Every finding on record at Yadkin Nursing and Care Center

Based on observations and staff interviews, the facility failed to maintain a clean and homelike environment in 3 of 21 resident rooms on 1 of 3 halls (100 hall) reviewed for a safe, comfortable, and homelike environment (Resident #9, Resident #21, Resident #28, Resident #69, and Resident # 72). The findings included: An observation of Resident #9's room on 03/02/26 at 1:01PM revealed a large area on the floor on the right side of the bed covered with a black residue that was able to be removed. A napkin, dental floss pick, and an empty medication cup were observed under bed. Crumbs and a heavy layer of dust were observed on the floor under the head of the bed, and on the top left side and under the base of the Packaged Terminal Conditioner (PTAC). A used glove was noted on the floor in front corner of room. The overbed tabletop was covered with sticky residue and the base of the table was covered with a raised, white residue. Resident #9 did not have a roommate. On 03/03/26 at 4:06PM an observation of Resident #9's room revealed a large area on the floor on the right side of the bed covered with a black residue. A napkin, dental floss pick, and an empty medication cup were observed under bed. Crumbs and a heavy layer of dust were observed on the floor at the head of the bed, and on the left side of the top and under the base of the PTAC unit. A used glove was noted on the floor in front corner of room. The overbed tabletop was covered with sticky residue and the base of the table was covered with a raised, white residue. The trashcan in the room had no liner but was full of trash. A pink, raised residue was observed on 2/3 sides of the trashcan. An observation of Resident #21 and Resident #69's room on 03/02/26 at 1:21PM revealed a heavy layer of dirt and dust behind Bed B. Food, paper particles, pieces of an artificial flower, and a thick layer of dust and dirt were observed on the floor under the PTAC unit. There was a thick layer of dust on the top and bottom surfaces of the baseboard throughout the room. In the bathroom behind the toilet a wallpaper patch that did not match the rest of the wallpaper was observed; the patch was stapled in place. On 03/03/26 at 4:15PM an observation of Resident #21 and Resident #69's room revealed a heavy layer of dirt and dust behind Bed B. Food, paper particles, pieces of an artificial flower, and a thick layer of dust and dirt were observed on the floor under the PTAC unit. There was a thick layer of dust on the top and bottom surfaces of the baseboard throughout the room. In the bathroom behind the toilet a wallpaper patch that did not match the rest of the wallpaper was observed; the patch was stapled in place. An observation of Resident #28 and Resident #72's room on 3/2/26 at 3:09 PM revealed a trash can without a liner. Used gloves and food particles were observed on the bottom of the trashcan. Thick splatters of a pink dried material were observed on the sides and base of the trash can. In the bathroom, an approximately 6-inch piece of wallpaper under the sink had been cut and held in place with 2 thumbtacks. On 3/3/26 at 4:09 PM an observation of Resident #28 and Resident #72's room revealed a trash can without a liner. Used gloves and food particles were observed on the bottom of the trashcan. Thick splatters of a pink dried material were observed on the sides and base of the trash can. In the bathroom, an approximately 6-inch area of the wallpaper under the sink had been cut and was observed to be held in place with 2 thumbtacks. An interview was conducted with Housekeeper #1 on 3/3/26 at 3:43PM. She stated that her shift was 8:00AM to 4:00PM and she had been assigned to the 100 hall on 3/2/26 and 3/3/26. She stated her daily responsibilities for each room on the hall included pulling trash from rooms and replacing the liner, cleaning the bathroom floor, sink, toilet, and mirror, dusting blinds, sweeping and mopping the room. She stated that floor cleaning included sweeping and mopping under the beds, pulling out and cleaning behind dressers and under the window units. She further stated she had completed the daily cleaning for Resident #9, Resident #21, and Resident #69's rooms on 3/2/26 and 3/3/26. An interview and observations of Resident #9, Resident #21/Resident #69 and Resident #28/Resident #72's rooms were conducted with the Director of Housekeeping on 3/3/26 PM from 4:43PM to 4:45PM. She stated that daily responsibilities for housekeepers included removing trash from each room and replacing the liner, cleaning the overbed tables tops and legs, cleaning the toilet, sink, and mirror, wiping the nightstands if needed, sweeping under each bed, and mopping from the window to door. The Director of Housekeeping stated that she conducts monthly inspections of every room using an audit sheet. She further stated if substandard work was observed, the assigned housekeeper must redo the room and training is provided. She stated housekeepers were trained to observe for potential needed room repairs and report to her. During her observation of Resident #9, Resident #21/Resident #69, Resident #28/Resident #72's rooms the Director of Housekeeping stated she stated the room cleanliness did not meet the standards of facility and she was embarrassed. An interview was conducted with the Maintenance Director on 3/4/26 at 3:31PM. He stated work orders were given to him through paper submission or staff approaching him on the unit. He stated that he did not conduct a routine inspection of each room to identify issues or to follow up on work completion by staff in his department. An observation of Resident #28/Resident #72's room was conducted with the Maintenance Director on 3/4/26 at 3:43PM. He observed the approximately 6-inch area of the wallpaper under the sink in the shared bathroom that had been cut and was held in place with 2 thumbtacks. The Director of Maintenance lifted the wallpaper held in place by thumbtacks which revealed a hole and exposed water pipes. He stated he was unaware of this issue, and the repairs were unacceptable and embarrassing. The Maintenance Director stated he had not observed the repair prior to this walking round and had not been notified of the repair. An observation of Resident #21/Resident #69's room was conducted with the Maintenance Director on 3/4/26 at 3:47PM. He observed the wallpaper patch that did not match the rest of the wallpaper behind the toilet in the shared bathroom; the patch was stapled in place. The Maintenance Director stated the wall repair appeared to be related to a major plumbing issue and the access needed was not properly repaired. The Maintenance Director stated he was unaware of the repair and that it was unsettling and unacceptable and not to facility standards. He further stated he did not have a work order for this room and had not been notified. The Administrator was interviewed on 03/04/26 at 3:55PM. She stated she was unaware of the way the repairs had been completed in Resident #21/Resident #69, Resident #28/Resident #72's shared bathrooms. The Administrator indicated she was not aware Resident #9, Resident #21/Resident #69, Resident #28/Resident #72's rooms were not clean, and it was unacceptable to have dirty resident rooms. The Administrator stated she did not know why the Housekeeping Director and Maintenance Director were unaware.

Based on observation, record review, and staff interviews, the facility failed to safely transfer a resident from a wheelchair to bed when one staff member performed a sit to stand lift transfer (Resident #164) for 1 of 3 residents reviewed. Resident #164 was assisted with a sit to stand lift transfer by a nurse aide and Resident #164 sustained a laceration to the back of her head when she fell during the transfer causing pain and requiring sutures. The findings included: Resident #164 was admitted to the facility on [DATE]. Her current diagnoses included dementia. A review of Resident #164's Physician Orders revealed no order for an anticoagulant. Review of an activities of daily living care plan dated 8/13/21 included the following intervention: Transfers- sit-to-stand lift. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #164 had severely impaired cognition and required one-person physical assistance with transfers. Review of a document titled Fall dated 11/05/23 read in part, Writer made aware by [nurse aide] that resident had fell from sit to stand, writer entered room to observe resident lying on floor with blood coming from her head. Immediate pressure was applied, writer went to call [medical doctor/responsible person and emergency medical services]. Nurse maintained pressure to laceration and vital signs were obtained. Vital signs were blood pressure139/73, pulse 66, respirations 19, temperature 96.5, oxygen saturation 97% on room air. Resident #164's level of pain was 8 of 10 and she was alert and oriented to person, place, time, and situation. The fall report determined the root cause to be failure of staff to follow the lift policy. Nurse Aide #1 (NA#1) was interviewed on 12/19/24 at 4:46 PM. NA #1 stated it was her first shift working alone on the floor and she volunteered to assist the resident to bed. She stated she was not very familiar with Resident #164 and was not aware of her limitations. NA #1 stated it was her first time using the lift by herself. NA #1 stated Resident #164 was sitting in her wheelchair and she put her feet onto the lift and then she just held on to the lift without being strapped on it. She stated Resident #164 told her she did not need the sling around her, that she just held on to the handles of the lift during transfer. NA #1 stated as soon as she moved the lift away from the wheelchair Resident #164 fell . She stated Resident #164 was not standing completely up when she fell backwards and hit her head. NA stated that Resident #164 was bleeding, and she stayed with her and called to the nurse for assistance. She stated the nurse came and assessed the Resident and sent her to the emergency room . NA #1 stated she had received training and completed a check-off prior to using the sit to stand lift. She stated when she talked to the Director of Nursing afterward she realized she should have transferred the Resident as she had been taught. NA #1 stated she received retraining on all lifts prior to returning to work on the floor. She stated since the incident she always used two people when using any lift. Review of a document titled Review to Ensure Quality 11/05/23 revealed an investigation was completed with the root cause analysis identified as Aide used lift without second person. She did not use lift pad or leg straps. Resident fell to floor due to staff (CNA) failure to follow proper process with use of lifts. Review of a nurses note by the nurse dated 11/05/23 at 7:03 PM read in part, Writer made aware by [nurse aide] that resident had fell from sit to stand, writer entered room to observe resident lying on floor with blood coming from her head. Immediate pressure was applied, writer went to call [medical doctor/responsible person and emergency medical services]. Recommendation to send to emergency department. Review of the Emergency Department provider note revealed Resident #164 had headache pain 10/10, blood loss was minimal, no anticoagulation, no visual change, no fever, no numbness, no abdominal pain, no nausea, no vomiting, and no loss of consciousness. Resident #164 had a 0.5 centimeter laceration to her scalp which was closed with two absorbable sutures to control bleeding. She received Tylenol 650 milligrams for pain. She was deemed stable and appropriate for discharge back to the facility. Resident #164 was not admitted to the hospital and was discharged back to the facility from the emergency department. Review of a Radiology Report dated 11/05/23 from the emergency department read in part; radiology report indicated the head CT scan found no evidence of an acute brain bleed or abnormal findings within the skull, but did identify a small to moderate-sized swelling on the left posterior scalp; additionally, a CT scan of the spine showed no signs of recent fractures, misalignment, or bleeding in the surrounding tissues (CT scan is a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body.) The Director of Nursing (DON) was interviewed on 12/18/24 at 3:00 PM. The DON stated the former DON and Corporate Nurse Consultant immediately investigated the fall and put a plan of correction in place for the fall involving Resident #164. She stated NA #1 had been trained to use the sit to stand lift during orientation and had been checked off on the competency check list prior to using the lift. She stated the facility used three types of lifts and all staff who use the lifts were trained during orientation and checked off during yearly competencies. She stated after the incident all the resident transfer/statuses were reviewed and updated, and all the staff were reeducated on the lift procedures and the proper way to transfer a resident. The facility implemented the following Corrective Action Plan with a completion date of 11/9/23. 1. On 11/5/23 The resident was assessed in the facility by the nurse on duty. Bleeding was noted to be coming from the resident's posterior head and the nurse applied pressure to affected area, completed a neurological assessment, obtained vital signs which included: temperature 96.5, pulse 66, blood pressure 139/73, and the On call Provider was called and an order was received to send to the local hospital for evaluation and treatment. 2. On 11/5/23 the Director of Nursing (DON) identified residents that were potentially impacted by this practice by completing a 100% audit on all current working mechanical lifts in the facility. This audit was completed by the maintenance director on 11/6/23. The results revealed 8 of 8 mechanical lifts were in appropriate and safe working order. On 11/6/23 there was no corrective action due to no deficient practice found during audits of mechanical lifts. On 11/6/23 the DON inspected all lift pads for tears, frays, or broken parts. The audit revealed 100 of 100 lift pads were in good repair and working order, there were no frays, tears, or broken parts. On 11/6/23 there was no corrective action due to no deficient practice found during inspection of lift pads. On 11/6/23 the DON audited careplan/kardexes for all current residents to ensure appropriate mechanical lifts were present on the Kardex to ensure proper transfer status. The results revealed 24 of 98 residents used a mechanical lift and had the type of lift identified on the careplan/kardex correctly. On 11/6/23 there was no corrective action for the current residents due to no deficient practice. On 11/6/23 the DON audited all nurses (Registered Nurses (RNs) and Licensed Practical Nurses (LPNs)) and nurse aids to ensure lift training with skills checklist had been completed upon hire. This audit completed on 11/6/23. The results concluded 62 of 62 RNs, LPNs, and nurse aids had received lift training upon hire using the mechanical lift transfer safety education and skills checklist completed. On 11/6/23 there was no corrective action for those staff members because there was no deficient practice. 3. On 11/6/23 the DON and Staff Development Clinician (SDC) began inservicing all nursing (RNs and LPNs) and certified nurse assistants including agency on the mechanical lift safety policy. This training included all current staff and agency. This training included: o When using any mechanical lift two caregivers should be present o Before transferring a resident have the equipment needed re: sling o If you have a question about any equipment ask the nurse or manager This education and return skills demonstration will be incorporated into new hire orientation for all RNs, LPNs, and nurse aids (including agency) and will be ongoing. The DON will ensure that any of the above identified staff who does not complete the in-service training by 11/8/23 will not be allowed to work until the training is complete. 4. The DON or designee will randomly monitor mechanical lift transfers weekly for four weeks and then monthly for two months beginning 11/13/23 to ensure staff are properly transferring residents. The Quality Assurance (QA) tool: ADL Care Provided for Dependent Residents will be used. Reports will be presented to the weekly QA Committee by the Administrator or DON to ensure corrective action is initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meeting. The weekly meeting is attended by the Administrator, DON, Minimum Data Set (MDS) Coordinator, Therapy, Health Information Manager (HIM) and the Dietary Manager (DM). 5. The facility's alleged compliance date was 11/9/23. The Corrective Action plan was validated on 12/19/24 and concluded the facility had implemented an acceptable corrective action plan on 11/09/23. Interviews with current nursing staff including agency staff revealed the facility had provided education and training on mechanical lifts and how to safely transfer a resident using each type of mechanical lift utilized in the facility. Staff were observed using proper procedure for transfers using mechanical lifts. Each nursing staff member conducted competency sheets to verify knowledge of how to operate the mechanical lift. The audits conducted starting on 11/05/23 revealed the facility management observed transfers to ensure that proper transfer technique was being utilized by staff. The audits continued weekly through the validation date. The corrective action plan was reviewed with the Quality Assurance committee on 11/05/2023.

Based on observations and staff interviews, the facility failed to protect residents' private health information by leaving confidential medical information unattended and exposed on a medication cart computer in an area accessible to others for 1 of 4 medication carts observed. Findings included: On 3/14/22 at 11:25 AM an observation of the 400 hall revealed the medication cart was left unattended by staff. The medication cart computer was opened and exposed ten resident names and room numbers. Nurse #1 was observed going in a supply room and was out of sight of the medication cart computer for four minutes. An interview with Nurse #1 at 11:35 AM revealed she knew the residents' medical information was to be protected but stated she was nervous and had forgotten to lock or hide the computer screen before she walked away from the medication cart. In an interview with the Administrator on 3/17/22 at 9:48 AM, she shared that she immediately spoke with Nurse #1 after the incident and stated that all nurses and med techs were aware that when they stepped away from a medication cart the computer screen should be locked or hidden. The Administrator added they were in the process of completing an in-service reminding staff the importance of keeping the residents' personal information private.

Based on observations, record review, and staff interviews, the facility failed to develop a care plan for activities of daily living (ADLs) for 1 of 3 (Resident #13) residents reviewed for ADLs, failed to follow care plan interventions for 2 of 8 residents reviewed for falls (Residents # 68 and 60), and failed to develop a care plan for 1 of 1 (Resident #70) reviewed for activities. The findings included: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had severe cognitive impairment, was always incontinent of bowel and bladder and was totally dependent on staff for activities of daily living (ADLs) that included transfers, bed mobility and repositioning. A review of the care plan section for Resident #13 revealed she did not have a focused area for ADLs. An interview was conducted with Nursing Assistant (NA) #1 on 3/15/2022 at 2:48 PM and revealed she had worked with Resident #13 as the assigned NA multiple shifts. She stated the Resident required two staff assist with transfers between the bed and chair via a mechanical lift and two staff assist with bed mobility. She added Resident #13 had used a mechanical lift for several months and she knew this information through report from a nurse or her Kardex. She was not able to locate the information in her tablet via the Kardex when requested to locate the information. An interview was conducted with Nurse #3 on 3/15/2022 at 2:51 PM and she revealed Resident #13 was recommended for a mechanical lift after a Physical therapy review was completed and two staff maximum assistance was recommended. She added this information was stored in a nursing communication book at the nursing station titled, Resident Care Reference Book, as well as the Resident's care plan in Point Click Care (PCC). When requested to demonstrate Resident #13's care plan for ADL's Nurse #3 stated, she did not see one and when requested to demonstrate Resident #13 listed in the reference book, she added the Resident was not listed in the book under the mechanical lift section. An interview was conducted with the Director of Rehabilitation (DOR) on 3/15/2022 at 3:08 PM and she revealed on 12/9/2021 Resident #13 received a recommendation to be transferred via a mechanical hoyer lift to a broda chair and her bed mobility required the maximum assist of two staff members. She added the standard practice of the facility would be for this information to be communicated to the unit manager and MDS coordinator in the morning meetings in order for the Resident's care plan to be updated and staff to be educated. An interview was conducted with the MDS coordinator on 3/15/2022 at 3:23 PM and she reviewed the cognitive status of Resident #13 and stated she had severe cognitive impairment. She reviewed the ADL section of the MDS dated [DATE] and stated the Resident required maximum assist of two staff members and then reviewed the care plan for the Resident and stated she did not see a focused area for ADLs. She added the Care Area Assessment (CAA), that coordinated with the 12/15/2021 MDS, should have triggered a focused care area for ADLs and did not. She was unsure why the CAA failed to trigger the care area and was going to report the failure to her Corporate Consultant and seek guidance. She stated the Resident needed a focused care plan for ADLs with Resident specific interventions to guide the NA's on the care they should provide the Resident. She stated she would add the focused area immediately and investigate the issue with the corporate consultant to avoid future issues. An interview was conducted with the Director of Nursing on 3/15/2022 at 3:48 PM and she revealed it was her expectation that Resident #13 had a focused area for ADLs and she would investigate the issue with the MDS coordinator. 2. Resident #68 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #68 had severe cognitive impairment, required extensive assistance of two staff members with bed mobility and total assistance of two staff members with transfers. The Resident was always incontinent of bowel and bladder and was identified to have had one fall with major injury since the last assessment. A review of the fall incident report for Resident #68, dated 1/25/2022 at 14:38 revealed Resident #68 was observed lying face down on the floor, repeating, get me up, get me up. Resident was assisted to her back and a new deformity was observed to her previously injured right arm. Resident was assessed, pain medication provided, MD and RP notified, and Resident sent out for treatment. The right humerus was fractured. A review of the Quality Assurance meeting notes dated 1/26/2022 revealed the interventions discussed by the interdisciplinary team included bilateral fall mats. A review of the care plan, dated 3/6/2022, revealed a focused area added to the care plan on 3/15/2022 that read, clarification intervention follow-up from the fall on 1/25/2022 bilateral fall mats while in bed. An observation was conducted on 3/14/2022 at 3:43 PM of Resident #68 lying in bed with one foot hanging off the bed and no fall mats in place. There was no fall prevention devices in place. An interview was conducted on 3/16/2022 at 10:50 AM with nursing assistant (NA) #4 and she revealed Resident #68 was care planned to have bilateral fall mats to each side of her bed while in bed and demonstrated where the fall mats were located in the room. On 3/16/2022 at 1:57 PM an observation was conducted of Resident #68 lying in bed with eyes closed without a fall mat on the door side of the bed. Only one fall mat was on the floor, on the wall side. An interview was conducted on 3/16/2022 at 2:00 PM with NA #4 and she revealed she forgot to place the second fall mat beside the bed for Resident #68, between the beds when she placed the Resident to bed. She added it must have slipped her mind. She then entered the room and placed the mat. 3. Resident #60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had severe cognitive impairment. She required extensive assistance with transfers and during transfers, was only able to stabilize with staff assistance. The care plan included a focused area of risk for and actual fall. A care plan intervention dated 3/3/22 stated, Fall mats to both sides of bed. A fall report dated 1/1/22 revealed Resident #60 was found on the floor next to her bed at 10:15 AM. Nursing staff completed an assessment which revealed no deformity and range of motion was within normal limits. The care plan was updated after the fall and floor mats were provided to both sides of the bed. On 3/15/22 at 3:27 PM an observation of Resident #60's room revealed the resident was in her bed asleep. The bed was in the low position. A fall mat was on the floor next to the left side of the bed. There was no fall mat on the right side of the bed; however, there was a fall mat that stood up against the wall behind the headboard of Resident #60's bed. Observations of Resident #60's room on 3/16/22 at 8:41 AM and 1:20 PM revealed the resident was in her bed. The bed was in the low position. A fall mat was on the floor next to the left side of the bed. There was no fall mat on the right side of the bed; however, there was a fall mat that stood up against the wall behind the headboard of Resident #60's bed. During an interview with Nurse Aide (NA) #7 on 3/16/22 at 1:56 PM, she reported Resident #60 needed assistance from staff with walking and transferring. She said the resident often tried to get up on her own and usually had not asked for help from staff. She shared fall interventions the facility implemented for Resident #60 included placing the bed in a low position and fall mats to both sides of the bed when the resident was in bed. NA #7 stated she had rounded on the resident during the day but had not looked to make sure both fall mats were on the floor next to the bed. She acknowledged she was supposed to check that the fall mats were in place when Resident #60 was in bed but had not checked during rounds and missed that one of the fall mats had been placed up against the wall behind the resident's bed. NA #7 added that she had not typically checked the care plan for fall prevention interventions but reviewed the tasks that were listed for the resident or asked the nurse about any fall prevention interventions. On 3/17/22 at 1:14PM an interview was completed with the MDS Nurse. She explained care plans were in Resident #60's electronic health record and nurses had access to the care plan and reviewed interventions for falls. She added NAs did not have access to care plan information unless the data pulled over to the NA's task list and stated not everything pulled over to the list. Staff were educated where to find care plan information and the MDS Nurse said NAs could also ask the nurses about care plan interventions. The Director of Nursing (DON) was interviewed on 3/16/22 at 1:33 PM and on 3/17/22 at 1:23 PM. She reported after Resident #60 fell in January 2022, the facility implemented interventions that included a low bed, fall mats next to both sides of the bed and posted a sign on the resident's door which reminded the resident to call for staff assistance before transferring or walking. She verified fall prevention interventions were added to the care plan after Resident #60 fell . She explained if interventions were flagged to the NA task list, the NA reviewed the interventions and ensured they were in place when they worked with a resident. The DON said staff also reviewed fall prevention interventions when they gave report at shift change. She stated nurses also went into the electronic health record and looked at the care plan. After reviewing Resident #60's care plan, the DON reported she flagged the intervention about the fall mats to the NA task list. She specified staff were supposed to follow the care plan and implement the interventions. 4. Resident #70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS) dated [DATE] documented Resident #70 had hearing difficulty and required corrective lenses for reading. A review of the activities assessment completed 1/25/2022 documented Resident #70 had poor vision and required glasses and was hard of hearing in both ears. Under the additional information tab it was documented the Resident reported her vision was not good due to her [CONDITION(S)] and her glasses did not help her to read any longer. Under the Resident's interest section, the Resident answered Reading was an interest. Under the question, how important is it to you to have books, newspapers, and magazines to read? The answer, Important but can't do it any longer was checked. How important is it for you to listen to music you like? Somewhat important was checked. How important is it for you to do your favorite activities? Very important. Under the section do you like to participate in group activities, the Resident stated, for very short time frames and in another area stated of little interest. A review of the care plan dated 2/24/2022 revealed activities focus that read, I enjoy attending and participating in most activities at the facility with a goal to attend and participate in activities daily for 90 days and the intervention was that the Resident will be invited to participate in all group activities. An interview was conducted with Resident #70 on 3/14/2022 and she revealed that she had been interviewed by someone from the activities department when she was admitted . She stated she told them she enjoyed reading but no longer could read books due to her vision and hearing being bad. She stated she loved reading. She denied anyone offering her books on tape. She asked how that would work with her roommate watching television so loudly. She denied being aware that books on tape could be listened to with a head set or ear buds. She denied being offered to listen to them in a different setting. She stated books on tape or music would be lovely. She stated she was bored and all she did was walk in the halls. An interview was conducted with Nurse #6 on 3/17/2022 at 10:08 AM and she revealed she had been the assigned hall nurse for Resident #70 on several shifts. She revealed the Resident was slightly hard of hearing and it was difficult for the Resident to hear in large groups and background noise would make it hard for the Resident to hear. She stated she observes the Resident walk in the hall and sees her roommate's television on but does not see the Resident participate in any other activities. An interview was conducted with the Activities Director on 3/17/2022 at 10:45 AM and reviewed the admission MDS and admission nursing assessment. She then reviewed the Resident's care plan and stated based on the care plan the Resident was encouraged to attend out of room activities. She then reviewed the activities assessment interview and revealed the Resident had revealed she was hard of hearing and had visual impairment and the glasses do not assist her to read or see due to her [CONDITION(S)]. She revealed the Resident stated reading was a favorite activity previously and that she could no longer do this activity. She revealed the Resident stated she enjoyed Music. She revealed the Resident stated doing her favorite activities were very important to her and that group activities were not important to her. She revealed that She did not have books on tape or such devices available and had not inquired from any local resources to obtain them or see if they would be available. She added she had offered music in the room, but a headphone type of option was not discussed that would allow her to hear it over the other noises. She stated this would be discussed with her. She added it was her expectation that the care plan reflects resident specific activities that had been answered in the interview.

Based on observations and staff interviews, the facility failed to ensure the food items stored in the snack/nourishment refrigerator in 1 of 2 residents' snack/nourishment rooms was maintained with food/beverage items that were dated and labeled with the residents' names and room numbers. Findings included: During an observation of Nourishment Room #1 on 3/15/22 at 1:45 p.m., the refrigerator contained the following items that were not dated or labeled with residents' names and room numbers: 1-16 oz (ounce) bottle of soda stored on the shelf of the door; and 2-opened cardboard cases of single-serve nutritional supplement beverages (8oz sealed bottles). There were no residents' names on the cases or the bottles. Also, there were multiple beverages labeled with initials only which the Administrator was able to identify as the names of residents of the facility. A follow-up observation of the refrigerator in Nourishment Room #1 was conducted with the Dietary Manager (DM) on 3/16/22 at 1:40 p.m. There were 52 (8oz) sealed bottles of nutritional supplement beverages in the refrigerator that were not dated and labeled with residents' names. The DM revealed the nutritional supplement beverages were not purchased by the facility's dietary department. On 3/16/22 at 1:43 p.m., Housekeeper #1 revealed that the day before she was instructed to remove the cardboard cases from the refrigerator and place the 52 bottles on the shelves in the refrigerator. She indicated there were no residents' names on the boxes or on any of the bottles of the nutritional supplements. She stated that she assumed the dietary department had purchased the 52 bottles of the nutritional supplement. On 3/16/22 at 1:45 p.m., the Administrator stated that she did not know who the 52 bottles of the nutrition supplement belonged but would investigate.

Based on observations, staff interviews and record review, the facility failed to provide a dignified dining experience by standing while providing assistance with feeding for 1 of 4 residents (Resident #72) reviewed for assistance with dining, and failed to provide a cover for a catheter drainage bag for 1 of 3 residents (Resident #92) reviewed for catheters. Findings included: 1. Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had impaired memory and severely impaired daily decision making skills. She required extensive assistance with eating. The care plan, updated 2/28/22, revealed focused areas of activities of daily living and weight loss. An intervention included, Requires total assistance to eat. On 3/14/22 at 12:55 PM, Resident #72 was observed in her bed. Unit Manager #1 entered the room with a meal tray and placed the resident in an upright seated position. She placed the meal tray on the overbed table next to Resident #72's bed. Unit Manager #1 stood while she fed the resident and remained above eye level of Resident #72 for the duration of the meal. Unit Manager #1 exited Resident #72's room at 1:09 PM after Nurse Aide (NA) #5 entered the room and assisted the resident with finishing the lunch meal. An interview was completed with Unit Manager #1 on 3/14/22 at 1:10 PM, during which she stated Resident #72 had to be fed her meal. She said she typically stood up when she fed residents, including Resident #72. Unit Manager #1 thought the facility discussed in the feeding class whether staff were to be seated or stand when they fed a resident. NA #5 was observed on 3/14/22 at 1:12 PM as she fed Resident #72. She stood up next to Resident #72 while she fed her and remained above eye level of the resident for the remainder of the meal. At 1:21 PM, NA #5 removed the lunch tray from the resident's room. In an interview with NA #5 on 3/14/22 at 1:22 PM, she explained she stood while she fed Resident #72 since she had filled in for Unit Manager #1, who had left the room. NA #5 shared that typically she sat when she fed a resident. During an interview with the Director of Nursing on 3/17/22 at 1:20 PM, she said staff were educated to be seated and at eye level when they fed a resident to promote dignity. She explained the facility monitored staff and made sure they were seated when the fed a resident and added the facility had completed inservices with staff in the past regarding dignity when feeding a resident. 2. Resident #92 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set assessment dated [DATE] revealed Resident #92 had moderately impaired cognition and had an indwelling catheter. On 3/14/2022 at 10:28 AM, Resident #92 ' s urinary drainage bag, containing urine, was observed from the hall. The bag was positioned on the door side of the bed, off the floor and without a privacy cover in place. On 3/15/2022 at 10:10 AM, Resident #92 ' s urinary drainage bag, containing urine, was observed from the hall. The bag was positioned on the door side of the bed, off the floor and without a privacy cover in place. On 3/15/2022 at 10:11 AM, an interview was conducted with Nursing Assistant (NA) #3. She stated she saw Resident #92 did not have a privacy cover for his urinary drainage bag and told the nurse. On 3/15/2022 at 10:20 AM, Nurse #5 was interviewed. She stated the night shift was going to change Resident #92 ' s catheter drainage bag because it looked like it was dirty, but they could not find the right bag. Nurse #5 stated she would have to check with the supply clerk. Nurse #5 then asked NA #3 to look in the supply closet located across from the nurse ' s station and NA #3 returned with a drainage bag with a privacy cover. On 3/17/2022 at 3:20 PM, the Director of Nursing was interviewed. She stated urinary drainage bags with privacy covers were in the supply closet and Resident #92 should have had one in place.

Based on staff interviews and record review, the facility failed to accurately code the medications received section (Section N) on the Minimum Data Set (MDS) assessment for 1 of 5 residents (Resident #38) reviewed for unnecessary medications. Findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] revealed Resident #38 received a diuretic medication zero of seven days during the look back period. On 3/17/22 at 11:01 AM, an interview was completed with MDS Nurse #1. She said when she coded medications on section N of the MDS they were coded per drug classification and not how they were used. She reviewed the quarterly MDS assessment for Resident #38 and said there was a part time MDS Nurse (MDS Nurse #2) who completed the assessment for Resident #38. MDS Nurse #1 verified the resident received [MEDICATION(S)] every day during the lookback period. She stated [MEDICATION(S)] was a diuretic and should have been coded as such on the MDS assessment. She thought MDS Nurse #2 may have overlooked the medication when she completed the assessment. An attempt to interview MDS Nurse #2 by telephone was unsuccessful. During an interview with the Director of Nursing on 3/17/22 at 1:18 PM, she said she was unsure if anyone in the facility routinely audited MDS assessments for accuracy. She added the corporate office provided education and support to the MDS staff related to MDS assessment accuracy.

Based on record review and staff interview, the facility failed to develop a baseline care plan to address the immediate needs of a resident at risk for falls for 1 of 8 residents reviewed for accidents (Resident #92). Resident #92 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Admission Review dated 2/8/2022 indicated a risk alert for falls. An admission Minimum Data Set assessment dated [DATE] revealed Resident #92 had moderately impaired cognition and was non-ambulatory. He required extensive assistance with 1-2 people for bed mobility and transfers. Resident #92 had an indwelling catheter and was incontinent of bowel. A review of the Care Area Assessment (CAA) revealed falls would be care planned due to antidepressant and antipsychotic drug use. A review of the care plan dated 2/9/2022 revealed no focus area for risk for falls. A focus area of alteration in hematologic status included an intervention to complete fall risk assessment and increase vigilance for falls. A comprehensive medical record review revealed a fall risk assessment was not completed. A nurse ' s note dated 3/10/2022 revealed Resident #92 ' s wife awoke to find Resident #92 on the floor. No injuries were noted. Resident #92 was very restless this shift and had not slept. On 3/14/2022 at 2:30 PM, Resident #92 was observed lying in bed. Resident #92 ' s family member was sitting in the recliner in Resident #92 ' s room and stated her and another family member were sleeping in the facility every night because Resident #92 tried to get out of bed on his own. On 3/17/2022 at 3:20 PM an interview was conducted with the Director of Nursing. She stated risk for falls should have been included in Resident #92 ' s baseline care plan.

Based on observations, staff interviews and record review, the facility failed to update the care plan to 1. address a fall for 1 of 8 residents reviewed for accidents (Resident #92) and 2. address contracture management for 1 of 1 resident (Resident #72) reviewed for limited range of motion. The findings included: 1. Resident #92 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set assessment dated [DATE] revealed Resident #92 had moderately impaired cognition and required extensive assistance of 1-2 people for activities of daily living. He was non-ambulatory. Resident #2 had an indwelling catheter, was incontinent of bowel and used oxygen continuously. A nurse ' s note dated 3/10/2022 revealed Resident #92 was found on the floor. Resident #92 was very restless and has had no sleep this shift. A record review revealed no evidence Resident #92 ' s care plan was updated to include the fall that occurred on 3/10/2022. On 3/17/2022 at 3:20 PM, the Director of Nursing was interviewed. She stated the care plan should have been updated to include the fall and new interventions put into place. She stated she thought she updated the care plan herself but could not find evidence the care plan was updated. 2. Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An occupational therapy (OT) discharge summary dated 12/14/21 and authored by OT #1, stated, in part, Seen for bilateral hand contractures and implemented hand grip splints during therapy treatment sessions. Upon discharge, the OT recommendation was for resident to wear the hand splints daily for six hours. Education and training were provided to staff in splinting/orthotic schedule, safety precautions and self-care/skin checks in order to wear splints. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had impaired memory and severely impaired daily decision making skills. She had impairment on both sides of her upper extremity. The care plan, updated 2/28/22, revealed a focused area of activities of daily living. An intervention included, Will receive staff assistance with all aspects of daily care . Further review of the care plan revealed no focused area or interventions that addressed contracture management. An observation of Resident #72 was completed on 3/14/22 at 2:41 PM. The resident was in bed and her hands were on top of the bed covers. The right and left hands were observed to be flexed inward, with fingers folded towards the palms of the hands. Resident #72 was non-verbal and unable to follow commands when asked to straighten out her fingers. The Director of Rehabilitation Services (DRS) was interviewed on 3/15/22 at 2:57 PM and stated Resident #72 was treated by occupational therapy for hand contractures from 10/18/21-12/14/21. She shared therapy had utilized a palm guard splint to both of the residents' hands. Upon discharge from therapy, nursing staff were educated and trained on the application of the palm guard splints to Resident #72's hands. In an interview with the MDS Nurse on 3/16/22 at 1:45 PM, she explained when therapy discharged a resident from their service they educated staff and completed a functional maintenance program form with any splinting instructions which was forwarded to the MDS Nurse. The information on the form was then added to the resident's care plan. MDS Nurse said she was unable to locate the instruction form for Resident #72 but stated the therapy department had educated staff on the palm guard splints for the resident. She added if she had received the maintenance program form she would have updated the care plan to reflect the usage of splints to Resident #72's hands. The Director of Nursing (DON) was interviewed on 3/16/22 at 1:22 PM. She said if a resident had contractures it should be addressed in the care plan since the contractures affected how staff provided care to the resident.

Based on observations, record review and staff and physician interviews, the facility failed to 1. Obtain orders for care of a central intravenous line for 1 of 1 resident reviewed for [CONDITION(S)] (Resident #254) and 2. Ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1. A review of Resident #254 ' s discharge summary dated 1/13/2022 included follow-up instructions for removal of her left central intravenous line. Resident #254 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Admission Review dated 1/13/2022 revealed Resident #254 had a central venous line place to left chest. An admission Minimum Data Set assessment dated [DATE] revealed Resident #254 had intact cognition and required extensive assistance of 1-2 people for activities of daily living. A review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/14/2022 at 12:10 PM Resident #254 was interviewed. She stated the hospital was supposed to remove the central line to her left chest before she left the hospital but the couldn ' t because her [MEDICATION(S)] had not been held and it needed to be held for 2-3 days prior to the procedure. On 3/15/2022 at 3:15 PM, an intravenous site was observed to Resident #254 ' s left chest. Resident #254 ' s family member was in room and stated it was a month before anyone changed the dressing. Resident #254 agreed and stated Nurse #6 changed the dressing last Wednesday and the Wednesday before that. She stated no one else has changed the dressing. On 3/15/2022 at 3:25 PM, an interview was conducted with Unit Manager #1 who stated the central line to Resident #254 ' s chest was scheduled to be removed so there were no orders for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/17/2022 at 3:03 PM, an interview was conducted with the facility physician who stated they were trying to get the left central line removed since she was admitted because she wasn ' t using it. He stated someone had changed the dressing but agreed there should be orders in place for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/17/22 at 3:20 PM, an interview was conducted with the Director of Nursing who stated orders should have been put in place on admission for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #253 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set, dated dated dated [DATE] revealed Resident #253 had moderately impaired cognition, required extensive assistance of 2 people for bed mobility, transfers and toileting. Resident #253 was at risk of pressure ulcer development and had a current stage 2 pressure ulcer. She had a pressure reduction device to her bed and received pressure ulcer care. The care plan included a focus area of current pressure ulcer to sacrum and risk for development of additional pressure ulcers due to decreased ability to re-position and bowel and bladder incontinence. Interventions included administer treatments as ordered. A physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/2022 at 10:05 AM, an observation of wound care for Resident #253 was conducted with Nurse #2. Resident #253 had an unstageable area to her sacral area. No other pressure areas were observed. Nurse #2 confirmed no open areas to Resident #253 ' s buttocks. On 3/17/2022 at 3:20 PM, an interview was conducted with the Director of Nursing. She stated orders for treatments should be accurate to include the correct location.

Based on observations, record review and staff interviews, the facility failed to reposition and provide incontinence care to 1 of 3 (Resident # 13) residents reviewed for activities of daily living (ADL). The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment, dated 12/15/2021, revealed Resident #13 had severe cognitive impairment, was always incontinent of bowel and bladder and was totally dependent on staff for activities of daily living (ADLs) that included transfers, bed mobility, repositioning and personal hygiene. A review of the care plan section for Resident #13 revealed she did not have a focused area for ADLs. An observation was conducted on 3/14/2022 at 2:52 PM of Resident #13 sitting in her room, in front of the wardrobe/closet area, with her call bell across her room, a strong lingering odor of urine was present. A mechanical lift pad was underneath her and a wet stain was visible about 2 inches around her bottom, and she was wet through her pants on the front side with the brief area swollen and bulging. An interview was conducted with Nursing Assistant (NA) #6 on 3/14/2022 at 2:58 PM and she revealed she was assigned to Resident #13 since 12 PM and the NA that had been assigned from 7 AM through 12 PM had left to go on an appointment with another resident. She added that during the morning, she and the other NA had assisted each other for all residents that required 2 staff assist. She stated she had not repositioned or completed peri-care on Resident #13 since she took over the assignment. She did not know what the other NA had done but she did not assist the NA in the morning to lay the Resident down and complete the peri-care. She revealed that the Resident was already up to the Broda chair prior to her arrival at 7 AM because 3rd shift gets her up in the mornings. She observed the Resident and stated she saw a large wet area to her pants, a swollen brief area that indicated it was wet and would get someone that was coming on for second shift to help her provide the needed care immediately. An interview was conducted with the Director of Nursing (DON) on 3/14/2022 at 4:12 PM and she revealed it was her expectation that all residents be repositioned according to their care plan and receive peri-care as needed.

Based on record review, observation, resident and staff interviews, the facility failed to provide a resident specific activity program that met the individual interest and needs to enhance the quality of life for 1 of 1 (Resident #70) residents reviewed for activities. The findings included: Resident #70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS) dated [DATE] documented Resident #70 had hearing difficulty and required corrective lenses for reading. A review of the activities assessment completed 1/25/2022 documented Resident #70 had poor vision, required glasses and was hard of hearing in both ears. Under the additional information tab it was documented the Resident reported her vision was not good due to her [CONDITION(S)] and her glasses did not help her to read any longer. Under the Resident's interest section, the Resident answered reading was an interest. Under the question, how important is it to you to have books, newspapers, and magazines to read? The answer, Important but can't do it any longer was checked. How important is it for you to listen to music you like? Somewhat important was checked. How important is it for you to do your favorite activities? Very important. Under the section do you like to participate in group activities, the Resident stated, for very short time frames and in another area stated of little interest. A review of the care plan dated 2/24/2022 revealed an activities focus that read, I enjoy attending and participating in most activities at the facility with a goal to attend and participate in activities daily for 90 days and the intervention was that the Resident will be invited to participate in all group activities. An interview was conducted with Resident #70 on 3/14/2022 at 11:03 AM and she revealed that she had been interviewed by someone from the activities department when she was admitted . She stated she told them she enjoyed reading but no longer could read books due to her vision and hearing being bad. She stated she loved reading. She denied anyone offering her books on tape. She asked how that would work with her roommate watching television so loudly. She denied being aware that books on tape could be listened to with a head set or ear buds. She denied being offered to listen to them in a different setting. She stated books on tape or music would be lovely. She stated she was bored and all she did was walk in the halls. An observation was conducted on 3/15/2022 at 10:43 AM of the Resident lying in bed staring at the window. She rolled over, sighed, stood up and walked out of the door. An observation was conducted on 3/15/2022 at 10:58 AM of Resident #70, when she returned from walking the hall, she entered her room and stated, I am bored. An interview was conducted with Nurse #6 on 3/17/2022 at 10:08 AM and she revealed she had been the assigned hall nurse for Resident #70 on several shifts. She revealed the Resident was slightly hard of hearing and it was difficult for the Resident to hear in large groups and background noise would make it hard for the Resident to hear. She stated she observes the Resident walk in the hall and sees her roommate's television on but does not see the Resident participate in any other activities. An interview was conducted with the Activities Director on 3/17/2022 at 10:45 AM and she reviewed the admission MDS and admission nursing assessment. She then reviewed the Resident's care plan and stated based on the care plan the Resident was encouraged to attend out of room activities. She then reviewed the activities assessment interview and revealed the Resident had revealed she was hard of hearing and had visual impairment and the glasses do not assist her to read or see due to her [CONDITION(S)]. She revealed the Resident stated reading was a favorite activity previously and that she could no longer do this activity. She revealed the Resident stated she enjoyed Music. She revealed the Resident stated doing her favorite activities were very important to her and that group activities were not important to her. She revealed that She did not have books on tape or such devices available and had not inquired from any local resources to obtain them or see if they would be available. She added she had offered music in the room, but a headphone type of option was not discussed that would allow her to hear it over the other noises. She stated this would be discussed with her. She added it was her expectation that a resident be offered activities per their individual preferences and choices and she would work with Resident #70.

Based on observations, record review, family member, staff and physician interviews, the facility failed to assess and implement interventions for pressure ulcer prevention for newly acquired heel redness for 1 of 4 residents reviewed for pressure ulcers (Resident #253). The findings included: Resident #253 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set assessment dated [DATE] revealed Resident #253 had moderate cognitive impairment. She required extensive assistance with two people for bed mobility, transfers and toileting. She was non-ambulatory. The assessment indicated Resident #253 had a current stage 2 pressure ulcer and was at risk for pressure ulcer development. Resident #253 received pressure ulcer care and had a pressure reduction device to her bed. A review of the care plan revealed a focus area of currently pressure and at risk for development of additional pressure ulcers due to decreased ability to re-position and incontinence. Interventions included, in part, notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises or discoloration noted during bath or daily care and weekly full body assessments. A skin assessment dated [DATE] revealed an existing pressure ulcer. No other areas were documented. A wound evaluation from the wound care physician dated 3/10/2022 revealed an unstageable area to Resident #253 ' s sacrum and a stage 2 area to the upper back. A review of Resident #253 ' s March 2022 physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/2022 at 11:45 AM, Resident #253 was observed lying in bed. A heel protector was observed to the right foot. The left foot was observed to be lying flat on the mattress. On 3/14/2022 at 11:45 AM, Resident #253 ' s family member was interviewed. He stated Resident #253 had a red heel and they said they were going to get something for it but haven ' t yet. On 3/16/2022 at 10:05 AM, an observation of Resident #253 ' s wound care was conducted. Upon entering the room, Resident #253 was observed lying in bed with her left heel lying flat on the mattress. Nurse #2 completed the wound care to Resident #253 ' s back and sacral wounds then was asked by the surveyor to observe her heels. Resident #253 ' s entire left heel was reddened. Nurse #2 observed the skin to blanch with pressure. Nurse #2 was not observed to apply a treatment to the left heel of float the heel off the mattress. On 3/16/2022 at 11:10 AM, an interview was conducted with Nurse #2. She stated she identified the redness to Resident #253 ' s left heel on Sunday, March 13, 2002. She stated she floated the resident ' s heel but did not put anything else in place. On 3/16/2022 at 11:15 AM, Unit Manager #1 was interviewed. She stated she thought the wound care physician saw the resident ' s heel when he last rounded and was not concerned. On 3/16/2022 at 2:35 PM, an interview was conducted with NA #2. She stated she had not worked since last week and did not know anything about Resident #253 having heel redness. On 3/17/2022 at 11:30 AM, the Wound Care Physician was interviewed. He stated he looks at heels when he makes rounds and was certain that Resident #253 could not have had a reddened left heel last week when he rounded on 3/10/2022. He stated he only documented a bootie was in place but could not say if it was for one or both heels. He added heels should be in a boot or off loaded for residents at risk for pressure ulcer development. On 3/17/2022 at 3:20 PM, the Director of Nursing was interviewed. She stated Nurse #2 should have documented the redness to Resident #253 ' s heel when it was first noticed, and interventions should have been put into place for care and treatment.

Based on observations, staff interviews and record review, the facility failed to provide application of bilateral palm guard splints according to therapy recommendations for 1 of 1 resident (Resident #72) reviewed for limited range of motion. Findings included: Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An occupational therapy (OT) discharge summary dated 12/14/21 and authored by OT #1, stated, in part, Seen for bilateral hand contractures and implemented hand grip splints during therapy treatment sessions. Upon discharge, the OT recommendation was for resident to wear the hand splints daily for six hours. Education and training were provided to staff in splinting/orthotic schedule, safety precautions and self-care/skin checks in order to wear splints. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had impaired memory and severely impaired daily decision making skills. She had impairment on both sides of her upper extremity. The care plan, updated 2/28/22, revealed a focused area of activities of daily living. An intervention included, Will receive staff assistance with all aspects of daily care . An observation of Resident #72 was completed on 3/14/22 at 2:41 PM. The resident was in bed and her hands were on top of the bed covers. The right and left hands were observed to be flexed inward, with fingers folded towards the palms of the hands. Resident #72 was non-verbal and unable to follow commands when asked to straighten out her fingers. There was no hand splinting device located in Resident #72's room. The Director of Rehabilitation Services (DRS) was interviewed on 3/15/22 at 2:57 PM and on 3/16/22 at 9:13 AM and stated Resident #72 was treated by occupational therapy for hand contractures from 10/18/21-12/14/21. She shared therapy had utilized a palm guard splint to both of the residents' hands. Upon discharge from therapy, nursing staff were educated and trained on the application of the palm guard splints to Resident #72's hands. The DRS added the therapy department typically had not entered orders in the resident's chart regarding splinting devices. During an interview with Nurse Aide (NA) #2 on 3/16/22 at 10:51 AM, she stated she had worked with Resident #72 and was familiar with her care. She explained if a resident needed a splinting device, she was notified by nursing staff or therapy staff when they gave report at the change of shift. NA #2 was not aware of any splints that were to be applied to Resident #72's hands. She added she looked at the ADL task list daily when she completed her charting and the task list indicated if a resident required any type of splinting device. NA #2 reviewed the ADL task list in the computer for Resident #72 and said there was no information regarding splinting to the residents' hands. Nurse #4 was interviewed on 3/15/22 at 3:34 PM. She was familiar with Resident #72's care and shared if there was a splint that was to be placed on the resident there would be an order in the chart. Nurse #4 reviewed Resident #72's medical record and said there was no order in the chart for a splint application to the residents' hands. On 3/15/22 at 3:31 PM an interview was completed with Unit Manager #1. She explained if a resident wore a splinting device there was an order in the chart. Unit Manager #1 stated she was not aware if staff had applied any splints to Resident #72's hands. Occupational Therapy Assistant (OTA) #1 was interviewed on 3/16/22 at 10:28 AM. She recalled Resident #72's hands were contracted and said she worked with the resident in December 2021. OTA #1 stated she placed palm guard splints in the resident's hands as part of treatment in therapy. During treatment and at the time therapy was discontinued, OTA #1 educated nursing staff to donn the splints daily to both hands for no longer than six hours. She added therapy had not typically entered orders for splinting devices. An observation of Resident #72 with OTA #1 at 10:35 AM revealed the resident was resting in bed and there were no splints on her hands. OTA #1 described Resident #72's hands as having contraction and OTA #1 assisted Resident #72 with opening her hands enough that a splinting device could be applied. OTA #1 looked through the resident's room during the observation and was unable to locate the palm guard splints. In an interview with the MDS Nurse on 3/16/22 at 1:45 PM, she explained when therapy discharged a resident from their service they educated staff and completed a functional maintenance program form with any splinting instructions which was forwarded to the MDS Nurse. MDS Nurse said she was unable to locate the instruction form for Resident #72 but stated the therapy department had educated staff on the palm guard splints for the resident. A follow up interview was completed with the DRS on 3/16/22 at 2:53 PM, during which she stated the therapy department had not recommended a functional maintenance program for Resident #72 because they thought all the resident needed was for staff to donn the palm guard splints during morning care as instructed by the therapist when Resident #72 was discharged from therapy caseload. The Director of Nursing (DON) was interviewed on 3/16/22 at 1:22 PM. She explained the facility process was that therapy gave a referral sheet to the MDS Nurse that included information on where to donn splints and the duration of the splints. Nursing then placed an order in the chart which displayed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged that splinting had not been in place for Resident #72 and the splints had been located in the laundry department. She did not know how long Resident #72 had not worn the palm guard splints. The DON added she thought maybe the staff who were educated by therapy in December 2021 might no longer be employed at the facility and there might be new staff. She stated the therapy department should have completed a referral form and forwarded it to nursing when they discharged the resident from therapy services.

Based on observations, staff interviews and record review, the facility failed to provide intervention for fall prevention for 2 of 8 residents (Residents #60 and 68) reviewed for falls. Findings included: 1. Resident #60 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia, [CONDITION(S)] and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had severe cognitive impairment. She required extensive assistance with transfers and during transfers, was only able to stabilize with staff assistance. The care plan included a focused area of risk for and actual fall. A care plan intervention dated 3/3/22 stated, Fall mats to both sides of bed. A fall report dated 1/1/22 revealed Resident #60 was found on the floor next to her bed at 10:15 AM. Nursing staff completed an assessment which revealed no deformity and range of motion was within normal limits. The care plan was updated after the fall and floor mats were provided to both sides of the bed. On 3/15/22 at 3:27 PM an observation of Resident #60's room revealed the resident was in her bed asleep. The bed was in the low position. A fall mat was on the floor next to the left side of the bed. There was no fall mat on the right side of the bed; however, there was a fall mat that stood up against the wall behind the headboard of Resident #60's bed. Observations of Resident #60's room on 3/16/22 at 8:41 AM and 1:20 PM revealed the resident was in her bed. The bed was in the low position. A fall mat was on the floor next to the left side of the bed. There was no fall mat on the right side of the bed; however, there was a fall mat that stood up against the wall behind the headboard of Resident #60's bed. During an interview with Nurse Aide (NA) #7 on 3/16/22 at 1:56 PM, she reported Resident #60 needed assistance from staff with walking and transferring. She said the resident often tried to get up on her own and usually had not asked for help from staff. She shared fall interventions the facility implemented for Resident #60 included placing the bed in a low position and fall mats to both sides of the bed when the resident was in bed. NA #7 stated she had rounded on the resident during the day but had not looked to make sure both fall mats were on the floor next to the bed. She acknowledged she was supposed to check that the fall mats were in place when Resident #60 was in bed but had not checked during rounds and missed that one of the fall mats had been placed up against the wall behind the resident's bed. The Director of Nursing (DON) was interviewed on 3/16/22 at 1:33 PM. She recalled Resident #60's fall in January 2022 and stated the resident was in a wheelchair next to the bed. The NA had left the room to obtain linens and during the time the NA was out of the room the resident got out of the wheelchair, walked around the foot of the bed and fell . After the fall, the facility implemented interventions that included a low bed, fall mats next to both sides of the bed and posted a sign on the resident's door which reminded the resident to call for staff assistance before transferring or walking. An observation of Resident #60's room with the DON on 3/16/22 at 1:39 PM revealed the resident was in bed and the bed was in a low position. A fall mat was observed on the floor to the left of the resident's bed. A second fall mat was observed as it leaned up against the wall behind the headboard of Resident #60's bed. There was no fal mat on the floor on the right side of the bed. The DON commented that when Resident #60 was in bed, both fall mats were supposed to be on the floor on either side of the bed. She added whomever placed Resident #60 in bed was responsible to ensure the fall mats were on the floor on both sides of the bed. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, and [CONDITION(S)]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #68 had severe cognitive impairment and required extensive assistance of two staff members with bed mobility and total assistance of two staff members for transfers from bed to a chair. The assessment documented she had a fall with major injury since the last MDS assessment. A review of the fall incident report for Resident #68, dated 1/25/2022 at 14:38 revealed Resident #68 was observed lying face down on the floor, repeating, get me up, get me up. Resident was assisted to her back and a new deformity was observed to her previously injured right arm. Resident was assessed, pain medication provided, MD and RP notified, and Resident sent out for treatment. The right humerus was fractured. A review of the Quality Assurance meeting notes dated 1/26/2022 revealed the interventions discussed by the interdisciplinary team included bilateral fall mats. A review of the care plan, dated 3/6/2022, revealed a focused area added to the care plan on 3/15/2022 that read, clarification intervention follow-up from the fall on 1/25/2022 bilateral fall mats while in bed. An observation was conducted on 3/14/2022 at 3:43 PM of Resident #68 lying in bed with one foot hanging off the bed and no fall mats in place. There was no fall prevention devices in place. An interview was conducted on 3/16/2022 at 10:50 AM with nursing assistant (NA) #4, with the Director of Nursing present, and the NA revealed Resident #68 was care planned to have bilateral fall mats to each side of her bed while in bed and demonstrated where the fall mats were located in the room. On 3/16/2022 at 1:57 PM an observation was conducted of Resident #68 lying in bed with eyes closed without a fall mat on the door side of the bed. Only one fall mat was on the floor, on the wall side. An interview was conducted on 3/16/2022 at 2:00 PM with NA #4 and she revealed she forgot to place the second fall mat beside the bed for Resident #68, between the beds when she placed the Resident to bed. She added it must have slipped her mind. She then entered the room and placed the mat.

Based on observations and staff interviews, the facility failed to lock an unattended medication cart for 1 of 4 medication carts (hall 400) observed. The findings included: An observation on 3/14/22 at 11:25 AM revealed Nurse #1 walking away out of eyesight from the medication cart on the 400 hall. The medication cart lock was not pushed in indicating a locked position. An interview on 3/14/22 at 11:35 AM with Nurse #1 revealed she walked away from the medication cart to retrieve a stock medication from the medication room and left the cart unlocked. She stated she knew she was supposed to lock the medication cart when unattended, but she got nervous and just forgot to do so. In an interview with the Administrator on 3/17/22 at 9:48 AM, she shared that she immediately spoke with Nurse #1 after the incident and stated that all nurses and med techs were aware that when they stepped away from a medication cart, it should be in the locked position. The Administrator added they were in the process of completing an in-service reminding staff the importance of locking the medication carts when walking away from it for any length of time.

Based on record reviews, resident and staff interviews the facility failed to follow-up with dental services when the broken tooth of 1 of 1 sampled resident was not extracted as scheduled. Resident #63 Findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #63 was cognitively intact and had no dental or swallowing problems. Review of the revised care plan dated 2/2/22 revealed Resident #63 received anticoagulant therapy with the risk for toxicity and abnormal bleeding. Interventions included: avoid activities that could result in injury. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the dental examination dated 11/4/21 documented Resident #63 had upper dentures and a lower partial denture in her mouth, with no pain. The dentist recommended extracting the fractured tooth in-house and provided referral to the Social Worker. The dental examination documentation dated 12/8/21 revealed the Dentist was unable to perform the tooth extraction because the resident was still receiving the [MEDICATION(S)] (anticoagulant medication). Review of the clinical records revealed no documentation indicating the facility followed-up with the dentist when the resident's broken tooth was not extracted as scheduled. During an interview on 3/14/22 at 12:55 p.m., Resident #63 revealed her mouth was sore making it difficult for her to chew food due to a broken tooth in the lower part of her mouth. She stated that she was scheduled for an on-site examination with the dentist but was told by staff (after continuously asking when she would visit with the dentist) the facility forgot to hold her [MEDICATION(S)] for three days before the broken tooth could be extracted. On 3/17/22 at 10:24 a.m., the Social Worker revealed the dentist contracted with the facility to provide dental exams visited every other month. She indicated she was aware the dentist did not extract Resident #63's tooth due to the resident was receiving [MEDICATION(S)]. During an interview on 3/17/22 at 11:11 a.m., the Administrator stated the dentist did not submit any pre-treatment orders for Resident #63 prior to his 12/8/21 visit for tooth extraction. She also revealed the dentist did not reschedule a follow-up visit with the resident. When asked, why did the facility not follow-up after reviewing the 12/8/21 dental visit documentation, the Administrator indicated the facility's unit managers reviewed all consult visits and followed-up with any issues or orders before the consult visit documentation was given to the facility's medical records. During an interview on 3/17/22 at 11:46 a.m., Unit Manager #2 stated prior to the dental visit on 12/8/21 the facility did not receive any pre-treatment orders concerning Resident #63. After reviewing the dentist's documentation dated 12/8/21, Unit Manager #2 noticed her initials were not on the document indicating she did not review the physical document. She revealed a couple days after the dentist's visit, the Social Worker informed her Resident #63's tooth extraction did not occur due to her medication, [MEDICATION(S)] was not stopped. The Unit Manager was unable to recall the resident complaining about a broken tooth when during her visits with the resident. The Unit Manager stated she did recall informing the hall nurses that the resident was unable to have her tooth extracted.

Based on record review and staff, Responsible party, physician and registered dietician (RD) interviews, the facility failed to notify the physician, RD and the Responsible party of a Resident's significant weight loss equaling 6% of body weight in two weeks and 11% of body weight in 30 days for 1 of 2 residents reviewed for nutrition (Resident #2). The Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician (MD) progress notes revealed the MD had assessed Resident #2 on 6/30/2020. The MD documented the Resident had a rapid decline in health over the past year and ordered Pro Stat (liquid protein nutritional supplement), 30 ml three times a day, based on a recent decrease in food intake. He added to monitor the resident for changes related to diuretic and hypertensive therapy combined with poor intake. Review of Resident #2's medical orders revealed Prostat 30 ml, three times a day was ordered on [DATE] by the facility medical director. Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident's admission [DIAGNOSES REDACTED]. The Resident was coded to be moderately cognitively impaired, require one-person limited assistance with eating and had an admission weight of 168.9 pounds (lbs.). The care area assessment (CAA) summary dated, 7/6/2020, indicated Resident #2 was at risk for a nutritional deficit and indicated the resident would be care planned for at risk for a nutritional deficit. Review of Resident #2's plan of care, dated 7/6/2020, included a focus area for being at risk for dehydration r/t diuretic therapy with interventions that included to monitor for interactions/adverse consequences and monitor for possible side effects every shift. A focus area for antidepressant medication with increased risk for adverse side effects of depression was documented. The interventions included to observe and report to the MD as needed ongoing signs and symptoms of depression unaltered by antidepressant meds and report to the nurse the following, decreased appetite, confusion, mood change, change in normal behavior, decline in ability to help with Activities of daily living. The care plan did not include a focus area for at risk for altered nutritional status. Review of the assessments revealed the Registered Dietitian (RD) assessed Resident #2 on 7/1/2020 and included a progress note that stated Resident #2 had poor food intake. The RD recommended the Resident maintain a weight of 175 lbs. and to continue to monitor and add to the plan of care. The RD documented the resident weight as 184 lbs. Review of the weights in the electronic medical record for Resident #2 documented a weight on admission, 6/30/2020, of 168.9 pounds (lbs.), on 7/1/2020 of 184.0 lbs. and on 7/30/2020 of 150.1 lbs. A review of documentation provided by the restorative nursing program and stored in an office filing cabinet revealed additional weight results for the Resident on 7/16/2020 of 158.4 lbs., on 7/21/2020 of 158.1 lbs. and on 7/28/2020 of 150.1 lbs. An interview was conducted on 2/3/2021 at 10:35 a.m. with the MDS nurse and she revealed that the facility process was to complete weekly weights 4 weeks, on all new admissions. She stated the weekly weights should be entered in a resident's chart on Wednesday of each week, after the weekly weights committee meeting. She stated the restorative aid was responsible for conducting weekly weights and reported them to the weights committee for review. She stated the nurse over the restorative program was responsible for ensuring the weights had been completed, as ordered. The MDS nurse added that she was the nurse responsible for the restorative program in June and July 2020. An interview was conducted on 2/3/2021 at 11:18 a.m. with the restorative nursing assistant. She stated Resident #2 had weekly weights during the facility stay. She provided documentation of weekly weights and stated the weights had been provided to the weekly weights committee on Wednesday of each week. She revealed the committee would then document the weight in the medical record and notify the family, MD and RD as indicated from the results. She stated Resident #2 was recommended to continue weekly weights after the 7/28/2020 weight of 150.1 lbs. An interview was conducted with the Director of Nursing (DON) on 2/3/2021 at 11:45 a.m. and she stated a note book with documentation of the weights committee meetings was maintained with orders and interventions during June and July of 2020. The DON stated the committee reviewed Resident #2 for the initial weight loss, dated 7/16/2020, and determined the 5% loss could be from diuretic therapy in the facility and intravenous therapy at the hospital, prior to admission. An intervention to continue to monitor was recommended by the team. The DON added that Resident #2 was discussed on the date of her discharge, 8/7/2020, and that interventions for weight loss had been recommended, that included, supplements with the meal tray, weekly weights and an RD evaluation. A telephonic interview was conducted with the RD, on 2/5/2021 at 11:47 a.m. She stated that the COVID-19 pandemic prevented in person visits and that she relied on accurate documentation of a weight to carry out an assessment. She stated the only weight available for the assessment of Resident #2, on 7/1/2020, was a weight of 184 in the electronic system titled, PCC, and the weight had been documented by the facility dietary manager from the Hospital discharge summary and facility admission paperwork. She stated the admission weight of 168.9, on 6/30/2020 was documented in PCC after her assessment, as a late entry. She revealed the facility process was for the weights committee to send an email to notify the RD of wounds and significant weight loss. She denied receiving notification of the inaccuracy of the weight, dated 7/1/2020, and denied receiving notification of weight loss during the month of July 2020 for Resident #2. The RD added that it was her expectation to receive notification for significant weight loss and that included anything greater than 5%. A telephonic interview was conducted with the MD, on 2/5/2021 at 1:48 p.m. and he stated that he had seen Resident #2 on 6/30/2020 and again on 8/7/2020. He denied receiving any notification of significant weight loss prior to the Resident's discharge on 08/07/20. He stated it was his expectation that any weight loss of greater than 5% in one month be reported to the MD for evaluation. He stated he was utilizing PCC documentation in July of 2020 and relied on accurate and timely documentation during visits. He denied having access to, or knowledge of, the weights documented by the restorative nursing assistant in July 2020. He stated he expected the facility to be aware of the federal regulations regarding the definition of significant weight loss, would educate the facility of his expectation for notifications and that he required a list of all areas that documentation was to be stored if not in the PCC system. A review of the medical record for Resident #2 revealed an MD notification for weight loss for Resident #2 initialed by the MD of receipt on 8/21/2020. Resident #2 was discharged to the emergency room , for evaluation, on 8/7/2020 and did not return to the facility. A telephonic interview was conducted with the responsible party (RP) for Resident #2 on 2/2/2021 at 2:04 p.m. The RP denied receiving any information regarding weight loss of the resident. She stated therapy staff would notify her that the resident had not been eating much.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of [DIAGNOSES REDACTED].#1) reviewed. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse ' s note dated 7/15/20 at 3:43 PM read, resident complaining of congestion and cough, bilateral lungs have scattered crackles, oxygen saturation level 97 percent on room air. Spoke with physician regarding ordering chest xray. Xray order obtained and called in. Results of the ordered chest xray ordered 7/15/20 revealed mild [MEDICAL CONDITION] infiltrate in the left lung base and small left pleural effusion was present consistent with [MEDICAL CONDITIONS] versus pneumonia. A physician ' s progress note dated 7/16/20 revealed a new [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] revealed [MEDICAL CONDITION] was not coded under Section I, Active Diagnoses. An interview with the MDS nurse responsible for completing the 8/15/20 assessment was not possible. An interview was conducted with the facility Administrator on 2/5/21 at 11:02 AM. The Administrator new [DIAGNOSES REDACTED]. She added the person responsible for entering the information into the electronic health record was new to her role and must have missed entering the new [DIAGNOSES REDACTED].

Based on record review and staff interviews, the facility failed to develop a care plan in the area of nutrition for 1 of 2 residents reviewed (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE]. Resident #2's comprehensive minimum data set (MDS), dated [DATE], revealed the Resident's admission [DIAGNOSES REDACTED]. The Resident was coded to require one-person limited assistance with eating and a weight of 168.9 pounds (lbs.). The Care area assessment summary (CAA) triggered the Resident to be care planned for nutritional status. The nutritional status care plan recommendation was coded that the area would be included in the care plan. The Physician (MD) progress notes revealed the MD had assessed Resident #2 on 6/30/2020. The MD documented the Resident had a rapid decline in health over the past year and ordered a nutrition supplement, Prostat 30 milliliters three times a day, based on a recent decrease in food intake. The assessments revealed the Registered Dietitian (RD) assessed Resident #2 on 7/1/2020 and included a progress note that stated Resident #2 had poor food intake. The RD recommended the Resident maintain a weight of 175 lbs. and to continue to monitor and add to the plan of care. The RD added that she had the ability to add a focus on the care plan or update the care plan for a resident, however, it was the standard practice of the facility for the Minimum data set (MDS) coordinator to manage the plan of care. Resident #2's plan of care, dated 7/6/2020, did not include a nutritional focus area. An interview was conducted on 2/3/2021 at 10:35 a.m. with the MDS nurse and revealed that she was not the MDS nurse during June and July of 2020. She stated that if an area was identified on a CAA and coded that it was going to be added to the care plan, she would include it as a focus area on a resident's care plan. The MDS nurse reviewed the care plan for Resident #2 and stated she did not see a nutritional focus. An interview was conducted on 2/3/2021 at 11:18 a.m. with the restorative nursing assistant. She stated that Resident #2 had weekly weights during the month of July 2020. She revealed the weights had been provided to the weights committee and the weights committee would then document the weight, make recommendations, and notify the family, physician and dietician as needed. She stated the intervention to continue weekly weights for Resident #2 was recommended to continue, on 7/28/2020, due to the amount of weight loss since admission. An interview was conducted with the Director of Nursing (DON) on 2/3/2021 at 11:45 a.m. and she stated it was her expectation that a resident with poor intake or significant weight changes have a care plan for nutrition. The DON stated the weight committee reviewed Resident #2 during the month of July 2020 and made a recommendation to continue to monitor the Resident due to a loss of weight. Review of the restorative aide's documentation of weekly weights for Resident #2, revealed the Resident weighed 168.9 on 6/30/2020, 158.4 lbs. on 7/16/2020, 158.1 lbs. on 7/21/2020 and 150.1 lbs. on 7/28/2020. Based on this documentation, a weight loss of 6% occurred from the date of 6/30/2020 to 7/16/2020. A weight loss of 11% occurred in less than 30 days. Resident #2 was discharged on [DATE].