5/19/21, shows R14, R36, R47, and R48 all received the PCV13 vaccine greater than one year prior: R14 on 3/3/15 R36 on 10/31/15 R47 on 10/24/17 R48 on 3/24/15. The document shows none of the residents were offered the PPSV23 at the facility. On 05/17/21 at 11:53 AM, V2 (Director of Nursing) stated the facility did not offer the PPSV23 vaccine. Policy Pneumococcal Vaccination, dated 5/15/217, fails to show the facility offered the PPSV23 vaccine. CDC (Centers for Disease Control) document Vaccination of Infants, Children, and Adults [AGE] years or Older, updated 11/21/2019, shows, For adults [AGE] years or older who do not have an immunocompromising condition, [CONDITION(S)], or cochlear implant and want to receive PCV13 AND PPSV23: Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later. If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23. Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose.

Based on observation, interview, and record review the facility failed to assist residents identified as needing assistance for grooming and hygiene. This applies to 1 of 2 residents (R3) reviewed for ADL (Activities of Daily Living) in the sample of 22, and 3 residents (R97, R352, and R353) in the supplemental sample. The findings include: 1. Based on R3's face sheet, R3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R3's nursing evaluation dated 6/29/19 shows that the resident is oriented to person only. The same nursing evaluation shows that R3 has limitation on his left arm & hand and contracture on his right arm & hand. On 7/08/19 at 10:31 AM, R3 was in bed with left short hand cast. R3 had accumulation of overgrown hair coming out of his ears and overgrown facial hair (on both side of his face and around the mouth). During this observation V9 (MDS (minimum data set) coordinator) was present. R3's current care plan shows the resident had functional ADL decline post hospitalization (from 6/24/19 through 6/29/19) due to a fall. R3 had left hip and left radius fractures. status [REDACTED]. 2. Based on R97's face sheet, R97 has multiple [DIAGNOSES REDACTED]. R97's admission MDS dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 15 which meant the resident is cognitively intact. The same MDS shows R97 requires extensive assistance from the staff with regards to personal hygiene. On 7/08/19 at 12:23 PM, R97 was inside the 2nd floor small dining room, eating lunch. R97 had overgrown dark and white facial hair on top of R97's upper lip. R97 stated that R97 wants the staff to remove R97's facial hair. V9 was made aware of the observation. R97's current care plan shows that the resident had a functional decline in ADL post hospitalization (from 6/22/19 through 6/24/19) for [MEDICAL CONDITION] and [MEDICAL CONDITION]/[DIAGNOSES REDACTED] ulcers. 3. Based on R352's face sheet, R352 has multiple [DIAGNOSES REDACTED]. R352's electronic clinical notes dated 7/09/19 shows the resident has a BIMS score of 14 which meant the resident is cognitively intact. R352's ADL verification worksheet from 7/04/19 through 7/10/19 shows the resident requires assistance with regards to personal hygiene. On 7/08/19 at 11:19 AM, R352 was sitting in a regular chair inside R352's room. R352 was alert, oriented and verbally responsive. R352 had multiple bruising on both arms. Per R352 it was from venipuncture while R352 was at the hospital and R352's use of blood thinner. R352 had long and uneven fingernails. Per R352 she wants her fingernails trimmed. V2 (Director of Nursing) was made aware of R352's fingernails. R352's current care plan shows the resident had functional ADL decline post hospitalization for [MEDICAL CONDITION] infarction. 4. Based on R 353's face sheet, R353 has multiple [DIAGNOSES REDACTED]. R353's 5-day MDS dated [DATE] shows a BIMS score of 15 which meant the resident is cognitively intact. The same MDS shows R353 requires assistance from the staff with regards to personal hygiene. On 07/08/19 at 12:16 PM, R353 was eating inside the 2nd floor small dining room. R353 had accumulation of overgrown facial fair on R353's chin. R353 stated R353 wants the staff to remove R353's facial hair. V9 was made aware of R353's facial hair and the request to have it removed. R353's current care plan shows the resident has functional ADL decline. The functional ADL decline care plan shows multiple interventions which included, Provide assist with dressing, bathing, personal hygiene, toileting and transferring as needed. On 7/10/19 at 11:04 AM, V2 stated it is the nursing staff's responsibility to make sure that all residents are properly groomed and with good hygiene. Per V2, the nursing staff are responsible for making sure that the residents' fingernails are trimmed & cleaned and residents' facial hair are removed.

Based on observation, interview, and record review, the facility failed to provide intervention to prevent development of a pressure ulcer to a resident identified as high risk for skin breakdown. This applies to 1 of 2 residents (R40) reviewed for pressure ulcers in a sample of 22. The findings include: On 7/08/19 at 11:28 A.M., R40 was sitting in a wheelchair having lunch in the main dining room. R40's bilateral lower legs and feet were shiny red and swollen. R40 was wearing a closed toe shoes made of leather like material. The pair of shoes were too tight because of R40's swollen feet. There was an indented mark on the frontal aspect of R40's feet due to the tightness of the shoes. V3 (Assistant Director of Nursing) was present during this observation and was informed of R40's swollen feet and the tightness of the shoes. V3 stated V3 will ask V8 (Nurse Practitioner) to check R40's swollen feet. The progress notes entered by V8 dated 7/08/19 showed R40 has bilateral chronic [MEDICAL CONDITION] and slight redness. The notes also showed that R40's skin was intact. V8 assessed the [MEDICAL CONDITION] with scale of 3+ (5-6 millimeter depression, with 10-30 seconds rebound time). The notes also showed the plan was lower extremity [MEDICAL CONDITION] monitoring. On 7/09/19 at 10:00 A.M., V3 stated the facility uses a visual skin check for monitoring R40's swollen feet. The visual check does not include quantitative assessment which would include measurement of the [MEDICAL CONDITION], the scale, and skin temperature to determine baseline and if the [MEDICAL CONDITION] is getting worse. On 7/09/19 at 11:00 A.M., together with V4 (Licensed Practical Nurse), R 40's swollen feet were checked. R40 was sitting in R40's wheelchair in R40's room. R40 was wearing the same tight shoes which had made an indented line across the frontal aspect of R40's feet. When V4 removed the shoes, R40's right bunion was discolored with persistent redness and was non-blanchable when touched. V4 stated the redness was a newly acquired pressure ulcer caused from the constant friction rubbed against the tight shoes. V4 also said there was no intervention to prevent pressure ulcer from developing due to constant friction from the tight shoes to R40's swollen feet. On 7/09/19 at 12:05 P.M., V15 (Registered Nurse/ Wound Treatment Nurse) stated she was just informed by V4 regarding R40's pressure ulcer on the right bunion. V15 also stated R40 had developed a stage 1 pressure ulcer which was caused from the friction of the tight shoes due to the swollen feet. V15 also stated there was no preventative measure to prevent pressure ulcer from developing regarding R40's swollen feet and the tight shoes. V15 also said V15 could have applied a protective foam dressing to serve as padding and prevent pressure ulcer from developing if V15 would have been notified on 7/08/19. V15 also said there was no care plan to prevent pressure ulcer from developing due to R40's swollen feet. The skin assessment dated [DATE] showed R40 has a stage 1 pressure ulcer on the right bunion. The pressure ulcer measurements' were 1.0 cm for the length and 1.20 cm for the width. It was also described as non blanchable redness to right bunion caused by friction and pressure to area with (R40) shoe that is narrow. The current care plan dated 12/6/18 with revision dates showed R40 is at risk for skin breakdown related to decreased mobility and history of [MEDICAL CONDITION] to lower extremities. There was no intervention to prevent pressure ulcer regarding R40's swollen feet and wearing R40 tight shoes.

Based on observation, interview, and record review the facility failed to follow physician order [REDACTED]. This applies to 1 of 3 residents (R36) reviewed for accidents/supervision in the sample of 22. The findings include: Based on R36's face sheet, R36 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R36's 14-day MDS (minimum data set) dated 6/05/19 shows a BIMS (Brief Interview for Mental Status) score of 15 which meant the resident is cognitively intact. The same MDS shows R36 requires extensive assistance of 1 staff member for transfers. On 7/08/19 at 12:39 PM, R36 was sitting in R36's wheelchair inside R36's room. R36 was alert and oriented. R36 was wearing an immobilizer on R36's left leg. R36 stated R36 had a left knee replacement and after this procedure R36 went home. While at home, R36 fell on the stairs and popped R36's left knee. R36 went to the hospital because of pain. Per resident no surgery was performed. However, the physician ordered for R36 to use the left leg immobilizer at all times when not in bed to ensure R36's left knee heals and prevent another incident of popping. During this interview, R36 stated V13 (CNA/Certified Nursing Assistant) gave R36 a hard time when R36 wanted to use the bathroom and that V13 refused to put on R36's left leg brace. R36's hospital records (orthopaedic consult) dated 5/20/19 shows the resident had left total knee arthroplasty on 5/06/19. R36 fell on R36's left knee on 5/16/19. R36 had increased pain after the fall but was able to walk with a walker. R36 presented to the hospital on [DATE] with increased pain and swelling of the left lower extremity. An X-ray was done in the emergency room which showed peri prosthetic fracture of left knee. R36's physician order [REDACTED]. R36's current care plan shows the resident has functional ADL (activities of daily living) decline with left periprosthetic distal femur fracture, only non-weight bearing to the left lower extremity and to apply knee immobilizer as ordered. On 7/10/19 at 12:10 PM, V13 was interviewed over the telephone. V13 stated that she was the CNA assigned to R36 on 7/07/19 from 11:00 PM through 7:00 AM. V13 stated during her shift on 7/07/19, V13 took R36 to the bathroom to use the toilet 5 to 6 times. Per V13, she used a gait belt to transfer R36 from the bed to the wheelchair, wheeled the chair to the bathroom and transferred R36 from the wheelchair to the toilet using a gait belt. V13 stated during all these transfers, R36 did not have the left leg immobilizer because she (V13) does not know how to apply it. On 7/10/19 at 12:36 PM, R36 stated on 7/7/19 during the night shift, V13 assisted R36 to the bathroom to use the toilet multiple times, without the left leg immobilizer. R36 stated R36 requested V13 to apply R36's left leg immobilizer but V13 did not, because she (V13) does not know how to put it on. On 7/10/19 at 1:25 PM, V13 was interviewed over the telephone. V13 was asked if V13 knows the reason why R36 uses the left leg immobilizer. V13 responded that V13 does not know why.

Based on observation, interviews, and record reviews, the facility failed to ensure isolation precautions were followed to prevent possible transmission to other residents. This applies to 1 of 1 residents (R52) reviewed for infection control in a sample of 22. Findings include: R52's face sheet showed R52 was admitted on [DATE] with [DIAGNOSES REDACTED]. R52's POS (physician order [REDACTED]. Progress notes dated 7/08/19 at 9:00 AM, showed R52's hemoglobin with a critical result of 6.5, brown loose stool was noted. Order for stool specimen to test for [MEDICAL CONDITIONS] and occult blood, additional precautions were added to the resident. On 07/08/19 at 10:19 AM, V14 (nurse) stated a stool sample was collected and sent from R52 for suspicion of [MEDICAL CONDITION] and occult blood. On 07/08/19 at 11:18 AM, V8 (Nurse Practitioner) went inside R52's room with a thick black stethoscope draped around her neck over the protective yellow gown. After using the stethoscope, V8 held the stethoscope with both gloved hands. Prior to going into the bathroom to wash hands, V8 placed the stethoscope on R52's table. V8 then picked it up with ungloved hands, placed it around V8's neck and left room without cleaning and/or sanitizing it. On 07/09/19 at 11:35 AM, V7 (nurse) entered R52's room stating R52 is on precaution [MEDICAL CONDITION] and did not mention precaution for [MEDICAL CONDITION]. V7 realized, after completing fingerstick, she did not have any blood testing strips for the glucometer. With gloved hands, V7 reached under V7's protective gown into V7's pocket, pulled out her phone and called someone to bring strips to R52's room. After waiting 5 minutes, V7 called someone else prior to placing phone back into pocket of scrub top. The phone surface was not cleaned and/or sanitized prior to exiting R52's room. On 07/09/19 at 12:18 PM, V7 moved R52 from dining room to the nursing office area to give a subcutaneous injection of insulin to R52. Upon returning R52 to the dining room, V7 removed gloves and used hand sanitizer instead of completing hand washing. 07/09/19 at 01:35 PM, V2 (Director of Nursing) stated R52 is on [MEDICAL CONDITION] as a precaution, but isolation precautions still should be followed and hand washing should have occurred instead of using hand sanitizer. 07/10/19 11:52 AM, lab results for R52 showed positive results for [MEDICAL CONDITION] toxin. Policy: Infection Control - General Policies last reviewed 3/5/18 showed contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically import microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment.