**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and policy review, the facility failed to process physician orders, and failed to provide and document physician ordered treatments such as wound care and dressing changes for 1 of 5 residents reviewed for skin conditions. The facility also failed to document a change in skin condition and the treatment interventions initiated for 1 of 5 residents reviewed for skin conditions (Resident # 32). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had diagnoses of heart failure, anemia, and Alzheimer's disease. The MDS indicated the resident had no skin issues. The Care Plan initiated 6/3/24 and revised on 9/3/24 revealed Resident #32 had abrasions to the left and right knee, top of her right foot, and right pinky toe/nail. The Care Plan directed staff to administer treatments as ordered, monitor for effectiveness, and document skin breakdown measurements. The electronic health record Progress Notes revealed the following: a. On 8/24/24 at 7:00 AM, skin tear on left shin 1.0 centimeter (cm) x 1.5 cm. Cleanse wound with wound cleanser, pat dry, cover with xeroform and a medipore dressing every AM (morning) and PRN (as needed) until healed. b. On 9/1/24 at 4:30 AM, cleanse all abrasions with wound wash and pat dry. Cover the right foot areas #1 and #2, right knee, left knee, right shoulder, and right pinky toe with xeroform, non-adherent pad, and gauze every day until OTA (open to air). An intervention note included to administer treatments as ordered and monitor for effectiveness. c. On 9/3/24 at 1:08 PM, the Assistant Director of Nursing (ADON) documented to discontinue current treatment to the foot and legs. New order obtained to cleanse the knees and right foot, cover with TAO (triple antibiotic ointment), and leave the areas OTA daily until the area healed. d. On 9/10/24 at 12:59 PM, the ADON documented to cleanse the left knee with wound wash, cover with hydrofera blue and a gauze wrap daily. Cleanse the right knee, cover with xeroform, telfa, and a gauze wrap daily. An Incident Report revealed on 9/1/24 at 4:05 AM, a CNA (certified nursing assistant) passed by the resident's room and observed her empty bed. The CNA entered the room and found the resident in a prone position alongside the bed on the floor, and a body pillow on top of her. The resident's bilateral knees had abrasions and the right shoulder had a small abrasion and ecchymosis (bruise). Abrasions cleansed with wound wash, and covered with xeroform, a non-adherent pad, gauze and tape. A Memo to the Physician (Dr) dated 9/1/24 revealed the resident found on the floor in a prone position next to the bed. The resident had superficial abrasions on her knees, the top of her right foot, and her right upper arm. No mass or lacerations noted. The resident surely must have hit her head due to the back of her head found against the bed. The resident moved all extremities, and able to bear weight without complaints. The right pinky toe toenail hung loosely. All areas cleansed with wound wash, and a xeroform and a non-adherent dressing applied. Dressing changes (to be completed) on the PM (evening shift). The Physician's Telephone Orders revealed the following: a. On 8/30/24: a skin tear on the left shin had scabbed over. Order to apply skin prep to the left shin area every AM for 7 days. b. On 9/1/24: cleanse all abrasions with wound wash and pat dry. Cover the right foot, right knee, and left knee with xeroform, non-adherent pad, and a gauze roll. Change the dressing daily until OTA. c. On 9/3/24: discontinue current treatment to the foot, legs, and shoulder. A new order to cleanse the knees and right foot areas, then apply TAO daily, and leave areas OTA until healed. The Order Summary Report revealed the following orders: a. Cleanse areas to bilateral knees and right foot with wound cleanser and pat dry. Cover areas with a thin layer of TAO, and leave OTA daily for wound healing had a start date 9/3/24. b. An order to cleanse bilateral knee abrasions with wound cleanser, pat area dry, then apply xeroform, telfa (a non-adherent dressing), and rolled gauze daily had a start date 9/9/24. c. Cleanse left knee with wound wash, cover with hydrofera blue, and wrap with gauze daily had a start date 9/11/24. d. Cleanse abrasions to right knee with wound cleanser and pat dry. Apply Xeroform, telfa (a non-adherent dressing), gauze, and tape daily started on 9/11/24. The Non-pressure Skin Condition Report dated 9/1/24 revealed the following: a. Left knee abrasion 5.5 cm x 4.5 cm b. Right knee abrasion 1.5 cm x 1.7 cm c. Top of right foot abrasion wound #1 measured 0.5 cm x 2 cm and wound #2 measured 1.5 cm x 1 cm. The section for nurse signature was left blank. d. Right foot pinky toe/toenail had incomplete documentation. e. Right shoulder/ lateral upper arm abrasion measured 9.5 cm x 5 cm. A Routine Medications form dated 9/1/24 revealed the following handwritten order: a. Cleanse left and right knee abrasion with wound wash, pat dry, apply xeroform, non-adherent pad, and a gauze roll every PM started 9/1/24. b. Cleanse top of right foot area #1 and #2 with wound wash, pat dry, apply xeroform, non-adherent pad, and gauze roll every PM started on 9/1/24. Wound #1 measured 0.5 cm x 2 cm and Wound #2 measured 6.0 cm x 1 cm. c. Cleanse right pinky toe/ toenail with wound wash, pat dry, gently weave xeroform around toenail and secure with a small kerlix and tape daily on the PM shift. The Treatment Record (TAR) dated 9/1 - 9/13/24 revealed: a. Apply skin prep to the left shin every AM for 7 days started on 8/30/24. The record lacked staff initials or documentation of the treatment performed 9/1/24 - 9/5/24. b. Cleanse left knee with wound wash, cover with hydrofera blue and gauze daily started on 9/10/24. c. Cleanse right knee with wound wash, cover with xeroform, telfa and gauze daily started on 9/10/24 d. Cleanse top of right foot, apply hydrofera blue and cover with bordered gauze daily until healed started on 9/10/24. e. Cleanse right pinky (little) toe, apply TAO and a Band-Aid daily until healed started on 9/10/24. The treatment record lacked a treatment for TAO and OTA (order started on 9/3/24), and nursing observations and comments about the wound areas. During observation on 9/10/24 at 11:18 AM, Staff C, Registered Nurse (RN), obtained supplies, washed hands, donned gloves, and removed dressings on Resident #32's right and left knee. Staff C cleansed the right and left knee wounds with wound wash and gauze. Staff C reported the left knee wound looked worse from when she previously had looked at the wounds and performed the treatment the prior week. Staff C stated she was going to go get the DON and ask her to look at the area. Staff C left the resident's room. At 11:24 AM, Staff C and the DON entered the resident's room. The DON looked at the resident's left knee wound and reported she planned to call the Dr to get a different treatment order. At the time, the DON asked the resident if her right knee hurt. Resident #32 responded Oh yea, the pain is all the way down there. Staff C measured the wounds and wrote the numbers on a piece of paper: Right knee: 2 cm x 1 cm Left knee: 3 cm x 6.5 cm The DON left the room. At 11:28 AM, Staff C donned a pair of gloves then applied xeroform, telfa, and gauze to the right knee wound. Staff C dated and initialed the dressing. At 11:39 AM, the DON returned to the room and provided supplies to Staff C. The DON told Staff C she would write the order received from the Dr. Staff C applied gloves and proceeded to apply sterile water to a piece of hydrofera blue foam dressing, then applied the hydrofera blue and a rolled gauze dressing to the left knee wound. During observation on 9/10/24 at 1:50 PM, Staff D, CNA, provided cares and assisted the resident into bed. Staff D removed the gripper sock on the resident's feet. The top of the resident's right foot had a border foam dressing and a large dark area of drainage that bled through the dressing. The dressing and tape had no date and no initials. At the time, Resident #32 reported her toe hurt when she walked and her foot caught on the floor. During an interview on 9/10/24 at 12:29 PM, Staff C reported she wrote the Dr's order on a Telephone order form whenever a new order was received. She also entered the order into the computer, faxed the order to pharmacy, wrote the order on the MAR (medication administration record) or TAR, and wrote a note in nurse's Progress Notes about the order and what was done. On 9/10/24 at 2:00 PM, the surveyor approached Staff C and asked about the treatment to Resident #32's foot. Staff C reported she didn't know anything about a treatment for Resident #32's foot. She last saw the resident on Tuesday, 9/3. The resident had a fall on 9/1/24. Staff C reported she normally did resident skin treatments on Mondays but she was not at the facility the past Monday due to the holiday, so she completed the residents' skin assessments and treatments on Tuesday, 9/3/24. On that day, Resident #32's foot had a scab over it, and she applied TAO and left it OTA. At the time, Staff C obtained some supplies and entered the resident's room with the surveyor. Staff C washed her hands, donned gloves, and removed the gripper sock on the resident's right foot. Staff C confirmed the dressing had no date or initials. Staff C stated she was uncertain when the dressing had been applied or last changed. Staff C reported the wound to the top of the foot had a lot of slough in it. The wound had redness around it. Staff C reported the wound was superficial and had a scab and almost healed the prior week. Staff were supposed to put TAO and OTA. She didn't know why or who covered the area. Staff C stated she planned to call the Dr to see about a treatment to the area. She thought the Dr would want therafera blue to help remove the slough. Staff C then removed the broken toenail from the resident's right little toe. Staff C reported to the surveyor the non-pressure skin condition reports for Resident #32's wounds were in Staff E's top desk drawer. She didn't know why the skin condition reports weren't in the treatment book. Normally the TAR and skin assessments were kept in the treatment book. Staff C recalled when she entered the order in the computer for TAO to the area, she printed it off and put it in the treatment book on 9/3/24. Staff C stated she didn't know why the TAR was not in the book today, but facility staff were sorting through papers and looking for it. On 9/10/24 at 2:15 PM, Staff C reported she spoke with the Dr and obtained an order for therafera blue and kerlix to the top of Resident #32's foot starting 9/10/24. Staff C reported she would enter the order. During an interview 9/10/24 at 2:18 PM, Staff E, RN, reported whenever she received a Dr's order, she wrote the order on a Telephone Order form, documented the order in the hard chart (paper) nurse's notes, wrote the order on the MAR or TAR, and sent the order to the pharmacy if it's a medication or treatment order. Staff E explained the Telephone order form was a triplicate form. The original form placed in the resident's chart, the yellow copy was sent to the DON, and the pink copy sent to the ADON/Care Plan Coordinator. Staff E reported the nurses helped enter orders whenever they had a stack of orders to process. Staff E reported skin assessments documented on a non-pressure skin record or pressure wound record. Staff C, Staff E, and the DON completed follow up skin assessments with measurements weekly. They determined if the wound or skin concern improved or deteriorated. Staff E reported she had covered a lot of night shifts so she hadn't been doing the skin assessments unless she found a new skin concern during her shift. Staff E stated she did treatments as ordered and called the Dr if a wound had not showed improvement. Staff E reported when staff found Resident #32 on the floor (9/1/24), she assessed the resident. The resident had abrasions to her knees and right foot. She wrote an order to apply xeroform and kerlix because the wounds looked wet. She suspected the treatment would change to TAO and OTA in a couple of days. She filled out the treatment record form and placed the form in the treatment book, but she had a couple things to write on the skin report so she put the skin report papers in her desk drawer to finish later. Resident #32 just had the abrasions. She planned to come in on Monday to finish filling out the skin record and sign the document but she got distracted and didn't get it done. That's why the forms were still in her desk drawer. She figured the nurse would just measure the areas each week. On 9/10/24 at 2:40 PM, Staff E provided the surveyor the orders she wrote on the TAR on 9/1/24 and reported her initials as the only entries signed off on the treatment on that day only. The TAR had no other staff initials listed 9/1/24 to 9/10/24. During an interview on 9/11/24 at 8:09 AM, the physician reported when he wrote an order, he expected or hoped staff carried out the order, such as a treatment. He reported the facility staff let him know if a medication or treatment was not available or a reason why a treatment should not be carried out. He expected staff to notify him if a wound got worse. The physician reported wounds could be tricky. He gave staff [NAME]-way especially if they were familiar with wound care. The facility had standing orders for nurses to initiate a wound treatment based on an assessment. He gave the nurse discretion about what to do until he could visualize the wound himself. The physician reported he had not seen Resident #32 since she had the fall but he was aware of it and the wound treatment implemented. During an interview 9/11/24 at 10:39 AM, the DON reported Staff C obtained wound measurements weekly. The facility had standing orders for nurses to implement a treatment until the Dr came to the facility and assessed the resident. During an interview 9/11/24 at 2:21 PM, the ADON stated she was also the MDS/ Care Plan Coordinator. The ADON reported she wasn't working on the day Resident #32 had a fall. She entered a nursing Progress Note in the EHR, then went into the resident's Care Plan and entered a comment to administer the treatment as ordered. She entered a comment whenever she updated or revised the Care Plan so she could track the changes and when they occurred. The ADON demonstrated on the computer the steps she took when she entered information into the Care Plan. She confirmed a revision on 9/3/24 on Resident #32 because the resident had a change in wound treatment. The ADON reported she only entered the information on the resident's Care Plan. The DON and Staff C entered the Dr's order into the computer and do what they needed to do to process the order. The ADON explained the process for when an order received. Order written on a telephone order form. The order form is a triplicate form. The white (original) was placed in the Dr's box to review and sign, the pink form went to the ADON to enter the information into the resident's Care Plan or MDS, and the green form given to the DON or Staff C to process the order. The white copy of the form got placed into the paper chart after the Dr signed off on the order. The ADON reported Staff C performed the skin assessments on residents with wounds each week but Staff F performed the skin assessments before Staff C took it over. During an interview 9/11/24 at 2:29 PM, Staff F, RN, reported she was the person designated to do skin assessments a while back but had not done the skin assessments since 5/2024. Staff C, RN, responsible for performing skin assessments since 5/2024. The skin assessment performed weekly on residents with wounds or a skin concern. During an interview 9/12/24 at 9:44 AM, the DON reported she came into the facility on the evening of 9/2/24 to report a COVID positive case at the facility. Staff H, RN, requested her to look at Resident #32's knees and foot. The DON stated she observed the areas. The areas looked dry and scabbed over. She told Staff H to start TAO and Staff C would look at the area the next day. The DON reported she couldn't find Resident #32's skin sheet or TAR. She found the TAR for September in the resident's paper chart, not in the treatment book. She was not able to find Resident #32's skin records but then found them in Staff E's desk this week after the surveyor asked for them. The DON reported Dr's order faxed to pharmacy, but the order not faxed to pharmacy whenever treatment supplies used from their stock. The DON reported Staff G, RN, changed Resident #32's treatment and implemented a standing order for xeroform because the resident's left knee area was too dry and had cracked open. The standing orders gave the nurses discretion to implement treatments for skin tears and abrasions. The DON reported Staff G didn't chart the change in treatment or write the order for the xeroform treatment when she initiated this treatment. The DON reported she expected staff to follow orders and document when treatments performed. The DON reported there were paper records everywhere. Staff had trouble deciphering some documentation and she had to call a nurse to have her relay the notes she wrote. The DON reported Staff E wrote the Incident report and the memo to the Dr about Resident #32's fall and abrasions. During an interview 9/12/24 at 9:54 AM, Staff G, RN, reported Resident #32 had a treatment order that Staff E wrote but Staff E's handwriting was awful. Staff G stated she couldn't read the order. Staff G reported when she came into work over the weekend on 9/8, no TAR found for Resident #32. She had just arrived to work when a CNA came and told her Resident #32's leg was bleeding and she wanted her to look at it. She looked at the area and then cleaned it. Staff G reported the resident's knees were scabbed over, but one knee had cracked open. Staff C oversaw the wounds but since Staff C not working and it was over the weekend, Staff G applied Vaseline and a kerlix over the area. She planned to write the order but it was a crazy day and she didn't get the order written before she left for the day. She wasn't 100 % sure what Staff C would want on the wound but she felt she needed to do something. Staff G explained they had standing orders and it was at the nurse's discretion on what treatment to use. She did what she thought would be the best treatment. Staff G confirmed she did not document a Nurse's Note when the resident's knee had bleeding, the steps she took, or the treatment performed. Staff G reported she couldn't find the TAR so she didn't document the treatment on the TAR either. An undated non-pressure skin condition assessment policy revealed weekly skin assessment of skin conditions documented on non-pressure skin assessment sheet to help prevent infections or other complications for all non-decubitus skin lesions and assure documentation of the healing. All skin conditions such as open areas or abrasions assessed and documented on a non-pressure skin sheet. Subsequent weekly documentation should show the response to treatment as well as a description of the size and appearance of the affected areas. Signs of infection or poor response to treatment reported to the physician. A Physician Order Transcription policy effective 7/2023 revealed orders received and orders transcribed by a nurse onto an order sheet in the patient's chart. Orders signed, dated, timed, and noted at the time it is written on the order sheet or entered into the computer system.

Based on observations, staff interview, and policy review the facility staff failed to serve food under sanitary conditions to prevent food borne illness during 1 of 2 meals observed. The facility identified a census 58 residents. Findings include: During observations on 09/10/24 at 8:40 AM, the Social Services designee peeled a banana for residents in the main dining room, then used her bare hand to remove the banana from the banana peeling and gave the banana to the resident or placed the banana onto the resident's plate. At 08:44 AM, Staff A, certified nursing assistant (CNA), peeled a banana for a resident, then used her bare hand to place the banana onto the resident's plate. Staff A then picked up a slice of toast, placed the bread in the palm of her bare hand and took a knife to apply jelly onto the toast. Staff A then placed the toast onto the resident's plate. During an interview 09/11/24 at 12:50 PM, the Food Service Supervisor reported staff should use a fork or something to hold ready to eat foods such as when they removed a banana peeling, or put jelly or butter on bread. The Food Service Supervisor stated staff could also wear a glove or use a paper towel to hold the food, but staff should not directly touch the resident's food. The facility's General Food Preparation and Handling policy dated 2013 revealed food items prepared to keep free of injurious organisms and substances. Bare hands should never touch raw food directly. Food such as bread or other items served with tongs, fork, or other suitable implements to avoid manual contact of prepared foods.

Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to follow infection control techniques to prevent the potential spread of infection for 1 of 1 residents on transmission-based precautions (Resident #19). The facility reported a census of 58 residents. Findings include: The Diagnosis Report revealed Resident #19 had an onset of COVID-19 on 09/02/24 that was acquired during his stay at the facility. The Care Plan initiated 09/30/21 and revised on 09/03/24 revealed Resident #19 had tested positive for COVID-19 and placed in isolation on 09/02/24. The paper Nurse's Notes revealed on 9/2/24 at 1:20 PM, resident not feeling good. A Covid test done and it was positive. The DON (Director of Nursing), physician, and son notified of positive Covid test. Resident placed in isolation precautions. Observations revealed the following: a. On 09/09/24 at 2:20 PM, a plastic bin with drawers sat outside Resident #19's room. The drawers had personal protective equipment (PPE) (gowns, N95 masks) inside. A box of surgical masks sat on top of the cart, and a container of sanitizing wipes and a box of gloves sat on the handrail in the hallway by the resident's room. The door and area by the resident's room and plastic bin had no signage posted to indicate a resident on isolation or transmission-based precautions (TBP), or the need to don PPE prior to entry into the room. b. On 09/09/24 at 2:23 PM, the surveyor asked Staff B, certified nursing assistant (CNA), about the PPE stored in the hallway area near Resident #19's room. Staff B reported Resident #19 in isolation because he had COVID. c. On 09/09/24 at 2:26 PM, Resident #19 coughed while he sat in a chair in his room. d. On 09/09/24 at 2:26 PM, Staff B, CNA, posted a sign on the wall by Resident #19's room labeled Contact / Droplet Precautions and another sign about the PPE required. Staff B reported Resident #19 was the last resident that tested positive for COVID. Staff B stated the resident would come out of isolation on 9/13/24. During an interview on 09/11/24 at 3:30 PM, the Director of Nursing (DON) reported no order written whenever a resident placed in isolation, they just followed the standard CDC's (Center for Disease Control) recommendations. During exit conference on 09/12/24 11:15 AM, the DON reported the isolation signage didn't get put up by the resident's room because the resident got placed in isolation over the weekend. An Isolation - Initiating Transmission-Based Precautions policy revised 8/2019 revealed TBP initiated whenever a resident developed signs and symptoms of a transmissible infection or had a laboratory confirmed infection and at risk of transmitting the infection to other residents. TBP included contact, droplet, or airborne precautions. The policy revealed when TBP's are implemented, the Infection Preventionist (or designee): a. Clearly identified the type of precautions, the anticipated duration, and the PPE that must be used. b. Determined the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors were aware of the need for and the type of precautions: (1) The signage informed the staff of the type of CDC precautions, the instructions for use of PPE, and/or instructions for visitors / staff to see a nurse before entered the room. (2) TBP's remained in effect until the attending physician or Infection Preventionist discontinued the precautions, which occurred after the criteria for discontinuation met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the manufacturer insulin packaging insert, the facility failed to prime the insulin pen prior to administration for 1 of 2 residents reviewed for insulin administration (Resident #6). The facility reported a census of 59 residents. Findings include: Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. The MDS included a diagnosis of diabetes mellitus (DM). The MDS reflected Resident #6 received insulin injections for 7 out of 7 days. The Care Plan revealed a focus area revised on 1/6/24 for Type II DM. The interventions dated 8/16/22 revealed diabetes medication as ordered by doctor. The Electronic Medical Record (EMR) revealed the following diagnoses: a. Type II DM with moderate nonproliferative diabetic retinopathy (the walls of the blood vessels in the retina weaken) with macular edema (swelling inside the retina), right eye. The EMR revealed the following physician orders: a. ordered 3/1/24 - Insulin Detemir subcutaneous solution - inject 18 unit subcutaneously one time a day During an observation on 4/23/24 at 7:58 AM, Staff A, LPN (Licensed Practical Nurse), prepped Resident #6 Detemir insulin pen for administration. She wiped the hub with alcohol, applied the needle, and turned the insulin pen knob to 18 units. She did not prime the insulin pen prior to turning the knob to 18 units. She then injected the insulin into Resident #6 abdomen. During an interview on 4/23/24 at 12:10 PM, Staff A queried if the insulin pen needed primed prior to administration and she stated sometimes, but sometimes they didn't need to because of the needles they used. Staff A stated she would read the box of the needles and make sure they didn't need to prime the needle. Staff A then stated she messed up and should of primed the needle. During an interview on 4/25/24 at 11:05 AM, the DON (Director of Nursing) queried on the prep prior to administering an insulin pen to a resident and she stated that all insulin pens needed primed to at least 2 units. The Facility Medication Administration Policy (no date identified) did not address the process of insulin pen administration. The Insulin Detemir Package Insert dated 1/17/19 revealed the following information: a. Prepare your pen 1. Check your insulin type 2. Attach a new needle 3. Prime your Pen - Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and facility policy review, the facility failed to ensure a resident was free from physical restraints. Specifically, the facility failed to assess, monitor, and implement interventions according to standards of practice during the use of a physical restraint that is used for treatment of a medical symptom, and provide ongoing monitoring and evaluation for the continued use for one of one (Resident (R) 47) sampled for physical restraints in a total sample of 27 residents. This failure placed the resident at risk for a diminished quality of life. Findings include: Review of the facility policy titled, Physical Restraints, revised 10/10/10 revealed, The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's physical medical symptoms. DEFINITION: Physical restraints are 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 restricts freedom of movement or normal access to one's body. During an observation on 11/14/22 at 11:58 AM, R47 was seated in a Merry [NAME] (a combination wheelchair and walker used for ambulation that utilizes a front gate and strap to enclose the resident) in the dining room, ambulating while in the Merry Walker. During an observation on 11/14/22 at 1:57 PM, R47 was seated in her Merry [NAME] in the main dining room. During an observation on 11/14/22 at 3:36 PM, R47 was seated in her Merry Walker, pulling at the strap. During an observation on 11/15/22 at 9:43 AM, R47 was in the main dining area seated in her Merry Walker. R47 appeared drowsy. During this same observation, this surveyor asked R47 if she could get out of her chair. R47 did not respond but attempted to engage the latch to unlock the Merry Walker. R47 attempted three times with one hand and then two times with both hands. The resident was unsuccessful in unlocking the lap belt clamp. During an observation on 11/15/22 at 11:23 AM, R47 was observed in dining room seated in Merry Walker. During an observation on 11/16/22 at 10:08 AM, with Certified Nursing Assistant (CNA) 3, R47 was observed in her room seated in her Merry Walker. R47 was prompted four times by CNA3 to unlatch the Merry [NAME] strap. R47 was unsuccessful in unlatching the strap. CNA3 revealed, I have never seen the resident unlatch the belt to get out. During an observation on 11/16/22 at 10:15 AM, with Registered Nurse (RN) 1, R47 was seated in hallway in her Merry Walker. RN1 prompted R47 to unlatch seatbelt and Merry [NAME] bar. R47 was unable to unlatch the seatbelt and unlock the bar. This observation revealed R47's Merry [NAME] had a two-part unlocking process to get out and the resident was unable to perform the process. RN1 stated, the two-part process included unlatching the seatbelt and pulling a small, round pin to release the bar. RN1 revealed, I've never seen her get out and that would mean it's a restraint. Review of R47 admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R47 was admitted to the facility on [DATE] with the following diagnoses, Parkinson's, depression, and dementia. Review of R47's Minimum Data Set (MDS) located in the EMR under the (MDS) tab with an Assessment Reference Date (ARD) of 09/29/22 revealed, R47 had a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen, indicating R47's cognition was moderately impaired. Review of a Social Services note located in the Social Services tab of the paper chart dated 10/06/22 revealed, R47 was able to complete the BIMS assessment her cognitive interview score was an 11 out of 15 indicating, moderately impaired cognitive ability. She has a diagnosis of dementia and neurocognitive disorder with lewy [sic] bodies. This score is higher than expected and not indicative of her daily cognition . Review of the Social Services note revealed, R47 has delusions, some safety concerns. She is very 'figety' [sic] & [and] wanders aimlessly about the facility in a Merry Walker. Review of Physician Orders located in the EMR under the Orders tab dated 09/29/22 revealed, may use Merry [NAME] as needed. Review of R47's History and Physical located in the paper chart written by the facility's physician, dated 09/29/22 indicated, We are going to try a Merry [NAME] to see if that helps maintain mobility with reduce chance of falls . She is extremely high risk for ongoing falls, which will not be able to be prevented due to her significant impulsivity, poor cognition, and desire to continuously walk. Review of R47's Care Plan located in the EMR under the Care Plan tab dated 10/06/22 revealed an Ambulation care plan which documented the following intervention, May use Merry walker [sic] as needed. An additional Falls care plan documented the following intervention receives comfort in the fact that she is able to move around. Due to her unsafe walking stance, she is currently using a Merry walker [sic] so that she may be more independent in the facility. Review of R47's Hospice Assessment provided by facility dated 09/29/22 revealed, Patient was being fitted into Merry walker for her safety and ability to walk safely in hallways. DON [Director of Nursing] assisted with it. Patient stood up and walked backwards, was instructed to walk forward. Was able to ambulate down three different hallways with standby assist for safely. Did sit down and used her feet to pedal also returned to nurses station and she was winded. Charge nurse gave her a drink of water. Tolerated new device well. Review of R47 EMR and paper chart revealed no other least restrictive interventions were implemented prior to the implementation of the Merry Walker. During an interview on 11/15/22 at 12:07 PM, CNA3 revealed, R47 uses a Merry [NAME] due to confusion and balance. CNA3 further stated that they try to take R47 out of the Merry [NAME] at least every hour. CNA3 was asked, Have you ever seen the resident unclip her belt? CNA3 stated, No I have not, I do not believe the resident can unclip herself. During an interview on 11/15/22 at 2:34 PM, the Minimum Data Set Coordinator (MDSC) stated the Merry [NAME] was not considered a restraint because she can stand up and move around in it. Surveyor asked the MDSC, Can the resident release the belt? The MDSC stated I do not know. I was not there. Surveyor asked were there any other least restrictive interventions implemented prior to the implementation of the Merry Walker. The MDSC stated, no other interventions were attempted. During an interview on 11/15/22 at 2:44 PM, the Physical Therapist (PT) reported, Restraints are something a person cannot be undone by themselves. If a resident required a seatbelt or lab buddy, I believe it is first addressed by nursing and physician and then referred to therapy. Surveyor asked the PT, Would you consider a Merry [NAME] a form of restraint if a resident could not release the belt to exit the chair? The PT stated Yes. During an interview on 11/15/22 at 2:56 PM, the Director of Rehabilitation (DOR) revealed, restraints are considered bed alarms, using a gait belt to tie around a resident in their wheelchair, and anything that would keep someone from moving or getting out of a chair or bed. During an interview on 11/15/22 at 3:02 PM, the Certified Occupational Therapist Assistant (COTA) revealed referring to the Merry Walker, If a resident cannot release the latch or belt, it is considered a restraint. During an interview on 11/15/22 at 3:20 PM, the DON stated, a restraint restricts the freedom of movement, all alarms are considered a restraint, and if a resident is seated in a wheelchair with a lap belt it is a restraint if they cannot remove it. When asked if at the time R47 was assessed for the Merry [NAME] if R47 asked to remove the lab belt, the DON stated, We did not ask the resident to release the belt when we were assessing her for the Merry Walker. The DON furthered shared that the facility Medical Director made the decision to place R47 in the Merry [NAME] and hospice came out to do the assessment. Surveyor asked the DON if during this assessment with hospice was R47 asked to release the seatbelt. The DON stated, No. Surveyor further enquired on how R47 was monitored to ensure that the Merry [NAME] continued to be appropriate. The DON stated, hospice keeps all of the assessments. Surveyor asked were any other least restrictive interventions implemented prior to the implementation of the Merry Walker. The DON stated, no other interventions were attempted. Review of R47 hospice documents provided by the facility revealed no ongoing assessments for the Merry Walker. During an interview on 11/15/22 at 3:46 PM, the Hospice Administrator (HA) revealed, R47 was assessed for the Merry [NAME] on 09/29/22. The HA stated, the facility staff spoke with the Medical Director about safety concerns due to falls. When the resident was placed in the Merry [NAME] the resident could stand, ambulate forward and down the hall by propelling with her feet. Surveyor asked the HA was R47 assessed to ensure she could release the seatbelt latch? The HA stated, the notes do not state if the resident was asked to release the latch. During an interview on 11/15/22 at 4:16 PM, the Medical Director stated there was a combination of things we were concerned about for safety issues she had a lot of falls at her previous. Therapy had failed at a previous facility and the resident was admitted to here and placed on hospice. Through brainstorming it was decided to use the Merry [NAME] to prevent the resident from falling. The Medical Director was asked what would be considered a restraint? The Medical Director stated, any restriction of movement or they cannot get out. Surveyor asked were there any other least restrictive interventions implemented prior to the implementation of the Merry Walker. The Medical Director stated, no other interventions were attempted.

Based on interview, record review, and policy review, the facility failed to ensure residents who were dependent on staff for shaving assistance received services for one resident (R) R48 reviewed for Activities of Daily Living (ADL) assistance. The sample size was 26 residents. Findings include: Review of the ''Vista Woods Care Center Activities of Daily Living'' policy dated 01/27/12 revealed ''A resident's ability to perform the activities of daily living will remain stable unless circumstances of the resident's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to bathe, dress, and groom self.'' ''Residents will be provided appropriate treatment and services to maintain or improve their abilities.'' The facility provided policy did not address ADL assistance for dependent residents. Observation on 11/14/22 at 9:52 AM of resident with chin and upper lip hairs. R48 indicated she would like to have the hairs trimmed and she has not gotten the hairs trimmed in weeks. Observation on 11/16/22 at 8:57 AM of resident with chin and upper lip hairs with the Director of Nursing (DON). The DON confirmed R48 had long chin hairs and the hairs needed to be trimmed. Review of the electronic diagnosis list located under the ''Diagnoses'' tab for R48 included age related physical debility, abnormalities of gait and mobility, hypertension, and type 2 diabetes mellitus with hyperglycemia. Review of the electronic annual ''Minimum Data Set (MDS)'' located under the ''MDS'' tab for R48 with an Assessment Reference Date of 10/03/22 revealed a ''Brief Interview for Mental Status (BIMS)'' score of 15 indicating R48 was cognitively intact. Further review of the ''MDS'' revealed R48 required extensive one person assistance for personal hygiene. Review of the electronic care plan located under the ''Care Plan'' tab dated 10/10/22 revealed ''ADL FUNCTIONAL: [R48] has an ADL self-care performance deficit r/t [related to] constipation, Diabetes Mellitus 2, insomnia, hyperlipidemia, hypertension, depression, pain in right leg, presences or right artificial knee joint, hypokalemia, glaucoma, debility, difficulty walking, pain, other abnormalities of gait and mobility, repeated falls, right femur fracture with Non weight bearing status right leg. COVID precautions.'' During an interview on 11/16/22 at 8:57 AM, the DON confirmed R48 had visible chin hairs. The DON stated the resident should be receiving shaving assistance when she received showers. The DON also confirmed the resident was scheduled for two showers a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure one (Resident (R) 13) of five residents reviewed for unnecessary medications had ongoing clinical indications for the use of an antipsychotic (Haldol). The facility failed to monitor for the target behavior related to the rationale for the antipsychotic. Findings include: Review of a document provided by the facility titled Psychoactive Drug Monitoring, undated indicated . Residents who receive . antipsychotic medications are monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects . Behavioral monitoring charts or a similar mechanism are used to document the resident's need for and response to drug therapy . Review of R13's electronic medical record (EMR) titled admission Record, undated located under Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R13's Physician Orders located under the Orders tab indicated the resident was to receive Haldol 1 milligram (mg) at bedtime for dementia with behaviors. Review of R13's EMR titled Care Plan located under the Care Plan tab dated 11/18/21 indicated the resident had a diagnosis of Alzheimer's disease, was considered unsafe and attempted to walk without assistance. The care plan indicated the resident was non-compliant with using her call light. The care plan indicated the resident was physically combative with staff during cares and picked at her cheek even though there was nothing on her face. The care plan revealed the resident would be delusional by crying out for her mother. The intervention was to monitor the resident's behaviors in an attempt to determine the underlying cause. The intervention directed staff to document her behavior and potential causes as needed. Review of R13's EMR significant change Minimum Data Set (MDS) with an Assessment Reference Date of 08/17/22 located under the MDS tab indicated the staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The staff determined the resident had short- and long-term memory problems. This assessment indicated the resident had delusions during the assessment period. During an interview on 11/16/22 at 8:38 AM, Licensed Practical Nurse (LPN) 1 stated R13 can become distressed and combative at times. LPN1 did not provide a response when asked about where the resident's behavior was documented. During an interview on 11/16/22 8:42 AM, Certified Nursing Assistant (CNA) 2 stated R13 cried a great deal and the resident missed her mother. CNA2 stated she just alerted the nurse if the resident had a behavior and confirmed the behavior was not documented by the CNA staff. During an interview on 11/16/22 at 9:36 AM, the Social Services Director (SSD) stated she observed R13 with behaviors such as crying each day but did not document. During an interview on 11/16/22 at 12:26 PM, the Director of Nursing (DON) stated R13 had many episodes of crying and tearfulness. The DON stated the resident will be resistive to showers. The DON stated the staff should be documenting the resident's behavior. During a subsequent interview on 11/16/22 at 12:46 PM, the DON confirmed there were no documented behaviors in R13's clinical records. During an interview on 11/16/22 at 3:25 PM, the Consultant Pharmacist stated R13 should have targeted behaviors documented to ensure the psychotropic medications were effective or not.

Based on observations, interviews, and policy review, the facility failed to provide food storage and maintain proper food temperatures in a safe and consistent manner. This practice had the potential to affect 56 out of 56 residents who consumed food from the kitchen. Findings include: Review of the facility's undated policy titled, Storage, indicated, food will be stored at the proper temperature and for the appropriate length of time to protect the quality of food, all refrigerated foods and freezer foods will be labeled (if unidentifiable) and dated at time of delivery. Review of the facility's undated policy titled Food Temperatures, indicated, to ensure that food is served at the appropriate temperature to prevent the growth of harmful bacteria and other food borne illnesses, hot food temperatures must read no less than 140F [Fahrenheit] when residents are served; cold, food temperatures should be below 41F at the times during meal service. Review of the facility's undated policy titled Maintenance, indicated, clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a water care professional to test the water quality and recommend appropriate water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing. Cleaner and Sanitizer are the only products approved for use in Manitowoc ice machines. During an initial kitchen walk-through with the Dietary Manager (DM) on 11/14/22 beginning at 9:38 AM, the following were observed: 1. Located in the reach in refrigerator, the parmesan cheese dressing, one gallon (gal) tub, 90 percent (%) consumed was not labeled or dated. DM stated, this should have been thrown out. 2. Located in the reach in refrigerator, the shredded lettuce dated 11/9 was brown, wilted, and slimy. 3. Located in the reach in cook's freezer, 25 pieces of cubed steak in plastic bag with freezer burn was opened and not dated. 4. Located in the reach in refrigerator, Hershey Carmel Ice Cream topping was not dated and opened. 5. Located in the reach in refrigerator, HyVee yellow mustard 1/2 consumed was not dated and expired on 10/08/22. 6. Located in the reach in refrigerator, Hyvee ketchup opened over 90 % consumed and was not dated. 7. Located in the reach in refrigerator, Smucker's strawberry jelly 25 % consumed was opened and not dated. 8. Located in the reach in refrigerator, heavy whipping cream was opened and expired on 11/12/22. 9. Located in the reach in refrigerator, lime juice over 90 % consumed had expired on 08/24/22. 10. Located in the walk-in pantry, opened bag of dry cereal 46 ounces (oz) expired on 03/03/22. 11. Located in the walk-in pantry, taco seasoning opened and dated 4/4 but no use by date. 12. Dry Lemonade drink mix 18 ounces (oz) opened not sealed, with no date received or use by date. 13. Located in the walk-in pantry, egg noodles, five-pound (lb) bag was opened and not dated. 14. Located in the cook's reach in freezer, four loaves of raisin bread, 28 slices per loaf was not dated, with visible ice crystals and freezer burned. 15. Located in the cook's reach in freezer, fajita mix 2.5 lb., five bags not labeled or dated with freezer burn. Observation of facility's main dining room area on 11/14/22 at 10:40 AM with the DM: 1. Facility ice machine in main dining room had a black and green slime like substance and build up inside the ice machine on the plastic bin that produces ice. 2. Within the Snack cart Rubber Maid ice cooler 48 quart were ten half pint milk assorted flavors, holding at 49 degrees. DM stated, the cold items should be lower than 41 degrees 3. Located in the snack cooler, apple juice and cranberry juice holding at 46 degrees. DM stated, the juice should be holding at 41 degrees or below. During an interview with the DM on 11/14/22 at 10:45 AM revealed, everyone should know that they are to label all food items received and any opened or expired food items should be thrown out. The DM further stated, the snack cooler should be filled with ice after placing the cold items in it. All cold items should be held at 41 degrees or below. Snacks are passed at 10:00 AM, 2:30 PM and HS [evening]. During this same interview the DM stated, the ice machine is cleaned and sanitized every three to six months or as needed per the manufacturers recommendation. I normally, check it more regularly but have not recently. During an interview on 11/14/22 at 11:42 AM, Dietary Aide (DA) 1 stated, normally, I would fill the cooler with ice before placing perishables items in it but today a resident was talking to me and telling me her coffee was not good. So, I went to get her another cup of coffee and forgot to fill the cooler with ice.