**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 46 residents with six residents selected for review and four residents sampled for notification of change. Based on record review and interview, the facility failed to notify the physician timely regarding lack of monthly catheter changes and failed to assess, document, and notify the physician with a change in condition when staff alerted the Licensed Nurse of swelling and redness to R2's penis and scrotum on 08/14/24 at 09:00 PM. On 08/15/24 at 03:52 PM, over 18 hours later, R2 required emergency medical transport for further evaluation and treatment. Findings included: - The Diagnosis tab for Resident (R) 2 included diagnoses of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting his right dominant side, aphasia (condition with disordered or absent language function), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, he did not reject care, and had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment dated 11/17/23 revealed due to R1's aphasia, he communicated by nodding, shaking his head, using hand gestures, and non-discernable vocalizations. R2 had a catheter due to neurogenic bladder, wore a leg bag for the catheter, and usually emptied himself per his preference. R2 usually did toilet transfers himself but would be safer with allowing staff to assist him. The Quarterly MDS dated 07/29/24, assessed R2 with a BIMS score of 13, indicating intact cognition, he rejected care daily, and continued to have an indwelling catheter. The Care Plan dated 08/12/21, revealed R2 may resist staff attempts to provide catheter care and the staff were to ensure he had the supplies to do his own cares at those times as he may of felt capable he could do it himself. The staff were to change his catheter every 30 days and R2 would frequently refuse to allow staff to do so. The staff were to observe for any pain and/or discomfort related to the use of the catheter and notify his physician as needed. R2 did not always get the valve tightened after draining his bag and it would leak, so the staff were to ensure his brief and clothes were clean and dry. Record review of the Electronic Treatment Administration Record (eTAR), dated April 2024 through August 2024, for R2 revealed the staff last changed his urinary catheter on 04/15/24. The eTAR instructed the staff to change the catheter monthly on the 15th and as needed. On 05/15/24, LN G documented a N for the catheter change, indicated treatment not administered. On 06/15/24 LN G documented a R for R2's catheter change, indicated resident refused. On 07/15/24 LN G documented R for R2s catheter change. The Interdisciplinary Notes dated 05/07/24 through 05/27/24 lacked notification to the physician regarding catheter change not administered. The facility failed to notify the physician R2's catheter did not get changed. The Interdisciplinary Notes lacked any entries between 08/07/24 at 03:21 PM and 08/15/24 at 03:03 PM. The Interdisciplinary Notes dated 06/20/24, revealed R2's physician was in the facility to see resident and discussed refusal of catheter changes. The facility failed to notify the physician until five days after the refusal. The Interdisciplinary Notes dated 07/18/24 revealed R2's physician was in the building and discussed resident refusal of catheter change. The facility failed to notify the physician until three days after the refusal. The Interdisciplinary Notes dated 08/15/24 at 03:03 PM, by LN H revealed R2 complained of not feeling well and pointed to his head when asked about pain. R2 accepted Tylenol (analgesic medication). A Certified Nurse Aide (CNA), lacked name, reported R2 had swelling of his scrotum and penis. LN H and Consultant Staff GG went to R2's room to assess and noted R2's penis and scrotum were swollen and red throughout, without warmth or tenderness to touch. The Interdisciplinary Notes dated 08/15/24 at 03:31 PM, by LN H revealed Consultant Staff GG seen R2 in the facility for a 60-day visit. Via a physician visit form, R2 had scrotal cellulitis (skin infection caused by bacteria) and catheter issues. The physician ordered Rocephin (antibiotic), one gram, intramuscular, every 24 hours, for three days, and Bactrim DS (antibiotic), twice daily, by mouth, for 14 days. The Interdisciplinary Notes dated 08/15/24 at 03:55 PM, by LN H revealed R2 had blood urine output, complained of increased pain, and feeling the need to empty his bladder. R2 agreed to go to the emergency room for evaluation. The staff called 911 and R2 left the facility with emergency medical services at 03:52 PM. On 08/20/24 at 08:35 AM, LN G stated she did not call R2's physician when he refused for his catheter to be changed. On 08/20/24 at 11:08 AM, LN H stated one of the CNA's, she could not recall who for sure alerted her on 08/15/24 that R2 had redness and swelling of his penis and scrotum. LN H stated R2 appeared not to feel very well, there was very little urine in his bag, and his urine was red. Consultant GG went with her to assess R2 and ordered Rocephin injection for three days and Bactrim DS for 14 days. LN H stated Administrative Nurse E accompanied her to tale with R2 about the Rocephin injection and Administrative Nurse E assisted R2 to the bathroom and emptied his urinary drainage bag which did not have much in it. R2 complained of feeling a lot of pressure and agreed to being sent out. Consultant Staff GG stated we could send him out if R2 became worse. LN H stated R2 was willing to go, and allowed the injection, which is how she knew he was not feeling well at all. LN H stated she did not receive any information in report about R2 having swelling and/or redness of his penis and scrotum. Additionally, LN H stated she would get report from the night shift of R2's refusal for the catheter to be changed, she did not try to change it when reported to her, she let Administrative Nurse D know, and waited for direction on how to go about that but did not receive any. LN H was not aware if the physician had been notified of not of R2's refusals, and stated if a resident refused she would fax the doctor to report the refusal. On 08/20/24 at 12:14 PM, Administrative Nurse E stated the CNA's (lacked names) told LN I about R2 having swelling to his penis and scrotum, and LN I did not document about it or report it on. The CNA's reported to LN H R2's complaint of pain and the swelling of his penis and scrotum, who did not know what the CNA's were talking about. Consultant Staff GG was in the facility at that time and so he went with LN H to look at R2. Administrative Nurse E stated LN H asked her to verify the Rocephin mixture with her and then she went with LN H to R2's room. Administrative Nurse E stated R2's penis was swollen and huge and one testicle was enormous and red and she could tell R2 did not feel well. Administrative Nurse E stated R2 had his leg beg and asked if he wanted it emptied, the bag lacked any fluids and inside the bag was a deep dark red/maroon color. Administrative Nurse E stated she informed R2 there was nothing in it, R2 denied emptying it when asked, and told R2 after pressing on bladder if he was not urinating, he should go to the hospital, which he agreed, and was sent to the emergency room. Administrative Nurse E stated LN H read R2's notes in the chart and it lacked documentation about the swelling. Administrative Nurse E stated what the CNA's observed on 08/14/24 should have been documented, reported to next shift, the on-call physician notified, and/or should have shipped him out. On 08/20/24 at 12:27 PM, attempted to interview LN I, which was unsuccessful. On 08/20/24 at 12:34 PM, attempted to interview CNA P, which was unsuccessful. On 08/20/24 at 12:36 PM, attempted to interview CNA Q, which was unsuccessful. On 08/20/24 at 12:38 PM, CNA LL stated on 08/14/24 she was in R2's room with CMA R and CNA M. CMA R assisted R2 to the bathroom while CNA LL and CNA M changed his sheets. CNA LL R2 could not stand for very long and normally R2 took himself to the bathroom. We had tried to put his catheter bag the correct way, but he would not let us, and she was not sure if he had urine in the bag or not because she was not close enough. CNA LL stated she did not bring up to the charge nurse, could not remember who it was, about needing help with toileting, but mentioned R2's catheter bag. On 08/20/24 at 02:00 PM CNA M stated she along with CMA R assisted R2 to the bathroom and get his sheets changed on 08/14/24, as R2 had a bowel accident. CNA M stated he had come out of his room and had feces coming out of his gown and showed us he was swollen. CNA M stated R2 required assistance of two in the bathroom and usually does on his own, but that night he struggled to standing up for very long. CNA M stated R2's urine in the drainage bag was dark red, looked lie blood, and his penis and scrotum were red and swollen. CNA M stated she reported to LN I around 09:00 PM on 08/14/24 the condition of R2's penis, scrotum, and the appearance of blood in his catheter bag, who said he was busy at the time but would go check on it. On 08/20/24 at 03:25 PM, Administrative Nurse D stated she expected LN I to assess R2 and report his change of condition, swelling, and urine color in the catheter bag to the physician. On 08/20/24 at 04:15 PM, CMA R stated on 08/14/24 she had assisted R2 in the bathroom and tried to do catheter care the best she could. CMA R stated R2's penis and scrotum, the whole area was bulging and red. CMA R stated R2 had come out of his room, which was strange as he liked to stay in his room. CMA R stated in the bathroom R2 required two staff to get him up and clean him after a bowel movement. CMA R stated she reported that to LN I as well as the catheter bag, at first, she has thought the bag looked purple and was full of blood, but then went back and told LN I it was just urine. CMA R stated she told LN I R2's penis and scrotum looked inflamed and did not look right. CMA R stated after that LN I had a phone call and did not know if he looked at R2 or not. The facility policy Notification Parameters - Primary Care Provider [PCP] dated 10/13/21, revealed Licensed Nurses have the responsibility of contacting a PCP any time a resident has developed a clinical problem requiring PCP intervention. Prior to contacting the PCP, an assessment must be performed by the Licensed Nurse. The following information should be available and provided to the PCP, as appropriate: vital signs, findings from a complete focused head-to-toe assessment, current mental status and whether it was a change, current diagnoses, allergies, current medications, relevant laboratory work/diagnostic studies, actions already taken, presence of advance directives, and hospice care/comfort measures. If situations requiring immediate action, contact emergency medical services to request immediate transport to the hospital. Notify attending PCP of the transport as soon as possible. The staff were to document in the clinical record assessment findings, all attempts to contact the PCP, information provided to the PCP, PCP's response and orders, resident status and response. For non-immediate notifications, the staff should notify the physician during normal office hours and generally not later than the next regular office day. The facility failed to notify the physician timely regarding lack of monthly catheter changes for May, June, and July 2024 for R2. The facility failed to assess R2 and notify the physician of R2's condition changes timely on 08/14/24 at 09:00 PM, who then over 18 hours later, required emergency medical transport for further evaluation and treatment on 08/15/24 at 03:52 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 46 residents with five residents selected for review, including three residents sampled for accidents. Based on record review and interview, the facility failed to investigate a fall on 07/16/24, conduct a complete assessment, and implement a new intervention following the fall for Resident (R)1, that had previous falls in the facility. On 07/17/24, R1 had an additional fall, which the facility failed to complete an assessment and implement a new intervention following the fall. Additionally, the facility failed to notify the responsible party and the physician following falls on 07/16/24 and 07/17/24. Findings included: - The Diagnosis tab lacked diagnosis for R1. The Minimum Data Set (MDS) tab in the electronic medical record revealed R1 entered the facility on 07/12/24 and discharged on 07/17/24. The admission MDS was not due during R1's stay. The Fax sheet dated 07/12/24, from the physician office included diagnoses for medication use, which included mixed incontinence and dystonia (impairment in muscle tone). The Baseline Care Plan dated 07/12/24 at 09:19 AM, located in the attachment tab, revealed R1 was orientated to person and place and had upper and lower dentures. He used a walker for mobility and required supervision for walking, limited to extensive assistance for transfers, and limited assistance for bed mobility. R1 had incontinent and continent episodes of bowel and bladder and required staff assistance with peri-care. R1 was a fall risk and interventions included a low bed and a wireless bed alarm/pad. The Fall Risk Assessment Tool dated 07/13/24, assessed R1 with a risk score of 18 indicating a high risk for falls. The facility Incident log, dated 05/21/24 through 08/19/24, revealed R1 fell on [DATE] at 07:00 PM and acquired a skin tear, and again on 07/14/24 at 09:50 PM. The log lacked any additional falls. The Interdisciplinary Notes dated 07/12/24, revealed the facility installed a handlebar in front of the toilet in R1's room to prevent falls. The Interdisciplinary Notes dated 07/12/24 through 07/17/24 revealed R1 fell four times during his six-day stay at the facility. The Interdisciplinary Notes dated 07/13/24 at 11:14 PM, revealed at 07:00 PM, an unidentified Certified Nurse Aide (CNA) notified Licensed Nurse (LN) G that R1 was on the floor. LN G assessed R1 to be alert and oriented, sitting on the floor by the nurse's station door with one hand holding onto a chair. R1 had a skin tear to his right elbow. The assessment revealed the fall was witnessed by three unidentified CNA's/Certified Medication Aides (CMA's). R1 required two facility staff to assist him to a chair. R1 stated he was standing up to go to his room and missed his walker handle and fell bottom down. The facility staff reminded R1 to never get up alone without nurse's help. The Interdisciplinary Note dated 07/14/24 at 11:20 PM, revealed at approximately 09:50 PM, an unidentified CNA notified LN G that R1 was sitting on the floor facing his bed with a new brief in his hand. R1 stated he slid from the bed when trying to reach for something. R1 required two staff to assist him to bed and they placed a fall mattress next to his bed. The Interdisciplinary Notes dated 07/15/24 at 11:40 AM, revealed response received from his physician about R1's diagnoses which included R1 had dementia (progressive mental disorder characterized by failing memory, confusion). The Interdisciplinary Notes dated 07/16/24 at 05:25 AM, revealed at approximately 05:00 AM, an unidentified CNA notified LN G that R1 was bleeding from his mouth. LN G examined R1, who had a small bleeding open wound on the inside of the upper lip, which looked like he bit his lip. The Interdisciplinary Notes dated 07/16/24 at 10:01 AM, revealed R1 came out to breakfast and LN J examined his mouth and a cut was present on his upper lip. R1 stated he lost some of his teeth. LN J examined and R1 did not have his lower denture in place and a chipped tooth to the right front upper denture plate. R1 stated he fell out of bed onto the floor. The facility failed to fully investigate the fall, conduct neurological checks (an assessment of sensory neurons and motor responses, to determine whether the nervous system is impaired), and implement a new intervention following the fall to prevent further falls. Furthermore, the facility failed to notify the responsible party and the physician. The Interdisciplinary Notes dated 07/17/24 at 11:26 AM, revealed an unidentified CNA informed LN K that R1 was sitting on his fall mat. R1 was on a fall mat with just a brief on and required two staff to assist him to the edge of the bed. The note lacked any further information regarding the fall, lacked assessment of resident for injury, lacked any new interventions following the fall, and lacked notification to the responsible party and the physician. The facility Notification Report dated 07/13/24 through 08/20/24, for R1 revealed the facility notified R1's family member and the physician on 07/13/24 at 07:30 PM and of his fall. On 07/14/24 at 10:20 PM the facility notified R1's family member and at 10:50 PM notified R1's physician. The report lacked a fall on 07/16/24 and 07/17/24. On 08/20/24 at 01:55 PM, LN L reported when a resident reports a fall and unseen by staff or evidence of and /or injury evident, that would be treated as a fall. LNL stated when a resident falls, the staff were to notify the physician, responsible party and Administrative Nurse D. On 08/20/24 at 02:10 PM, R1's family member stated the staff informed her of the fall in the dining room and the next day when she came in R1 told her he had stumbled on the bed on his way back from the bathroom a little after 03:00 AM. The family member stated two days later the same thing happened during the night, R1 had tripped fell towards the side of the bed and when he was talking, she noticed he did not have his bottom plate in and the big tooth on the top plate was broken. R1's family member stated she was not made aware of those falls and when addressed with Administrative Nurse D why the staff did not notify her, Administrative Nurse D responded probably because it was the middle of the night. R1's family member stated she had told the facility to call her or text, she had her phone with her 24 hours a day, seven days a week. R1's family member stated it was that day she informed the facility she was going to take him home and did the following day as she felt the facility had neglected him. On 08/20/24 at 03:00 PM, attempted to reach CNA N for an interview, which was unsuccessful. On 08/20/24 at 03:03 PM, attempted to reach CNA O for an interview, which was unsuccessful. On 08/20/24 at 03:15 PM, attempted to reach LN G for an interview, which was unsuccessful. On 08/20/24 at 03:20 PM, Administrative Nurse D reported when a resident falls, staff were to use the facility's standard fall protocol, assess for injury, start vital signs, and start neurological checks if the fall had been unwitnessed or if there was a suspicion or observation of them hitting their head. Follow up vital signs are to be done for 72 hours after a fall, and notification to the physician and the family after every fall. If a resident with cognitive impairment says they fell out of the bed, then that should be investigated. Each fall should have a new intervention put in place. The facility policy Fall dated 10/12/22, revealed following a fall the staff were to assess the resident for injury, treat the initial injury, obtain a complete set of vital signs including one orthostatic (measurements of blood pressure and pulse taken with the patient in the supine, sitting, and standing positions to assess low blood pressure and possible blood pooling in the lower extremities resulting in dizziness) blood pressure, and blood sugar if indicated. The staff were to document assessment of resident and investigative elements, review the Fall Intervention Reference sheet for ideas and document in the care plan. Residents with unwitnessed falls should be considered to have hit their head unless they are a reliable historian and can definitely say they did not hit their head. Baseline neurological checks will be done on residents observed on the floor or have unwitnessed falls. With the occurrence of a fall, the staff were to notify the responsible party, physician, and the Registered Nurse (RN) supervisor. If off hours, the staff were to notify the RN on call. The facility failed to investigate a fall on 07/16/24, conduct a complete assessment, and implement a new intervention following the fall for Resident (R)1, that had previous falls in the facility. On 07/17/24, R1 had an additional fall, which the facility failed to complete an assessment and implement a new intervention following the fall. Additionally, the facility failed to notify the responsible party and the physician following the falls on 07/16/24 and 07/17/24.

The facility had a census of 48 residents, with three reviewed for the Center for Medicare and Medicaid Services (CMS) beneficiary liability notices. Based on record review and interview, the facility failed to provide a CMS Form 10055 which included the estimated costs for Resident (R) 32 and R41. This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare Advance Beneficiary Notice (ABN) Form 10055 informed the beneficiaries that Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services but lacked documentation regarding which option the residents choose. A review of the ABN Form 10055 provided to R32 (or their representative) lacked the estimated cost to continue services or which option R32 chose when the resident's skilled services ended on 04/09/24. A review of the ABN Form 10055 provided to R41 (or their representative) lacked the estimated cost to continue services and which option R41 chose when the resident's skilled services ended on 11/10/23. On 04/11/24 at 11:11 AM, Administrative Staff B stated she was responsible for providing the CMS Form 10055. Administrative Staff B verified the forms for R32 and R41 did not include the estimated cost to continue services or the option the residents or their representative chose. Administrative Staff B said she was unaware she was supposed to provide the estimated cost and said she must have missed the fact the residents or representatives had not chosen an option for the beneficiaries. On 04/11/24 at 11:11 AM, Administrative Staff A verified the facility lacked documentation staff provided the estimated cost on the ABN form. Upon request, the facility did not provide a policy regarding beneficiary notification. The facility failed to provide R32 and R41 with the estimated cost to continue services or the option chosen on the CMS Form 10055, placing the residents at risk for uninformed decisions regarding skilled services.

The facility had a census of 48 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide a clean, comfortable, and homelike environment in Resident (R) 35's room. This placed the resident at risk for impaired comfort and dignity. Findings included: - On 04/09/24 at 08:10 AM, observation revealed R35 rested in bed with his eyes closed. There was an overwhelming urine odor in the room. R35's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) was not visible. On 04/09/24 at 10:00 AM, R35's room door was open, and a strong urine odor was noted in the hall in front of R35's door to his room. Further observation revealed an approximately 12-inch (in) x 12-inch area of a yellowish wet spot visible on his sheet. R35 was not in his room. On 04/10/24 at 08:10 AM, observation revealed R35's door was closed, but an overwhelming urine odor was still evident by the entrance to his room. On 04/10/24 at 10:00 AM, observation revealed two maintenance staff cleaned R35's carpet and air-conditioner. There was a strong urine odor noted in the room. On 04/11/24 at 08:00 AM, R35's room door was closed, but a strong urine odor was noted by the door to his room. On 04/11/24 at 08:31 AM, observation revealed R35 sat up in bed with his glasses on. There was an overwhelming urine odor noted in the room. On 04/15/24 at 08;30 AM, observation revealed R35 rested in bed with his eyes open. There was a strong urine odor in the room. R35's clinical record including the plan of care lacked interventions or documentation regarding staff or facility efforts to decrease the urine odor in R35's room. On 04/11/24 at 01:17 PM, Licensed Nurse (LN) G) stated the urine odor in R35's room was from R35 emptying his urinary catheter bag. LN G said most of the time, the urine ended up on the floor. LN G said R35 refused to let staff assist him with emptying it. On 04/10/24 at 09:35 AM, Administrative Staff A verified the urine odor in R35's room and stated she was unaware of where the urine odor was coming from. Administrative Staff A said she would have maintenance clean the carpet and check the room out. On 04/10/24 at 10:16 AM, Administrative Nurse D stated R35 was fiercely independent and emptied his catheter bag himself. Administrative Nurse D said R35 frequently spilled urine on the carpet. Upon request, the facility did not provide a room cleaning policy. The facility failed to provide a clean, comfortable, and homelike environment for R35. This placed the residents at risk for impaired comfort and dignity.

The facility identified a census of 48 residents. The facility had three medication carts. Based on observation, record review, and interview, the facility failed to ensure reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently and per industry standards. This placed residents at risk of medication misappropriation. Findings included: - On 04/11/24 at 07:50 AM a review of the April 2024 Eight Hour Verification Controlled Substance Count sheet on the locked memory care unit revealed a missing signature either for the on-coming nurse signature or the off-going nurse signature on 13 of 62 opportunities. On 04/15/24 at 10:45 AM a review of the April 2024 Eight Hour Verification Controlled Substance Count sheet on the nurse's cart revealed a missing signature either for the on-coming nurse signature or the off-going nurse signature on four of 84 opportunities. On 04/15/24 at 10:50 AM a review of the April 2024 Eight Hour Verification Controlled Substance Count sheet on the medication aide's cart revealed a missing signature either for the on-coming nurse signature or the off-going nurse signature on 12 of 84 opportunities. On 04/11/24 at 07:50 AM Certified Medication Aide (CMA) R stated that the narcotic sign-on/off sheets should be signed by both the nurse and or medication aide when coming on shift or when going off shift after the narcotic count has been completed and reconciled by both staff. On 04/15/24 at 10:55 AM Licensed Nurse H stated that at the beginning or end of every shift, each staff member either coming on or going off their shift should be signing off that the count had been completed on the controlled narcotic medications. On 04/15/24 at 11:00 AM Administrative Nurse D stated she was aware that all the nursing staff passing medications had not been signing off and on for the narcotic counts as they should have been doing. Administrative Nurse D stated had just started a performance improvement project (PIP) to reconcile this issue. Administrative Nurse D stated the facility had not had an issue with controlled medications missing or the count being off on them. The Medication Storage-Controlled Meds policy last revised 10/08/21 documented that the nurse on duty who accepted the count would maintain possession of the key to the controlled medication storage areas at all times until the next count. The Count Reconciliation Log will be placed in front of each narcotic sign-out book. At the beginning of each narcotic count, count the number of medication accountability records to see that the number of count sheets matches the number on the reconciliation log. At each shift change, a physical inventory of controlled medications was to be conducted by two licensed/certified staff, one oncoming, and one offgoing, and was documented on the Eight Hour Verification Controlled Substances Count form. The Director of Nursing (DON) or designee should routinely complete an audit of controlled substances using the Weekly Narcotic Audit form. This audit was to ensure records were accurate and was a part of the community's Quality Assurance and Performance Improvement (QAPI) process. A record of the audit would be maintained in the quality assurance (QA) records. The facility failed to ensure an accurate reconciliation of controlled medications was completed. This placed residents at risk of medication misappropriation and diversion.

The facility had a census of 48 residents. The sample included 13 residents. Based on record review and interview, the facility failed to ensure the required members, including the infection preventionist, attended the Quality Assessment and Assurance (QAA) Committee meetings at least quarterly. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 04/12/23, 07/19/23, 10/18/23, 01/24/24, the facility's Quarterly Quality Assurance Performance Improvement (QAPI) Meeting Attendance Sheets lacked evidence the designated infection preventionist attended the meetings. On 04/15/24 at 12:30 PM, Administrative Nurse D verified the lack of a designated infection preventionist signature on the quarterly meeting sign-in sheets and stated the facility had not employed an infection preventionist at the times of the quarterly meetings. The facility's Quality Assurance Process Improvement Plan (QAPI), revised 01/15/24 documented that the goal of the QAPI was to promote autonomy while maintaining safety and quality of care. The steering committee, comprised of department directors, would oversee the QAPI process and would meet monthly to prioritize and monitor the plans in place as well as new projects. The facility failed to ensure the required participants, including the infection preventionist, attended QAPI/QAA meetings at least quarterly. This placed residents at risk of decreased quality of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 13 residents with one reviewed for positioning. Based on observation, interview and record review the facility failed to ensure proper positioning and utilize the positioning devicefor sampled Resident (R)1. This deficient practice placed the resident at risk for further decrease in range of motion. Findings included: - R1's Electronic Medical Record (EMR) documented a diagnosis of multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue, anxiety, depression). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10. The MDS documented R1 required supervision for eating and extensive assistance of two staff for all other activities of daily living (ADL). R1 had range of motion (ROM) impairment in one upper extremity and both lower extremities, used a wheelchair, received physical therapy, and restorative therapy. The ADL Care Plan, dated 11/03/22, directed staff to provide assistance of one staff for repositioning, ensure care when transporting wheelchair through doorways to reduce trauma to forearms and elbows. Encourage R1 to transfer to recliner or bed instead of sitting in a wheelchair. Transfer R1 with the standing lift and two staff; he could help reposition himself in his wheelchair if staff positioned him by a wall with a handrail. The Occupational Therapy discharge recommendations, dated 10/21/22, included partial to moderate assistance. R1 would position or reposition self while sitting in the wheelchair with supervision or touching assistance without the use of positioning devices. On 11/21/22 at 08:20 AM, observation revealed R1 sat in his wheelchair at a dining table independently eating. R1 leaned to his left with his head leaning over. The wheelchair had a headrest for positioning, but R1's head and neck area leaned too far over to touch it. The wheelchair lacked a cushion or other positioning device on his left side. R1's left elbow, wrapped with gauze, hung over the side of his wheelchair arm. During the meal, staff did not attempt to re-position the resident. On 11/21/22 at 12:05 PM, observation revealed R1 sat at the dining table, leaning to his left side with a short-sleeved shirt on. Speech therapy sat at the table with four male residents. During the meal, staff did not attempt to re-position the resident. R1 ate independently with some food spilled onto his shirt protector. On 11/21/22 at 12:00 PM, Certified Nurse Aide (CNA) M stated sometimes R1 could reposition himself. On 11/22/22 at 08:55 AM, Administrative Nurse D stated the resident had removed or refused to leave in place a positioning device in his wheelchair and the facility lacked documentation of resident education. On 11/22/22 at 12:18 PM, Therapy Staff GG searched for a lateral cushion for R1's wheelchair. Therapy Staff GG stated R1 used to be in another wheelchair and therapy worked with him on toning. Therapy Staff GG stated therapy staff got an arm cushion for the armrest, but R1 kept removing it. He stated the lateral cushion was supposed to be in R1's wheelchair. Upon request the facility did not provide a policy for positioning. The facility failed to ensure proper positioning in the wheelchair for R1, placing him at risk for less than optimal positioning for eating and swallowing and at risk for further decline in abilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 14 residents with three reviewed for bowel and bladder. Based on observation, interview, and record review the facility failed to provide catheter (tube inserted into the bladder to drain urine) care routinely, including monitoring urinary output as ordered and directed by the plan of care. This deficient practice placed R1 at risk for complications of urinary catheter use. Findings included: - R1's Electronic Medical Record (EMR) documented a diagnosis of multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue, anxiety, depression). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10. The MDS documented R1 required supervision for eating and extensive assistance of two staff for all other activities of daily living (ADL). R1 had range of motion (ROM) impairment in one upper extremity and both lower extremities, used a wheelchair, received physical therapy, and restorative therapy. The Neurogenic Bladder Care Plan, dated 11/03/22, directed staff to provide care for the #22 catheter with a five cubic centimeters (cc) bulb, flush with 12 cc sterile water in the bulb. The care plan instructed staff to flush the catheter per urologist orders, place a towel around the stoma site of the suprapubic catheter (catheter inserted through the abdominal wall into the bladder) when leakage occurs, and provide catheter care every shift and as needed (prn). Staff were to empty the drainage bag every shift, place the tubing/catheter under clothing, and ensure the tubing and bag did not touch the floor or become elevated above his bladder. Staff were to ensure the catheter appropriately positioned during transfers to prevent any obstruction, infection control issue and accidental removal, observe for Urinary Tract Infection (UTI), encourage fluids, and obtain labwork per physician orders. The Physician Order, dated 01/07/22, directed staff to change the suprapubic catheter 22 Fr. monthly catheter, provide catheter care every shift, change drainage bag every 14 days and prn. The order directed staff to monitor R1's intake and output every shift. The facility's record of R1's urinary output lacked documentation for 20 shifts for 11/01/22 through 11/20/22 and lacked 10 shifts of catheter care documentation. On 11/21/22 at 01:12 PM, observation revealed Certified Nurse Aide CNA) M and CNA S used a sit to stand lift to transfer R1 from his wheelchair to his recliner. CNA S hung the catheter drainage bag on the knee rest of the lift. The catheter tubing was inside his brief and security strap on his left thigh. Observation revealed CNA M provided incontinence care and then, after transferring R1 to his recliner, hung the catheter bag to dependent drainage on recliner in a privacy bag. On 11/21/22 at 01:17 PM, observation revealed CNA S emptied the catheter drainage bag. She placed a clean paper towel on the floor and put the measuring container on it, drained the collection bag and disinfected the port and port holder with an alcohol wipe. CNA S measured and observed the drained urine. On 11/21/22 at 01:17 PM, CNA S stated she emptied the urinary catheter in the morning approximately 0:630 AM, and at end of shift at 01:15 PM, daily. On 11/21/22 at 05:15 PM, Licensed Nurse (LN) I verified the lack of thorough catheter output monitoring by staff and the missing spaces for catheter care documentation. On 11/22/22 at 08:55 AM, Administrative Nurse D verified the facility lacked documentation of R1's catheter care and output as ordered, and care planned. Upon request the facility failed to provide a policy for urinary catheter use. The facility failed to routinely provide care and monitoring for R1's urinary catheter as physician ordered and care planned, placing R1 at risk for complications of urinary catheter use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 13 residents, with three reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary dementia (progressive mental disorder characterized by failing memory and confusion) for Resident (R) 32, who had dementia related behaviors. This placed the resident at risk decreased quality of life and unmet needs. Findings included: - The Electronic Medical Record (EMR) for R32 documented diagnoses of dementia without behavioral disturbance and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R32 had severely impaired cognition and required supervision of one staff for transfers, ambulation, wandered daily and had unsteady gait. The MDS further documented R32 intruded on others, wandered to dangerous places one to three times per week, had a motion sensor, and a wander/elopement alarm. The Care Plan, dated 11/16/22 documented R32's behaviors have an impact on others as residents become upset with R32 when she goes into their rooms or attempts to push them in their wheelchairs. The care plan further documented offer R32 a snack, go outside to sit when she wandered, had a motion sensor in her room to alert staff when she wandered at night, and check her personal alert band on her wrist for placement and functioning every day. The Nurse's Note, dated 09/03/22 at 03:48 PM, documented R32 walked up and down the hall entering a different resident's room, when a Certified Nurse Aide (CNA) attempted to redirect the resident, she raised her hand back but stopped prior to bringing it forward in a striking manner as though she recognized and was able to redirect her actions. The note further documented R32 looked at the CNA and stated in a loud, high pitched voice, That's not my husband and exited the room quickly. R32 ambulated to the dining room area and rested in a chair for approximately 15 minutes and attempted to enter other resident rooms. Redirection was attempted by a CNA but resident continued forward, pushing against the staff. The note documented R32 required consistent one on one observation and redirection. The Nurse's Note, dated 09/11/22 at 09:37 AM, documented R32 was agitated, appeared to believe another resident was her husband, followed him around and attempted to hang onto him. The note further documented staff attempted to intervene and inform her that the resident was not her husband. The male resident told R32, I'm not your husband, and attempted to walk away. R32 began to follow the male resident and staff attempted to redirect her but she became increasingly agitated and grabbed at the staff arms. The note documented the doors to the hall was shut in an attempt to keep R32 from following the male resident but R32 was able to push on the door and open it. The Nurse's Note, dated 09/21/22 at 06:16 PM, documented R32 walked up to another wheelchair bound resident and insisted on pushing the resident down the hallway. The note further stated the other resident intermittently allowed R32 to put her but when she would tell R32 to stop or to leave her alone R32 became frustrated, attempted to shake handles or ignored the other residents request to stop. Staff redirected R32 multiple times and removed the other resident from the area. The Nurse's Note, dated 09/25/22 at 02:17 PM, documented R32 was noted to push around another resident who was in a wheelchair. The wheelchair resident asked R32 to stop which caused R32 to turn the other resident around and push her into the sofa. The noted further documented staff intervened and took the other resident out of the area. The Nurse's Note, dated 11/09/22 at 07:02 PM, documented R32 had increased behaviors throughout the day such as entering other resident rooms, pushing other residents in wheelchairs without consent, and continued to push the resident's after residents and staff have redirected. Continued redirected caused R32 agitation to increase with R32 cussing at staff. The note documented staff would continue to initiate intervention and only observe when possible. On 11/21/22 at 09:06 AM, observation revealed R32 wandered into R9's room, and staff had to redirect the resident. On 11/21/22 at 09:20 AM, CNA O stated when R32 wandered, they would redirect her and if it didn't work, other staff would try. On 11/22/22 01:48 PM, Licensed Nurse (LN) I stated staff try redirection or distraction with R32 when she had behaviors. LN I further stated R32 wandered and would often become close to being combative with staff but never to residents. LN I stated R32 was not on any medication for her behaviors and did not see any other doctor except for there primary care doctor. LN I stated she had training for behaviors through her computerized mandatory training. On 11/22/22 at 04:15 PM, Administrative Nurse D stated staff try to do activities with R32 when she had behaviors as well as redirection. Administrative Nurse D further stated when the weather was nice, they would take R32 outside. Upon request a policy for Resident Behaviors was not provided by the facility, The facility failed to provide the necessary dementia care and services for R32, who had dementia related behaviors, placing the resident at risk for unmet needs.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide routine pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs for one of six reviewed for unnecessary medications, when staff failed to reorder R26's lidocaine 5% patch(a soft, stretchy adhesive patch containing 5% lidocaine (700 mg), daily, for the topical treatment of pain). This placed the resident at risk for ineffective medication regimen. Findings included: - R26's Electronic Medical Record (EMR) documented the resident had diagnoses of Parkinson's (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), chronic (persisting for a long period, often for the remainder of a person's lifetime) pain, osteoarthritis (chronic arthritis without inflammation), age related physical debility, and pain in left and right shoulders. R26's Quarterly Minimum Data Set (MDS), revised on 10/06/22, documented tR26 had a Brief Interview for Mental Status score of 14, which indicated intake cognition. The MDS documented the resident required extensive staff assistance with activities of daily living (ADLs) except supervision with eating. The MDS documented R26 had impairment on one side of upper extremity and both sides lower extremities. The MDS documented the resident had frequent pain and received scheduled and as needed (prn) pain medications and non-medication interventions for pain. The MDS documented R26 received an opioid (narcotic used to treat pain) medication once in the look back period. The ADL Care Plan, revised 10/06/22, documented the resident had impaired physical function related to Parkinson disease, required extensive two staff assistance with ADL's such as repositioning, toileting, bathing, grooming and transferring and instructed staff to use a sling lift for transfers. The Pain Care Plan, revised 10/06/22, documented 26 had chronic pain due to arthropathies, osteoarthritis, edema, and peripheral venous insufficiency which had affected her ADLs and activity participation. The care plan documented R26 received gabapentin (medication used to relieve nerve pain), Tylenol, a fentanyl patch(used for the management of persistent, moderate to severe chronic pain in opioid-tolerant patients when a continuous, around-the-clock opioid and a lidocaine patch for pain management. The November 2022 Medication Administration Record revealed R26's lidocaine patch was unavailable on 11/19, 11/20,and 11/21. R26's EMR lacked documentation the physician or pharmacy had been contacted regarding the unavailability of R26's lidocaine patch. On 11/21/22 at 2:45 PM, Certified Medication Aide (CMA) R stated when the resident was down to one or two lidocaine patches she would call the pharmacy and get them refilled. If the pharmacy does not deliver the patches on her shift the next shift should see it is unavailable should notify the pharmacy and the physician. On 11/21/22 at 03:00 PM, Administrative Nurse D stated she was unaware R26' lidocaine patch was unavailable for the last three days. Administrative Nurse D stated staff should have reordered it and if it was still unavailable should notify her, the pharmacy, and the physician. Administrative Nurse D stated she would go and call the pharmacy for the refill on the medication. On 11/21/22 at 03:34 PM, Licensed Nurse (LN) I stated she was unaware R26's lidocaine patch was unavailable and had not been reordered, ideality the protocol was to contact the pharmacy, if the next person on the following shift had not received it they should call again until the medication outage had been addressed. LN I stated usually the medication aide or the nurse will pass on in report if the medication is not received that evening. LN I stated usually staff reorder whatever it is color coated on the blister package 5 days ahead on a lidocaine patch box it is reordered when there is two left. LN I stated it was her understanding the lidocaine patch had not been reordered. The facility's Medication Administration Policy, revised 03/15/22, documented if medication is ordered but not present: notify the charge nurse check pharmacy delivery sheet for listing notify pharmacy to request emergency dose notify physician retrieve dose immediately if beyond standards of proactive for time , complete medication error report, notify physician and family, submit to Quality Assurance Program Improvement officer. The facility failed to provide routine pharmaceutical services to meet the needs of R26 when staff failed to address the unavailability of R26's lidocaine patch for three days. This placed the resident at risk for ineffective medication regimen.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to the facility failed to ensure Resident (R)190's medication administration was free from significant errors when staff crushed an extended-release medication. This placed the residents at risk for the medications being improperly released. Findings included: - On 11/21/22 at 09:38 AM, observation revealed Certified Medication Aide (CMA) T, during medication administration, crushed R190's metoprolol succinate (medication used to lower blood pressure), 25 milligram (mg,) extended release (ER)and placed it in a medication cup by itself. Observation revealed CMA T checked the resident's pulse and blood pressure and stated they were within parameters, then placed the metoprolol in a medication cup with the other medications in clear thickened liquid and administered the medications to R190. On 11/21/22 at 12:58 PM, CMA T verified he had crushed the above medication and was unaware he was not supposed to. CMA T pulled up R190's Electronic Medical Record (EMR) and stated there was no warning on his screen. On 11/21/22 at 2:00PM, Administrative Nurse D verified R190's EMAR lacked a warning for her metoprolol succinate ER was not to be crushed. Administrative Nurse D stated she was aware the medication should not be crushed, and she would place a warning in the computer. On 11/28/22 at 3:52 PM, Consultant Staff II stated typically metoprolol ER medications should not be crushed. Consultant Staff II stated if a resident had troubles swallowing the medication and it was scored it could be broken in half but not crushed. Consultant Staff II stated when metropolot ER was crushed it affects the way the medication was released. It was intended to be released gradually over 24 hours, if crushed the medication could be released all at once. The facility's Medication Administration Policy, revised 03/15/22, document medication that should not be crushed or chewed the solid dosage forms of May medications should not be crushed or chewed for a variety of reasons. When a resident's condition prohibits the administration of solid dosage forms (tablets, capsules etc.) the nurse administering the medication should check to see that there are no contraindications to crushing the medications in question. if crushing is contraindicated, the nurse should consult the pharmacist for assistance in obtaining the medication in liquid form, if possible and obtain a physician order to change dosage forms and directions. The facility failed to ensure R190's medication administration record was free from significant medication errors, when staff crushed her metoprolol succinate extended release medication. This placed the residents at risk for receiving an inaccurate dose of medication.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to maintain Resident (R) 15's oxygen tubing, nasal cannula and breathing treatment mask in a sanitary fashion which placed R15 at risk for respiratory illness. Findings included: - On 11/17/22 at 09:33 AM observation revealed R15's nasal cannula oxygen tubing had been uncovered laying on the floor next to the oxygen canister. On 11/17/22 at 11:42 AM observation revealed R15's breathing treatment mask sat on the bedside table uncovered. On 11/22/22 at 11:30 AM observation revealed R15's oxygen tubing and nasal cannula uncovered draped over the oxygen concentrator. On 11/22/22 at 11:34 AM Licensed Nurse I verified the observation of the oxygen tubing, nasal canula and breathing treatment mask had been uncovered and should have been stored in a plastic bag. On 11/22/22 at 12:22 PM Administrative Nurse D stated staff should store oxygen cannula and breathing treatment mask in a plastic bag or some kind of storage container. The facility's Oxygen Therapy policy, dated 10/08/21, documented oxygen can be delivered by nasal cannula, several types of masks, hookups, etc. The policy further documented when devices are not in use, store in a plastic or other bag to keep tubing and device off floor, and appropriate infection control measures with handling tubing and use of breathing treatment mask. The facility failed to store oxygen tubing, nasal canula, and a breathing treatment mask in a sanitary manner which placed the R15 at risk for respiratory illness.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to educate residents routinely of their Resident Rights which placed the resident at risk for inability to exercise their rights. Findings included: -On 11/22/22 record review of the Resident Council Meeting Minutes revealed a lack of evidence staff reviewed the Resident Rights. On 11/22/22 at 01:30 PM Resident Council member, Resident (R) 26, reported the staff had not reviewed the Resident Rights during the Resident Council meetings. On 11/22/22 at 03:15 PM Social Service Designee (SSD) X stated she had not reviewed the Resident Rights during the Resident Council meetings. SSD X stated the Resident Rights were given on admission, mailed out for the care plan meetings, and staff inquired after care plan meetings if residents had concerns related to their rights. Upon request the facility failed to provide a policy related to Resident Rights. The facility failed to review/educate residents routinely of Resident Rights which placed the resident's at risk of impaired autonomy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, The facility failed to place interventions on the care plan to prevent falls for Resident (R) 9, and R12, failed to add interventions related to the positioning device for R1, and bowel management for R37. This placed the residents at risk for uncommunicated care needs. - The Electronic Medical Record (EMR) for R9 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required set up assistance with supervision for bed mobility, transfers, ambulation, had steady balance, and had no functional impairment. The MDS further documented R9 had two injury falls and had a wander alarm (designed to help protect residents against elopement). R9's Quarterly MDS, dated 07/18/22, documented R9 had intact cognition and required set up assistance with supervision for bed mobility, transfers, ambulation, had steady balance, and had no functional impairment. The MDS further documented R9 had two non-injury falls, wandered one to three days per week and had a wander alarm. The Fall Risk Assessment, dated 10/24/21, 12/09/21, 04/09/22, 07/02/22, 07/24/22, 09/04/22, 11/09/22, and 11/17/22 documented R9 was a high risk for falls. The Care Plan, dated 09/28/22, originally dated 12/13/21, directed staff to ensure R9 had nonslip socks on at bedtime to prevent falls. The update, dated 04/12/22, directed staff to ensure my foam mattress pad was secured in place before R9 laid down in bed and put nonskid socks on the resident. The update, dated 04/21/22, directed staff to check the placement of her personal alert band every shift and functioning daily. The update, dated 06/29/22, directed staff to place a bolster (a long, thick pillow or cushion placed under other pillows for support), on the edge of R9's bed to help define it when she was asleep. The update, dated 07/22/22, directed staff to encourage R9 to lie down if staff see the resident sitting on the side of the bed in the middle of the night. The update, dated 07/26/22, directed staff to ask the resident if she would like to sit in the recliner when she was restless. The update, dated 08/14/22, directed staff to ask R9 if she would like to sit in the commons area in a recliner so she would not fall asleep on the ed of the bed and slide out of bed. The update, dated 08/12/22, directed staff to not allow R9 to keep scissors in her room because she cuts off her wanderguard. The update, dated 09/04/22, directed staff to ensure the bolster was in place throughout the night. The update, dated 10/29/22, directed staff to ensure there was only one layer on the seat of her chair. The update, dated 11/08/22, directed staff to ask R9 if she would like help lying back down or sit in her recliner to prevent her from falling or sliding off her bed. The update, dated 11/15/22, directed staff to check her feet during the night to make sure the nonskid socks have not been removed. The Nurse's Note, dated 04/12/22 at 11:55 PM, documented R9 fell on the floor next to her bed, her right was leg stretched out and the left leg bent and crossed underneath her. R9 stated, Just like the other day, I was sitting and suddenly I was sliding. R9 pointed to the foam mattress and stated, this was part of the problem. The note further stated R9 did not receive any injury. The Nurse's Note, dated 06/29/22 at 01:08 AM, documented R9 fell out of her bed. The note further documented the nurse went to the resident's closet and placed a bolster pillow on the side of the resident's bed. The note further documented R9 did not receive any injury. The Nurse's Note, dated 07/21/22 at 05:43 AM, documented R9 rolled out of bed onto the floor. The note further documented R9 most likely fell asleep while seated on the side of the bed and did not receive any injury. The Nurse's Note, dated 07/24/22 at 04:00 AM, documented R9 rolled out of bed onto the floor. The note further documented R9 did not receive any injury. The Nurse's Note, dated 08/14/22 at 12:30 AM, documented R9 had slid out of bed onto the floor. The note further documented R9 did not receive any injury. The Nurse's Note, dated 10/29/22 at 08:00 AM, documented R9 slid out of her recliner to the floor. The note further documented there were five blankets and sheets in the recliner. The note further documented R9 did not receive any injury. The Nurse's Note, dated 11/08/22 at 02:50 AM, documented R9 slid off the bed onto the floor. The note further documented R9 did not receive any injury. The Nurse's Note, dated 11/15/22 at 09:00 AM, documented R9 slid off the bed onto the floor. The noted further documented R9 obtained a skin tear (a traumatic wound caused by mechanical forces) to right hand 2 centimeter (cm) long and 0.2 cm wide. The wound was cleansed and an Aquacel dressing (a moisture-retention dressing) was placed on the residents right hand. On 11/21/22 at 08:45 AM, observation revealed Licensed Nurse (LN) I placed R9's walker in front of her, assisted her to stand, and LN I walked with the resident to a recliner in the dining room. On 11/21/22 09:06 AM, LN I stated when the resident fell, the nurse was able to implement an immediate intervention and when the administration had a weekly risk meeting, they would decide if they wanted to keep the intervention or change it. LN I stated R9 was starting to have dementia and would fall when she would try to get up alone. LN I further stated because she had intermittent confusion, staff put the soft call light close to her in hopes she would use it when she needed to get up. On 11/21/22 at 03:00 PM, Certified Nurse Aide (CNA) N stated R9 was often confused and would get up on her own and fall. On 11/22/22 at 03:45 PM, Administrative Nurse D stated, R9 had falls and staff would try to put new interventions into place to prevent her from falling. The Care Plan Guideline policy, dated 10/19/21, lacked direction for reviewing and updating care plans. The facility failed to implement different interventions to prevent further falls for R9 which placed R9 at risk for further falls and or injury. - R37's Electronic Medical Record (EMR) documented the resident admitted to the facility on [DATE] with a diagnosis of an ileus. R37's Significant Change Minimum Data Set (MDS), dated [DATE], documented R37 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R37 required extensive staff assistance with most activities of daily living (ADL) except supervision with eating. The MDS documented R37 was always continent of bowel and not on a bowel toileting program. R37's Care Area Assessment (CAA) did not trigger for bowels. R37's ADL Care Plan, documented the resident had impaired physical function related to left femoral neck fracture, weakness, and impaired mobility. The care plan documented an intervention dated 10/27/21 directing R37 required limited to extensive staff assistance with ADL such as grooming, repositioning, toileting, bathing, transfers, and locomotion. An intervention dated 05/23/22 directed staff not to leave R37 alone in the bathroom. The care plan lacked direction to staff regarding bowel management or R37's history of ileus until after 09/02/22. The Nurse's Note, dated 08/21/22 at 04:18 PM, documented at 12:30 PM, R37 reported to the nurse she had stomach pain, nausea, and a protruding (bulging) abdomen. R37 reported she had not had a bowel movement (BM) that day. The note recorded the BM charting revealed R37 had a large BM on 08/20/22. The note documented staff assisted R37 to a commode per R37's request and R37 had a large liquid stool. The Nurse's Note, dated 08/22/22 at 04:27 PM, documented staff reported to R37's family member the resident was not conversing that day per usual. R37 complained of abdominal discomfort. The note lacked evidence the staff performed an abdominal/bowel assessment in response to R37's complaint or condition. Review of R37's Bowel Observation Sheet and the EMR revealed R37 had no recorded bowel movement from 08/22/22 through 08/25/22. R37's clinical record lacked evidence and/or documentation staff preformed a bowel assessment in response to the lack of bowel movements. The Bowel Observation Sheet documented on 08/26/22 R37 had one bowel movement and on 08/27/22, the record indicated R37 had two bowel movements. The Nurse's Note, dated 08/28/22 at 05:00 PM, documented R37's family member voiced concern about R37's stomach and how never been so big. The note documented R37's abdomen was distended since admission, appeared to have increased in size recently. R37's family member stated, if R37 did not have a bowel movement here soon, she's going to explode or she'll need to go to the hospital. The note documented the family member requested R37 have something to make her have a bowel movement. The note documented staff reviewed and noted the bowel movements from the two previous days, administered an as needed medication from a standing order, but failed to assess R37's bowel sounds to identify concerns prior to administration of the medication. The Nurse's Note, dated 08/29/22, documented R37 had increased abdominal pain and distention and was sent to the emergency room (ER). The Nurse's Note, dated 08/29/22 at 06:12 PM, documented a family member reported to the facility R37 admitted to the hospital for diagnoses of bowel obstruction. The Nurse's Note, dated 09/02/22 at 12:48 PM, documented R37 was readmitted to the facility on hospice (end of life care) services regarding a diagnosis of unresolved ileus. On 11/22/22 at 09:18 AM, Administrative Nurse D verified staff had not assessed R37's bowels on the dates recorded above. Administrative Nurse D stated staff should have assessed R37's bowels on those dates, should have measured her abdomen girth, and should have sent her to the emergency room earlier. Administrative Nurse D confirmed she could not see interventions on the care plan prior to 09/02/22, for bowel management and/or care of an ileus but stated the MDS coordinator would need to verify because Administrative Nurse D was not familiar with where the information would be found. On 11/22/22 at 12:09 PM, LN H verified R37's care plan lacked a section for bowel management and stated the computer program did not have a section for bowel management, so it was sometimes placed in the ADL section of the care plan. LN H verified R37's care plan lacked directives related to bowel management in any section. The facility's Care Plan Guidelines Policy, revised 10/19/21, documented the community must develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical nursing, and psychosocial needs identified in the comprehensive assessment. The policy documented the comprehensive assessment would be periodically reviewed and revised by a team of qualified persons. The facility failed to update R37's, who was admitted to the facility with history of ileus, care plan with a section regarding bowel management. - R12's Electronic Medical Record (EMR) documented diagnoses of macular degeneration (common eye disorder which causes blurred or reduced central vision), hypertension (high blood pressure), and diabetes (the body doesn't make enough insulin or can't use it as well as it should). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14. The MDS documented R12 required supervision for all activities of daily living (ADL), unsteady balance but able to stabilize self, and no range of motion impairment. R12 used a walker or wheelchair and had one minor injury fall since the previous assessment. The Fall Care Plan, undated, directed staff to ensure the room free of clutter due to R12's macular degeneration. The care plan directed staff to ensure R12 had a walker for ambulation, ensure his bed in proper position, and remind him to sleep in the middle of his bed. Further interventions included: Non-skid socks to bed (8/2/22 fall). Place locked walker right in front of bed (10/17/22 fall). Door open at night (10/25/22 fall) remind to use wheelchair and staff assistance for toileting (10/28/22 fall). Adjust bed to lower position where feet are firmly planted on the floor when he sits on the edge of his bed (fall 11/10/22). This same intervention had been on the care plan since October 2021. The Fall Risk Assessments, dated 01/24/22 through 10/17/22 all indicated R12 was a high risk for falls. The Fall Note, dated 08/2/22 at 02:00 AM, documented staff found R12 on the floor of the bathroom, barefoot and wearing a pearl snap long sleeve shirt and pull up. His walker was in the doorway of the bathroom and resident was incontinent and sitting in a very large puddle of liquid. The nurse assisted the resident to put on another pearl snap shirt and he stated he was feeling much better. Staff notified family and notified the physician by fax. The Fall Note, dated 10/17/22 at 04:02 PM, documented an aide reported the resident was on the floor. The nurse found the resident with his head near foot of bed and feet out towards center of room, on his back with both legs bent at knees, feet off floor, and arms to his side. Resident stated to nurse I'm not hurt anywhere, and I didn't hit my head No injury noted at this time. The resident stated, I just slid out of bed. The note documented the nurse put in a work order for maintenance to apply nonskid strips next to bed. The Fall Note, dated 10/25/22 at 12:55 AM, documented staff found R12 on the floor, injured, and bleeding from his head. The resident was on the floor next to his bed with his back against the side of the bed, bleeding from the top of his head, right eyebrow and lower eye lid, and right hand. He was barefoot, wearing pajama pants, and a button up shirt. R12 stated he stood up from his recliner to go to the bathroom and missed the handle when he reached for his walker, causing him to fall forward, face first into the floor. Resident was alert and oriented but was anxious and distracted by his need to get to the bathroom. The nurse faxed his physician about the injury fall and transfer to the emergency room. The resident returned from the emergency room with lacerations and skin tears, six stitches to right hand, two stitches under right eye, two stitches above right eyebrow, and three stitches to the top of his head. The Fall Note, dated 10/28/22 at 07:15 AM, staff found the resident on his floor lying supine, knees bent, clothed in pajamas without socks. The resident stated I didn't fall. I was walking back form the bathroom and felt like my legs just couldn't make it, so I sat down right here. The Fall Note, dated 11/10/22 at 09:12 AM, documented R12's call light was on and an aide found the resident on the floor. The resident stated he slipped out of bed, that he didn't hurt himself or hit his head. Care plan updated to have nightshift shift check that resident has gripper socks on. On 11/21/22 at 09:41 AM, observation revealed R12 in bed, feet elevated with gripper socks on. He sat up on the side of the bed with his feet on the floor, his walker in reach of the bed, call light in reach, and the bed in position for easy exit for the resident. On 11/21/22 at 1200 PM, Certified Nurse Aide (CNA) M stated R12 was independent in his room, would occasionally call for assistance, but usually stayed in his bed except for toileting. On 11/22/22 at 09:03 AM, Administrative Nurse D verified the fall care plan included the same intervention twice and staff should attempt to find the root causes of the falls to find different interventions The Fall policy, dated 10/12/22, documented following a fall staff were to document assessment of the resident and investigative elements, review Fall Intervention Reference Sheet for ideas to implement and document in the care plan. The QA nurse would review fall interventions in the care plan and update as needed. The Care Plan Guideline policy, dated 10/19/21, lacked direction for reviewing and updating care plans. The facility failed to implement different interventions to prevent further falls for R12 who experienced four falls in a 30-day period. This deficient practice placed R12 at risk for further falls and or injury. - R1's Electronic Medical Record (EMR) documented a diagnosis of multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue, anxiety, depression). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10. The MDS documented R1 required supervision for eating and extensive assistance of two staff for all other activities of daily living (ADL). R1 had range of motion (ROM) impairment in one upper extremity and both lower extremities, used a wheelchair, received physical therapy, and restorative therapy. The ADL Care Plan, dated 11/03/22, directed staff to provide assistance of one staff for repositioning, ensure care when transporting wheelchair through doorways to reduce trauma to forearms and elbows. Encourage R1 to transfer to recliner or bed instead of sitting in a wheelchair. Transfer R1 with the standing lift and two staff; he could help reposition himself in his wheelchair if staff positioned him by a wall with a handrail. The Occupational Therapy discharge recommendations, dated 10/21/22, included partial to moderate assistance. R1 would position or reposition self while sitting in the wheelchair with supervision or touching assistance without the use of positioning devices. On 11/21/22 at 08:20 AM, observation revealed R1 sat in his wheelchair at a dining table independently eating. R1 leaned to his left with his head leaning over. The wheelchair had a headrest for positioning, but R1's head and neck area leaned too far over to touch it. The wheelchair lacked a cushion or other positioning device on his left side. R1's left elbow, wrapped with gauze, hung over the side of his wheelchair arm. During the meal, staff did not attempt to re-position the resident. On 11/21/22 at 12:05 PM, observation revealed R1 sat at the dining table, leaning to his left side with a short-sleeved shirt on. Speech therapy sat at the table with four male residents. During the meal, staff did not attempt to re-position the resident. R1 ate independently with some food spilled onto his shirt protector. On 11/21/22 at 12:00 PM, Certified Nurse Aide (CNA) M stated sometimes R1 could reposition himself. On 11/22/22 at 08:55 AM, Administrative Nurse D stated the resident had removed or refused to leave in place a positioning device in his wheelchair and the facility lacked documentation of resident education or previous care plan interventions regarding positioning. On 11/22/22 at 12:18 PM, Therapy Staff GG searched for a lateral cushion for R1's wheelchair. Therapy Staff GG stated R1 used to be in another wheelchair and therapy worked with him on toning. Therapy Staff GG stated therapy staff got an arm cushion for the armrest, but R1 kept removing it. He stated the lateral cushion was supposed to be in R1's wheelchair. The Care Plan Guideline policy, dated 10/19/21, lacked direction for reviewing and updating care plans. The facility failed to care plan proper positioning in the wheelchair for R1, placing him at risk for less-than-optimal positioning for eating and swallowing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 13 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for five sampled residents. Resident (R) 9, R32, R22, and R26. This placed the residents at risk for complications related to poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R9 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required limited assistance of one staff for bathing and set up assistance with supervision for all other ADLs. The MDS further documented R9 had no skin issues. The Care Plan, dated 09/28/22, directed staff to encourage R9 to take baths or showers and remind her it was good for her skin. The care plan documented R9 preferred whirlpool baths in the evenings and directed staff to assist her with drying afterwards. The August and September 2022 Bathing and Facility Bathing Sheets, documented R9 requested showers on Wednesday and Saturday and documented R9 had not received a bath or shower during the following days: 08/11/22-09/08/22 (29 days) 09/11/22-09/23/22 (13 days) The EMR lacked documentation R9 refused a shower or bath. The October and November 2022 Bathing and Facility Bathing Sheets, documented R9 requested showers on Wednesday and Saturday and documented R9 had not received a bath or shower during the following days: 10/02/22 - 10/14/22 (13 days) 10/15/22-11/15/22 (32 days) The EMR lacked documentation R9 refused a bath or shower. On 11/17/22 at 12:15 PM, observation revealed R9 at the dining table, her hair was very disheveled. On 11/22/22 at 08:49 AM, observation revealed R9 seated on the couch, her hair was very disheveled. On 11/21/22 at 03:00 PM, Certified Nurse Aide N stated staff chart bathing in the kiosk (a small, standalone device providing information for staff on a computer screen and was often used for entering services provided) as well as a shower sheet. CNA N stated R9 did not typically refuse her showers but if she did, they chart refused. On 11/22/22 at 03:30 PM, Licensed Nurse (LN) I stated they had just recently started using shower sheets and if a resident refused, they would try to encourage and offer alternatives. On 11/22/22 at 04:15 PM, Administrative Nurse D stated R9 did not refuse showers and felt staff did not document showers appropriately. Upon request, a policy for Bathing was not provided by the facility. The facility failed to provide R9 consistent bathing services as care planned, placing her at risk for complications related to poor hygiene. - The Electronic Medical Record (EMR) for R22 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), disorientation (having lost ones sense of direction), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition and required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS further documented R22 had no skin issues. The Care Plan, dated 09/28/22, documented R22 preferred to shower in the mornings, offer her a shower twice per week, and the beauty shop would wash her hair. The August and September 2022 Bathing and Facility Bathing Sheets, documented R22 requested showers on Sunday and Thursday and documented R22 had not received a bath or shower during the following days: 08/08/22-09/14/22 (38 days) The EMR lacked documentation R22 refused a bath or shower. The October 2022 Bathing and Facility Bathing Sheets, documented R22 requested showers on Sunday and Thursday and documented R22 had not received a bath or shower during the following days: 10/01/22-10/26/22 (26 days) The EMR lacked documentation R22 refused a bath or shower. The November 2022 Bathing and Facility Bathing Sheets, documented R22 requested showers on Sunday and Thursday and documented R22 had not received a bath or shower during the following days: 11/08/22-11/19/22 (12 days) The EMR lacked documentation R22 refused a bath or shower. On 11/17/22 at 12:15 PM, observation revealed R22 at the dining table, her hair was disheveled. On 11/21/22 at 12:59 PM, observation revealed R22 in her room, her hair was very disheveled. On 11/21/22 at 03:00 PM, Certified Nurse Aide N stated staff chart bathing in the kiosk (a small, standalone device providing information for staff on a computer screen and was often used for entering services provided) as well as a shower sheet. CNA N stated R22 did not typically refuse her showers but if she did, they chart refused. On 11/22/22 at 03:30 PM, Licensed Nurse (LN) I stated they had just recently started using shower sheets and if a resident refused, they would try to encourage and offer alternatives. On 11/22/22 at 04:15 PM, Administrative Nurse D stated R22 did not refuse showers and felt staff did not document showers appropriately. Upon request, a policy for Bathing was not provided by the facility. The facility failed to provide R22 consistent bathing services as care planned, placing her at risk for complications related to poor hygiene. - The Electronic Medical Record (EMR) for R32 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion) and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R32 had severely impaired cognition and required extensive assistance of one staff for personal hygiene, dressing, and bathing. The MDS documented R32 had no skin issues. The Care Plan, dated 11/16/22, documented R32 preferred showers and had a history of being resistant with bathing. The September 2022 Bathing and Facility Bathing Sheets, documented R32 requested showers on Tuesday and Friday and documented R32 had not received a bath or shower during the following days: 09/14/22 - 09/29/22 (16 days) The EMR lacked documentation R32 refused a bath or shower. The October 2022 Bathing and Facility Bathing Sheets, documented R32 requested showers on Tuesday and Friday and documented R32 had not received a bath or shower during the following days: 10/19/22- 10/30/22 (12 days) The EMR lacked documentation R32 refused a bath or shower. The November 2022 Bathing and Facility Bathing Sheets, documented R32 requested showers on Tuesday and Friday and documented R32 had not received a bath or shower during the following days: 11/13/22-11/20/22 (8 days) The EMR lacked documentation R32 refused a bath or shower. On 11/21/22 at 09:06 AM, observation revealed R32's hair disheveled. On 11/21/22 at 03:00 PM, Certified Nurse Aide N stated staff chart bathing in the kiosk (a small, stand alone device providing information for staff on a computer screen and was often used for entering services provided) as well as a shower sheet. CNA N stated R32 did refuse her showers but if she did, they chart refused. On 11/22/22 at 03:30 PM, Licensed Nurse (LN) I stated they had just recently started using shower sheets and R32 did refuse showers sometimes, they attempt three times and would call family for support. On 11/22/22 at 04:15 PM, Administrative Nurse D stated R32 did refuse showers sometimes and felt staff did not document showers appropriately. Upon request, a policy for Bathing was not provided by the facility. The facility failed to provide R32 consistent bathing services as care planned, placing her at risk for complications related to poor hygiene. - R26's Electronic Medical Record (EMR) documented she had diagnoses Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), chronic pain, and osteoarthritis(chronic arthritis without inflammation). R26's Quarterly Minimum Data Set (MDS), dated [DATE] documented the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required total two staff physical assistance with bathing, extensive staff assistance with bed mobility, transfers, toileting, locomotion on unit, dressing, personal hygiene, and staff supervision with eating. R26's Activities of Daily Living Care Plan, revised on 10/06/22, documented the resident had impaired physical function and required extensive two staff assistance with repositioning, toileting, bathing, grooming and transferring. The care plan instructed staff to use a sling lift for transfers. The MDS instructed staff to offer R26 her choice of bathing, shower, tub or whirlpool and R26 preferred to bathe during the day. The Bathing Schedule documented the resident scheduled for a bath on Tuesdays and Fridays. The Bathing Sheets and EMR Bathing Task documented the resident received a bath on the following days: October- 14,17, and 26 November 1, On 11/22/22 at 8:00 AM, Certified Nurse Aide (CNA) M stated staff do not make out a bath sheet for R26 when they provide her a bath, she records R26's bathing in the EMR under tasks. On 11/22/22 at 09:12 AM, Administrative Nurse D verified the lack of preferred scheduled bathing for R26 and stated residents should receive their bath per their requested day and time. Upon request the facility failed to provide a policy regarding bathing. The facility failed to provide consistent baths for the time and days R26 had requested. This placed the resident at risk for poor hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) for R9 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required set up assistance with supervision for bed mobility, transfers, ambulation, had steady balance, and had no functional impairment. The MDS further documented R9 had two injury falls and had a wander alarm (designed to help protect residents against elopement). R9's Quarterly MDS, dated 07/18/22, documented R9 had intact cognition and required set up assistance with supervision for bed mobility, transfers, ambulation, had steady balance, and had no functional impairment. The MDS further documented R9 had two non-injury falls, wandered one to three days per week and had a wander alarm. The Fall Risk Assessment, dated 10/24/21, 12/09/21, 04/09/22, 07/02/22, 07/24/22, 09/04/22, 11/09/22, and 11/17/22 documented R9 was a high risk for falls. The Wander Check for September 2022 lacked documentation staff checked R9's wanderguard on the following days: 09/06/22-09/07/22 09/09/22-09/12/22 09/14/22-09/21/22 09/23/22-09/31/22 The Wander Check for October 2022 lacked documentation staff checked R9's wanderguard on the following days: 10/1/22-10/17/22 10/20/22-10/31/22 The Wander Check for November 2022 lacked documentation staff checked R9's wanderguard on the following days: 1/11/22-11/21/22 The Care Plan, dated 09/28/22, originally dated 12/13/21, directed staff to ensure R9 had nonslip socks on at bedtime to prevent falls. The update, dated 04/12/22, directed staff to ensure my foam mattress pad was secured in place before R9 laid down in bed and put nonskid socks on the resident. The update, dated 04/21/22, directed staff to check the placement of her personal alert band every shift and functioning daily. The update, dated 06/29/22, directed staff to place a bolster (a long, thick pillow or cushion placed under other pillows for support), on the edge of R9's bed to help define it when she was asleep. The update, dated 07/22/22, directed staff to encourage R9 to lie down if staff see the resident sitting on the side of the bed in the middle of the night. The update, dated 07/26/22, directed staff to ask the resident if she would like to sit in the recliner when she was restless. The update, dated 08/14/22, directed staff to ask R9 if she would like to sit in the commons area in a recliner so she would not fall asleep on the ed of the bed and slide out of bed. The update, dated 08/12/22, directed staff to not allow R9 to keep scissors in her room because she cuts off her wanderguard. The update, dated 09/04/22, directed staff to ensure the bolster was in place throughout the night. The update, dated 10/29/22, directed staff to ensure there was only one layer on the seat of her chair. The update, dated 11/08/22, directed staff to ask R9 if she would like help lying back down or sit in her recliner to prevent her from falling or sliding off her bed. The update, dated 11/15/22, directed staff to check her feet during the night to make sure the nonskid socks have not been removed. The Nurse's Note, dated 04/12/22 at 11:55 PM, documented R9 fell on the floor next to her bed, her right was leg stretched out and the left leg bent and crossed underneath her. R9 stated, Just like the other day, I was sitting and suddenly I was sliding. R9 pointed to the foam mattress and stated, this was part of the problem. The note further stated R9 did not receive any injury. The Nurse's Note, dated 06/29/22 at 01:08 AM, documented R9 fell out of her bed. The note further documented the nurse went to the resident's closet and placed a bolster pillow on the side of the resident's bed. The note further documented R9 did not receive any injury. The Nurse's Note, dated 07/21/22 at 05:43 AM, documented R9 rolled out of bed onto the floor. The note further documented R9 most likely fell asleep while seated on the side of the bed and did not receive any injury. The Nurse's Note, dated 07/24/22 at 04:00 AM, documented R9 rolled out of bed onto the floor. The note further documented R9 did not receive any injury. The Nurse's Note, dated 08/14/22 at 12:30 AM, documented R9 had slid out of bed onto the floor. The note further documented R9 did not receive any injury. The Nurse's Note, dated 10/29/22 at 08:00 AM, documented R9 slid out of her recliner to the floor. The note further documented there were five blankets and sheets in the recliner. The note further documented R9 did not receive any injury. The Nurse's Note, dated 11/08/22 at 02:50 AM, documented R9 slid off the bed onto the floor. The note further documented R9 did not receive any injury. The Nurse's Note, dated 11/15/22 at 09:00 AM, documented R9 slid off the bed onto the floor. The noted further documented R9 obtained a skin tear (a traumatic wound caused by mechanical forces) to right hand 2 centimeter (cm) long and 0.2 cm wide. The wound was cleansed and an Aquacel dressing (a moisture-retention dressing) was placed on the residents right hand. On 11/21/22 at 08:45 AM, observation revealed Licensed Nurse (LN) I placed R9's walker in front of her, assisted her to stand, and LN I walked with the resident to a recliner in the dining room. On 11/21/22 09:06 AM, LN I stated when the resident fell, the nurse was able to implement an immediate intervention and when the administration had a weekly risk meeting, they would decide if they wanted to keep the intervention or change it. LN I stated R9 was starting to have dementia and would fall when she would try to get up alone. LN I further stated because she had intermittent confusion, staff put the soft call light close to her in hopes she would use it when she needed to get up. On 11/21/22 at 03:00 PM, Certified Nurse Aide (CNA) N stated R9 was often confused and would get up on her own and fall. On 11/22/22 at 03:45 PM, Administrative Nurse D stated, R9 had falls and staff would try to put new interventions into place to prevent her from falling. Administrative Nurse D further stated staff were to check for wander guard placement every shift. The facility Fall policy, dated 10/12/22, documented a resident would be identified for risk of falls and interventions implemented to reduce the risk. The policy further documented the fall risk screen was completed on admission, quarterly and when there is a significant change of condition and as applicable after a fall. The facility would review fall intervention reference sheet for ideas to implement and document in the care plan. Residents with falls would be discussed weekly in the risk management meeting to determine further possible interventions to prevent future falls. The facility failed to provide interventions to prevent further falls, and failed to check R9's wanderguard bracelet, placing R9 at risk for further falls and elopement. - The Electronic Medical Record (EMR) for R22 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), disorientation (having lost ones sense of direction), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R22 had severe cognitive impairment and required extensive assistance of one staff for bed mobility, transfers, toileting, and personal hygiene. The assessment further documented R22 had unsteady balance, no functional impairment, and had two non-injury falls. R22's Quarterly MDS, dated 10/28/22, documented the same as above. The Fall Risk Assessments, dated 01/18/22, 02/15/22, 05/08/22, 05/29/22, 09/11/22 and 10/22/22 was a high risk for falls. The Care Plan, dated 09/28/22, originally dated 06/24/21, directed staff to put nonskid sock on at bedtime. The update, dated 01/16/22, directed staff to ensure R22 wore shoes or nonskid socks on throughout the day. The update, dated 03/31/22, directed staff to toilet R22 between 04:00 PM and 05:00 PM. The update, dated 04/26/22, directed staff to place her soft touch call light next to R22 where it was easy for her to activate when she was in bed. The update, dated 05/26/22, directed staff to check R22 at night to make sure she had not removed her nonskid socks. The update, dated 09/06/22, directed staff to offer R22 the restroom after her evening meal so she did not try to go unassisted and fall. The update, dated 11/05/22, directed staff to offer R22 the restroom after her evening meal so she would not try to go unassisted and fall. The Nurse's Note, dated 04/17/22 at 12:29 AM, documented at 06:15 AM, R22 was seated on the floor in her room between her closet and bed facing the wall. The note further documented R22 was incontinent of bowel and bladder and reminded R22 she needed to use her call light for assistance. The Nurse's Note, dated 04/26/22 at 04:55 AM, documented R22 fell in her room after she had not used her walker when she got out of bed. The note further document R22 stated she must have tripped on something. The staff placed the resident back into bed and moved her soft touch call light to her side so it would go off if she sat up on the side of the bed again. The Nurse's Note, dated 05/26/22 at 08:12 PM, documented R22 had not used her call light and slid off the bed. The note further stated staff put nonskid socks on R22 and placed her soft call light at her side so that it would go off if she rolled over to sit up. The Nurse's Note, dated 09/09/22 at 07:00 PM, documented R22 fell in her bathroom. The note further documented R22 had one slipper on and one off. The note documented staff made sure her call light was lying by her side in case she would try to get up again and changed her slippers to nonskid socks. The Nurse's Note, dated 11/05/22 at 08:20 PM, documented at 07:15 PM, R22 fell in her room and was incontinent of urine. The note further documented R22 did not have any injury. On 11/21/22 at 09:00 AM, observation revealed Certified Nurse Aide (CNA) P and CNA Q took R22 to a chair in the dining room. CNA P placed her left arm under R22's left arm and CNA Q placed her right arm under the resident's right arm to assist R22 to stand. CNA P grabbed the back of R22's waistband on her pants and pulled upward to assist the resident to stand and transfer. On 11/21/22 at 09:00 AM, CNA P stated, they would look on the end of the bed of the resident's room and it would say whether they needed to use a gait belt with the resident and R22 was one of the resident's that they did not need to use a gait belt. CNA P further stated R22 did have falls because she would try to transfer herself and fall. On 11/21/22 at 9:06 AM, Licensed Nurse (LN) I stated when the resident had falls, the nurse was able to implement an immediate intervention and when the administration had a weekly risk meeting, they would decide if they wanted to keep the intervention or change it. LN I stated R22 was starting to have dementia and would fall when she would try to get up alone. LN I further stated R22 was confused and would try to transfer her self and would fall. On 11/22/22 at 03:45 PM, Administrative Nurse D stated, R22 had falls and staff would try to put new interventions into place to prevent her from falling but was hard to find new interventions for the resident. The facility Fall policy, dated 10/12/22, documented a resident would be identified for risk of falls and interventions implemented to reduce the risk. The policy further documented the fall risk screen was completed on admission, quarterly and when there is a significant change of condition and as applicable after a fall. The facility would review fall intervention reference sheet for ideas to implement and document in the care plan. Residents with falls would be discussed weekly in the risk management meeting to determine further possible interventions to prevent future falls. The facility failed to provide interventions to prevent falls for cognitively impaired R22, placing her at risk for further falls and injury. - The Electronic Medical Record (EMR) for R32 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion) and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R32 had severely impaired cognition and required supervision of one staff for transfers, ambulation, wandered daily and had unsteady gait. The MDS further documented R32 intruded on others, wandered to dangerous places 1 to 3 times per week, had a motion sensor, and a wander/elopement alarm. The Elopement Risk, dated 09/01/22, documented R32 was at risk for elopement. The Care Plan, dated 11/16/22 documented R32 had exit seeking behaviors and wore a personal alert band on her wrist, check the placement and functioning of the band every shift, and a motion sensor in her room to alert staff if she wandered at night. The Wander Check for September 2022 lacked documentation staff checked R32's wanderguard on the following days: 09/06/22-09/07/22 09/09/22-09/12/22 09/14/22-09/21/22 09/23/22-09/31/22 The Wander Check for October 2022 lacked documentation staff checked R32's wanderguard on the following days: 10/1/22-10/17/22 10/20/22-10/31/22 The Wander Check for November 2022 lacked documentation staff checked R32's wanderguard on the following days: 1/11/22-11/21/22 On 11/21/22 at 01:09 PM, observation revealed R32 independently ambulating down the hallway and had a wanderguard bracelet on her left wrist. Further observation revealed R32 stopped by the exit door but did not try to go out of the door. On 11/21/22 at 01:15 PM, Licensed Nurse (LN) I stated the only time the wander guard on the exit door would sound would be if R32 breached the doors and physically went out the door. LN I further stated her wander guard was checked nightly by staff. On 11/22/22 01:45 PM, Certified Medication Aide (CMA) R stated staff documented daily in the wander guard book and document in the Medication Administration Record. CMA R verified staff were not documenting on the wander guard check form they had checked placement and function. On 11/22/22 at 03:45 PM, Administrative Nurse D stated staff were to check the wander guards function and placement daily and document in the wander guard book. Upon request a policy for wander guard was not provided by the facility. The facility failed to document R32's wander guard function and placement as care planned, placing her at risk for elopement. - The Electronic Medical Record (EMR) for R34 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), dystonia (a state of abnormal muscle tone, resulting in muscular spasm and abnormal posture), tremors (an involuntary quivering movement) and hypertension (high blood pressure). R34's Significant Change Minimum Data Set (MDS), dated [DATE], documented R34 had intact cognition and required extensive assistance of one staff for ambulation, supervision and one staff assistance for toileting and personal hygiene, and supervision and set up assistance for bed mobility, transfers. and eating. The MDS further documented R34's balance was unsteady, had no functional impairment, had two non injury falls and one injury fall. The Quarterly MDS, dated 10/22/22, documented R34 had severely impaired cognition and required limited assistance of one staff for all activities of daily living (ADLs), had inattention, disorganized thinking, had unsteady balance, no functional impairment, and had two non-injury falls, and one injury fall. The Fall Risk Assessment, dated 04/06/22, 04/09/22, 08/11/22, 10/02/22, 10/16/22, 10/20/22,10/26/22, and 11/07/22 was a high risk for falls. The Care Plan, dated 09/28/22, originally dated 04/06/22, documented R34 was educated to utilize the call light prior to getting out of bed. The update, dated 04/09/22, directed staff to ensure that her slippers were near her bed before bedtime. The update, dated, 04/28/22, directed R34 to use her call light at night and when she woke up in the morning. The update, dated 08/11/22, directed staff to toilet the resident between 07:30 AM and 08:00 AM. The update, dated 08/18/22, directed staff to toilet the resident between 12:30 PM and -01:00 PM. The update, dated 09/30/22, directed staff to move the glove container closer to the toilet so staff do not have to walk away from the resident to get gloves. The update, dated 10/11/22, directed staff to offer to assist with nonskid socks in case she needed to walk to the bathroom. The update, dated 10/31/22, directed staff to encourage R34 to use her call light before standing. The update, dated 11/15/22, directed staff to check to make sure R34 had not removed her nonskid socks. The Nurse's Note, dated 04/09/22 at 12:05 AM, documented R34 fell in her bathroom after she had slipped on the slippery floor. The note further documented staff put slippers on the resident and took her back to bed. The Nurse's Note, dated 09/30/22 at 5:55 PM, documented staff assisted R34 with a gait belt to the bathroom and while R34 was standing with her walker, and as the Certified Nurse Aide (CNA) walked four steps to grab some glove, R34 leaned forward and fell. The note further documented R34 did not receive any injury. The Nurse's Note, dated 10/12/22 at 04:32 AM, documented R34 fell in her bathroom. The note further documented R34 received a skin tear to her outer left forearm 1 centimeter (cm) x 2.5 cm. Staff cleansed the skin tear and applied a 3 x 3 foam dressing (an absorbent dressing). The Nurse's Note, dated 10/20/22 at 07:45 AM, documented R34 fell in her room between the bathroom and her bed, her pants were pulled halfway down, had no socks or shoes or gripper socks on. The note further documented R34 did not receive any injury. The Nurse's Note, dated 10/31/22 at 04:55 PM, documented R34 got up to go see her husband and rolled out of bed. The note further documented staff encouraged her to remember to use her call light. The Nurse's Note, dated 11/03/22 at 06:32 PM, documented R34 fell in her room while she tried to check on her husband that was in the bathroom. The note further documented R34 did not receive any injury. The Nurse's Note, dated 11/15/22 at 03:40 AM, documented R34 fell in her room next to her husband's bed. The note further documented R34 had on her husband's tank top and had no brief or socks on. The note further documented R34 did not receive any injury. On 11/21/22 at 01:19 PM, observation revealed CNA Q took the foot pedals off of R34's wheelchair, took her left arm and placed it under R34's left arm, grabbed the back of the resident's pants, pulled upward and transferred R34 into her recliner. On 11/21/22 at 09:06 AM, Licensed Nurse (LN) I stated when the resident had falls, the nurse was able to implement an immediate intervention and when the administration had a weekly risk meeting, they would decide if they wanted to keep the intervention or change it. LN I stated R34 got up a lot on her own and would fall. On 11/21/22 at 01:19 PM, CNA Q stated no one told her she needed to use a gait belt with R34, even though it was marked on the end of the bed that R34 required the use of a gait belt. CNA Q further stated she did not even know where a gait belt was for the resident. On 11/22/22 at 03:45 PM, Administrative Nurse D stated, R34 had falls and staff would try to put new interventions into place to prevent her from falling but was hard to find new interventions for the resident. Administrative Nurse D further stated R34 would be placed on hospice and would hope someone from hospice could sit with the resident. The facility Fall policy, dated 10/12/22, documented a resident would be identified for risk of falls and interventions implemented to reduce the risk. The policy further documented the fall risk screen was completed on admission, quarterly and when there is a significant change of condition and as applicable after a fall. The facility would review fall intervention reference sheet for ideas to implement and document in the care plan. Residents with falls would be discussed weekly in the risk management meeting to determine further possible interventions to prevent future falls. The facility failed to provide interventions to prevent falls for cognitively impaired R34, placing her at risk for further falls and injury. The facility had a census of 36 residents. The sample included 14 residents with nine reviewed for accidents. Based on observation, interview, and record review the facility failed to provide adequate supervision for elopement and/or fall prevention for Residents (R) 30, R22, R32, R34, and R12 to prevent falls. The facility further failed to secure hazardous chemicals on three of four onsite survey days. These deficient practices placed six residents at risk for further falls and four cognitively impaired residents at risk for accidental harm from chemicals. Findings included: - R30's Electronic Medical Record (EMR) documented he had diagnoses dementia (progressive mental disorder characterized by failing memory, confusion), wandering diseases, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R30's admission Minimum Data Set (MDS), dated [DATE], documented he had short and long term memory problems, modified independence with cognitive skills for daily decision making, and continuous inattention, and disorganized thinking. The MDS documented R30 required extensive staff assistance with bed mobility, transfers, dressing toilet use, and personal hygiene, limited staff assistance with walk in room or corridor, and locomotion on and off unit. The MDS documented R30 exhibited wandering behavior, daily, during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/05/22, documented R30 a new admission to the facility, due to his increased wandering and needs. The CAA documented R30 wandered often throughout the day, but could be redirected by staff. The Activities of Daily Living CAA, dated 09/05/22, documented R30 had worsening dementia and wandering and was no longer safe at home. The CAA documented R30 was unable to bathe himself, control his bladder, cook meals, converse in a meaningful manner, dress himself, drive a car, find his way home, live independently, could recognize familiar faces, and remembered where he lived and current date. The CAA documented R30 wandered throughout the facility independently, required limited to extensive staff assistance with self-care ADLs. The Cognitive Loss/Dementia Care Plan, revised 09/05/22, documented R30 had alteration in thought processes, long term and short-term memory problems, and severely impaired cognition. The ADL Care Plan, revised 09/05/22, documented 30 ambulated independently, and instructed staff to make sure he had correct footwear on. The Behavior Problem Care Plan, revised 09/05/22, documented R30 had wandering behaviors, instructed staff to make sure his environment was safe. The care plan documented R30 may have an impact on others, since he may wander into their rooms or stand over them when they are eating or watching television. The care plan documented the resident had potential for elopement, wore a personal alert band (wanderguard) on his wrist, and instructed staff to check placement of the wanderguard every shift and functioning every day. The care plan instructed staff to offer him snacks or drinks when he was anxious, walk with him if he was going into other resident's rooms, take him outside on nice days, and if he was standing over or wandering towards other residents, take him to an area of the building and offer restroom and snack. R30s Medication Administration Record (MAR)/Treatment Administration Record (TAR) lacked documentation regarding staff checking the resident's wandering device for placement and functioning. The Wander Check Paperwork, lacked documentation regarding checking R30's wanderguard placement or functioning for the following dates: September 2022-5,7,9,10,11,12,14,15,16,17,18,19,20,21,23,24,25,26,27,28,29,30,31 October 2022-1,2,3,4,5,6,7,8,9,10,12,13,14,15,16,17,20,21,22,23,24,25,26,27,28,29,30,31 November 2022-1,2,3,4,5,6,7,8,9,10,11,12,15,16,17,18,19,20,21 On 11/17/22 at 12:13 PM, observation revealed sat quietly in a chair with wanderguard bracelet on his left wrist in the dining area, glasses and black Velcro shoes on. On 11/22/22 at 10:38 AM, Licensed Nurse (LN) I stated R30 would stand by the exit to the door to the maintenance hall, but does not realize it is an exit. LN I stated if another resident pushed on the door R30 would mimic their reaction, but would not try to exit the building. LN I stated staff make sure he has his shoes on, assist him to bathroom, guide him to chair to sit down, away from other residents for less stimuli. LN I stated R30 liked to pick things up off the floor, so staff make sure his environment is clean and well kept. On 11/22/22 at 04:15 PM, Administrative Staff D verified the lack of documentation on the above dates regarding wanderguard placement and function. Upon request the facility failed to provide a policy regarding wanderguard placement and function monitoring. The facility failed to provide adequate assistive devices to prevent accidents when staff failed to check R30's wanderguard placement and function. This placed the resident at risk for elopement. - R12's Electronic Medical Record (EMR) documented diagnoses of macular degeneration (common eye disorder which causes blurred or reduced central vision), hypertension (high blood pressure), and diabetes (the body doesn't make enough insulin or can't use it as well as it should). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14. The MDS documented R12 required supervision for all activities of daily living (ADL), unsteady balance but able to stabilize self, and no range of motion impairment. R12 used a walker or wheelchair and had one minor injury fall since the previous assessment. The Fall Care Plan, undated, directed staff to ensure the room free of clutter due to R12's macular degeneration. The care plan directed staff to ensure R12 had a walker for ambulation, ensure his bed in proper position, and remind him to sleep in the middle of his bed. Further interventions included: Non-skid socks to bed (8/2/22 fall). Place locked walker right in front of bed (10/17/22 fall). Door open at night (10/25/22 fall)remind to use wheelchair and staff assistance for toileting (10/28/22 fall). Adjust bed to lower position where feet are firmly planted on the floor when he sits on the edge of his bed (fall 11/10/22). This same intervention had been on the care plan since October 2021. The Fall Risk Assessments, dated 01/24/22 through 10/17/22 all indicated R12 a high risk for falls. The Fall Note, dated 08/2/22 at 02:00 AM, documented staff found R12 on the floor of the bathroom, barefoot and wearing a pearl snap long sleeve shirt and pull up. His walker was in the doorway of the bathroom and resident was incontinent and sitting in a very large puddle of liquid. This nurse asked if the puddle caused him to slip and resident denied, stating he did that after, or during but wasn't completely sure. The resident stated he was rushing to sit on the stool and suddenly felt weak or dizzy when he tried to turn to sit down. The resident complained of nausea and weakness. Resident was alert and oriented to person, place, time and situation. A skin tear was noted on his right outer elbow. Resident could move all extremities without pain or difficulty, but stated he wasn't sure he could stand due to feeling weak. The nurse applied non-slip socks at this time. With CNA's help, this nurse assisted resident into standing position. He stated he felt like he needed to sit on the stool to go more and was able to grab the railing, turn himself and step towards the toilet to sit down. Resident continued to have loose stools. This nurse attempted to obtain another set of vitals at this time but could not get a blood pressure, pulse or oxygen saturation. This nurse the attempted manual blood pressure cuff but still could not obtain blood pressure. Resident was still alert and wanted to get back to bed. He was able to stand at the toilet and this nurse cleaned him up and provided a clean brief. Once resident was in the wheelchair this nurse attempted, unsuccessfully, to obtain vitals again. R12 stated I can't hold my head up I'm so weak so this nurse assisted him into the bed and into the lying position. It was at this time that this nurse found an empty bottle of milk of magnesia in his bed and another in his trash can. When asked how much milk of mag the resident had taken, he responded that he didn't think he had taken any. By this time it was approximately 03:00 AM, and the nurse obtained a set of vitals, 54, 16, 82/50. This nurse ensured the resident was comfortable and attached his call light to his handrail, asking him to please not get up without calling due to his low blood pressure. This nurse explained that his skin tear needed a dressing and that I was leaving the room to get supplies. After returning, this nurse noted a very long period of apnea in the resident and he was very difficult to wake. The nurse assisted the resident to put on another pearl snap shirt and he stated he was feeling much better. Staff notified family and notified the physician by fax. The Fall Note, dated 10/17/22 at 04:02 PM, documented an aide reported the resident was on the floor. The nurse found the resident with his head near foot of bed and feet out towards center of room, on his back with both legs bent at knees, feet off floor, and arms to his side. Resident stated to nurse I'm not hurt anywhere, and I didn't hit my head No injury noted at this time. The resident stated, I just slid out of bed. The note documented the nurse put in a work order for maintenance to apply nonskid strips next to bed. The Fall Note, dated 10/25/22 at 12:55 AM, documented staff found R12 on the floor, injured, and bleeding from his head. The resident was on the floor next to his bed with his back against the side of the bed, bleeding from the top of his head, right eyebrow and lower eye lid, and right hand. He was barefoot, wearing pajama pants, and a button up shirt. R12 stated he stood up from his recliner to go to the bathroom and missed the handle when he reached for his walker, causing him to fall forward, face first into the floor. Resident had blood all over the palms of both hands and running down his face. Resident was alert and oriented but was anxious and distracted by his need [TRUNCATED]

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review and interview, the facility lacked posting of the Ombudsman and State Hotline contact numbers which placed the residents at risk of unmet care concerns and impaired ability to contact to the state agencies. Findings included: - On 11/21/22 at 03:15 PM Social Service Designee (SSD) X reported the Ombudsman and state reporting information was posted on C Hall, which was under construction and not accessible to residents. On 11/21/22 at 03:21 PM Administrative Staff A verified the Ombudsman and state reporting information was not posted in a visable location due to construction since September 2022. On 11/22/22 at 09:12 AM Administrative Nurse D stated the Ombudsman and state reporting information should be posted where residents could see them. Upon request the facility failed to provide a policy which regarded the Ombudsman and state reporting information. The facility failed to provide the residents information which included contact information for the Ombudsman and state reporting contacts which placed the residents at risk for unmet concerns related to care and services.

The facility has a census of 36 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to employ a full time certified dietary manager for the 36 residents who reside in the facility and receive their meals from one of one kitchen, placing the residents at risk for inadequate nutrition Findings included: - On 11/17/22 at 08:31 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. Dietary Staff BB stated he/she had no certification as a dietary manager and was currently enrolled in the dietary manager classes. Upon request, the facility did not provide a policy regarding Certified Dietary management requirements. The facility failed to employ a full time Certified Dietary Manager, for the 36 residents residing in the facility who received meals from one of one kitchen, placing the residents at risk for inadequate nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 38 residents with 13 selected for review, including five residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure interventions implemented after Resident (R)5 had a fall to prevent further falls. Findings included: - The Physician Orders, dated 03/08/21, included diagnoses for Resident (R)37 included history of falling, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain )with behaviors, and wandering. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed R5 with a Brief Interview of Mental Status Score (BIMS) of two, indicating severely impaired cognition. She required extensive assist of one for bed mobility, limited assist of one for transfers and locomotion on the unit, she did not ambulate in her room, and extensive assist of two or more for toilet use. She required limited assistance of two or more for walking. R5's balance during transitions and walking were not steady and she was only able to stabilize with staff assistance. She used a walker and wheelchair for mobility and had one non-injury fall since the last assessment. The Falls Care Area Assessment, (CAA), dated 07/28/20, revealed that R5 had impaired cognition and required assistance to complete her activities of daily living (ADL's) and mobility. She had a non-injury fall. The quarterly MDS dated [DATE], assessed R5 with a BIMS score of three, indicating severe cognitive impairment. She required extensive assistance of two or more for bed mobility, transfers, and toileting. She did not walk in her room and required limited assistance of two or more for walking in the corridor. There were not changes to her balance during transitions and walking and she continued to use a walker and a wheelchair for mobility. R5 has two non-injury falls since the last assessment. The quarterly MDS dated [DATE], assessed R5 with a BIMS score of two. She required extensive assistance of one for bed mobility and extensive assist of two for toilet use. R5 required limited assistance of one for transfers and locomotion. She did not ambulate in her room, however, she did ambulate in the corridor with limited assistance of two or more staff. There were no changes to her balance during walking or transitions and she continued to use the walker or wheelchair for mobility. She had one non-injury fall since the last assessment. The quarterly MDS dated [DATE], assessed R5 with a BIMS score of three. She required extensive assistance of one for bed mobility, transfers, and toilet use, and did not walk in her room. R5 required supervision and assistance of one with walking in the corridor and there were no changes to her balance during transitions and walking. She continued to use the same devices for mobility and had one non-injury fall and two or more injury falls (except major) since the last assessment. The Fall Risk Assessment Score, dated 11/08/20, indicated R5 was a high risk for falls. The Care Plan, dated 04/26/21, included, but was not limited to, the following fall interventions: 1. On 11/22/18, R5 had auto-lock brakes applied to her wheelchair. 2. On 11/22/18, staff were to ensure the slip-resistant mat was on the seat of her wheelchair. 3. On 10/01/19, staff were to place her wheelchair within easy reach/easy access of her bed when she was in bed. 4. On 12/06/19, a foot bed cradle was to be placed to prevent her blankets from being entangled in her feet. 5. On 01/04/20, staff should secure the resident's blankets with plastic clips over her foot cradle. 6. On 09/03/20, staff should ensure the slip-resistant mat was on the seat of her wheelchair. This intervention was already placed on 11/22/18. 7. On 12/31/20, staff should ensure a slip-resistant mat was between the wheelchair cushion and the seat of the wheelchair. 8. On 03/08/21, staff were to check her finger stick blood sugar for one week at 09:00 AM. However, the facility failed to implement an intervention to prevent further falls. 9. On 03/30/21, staff were to obtain a urine sample for analysis due to changes in her behavior. However, the facility failed to implement an intervention to prevent further falls. 10. On 04/24/21, staff adjusted the wheelchair seat to tilt down in the back and up in the front. The electronic medical record (EMR), revealed R5 had falls on the following dates: 12/07/20, 12/31/20, 03/06/21, 03/28/21, and 04/24/21. The Interdisciplinary Notes (ID), dated 12/07/20 indicated R5 was found lying on the floor about 09:19 AM. The Investigation/Follow Up Report, dated 12/10/20, indicated the intervention was to have staff place auto-lock brakes to her wheelchair. The care plan had this intervention put in place on 11/22/18. The facility failed to implement a new intervention to prevent further falls. The ID notes, dated 12/31/21, indicated that about 10:20 AM, staff found the resident on the floor. The intervention was to lotion her legs and place a slip-resistant mat into her wheelchair. The care plan had the intervention in place on 11/22/18 to have a slip-resistant mat in place on the seat of the wheelchair. This intervention was repeated on 09/03/20. The facility failed to ensure the slip-resistant mat was in place to the wheelchair and added a new intervention to ensure a skip-resistant mat was between the wheelchair seat and the cushion. The ID notes, dated 03/06/21, revealed at about 09:40 AM, housekeeping staff alerted nursing staff to the dining area. R5 was lying on the floor in front of her wheelchair and the resident received two skin tears to her right upper wrist. Staff applied a slip-resistant mat to the seat of her wheelchair before assisting her back to the wheelchair. The facility failed to ensure the slip-resistant mat was in place to her wheelchair. The Investigation/Follow Up Report, dated 03/08/21, revealed staff were to assess her blood sugar daily at 09:00 AM for one week. The care plan lacked a new intervention to prevent further falls. The ID notes, dated 03/28/21, revealed at 07:35 PM, staff found R5 on the floor and she received a small abrasion beneath her left knee. The Investigation/Follow Up Report, dated 03/30/21, revealed staff were to obtain a urine specimen for analysis due to changes in her behavior. The care plan lacked an immediate intervention to prevent further falls. The ID note, on 04/24/21, revealed that R5 slipped off the edge of her wheelchair and fell to her knees. Staff placed a slip-resistant mat on her wheelchair pad to prevent further falls. The facility failed to ensure a slip-resistant mat was in place as previously care planned. On 05/04/21 at 09:14 AM, R5 was in her bed, the resident's wheelchair was parked at the end of the bed, and the bed lacked a foot cradle. The facility failed to keep the wheelchair within easy reach and the foot cradle in place as her individualized care plan instructions. On 05/05/21 at 01:45 PM, Certified Nurse Aide (CNA) N revealed that R5 should have a slip-resistant mat on the top of her wheelchair cushion. On 05/05/21 at 01:47 PM, CNA M was not sure if R5 had the slip-resistant mat on her wheelchair cushion. On 05/05/21 at 01:48 PM CNA N and CNA M were going to assist R5 to stand to check for placement of a slip-resistant mat, when CNA N revealed there was no need to stand the resident up, as she located the slip-resistant mat a bag that hung from the back of her wheelchair. The mat had numerous folds to it and had debris stuck to it. On 05/05/21 at 01:52 PM, CNA N and CNA M assisted the resident to stand to replace the slip-resistant mat on the top of the cushion. R5 had one in place between the resident's wheelchair seat and the wheelchair cushion. On 05/05/21 at 01:59 PM, CNA O revealed that R5 would sometimes remove the slip-resistant mat herself, and that she was unaware if R5 should have a mat between the seat and the cushion of the wheelchair. CNA O stated that R5 used to have a foot cradle on her bed but did not have a foot cradle anymore, and when a resident had a fall, staff try to figure out why the resident fell and see if there was anything staff could do so the resident would not have another fall. CNA O stated that notifications of new falls and interventions were communicated to her by email, report, or by the charge nurse, and that the nurse would be informed if an intervention was not working. On 05/05/21 at 02:11 PM, Licensed Nurse (LN) G revealed that when a resident had a fall, a new intervention should be implemented at the time of the fall. The nurse should update the care plan and the new intervention should be communicated in shift report. On 05/05/21 at 02:15 PM, Administrative Nurse E stated when a resident had a fall, the nurse on duty should update the care plan with a new fall intervention. The quality assurance nurse, the director of nursing, and administrator would review the fall and the intervention and would update the care plan at that time to include an additional or changed intervention. Administrative Nurse E was not sure if the food cradle should be removed from the care plan or not and the intervention for the fall on 12/31/21 was for an additional slip-resistant mat so he had one under and on top of the wheelchair cushion. Furthermore, she confirmed that a urine sample for analysis and to check finger stick blood sugars was not an immediate intervention to prevent further falls. Interventions should not be duplicated. On 05/05/21 at 02:30 PM, Administrative Nurse D revealed that R5's foot cradle was found on her roommates bed, the slip-resistant mat was a duplicate intervention and it should be in place on the cushion and under the wheelchair cushion. Furthermore, Administrative Nurse D reported immediate interventions should be placed when a resident had a fall. The intervention for checking R5's urine for analysis and fingerstick blood sugars for a week were not immediate interventions to prevent further falls. The facility policy Accidents and Incidents, revised 04/08/19, lacked instruction to the staff on what measures to take when a resident has a fall. The facility failed to ensure appropriate interventions implemented after Resident (R)5 had repeated falls, to prevent further falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 38 with 13 residents selected for review including one resident reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag.) Based on observation, interview, and record review, the facility failed to keep the catheter drainage bag from touching directly on the floor for Resident (R)4, creating a risk for developing urinary tract infections. Findings included: - The Order Summary Report, dated 03/16/21, for Resident (R)4, included diagnoses of flaccid (weak, soft and flabby) neurogenic bladder(dysfunction of the urinary bladder caused by a lesion of the nervous system), and multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord.) The annual Minimum Data Set (MDS) dated [DATE], assessed R4 with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. R4 required extensive assist of two person for toilet and had an indwelling urinary catheter in place. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 05/06/20, revealed R4 had a long-term suprapubic catheter (urinary bladder catheter inserted through the skin) that was maintained by the staff and he was at risk for urinary tract infections related to the long-term indwelling, suprapubic catheter use. The quarterly MDS, dated [DATE], assessed R4 with a BIMS score of 13, indicating intact cognition. He continued to require extensive two- person assistance for toileting and continued to have an indwelling catheter in place. The Care Plan, dated 02/02/21, revealed that R4 had a long-term indwelling catheter, staff were to monitor the catheter drainage bag to ensure the bag did not touch the floor. On 05/03/21 at 03:36 PM, R4 sat in his recliner, in his room, and the catheter drainage bag touched directly on the floor. The catheter bag lacked a barrier between the manufacturer's urinary drainage bag and the floor. On 05/04/21 at 01:30 PM, R4 satin his recliner. The resident's catheter drainage bag was in contact with the floor. The catheter bag lacked a barrier between the manufacturer's urinary drainage bag and the floor. On 05/05/21 at 09:57 AM, R4 sat in his recliner and the catheter drainage bag continued to rest directly on the floor. The catheter bag lacked a barrier between the manufacturer's urinary drainage bag and the floor. On 05/05/21 at 10:30 AM, Certified Medication Aide (CMA) R, confirmed the bag should not touch the floor. On 05/05/21 at 10:43 AM, Administrative Nurse D, stated the urinary catheter drainage bag should not touch the floor. The facility policy, Catheter Care-Urinary Foley, dated 06/10/19, lacked guidance on positioning of catheter drainage bag, to prevent infection. The facility failed to keep R4's urinary catheter drainage bag from touching directly on the floor, that could increase the risk for this resident that required a suprapubic catheter, from developing a urinary related infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -The Order Summary Report, dated 03/03/21, for Resident (R)1, included diagnoses of personal history of nicotine dependence and emphysema (long-term, progressive disease of the lungs characterized by shortness of breath.) The annual Minimum Data Set (MDS), dated [DATE], assessed R 1 with a Brief Interview of Mental (BIMS) score of 10, indicating moderately impaired cognition and she received oxygen therapy. The Care Plan, dated 04/27/21, instructed staff to ensure the oxygen tubing, canister, and other oxygen supplies labeled, bagged, and changed to reduce the risk of infection. The Order Summary Report, dated 03/03/21, included an order dated 06/16/20, to change the disposable humidifier bottle every 30 days, and change the oxygen tubing and clean the oxygen concentrator filter once weekly on Wednesdays on the night shift. On 05/03/21 at 01:14 PM, observation revealed R1's humidifier bottle unlabeled and the oxygen concentrator filter had a build-up of lint. On 05/04/21 at 10:49 AM, the oxygen concentrator filter continued to have a build-up of lint and the humidifier bottle continued to lack a date. On 05/04/21 at 02:44 PM, Licensed Nurse (LN) J stated the oxygen humidifier bottle should be changed monthly and as needed. The filters should be cleaned weekly. LN J confirmed the humidifier lacked a date. On 05/04/21 at 04:00 PM, Administrative Nurse D confirmed the oxygen humidifier bottle should be labeled upon attaching to the concentrator and the oxygen concentrator filter should be cleaned weekly. The facility policy, Oxygen Therapy, dated 10/2016, indicated the disposable prefilled humidifier bottle should be changed every 30 days or as needed, and to date and initial each disposable humidifier bottle when changed or if contaminated. The policy also directed staff to wash the concentrator filter weekly with warm tap water and dry thoroughly before replacing the filter. The facility failed to clean R1's oxygen concentrator filter to prevent a build-up of lint. In addition, the facility failed to date and initial the disposable prefilled humidifier bottle when opened appropriately to prevent contamination. - The Physician Orders, dated 03/19/21, for Resident (R)37, included diagnoses of dependence on supplemental oxygen and chronic respiratory failure with hypoxia (inadequate supply of oxygen). The annual Minimum Data Set (MDS), dated [DATE], assessed R37 with a Brief Interview of Mental Status (BIMS) score of 13, indicating cognition intact, and did not require oxygen therapy. The quarterly MDS, dated [DATE], revealed no changes in cognition but she required oxygen therapy. The Care Plan, dated 04/21/21, revealed R37 had a history of impaired gas exchange due to chronic respiratory failure with hypoxia and she used oxygen via nasal cannula per her physician orders and as needed. Staff were to ensure the oxygen tubing labeled, bagged, and changed to reduce the risk of respiratory infection. The Physician Orders, dated 03/19/21, included an order, dated 01/31/21, for oxygen as needed. The Treatment Administration Record (TAR), from 02/01/21 to 05/05/21 revealed the resident did not require the as needed oxygen. Staff should change the oxygen tubing weekly, when the resident required the as needed oxygen. Review of the Interdisciplinary Notes, from 01/31/21 to 05/05/21, revealed the resident required the oxygen on 12 different days. On 05/03/21 at 01:22 PM, observation revealed the resident had an oxygen concentrator at her bedside. The resident's oxygen nasal cannula tubing was not stored in a bag or labeled with a date, and the oxygen tubing wrapped around the oxygen concentrator handle at the top of the machine. On 05/04/21 at 08:39 AM, revealed no changes to the storage or labeling of the oxygen nasal cannula tubing for R37. On 05/05/21 at 08:45 AM, revealed no changes to the storage or labeling of the oxygen nasal cannula tubing for R37. On 05/03/21 at 01:23 PM, R37 revealed she should wear the oxygen every night. On 05/05/21 at 09:33 AM, Licensed Nurse (LN) G revealed that R37 used oxygen previously when she had COVID-19 and staff were to change the tubing weekly, as needed. On 05/05/21 at 02:51 PM, Administrative Nurse D revealed staff should document on the TAR when the resident required oxygen and that the tubing should be stored in a bag when not is use. The facility policy Oxygen Therapy, revised 10/2016, directed staff to change the oxygen tubing once a week or when soiled, date/time/initial tubing when changed, and when not in use, the tubing should be stored in a plastic or other bag. The facility failed to appropriately change, label, and store the oxygen nasal cannula for R37 to avoid contamination and increase the risk of a respiratory infection. The facility reported a census of 38 residents with 13 selected for review, which included three residents sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice and person centered care plan for three Residents (R)33 related to storage of the oxygen tubing and cannula when not in use and changing of the oxygen concentrator's humidifier bottle and tubing/cannula. R 37, related to storage of the nasal cannula and tubing when not in use, and R 1 the cleaning of the concentrator filter. Findings included: - Review of Resident (R)33's undated Physician Orders, documentation included diagnoses history of nicotine dependency, and encounter for palliative care (end of life care). The admission Minimum Data Set (MDS) dated [DATE], documentation included the Brief Interview for Mental Status (BIMS) score of 14, which indicated cognitively intact. The resident received oxygen prior to admission and continued to require oxygen after admission . The care plan (CP), dated 04/07/2021, directed staff the resident received oxygen by way of nasal cannula, P.R.N (as needed), per physician orders to maintain her oxygen saturation rate at or above 90 percent Staff should ensure her oxygen tubing, humidifier bottle, and other supplies labeled when changed and stored in a bag when not in use, to prevent cross contamination and the spread of infection. Review of the Physician Orders, dated 03/27/2021, documented Oxygen, two to four liters, per nasal cannula prn (as needed) for shortness of air or resident comfort. On 05/03/2021 at 12:35 PM, 33's had the oxygen nasal annular positioned in her nose. The oxygen concentrator was set a two liters per minute. Staff failed to date the humidifier bottle and tubing/annular. to determine the duration of the used oxygen supplies. There was not a bag for storage of the tubing when not in use. On 05/04/2021 at 09:05 Am, The humidifier bottle and tubing/annular remained undated, and Continued to lack a bag for storage of the tubing when not in use. On 05/04/2021 at 01:45 PM, Certified Nurse Aide (C.N.A.) P stated the oxygen tubing and cannulas should be stored in a bag when not in use to prevent infections. She confirmed the nurse was responsible for changing the humidifier bottles and tubing. On 05/04/2021 at 02:20 PM, Licensed Nurse (LN) K reported changing of the oxygen equipment which included nasal cannula with tubing and humidifier bottles should be done by the night shift nurse weekly. She reported tubing and humidifier bottles should be labeled with the date changed. She stated the tubing and cannulas should be stored in a bag when not in use to prevent cross contamination. On 05/04/2021 at 02:51 PM, LN K verified the oxygen concentrator's humidifier bottle and tubing/cannula lacked a date that indicated when last changed and there was not a bag for storage of the tubing when not in use. On 05/05/2021 at 09:17 AM, LN L stated she thought humidifier bottles were changed monthly. She was not sure who was responsible for changing out the oxygen supplies. LN L stated the tubing and humidifier bottles should be labeled with the date when changed. Oxygen tubing and cannulas should be labeled with the date when changed. On 05/05/2021 at 09:48 AM, Administrative Nurse D stated oxygen tubing should be dated and labeled when changed by the night nurse on a weekly basis. She stated the policy documented monthly but the nurse on nights changed them out on a weekly basis. She reported that tubing and cannulas should be stored in a bag when not in use and a bag should be located on the concentrator to ensure access for storage when not in use. The facility policy for Oxygen Therapy, dated 10/2016, documentation included these delivery devices would be maintained in a sanitary manner. Change disposable prefilled humidifier bottles every 30 days. Change tubing once a week or when soiled. Date, time, and initial the tubing when changed. Non-disposable humidifier bottles should be changed every seven days. When the device was not in use, store the device in a plastic or other bag to keep the tubing and the device off the floor. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice and the person-centered care plan for this resident who required oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 38 residents with 13 selected for review including five reviewed for unnecessary medications. Based on interview and record review, the pharmacy consultant failed for one of the residents, to report irregularities to the facility for Resident (R)5, when the facility failed to hold a medication used to treat heart conditions when her pulse was out of parameters on five occasions and failed to notify the physician when her pulse was out of parameters on two occasions, placing her at risk for further decreased heart rate. Findings included: - The Physician Orders, dated 03/08/21, included diagnoses of atrial fibrillation (rapid, irregular heartbeat), presence of a cardiac pacemaker, and heart failure. The Significant Change Minimum Data Set, (MDS), dated [DATE], assessed R5 with a diagnoses of heart failure and hypertension (elevated blood pressure). The quarterly MDS, dated [DATE], included the same diagnoses. The Care Plan, dated 04/26/21, revealed that the staff should take R5's apical pulse (a pulse site on the left side of the chest over the heart) prior to administration of digoxin (medication used to treat heart conditions) and hold the medication if R5's pulse was less than 60 (beats per minute), and notify they physician if R5's pulse was less than 50 (beats per minute). The Physician Orders, dated 03/08/21, included an order dated 12/11/15, for digoxin, 125 micrograms (mcg), daily, for atrial fibrillation. Take R5's pulse prior to administration and hold if her apical pulse is less than 60 and notify her physician if her apical pulse is less than 50. The Medication Administration Record (MAR), dated 02/2021, 03/2021, and 04/2021, revealed: 1. On 02/02/21, R5 had a pulse of 57, and the staff administered digoxin. 2. On 02/14/21, R5 had a pulse of 48, below the parameters that required physician notification. 3. On 02/22/21, R5 had a pulse of 55, and the staff administered digoxin. 4. On 02/23/21, R5 had a pulse of 59, and the staff administered digoxin. 5. On 03/03/21, R5 had a pulse or 49, below the parameters that required physician notification. 6. On 04/02/21, R5 had a pulse of 56, and the staff administered the digoxin, then later notified the physician they administered the medication when the pulse was out of parameters. 7. On 04/03/21, R5 had a pulse or 55, and the staff administered the digoxin. Review of the electronic medical record (EMR) lacked documentation that the staff notified the physician when R5's pulse was below 50, the ordered parameters. The Interdisciplinary Disciplinary (ID) notes, revealed that on 02/10/21, and 04/14/21, there were no concerns with the monthly pharmacy review. On 03/19/21 the notes revealed a concern, however, it was not related to R5's digoxin therapy. On 05/05/21 at 09:40 AM, Licensed Nurse (LN) G stated if R5's pulse was below 50, the physician would be notified per phone call and the notification would be documented in the progress notes. LN G stated that the EMR lacked physician notification for R5's pulse when it was below 50 on 02/14/21 and 03/03/21. Furthermore, LN G confirmed that the digoxin should not have been administered on 02/02, 02/22, 02/23, 04/02, and 04/03/21. On 05/05/21 at 10:32 AM, Administrative Nurse D stated that on the MAR the staff should enter the pulse and mark the medication as held and notify the physician as ordered. On 05/05/21 at 11:23 AM, Administrative Nurse D confirmed the digoxin was not held on the above dates and she was not able to find physician notification when R5's pulse was below 50. On 05/11/21 at 05:12 PM, pharmacy Consultant staff GG stated that she had made herself a note to monitor it on March 19th, 2021, however she failed to notify the facility, as she was going to See if it was an ongoing problem or not. The facility's policy for Drug Regimen Review, revised 06/10/19, revealed a drug regimen review included a review of drug regimen to identify, and if possible, prevent potential clinically Significant medication adverse consequences. Any irregularities, significant risks or actual /potential adverse consequences should be identified in the report. The pharmacy Consultant staff GG failed to report irregularities to the attending physician, the facility's medical director, and the director of nursing, so they could be acted upon, for this resident that required monitoring of her pulse with medication used to treat her heart condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 38 residents with 13 selected for review including five sampled for unnecessary medications. Based on interview and record review, the facility failed to hold one of the five residents, Resident (R)5, medication used to treat heart conditions, when her pulse was out of the physician ordered parameters on five occasions and failed to notify the physician when her pulse was out of parameters on two occasions, placing her at risk for further decreased heart rate. Findings included: - The Physician Orders, dated 03/08/21, included diagnoses of atrial fibrillation (rapid, irregular heartbeat), presence of a cardiac pacemaker, and heart failure. The Significant Change Minimum Data Set, (MDS), dated [DATE], assessed R5 with a diagnoses of heart failure and hypertension (elevated blood pressure). The Care Plan, dated 04/26/21, revealed staff should assess R5's apical pulse (a pulse site on the left side of the chest over the heart) prior to administration of digoxin (medication used to treat heart conditions) and hold the medication if R5's pulse was less than 60 beats per minute, and notify they physician if R5's pulse was less than 50 beats per minute. The Physician Orders, dated 03/08/21, included an order dated 12/11/15, for digoxin, 125 micrograms (mcg), daily, for atrial fibrillation. Take R5's pulse prior to administration and hold if her apical pulse is less than 60 and notify her physician if her apical pulse is less than 50. The Medication Administration Record (MAR), dated 02/2021, 03/2021, and 04/2021, revealed: 1. On 02/02/21, R5 had a pulse of 57, and staff administered digoxin. 2. On 02/14/21, R5 had a pulse of 48, below the parameters that required physician notification. 3. On 02/22/21, R5 had a pulse of 55, and the staff administered digoxin. 4. On 02/23/21, R5 had a pulse of 59, and the staff administered digoxin. 5. On 03/03/21, R5 had a pulse or 49, below the parameters that required physician notification. 6. On 04/02/21, R5 had a pulse of 56, and the staff administered the digoxin, then later notified the physician they administered the medication when the pulse was out of parameters. 7. On 04/03/21, R5 had a pulse or 55, and the staff administered the digoxin. Review of the electronic medical record (EMR) lacked documentation that the staff notified the physician when R5's pulse was below 50, the ordered parameters. On 05/05/21 at 09:40 AM, Licensed Nurse (LN) G reported if R5's pulse was below 50, the physician should be notified per phone call and the notification would be documented in the progress notes. LN G stated that the EMR lacked physician notification for R5's pulse when it was below 50 on 02/14/21 and 03/03/21. Furthermore, LN G confirmed that the digoxin should not have been administered on 02/02, 02/22, 02/23, 04/02, and 04/03/21. On 05/05/21 at 10:32 AM, Administrative Nurse D stated staff should document the resident's pulse on the MAR. Staff should also document, on the MAR, when the medication was held. Staff should notify the physician, as ordered, when the resident's pulse was below the physician ordered parameters. On 05/05/21 at 11:23 AM, Administrative Nurse D confirmed the digoxin was not held on the above dates and she was not able to find physician notification when R5's pulse was below 50. The facility policy Notification Parameters-Primary Care Provider (PCP), revised 06/10/19, included the licensed nurses have the responsibility of contacting a primary care provider any time a resident has developed a clinical problem requiring primary care provider intervention. Documentation in the medical record should include assessment findings, all attempts to contact the primary care provider, information provided, and the provider's response. The facility failed to hold a medication used to treat heart conditions when R5's pulse was out of parameters on five occasions and failed to notify the physician when her pulse was out of parameters on two occasions, placing her at risk for further decreased heart rate.

- The facility reported a census of 16 residents on the memory care unit. Observations revealed the following items of concern: On 05/03/21 at 11:42 AM, observed housekeeping staff U transported an uncovered linen cart in the memory care unit to the linen closet and placed linens out of the cart into the closet. On 05/03/21 at 11:45 AM, housekeeping staff U reported that she Forgot to cover the cart and reported staff should cover the linen carts during transport. On 05/03/21 at 11:46 AM, housekeeping staff U then continued to push the uncovered linen cart down the memory care unit to the exit door of the unit. On 05/05/21 at 05:30 PM, Administrative staff A was alerted to the uncovered cart in the memory care unit. The facility policy Laundry, dated 10/02/17, lacked instruction on storage/handling of clean linens when taking to resident areas to distribute. The facility failed to manage linens appropriately to prevent contamination. - Observation, on 05/04/21 at 08:45 AM, Licensed Nurse (LN) I and Certified Nurse Aide (CNA) M assisted Resident (R)7 in her room out of her bed and into her chair. After transferring R7 out of bed, CNA M placed three soiled blankets from the bed onto the carpeted floor, stripped the linens off of the bed, informed LN I that the linens had been soaked through with urine, then placed the wet soiled linens on the carpeted floor. CNA M left R7's room to obtain a blue cloth laundry bag, returned to the resident's room, and placed the soiled linens in the laundry bag. CNA M failed to sanitize the urine-soaked mattress and placed clean linens back onto the soiled bed. On 05/04/21 at 09:04 AM, CNA M confirmed the mattress should be sanitized before applying the clean linens. Soiled and used linens should not be placed on the floor. On 05/06/21 at 05:30 PM, Administrative Nurse D stated that linens should not be on the floor and the mattress should be sanitized. The facility policy Laundry, dated 10/02/17, lacked instructions to not store clean and/or soiled linens on the floor. The facility failed to sanitize a mattress contaminated with urine before proceeding to apply clean linens and failed to keep soiled linens off the carpeted floor to prevent contamination of the linens and the floor. The facility reported a census of 38 residents. Based on observation, interview and record review the facility failed to provide a sanitary environment to help prevent cross contamination and the spread of infections, to the residents of the facility, as exhibited by the communal shower room/bath house had a used, unlabeled toothbrush that was stored on the back of the sink, an unlabeled used comb with hair in the sink, a used unlabeled roll on deodorant stored on the sink, a used bar of soap stored on a shelf behind the whirlpool. In addition, the laundry staff transported uncovered linen to the memory care unit. Furthermore, direct care staff placed urine soaked, soiled linen on the carpeted floor of Resident (R)7,and failed to sanitize the soiled mattress prior to applying clean linen. Findings Included: - During the initial tour of the facility, on 05/03/21 at 12:49 PM, revealed the following concerns in the resident's shower room/bath house: 1.) An unlabeled used toothbrush on the back of the sink covered with a washcloth laying across the bristles. 2.) An unlabeled comb with hair in the sink. 3.) Two unlabeled used roll-on deodorants laying on the sink. 4.) A used bar of soap laying on a shelf behind the whirlpool. On 05/03/2021 at 12:52 PM, Licensed Nurse (LN) L verified the above findings. She stated residents individual personal care items should not be left in a shared/communal area. Personal care items should be labeled with the resident's name and stored in a sanitary manner in the resident's room when not in use. On 05/05/2021 at 09:48 AM, Administrative Nurse D confirmed personal hygiene items should not be left in a shared bathing area where they could be used by other residents. She stated staff should store personal care items in the resident's room, when not in use. Additionally, resident's personal hygiene items should be labeled to identify who they belong to and stored in a sanitary manner to prevent cross contamination. The facility policy for Infection Control, dated 05/11/2020, documentation included precautions to avoid sharing non-critical resident care equipment between residents. The policy lacked address of personal hygiene items storage. The facility failed to provide a sanitary environment to help prevent cross contamination and the spread of infections, for the residents of the facility.