**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to provide a comfortable and homelike environment for all residents when they did not ensure cobwebs were cleaned from the dining room as well as the common area near the facility entrance, and failed to match the paint when repairing drywall in the dining room, or to ensure ceiling trim in the dining room was secure around attic access in the dining room. Additionally, the facility failed to maintain resident safety when they did not ensure a handrail was secure, and failed to provide a homelike environment when they did not fix or replace dining room chairs that are had tearing in the fabric. The facility census was 55. The facility did not provide a policy for regarding maintaining the facility. 1. Observation of the diningroom on 11/18/24 at 10:59 showed: -Dining room chairs vinyl was peeling off and fabric was torn. -Cobwebs near ceiling next to large upper window in dining room. -Wood trim strip around attic access panel in dining room was pulling away from the celiing with nails exposed. 2. Observation of the diningroom on 11/21/24 at 09:11 AM showed: -Cobwebs on the ceiling by the top of the TV in dining room. 3. Observation on the 100 hallway on 11/21/24 at 09:26 AM showed: -Handrail outside room [ROOM NUMBER] is loose. 4. Observation on 11/21/24 at 09:53 AM showed: -Cobwebs near ceiling in common area across from the nurse's station. -Dark water spots about 12 inches x 4 inches near light fixture in common area by main entrance and a large stain on ceiling near vent by main entrance. During an interview on 11/21/24 at 09:42 AM, housekeeping supervisor said twice a week housekeeping does deep cleaning tasks. Deep cleaning in common areas happens once every other week. High dusting to get cobwebs in common areas happens every other day. During an Interview on 11/21/24 at 12:52 PM, the administrator said that he would expect furnishings to be in good repair and free from peeling material and tears. He also stated that said there should not be accumulated cobwebs, and the facility should be clean at all times and housekeeping is responsible for ensuring all areas are clean. During an interview on 11/21/24 09:48 AM, the maintenance supervisor stated that they are looking into getting the dining chairs reupholstered and that there is no schedule for painting walls, however does attempt to get to painting needs as they are seen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, complete morning hygiene cares, offer fluids, or toilet dependent residents. These failures affected three of the 14 sampled residents (Residents #4, #34and #44). The facility census was 55. Review of the facility's policy for peri care - female, revised 2/1/24, showed, in part: - Purpose: To provide comfort for the resident and to prevent infection. - (7.) Expose peri area, separate inner labia and gently wash from front to back. - (8.) With new wipe, gently open all inner skin folds and wash inner area from front to back. - (9.) With new wet wipe, wash the outer skin fold from front to back. - (10.) With new wet wipe, wash inner legs and outer peri area. - (16.) Offer resident fluids. 1. Review of Resident #4's care plan (a detailed written document created by the facility that outlines the specific needs of a resident, with the goal of maintaining their quality of life in the facility) revised 4/16/2024 showed, in part: - Needs assistance with most ADLs - Requires one person to assist with toilet transfers, toilet hygiene, pericare/incontinence cares and wears briefs for dignity. - Requires one person to assist with transfers. - Is at risk for skin breakdown. - Staff are to keep clean and dry as much as possible, minimize skin exposure to moisture. - Resident #4 is cognitively intact and able to verbalize needs to staff. - Resident #4 is hard of hearing and does not wear his/her hearing aids. During an observation and interview on 11/20/2024 at 7:14 A.M. showed: - CNA C, NA A, and NA B entered Resident #4's room to provide peri care/incontinence care, provide morning cares, and transfer the resident to his/her wheelchair for breakfast. - Resident #4 kept his/her legs tightly closed throughout peri care. - CNA C and NA A failed to expose or clean the peri area throughout peri care. With the resident on his/her back, CNA C, assisted by NA A, wiped the lower portion of Resident #4's pubic area (the lower part of the abdomen just above the external genital organs). After each wipe, staff then pushed the used wet wipes between Resident #4's tightly closed legs into the used brief beneath the resident. - CNA C and NA A failed to expose or clean labial/vaginal folds throughout peri care. With the resident on his/her back, CNA C, assisted by NA A, wiped the outermost portion of the labia (the fleshy folds that surround the opening of the vagina) as they pushed clean wet wipes between Resident #4's tightly closed legs but never cleaned between skin folds or opened Resident #4's legs to allow access to provide complete care. - NA A failed to remove his/her used gloves and complete hand hygiene after assisting to provide peri care to Resident #4. NA A continued Resident #4's morning cares wearing the same gloves he/she wore during peri care. - NA A and NA B failed to change Resident #4's shirt while dressing him/her, leaving the resident to wear the same shirt he/she wore the previous day and had slept in. - NA B failed to provide oral care to Resident #4 or to set up supplies for Resident #4 to complete oral care for himself/herself. NA B rinsed Resident #4's dentures with water and assisted Resident #4 to put them in. - CNA C, NA A, and NA B failed to wash Resident #4's face, to set up supplies for Resident #4 to complete this morning care for himself/herself, or to ask the resident if this is a care he/she would like completed. - During an interview with CNA C and NA B, both staff members reported that they had been trained to open inner perineal folds and clean this area. Neither staff member was aware that washing the resident's face was part of morning cares reporting that night shift handles that. NA B reported that he/she didn't think dentures needed to be brushed because they had been soaking overnight. 2. Review of Resident #34's care plan, revised 6/20/2024, showed, in part: - Requires assistance with most ADLs. - One person to assist with dressing/undressing, and mobility. - Urinary incontinence and require assist with toileting, and incontinent brief changing. - One person to assist with incontinence cares/pericares. - Not able to communicate needs. - Allow sufficient uninterrupted rest periods. - At risk for pressure ulcers R/T decreased mobility. Observation on 11/20/24 from 5:56 A.M. until 12:21 P.M showed the following interactions with the resident: - Resident #34 was seated in his/her broda chair (a specialized wheelchair) next to his/her bed, dressed in the same clothes as the day before at 5:56 A.M. - At 7:45 A.M. Resident #34 was moved to the dining room for breakfast. Resident #34 was still wearing yesterday's clothes and had not been repositioned since this surveyor first observed the resident at 5:56 A.M. - At 9:00 A.M. Resident #34 was observed sleeping in his/her broda chair in the T.V. room. Resident #34 was still in the same position and wearing the same clothes with no indication that he/she had been repositioned or toileted since this surveyor's first observation of the resident that day. - At 9:52 A.M. Resident #34 was moved from the T.V. room to the activity room for bible study. The resident remained in the same position and wearing yesterday's clothes. No indication that Resident #34 had been repositioned, toileted, or allowed to rest in bed was observed. - At 10:54 A.M. Resident #34 was moved from the activity room back to the dining room for lunch. Resident #34 remained within this surveyor's line of sight for the entirety of his/her time in the activity room. No observation of staff repositioning, toileting, or ADL care. - At 11:51 A.M. Resident #34 was observed being fed by the activities director in the dining room. - At 12:21 P.M. Resident #34 was taken to his/her room. Nursing staff transferred the resident into bed, and did not change the resident into clean clothes. - Resident #34 was not interviewable, however the average person would expect to have clean clothes, positioning changes, and hygiene needs met. During an interview on 11/20/24 at 12:42 P.M., NA B said: - Residents that require a lot of help from staff are usually gotten up by the night shift and are already up when he/she arrives at work in the morning. - He/she thinks staff is supposed to check and reposition residents every 2 hours, but he/she thinks that might depend on the resident. During an interview on 11/20/24 at 12:46 P.M., NA A said: - Residents should be turned and repositioned every 2 hours and that toileting residents should also happen every 2 hours or as needed. During an interview on 11/21/24 at 12:52 P.M., the DON said: - Residents are gotten up by staff at a time that is based on each resident's routines and preferences. - If a resident is up a 5:55 A.M., that resident should be repositioned after breakfast. - It is unacceptable for a resident to be up from 5:55 A.M. to 12:21 P.M. without being repositioned. During an interview on 12/2/24 at 10:35 A.M. the DON said: - During morning cares, everything should be addressed, peri care, washing face and hands, and brushing teeth. - A resident's dentures should be brushed every morning, regardless of how long they had been soaking. - Staff is expected to change resident's clothing according to their personal preference. Non-verbal residents or resident who are not able to make their needs known should have their clothes changed daily. - It is expected that staff anticipate the needs of non-verbal residents or residents who cannot make their needs known, and act on them accordingly. 3. Review of Resident #44's Quarterly MDS, dated [DATE] showed: - Long term and short term memory problems; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included dementia (inability to thing), senile degeneration of the brain (a progressive decline in cognitive function that occurs with age). Review of the resident's care plan, revised 9/13/24 showed: - The resident needed assistance with all activities and and daily cares. Required the assistance of one staff for showering, with repositioning in bed, dressing and to propel him/her in the Broda chair (a type of reclining geri chair). The resident required the assistance of two staff for incontinent care and to assist with transfers using the mechanical lift. Observation on 11/20/24 showed: - At 5:55 A.M., the resident was already dressed and up in his/her Broda chair; - At 7:45 A.M., staff propelled the resident to the dining room for breakfast and the resident's eyes were closed; - At 8:45 A.M., staff propelled the resident from the dining room to the front lobby area by the nurse's station and his/her eyes were closed; - At 8:54 A.M., staff propelled the resident to the TV room; - At 9:42 A.M., the resident remained in the the TV room in the Broda chair; - At 9:46 A.M., staff propelled the resident to the large activity room; - At 10:54 A.M., staff propelled the resident from the large activity room directly to the dining room for lunch. Staff did not offer to toilet the resident or offer him/her any fluids since breakfast and he/she has not been repositioned in the Broda chair; - At 11:41 A.M., staff sat down to assist the resident to eat; - At 11:58 A.M., staff propelled the resident from the dining room to the front lobby area by the nurse's station; - At 12:21 P.M., Nurse Aide (NA) A and NA B propelled the resident to his/her room and used the mechanical lift and transferred the resident from the Broda chair to his/her bed and provided incontinent care in the following manner; - NA A and NA B turned the resident side to side in bed and removed the lift pad and pulled the resident's pants down and unfastened the incontinent brief with a strong odor of urine noted; - NA A used the same area of the wipe and wiped down one side of the groin, across the pubic area and down the other side of the groin; - NA A used a new wipe and wiped once down the middle perineal folds; - NA A and NA B turned the resident onto his/her side; - NA A wiped three times from front to back with fecal material on each wipe; - NA A used the same area of the wipe and wiped up both sides of the buttocks, removed gloves, washed hands, applied new gloves and applied house barrier to the resident's red buttocks; - NA A and NA B placed a clean incontinent brief under the resident and fastened it. During an interview on 11/20/24 at 12:42 P.M., NA B said: - The night shift got the resident up this morning; - The resident was normally up when the day shift arrived to work; - The resident had not been toileted or laid down since he/she came to work this morning; - With one of the residents, they have to be checked every two hours but he/she thought it would depend on the resident on how often they were checked; - He/she had started in August and was in-serviced on peri care. During an interview on 11/20/24 at 12:46 P.M., NA A said: - The residents should be turned and repositioned every two hours and toileted as needed or at least every one or two hours; - The resident should have turned and repositioned every two hours; - He/she should have separated and cleaned all areas of the skin where urine or feces had touched; - He/she should not have used the same area of the wipe to clean different areas of the skin. During an interview on 12/2/24 at 11:16 A.M., the DON said: - If a resident is up at 5:55 A.M., then staff should reposition and toilet them after breakfast; - It is not acceptable for a resident to be up from 5:55 A.M. until 12:21 P.M., before they are repositioned or toileted; - Staff should not use the same area of the wipe to clean different areas of the skin; - Staff should separate and clean all the skin folds. Review of the facility's shower schedule showed: - Resident #44 was scheduled to have a shower on Wednesday evening; - The resident was listed under Hospice (end of life care) on Friday evenings. Review of the resident's shower sheets shower sheets for August, 2024 showed: - The resident had two showers out of nine opportunities, 8/17 and 8/14. Review of the resident's shower sheets shower sheets for September 2024 showed: - The resident had four showers out of eight opportunities , 9/4, 9/11, 9/18, and 9/25. Review of the resident's shower sheets shower sheets for October 2024 showed: - The resident had four showers out of eight opportunities, 10/2, 10/9, 10/16 and 10/23. Review of the resident's shower sheets shower sheets for November 2024 showed: - The resident had one shower out of six opportunities, 11/6. Observation on 11/20/24 at 12:21 P.M., showed the resident's hair was dull and the resident had a strong odor of urine. During an interview on 11/20/24 at 12:46 P.M., NA A said: - They have two shower aides on days, the aides do the showers on evening shift; - On Friday evening, they have a shower aide come in to do the showers; - All of the residents should get two showers a week if that's what they want; - If a resident refused their shower, the staff would try to get it made up at some point. During an interview on 12/2/24 at 11:16 A.M., the DON said: - She would expect the residents to get a shower twice a week unless their care plan had something differently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents' safety and independence by pushing residents in their wheelchairs who are able to propel themselves for four of the fourteen sampled residents (residents #17, #10, #39, and #19). The facility census was 55. Review of the Accidents and Incidents policy did not show any details regarding footrest safety. 1. Review of Resident #17's Quarterly MDS (minimum data set), a federally mandated assessment tool completed by facility staff, dated, 9/19/24, showed: -Resident has severely impaired cognition. -Resident is able to wheel themselves in a wheelchair for 150 feet without assistance from helper. -Diagnoses included traumatic brain dysfunction, high blood pressure, anxiety, and depression. Observation on 11/18/24 at 11:29 A.M. showed: -Out of convenience, to move wheelchair traffic out of the hall more quickly. CNA A pushed resident #17 in her/his wheelchair out of dining room without footrests, The resident was instructed to hold feet up while being pushed down the hall, which poses a safety risk, and aides in promoting decline in resident's mobility. 2. Review of Resident #10's Quarterly MDS dated [DATE], showed: -Resident is cognitively intact. -Diagnoses included diabetes, osteoporosis, dementia, and depression. -Resident is able to independently walk 150 feet. -Resident uses a manual wheelchair. Observation on 11/19/24 04:03 P.M. showed: -Out of convenience to move wheelchair traffic out of the hall more quickly,CNA B pushed resident #10 in his/her wheelchair to his/her room without footrests. Resident was instructed to hold feet up while being pushed down the hall, which poses a safety risk, and aides in promoting decline in resident's mobility. which poses a safety risk, and aides in promoting decline in resident's mobility. 3. Review of Resident #39's Quarterly MDS dated [DATE] showed: -Resident has moderately impaired cognition. -Diagnoses included diabetes. -Resident requires partial/moderate assistance to wheel themselves 150 feet. Observation on 11/18/24 at 3:53 P.M. showed: -Out of convenience to move wheelchair traffic out of the hall more quickly, the kitchen manager pushed resident #39 in his/her wheelchair into dining room without putting footrests down Resident was instructed to hold feet up while being pushed down the hall, which poses a safety risk, and aides in promoting decline in resident's mobility. 4. Review of Resident #19's Annual MDS dated , 8/29/24, showed: -Resident is cognitively intact. -Diagnoses include stroke, high blood pressure, paralysis on one side of the body, and seizure disorder. -Resident is able to wheel themselves in a wheelchair for 150 feet without assistance from helper. Observation 11/19/24 at 3:30 P.M. showed: -Out of convenience to move wheelchair traffic out of the hall more quickly, the Activities director pushed resident #19's wheelchair out of the dining room without footrests, Resident was instructed to hold feet up while being pushed down the hall, which poses a safety risk, and aides in promoting decline in resident's mobility Residents #17, #10, #39, and #19 were not interviewable, however a reasonable person would want to propel their self if possible or have a foot rest to protect their feet. During an interview on 11/21/24 at 10:00 A.M., CNA A said there are foot pedals accessible for residents that need them. She said it is standard practice to push a resident without foot pedals if the resident can lift their feet because they don't want the resident to get hurt. During an interview on 11/20/24 at 4:11 P.M., LPN A, said that nursing staff will recommend footrests if a resident's feet are dragging. He/She said there needs to be footrests if a resident is not able to propel themselves but believes it to be ok for staff to push a resident without footrests if they are able to lift their feet up. He/She stated that it is probably a gray area because residents could get hurt. During an interview on 11/21/24 at 12:52 P.M., the DON said residents in wheelchairs should not be pushed by staff if their wheelchair does not have footrests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed: -Resident was rarely/never understood. -Resident had a memory problem. -Resident's cognitive skills for daily decision making was moderately impaired. -Resident required partial/moderate assistance to move from lying to sitting on side of bed. -Resident required partial/moderate assistance to move from sitting to lying on back in bed. -Resident's diagnoses included traumatic brain dysfunction, heart disease, high blood pressure, and depression. Observation on 11/21/24 at 11:07 A.M., showed resident has a U-shaped cane rails on both sides of the bed. Review of care plan, dated 4/25/24, showed: -Family had expressed a desire for me to use positioning bars to serve as an enabler to promote independence. -Family had consented for me to use positioning bars. -Order per my PCP, may use positioning bars for bed mobility and transfers -Positive and negative aspects of positioning bar use have been discussed with resident and/or family and are aware of risks involved with use of positioning bars -Review of positioning bar use every quarter and with significant status change. Remove bars if no longer appropriate. Review of physician orders, dated 4/23/24, showed the reisdent may use positioning bars for mobility and transfers. Review of Bed Rail Safety Assessment, dated 5/20/24, showed the resident was assessed for bed rails. Review of Side Rail Use Assessment Form, dated 4/24/24, showed a recommendation for side rails on both sides of the bed to help with independence. A quarterly bedrail assessment was requested and not provided. During an interview on 11/21/24 at 09:59 A.M., NA A said the U-shaped rails are used to assist the resident in turning in bed or to get out of bed or to grab to position while receiving cares. During an interview on 11/20/24 04:11 PM LPN A said the U-shaped rails are for mobility. 4. Review of Resident #42's Quarterly MDS, dated [DATE], showed: -Resident had severe cognitive imparment. -Resident had no imparment in upper or lower extremity functional range of motion. -Resident was able to roll from left to right independently. -Resident required no assistance to move from lying to sitting on side of bed. -Resident required no assistance to move from sitting to lying on back in bed. -Resident's diagnoses included traumatic brain dysfunction, high blood pressure, and Alzheimer's disease. Observation on 11/21/24 at 11:07 A.M., showed resident has a U-shaped cane rail on left side of the bed. Review of care plan, dated 4/25/24, showed: -Family had consented to use positioning bars. -Order per PCP, may use positioning bars for bed mobility and transfers -Positive and negative aspects of positioning bar use have been discussed with resident and/or family and are aware of risks involved with use of positioning bars -Review of positioning bar use every quarter and with significant status change. Remove bars if no longer appropriate Review of Bed Rail Safety Assessment, dated 5/24/24, showed the resident was assessed for bed rails. Review of Side Rail Use Assessment Form, dated 4/24/24, showed the recommendation for side rails on the left side of the bed to help with independence. Review of care plan, dated 4/25/24, showed: -Family has expressed a desire to use left positioning bar to serve as an enabler to promote independence. -Family has consented to use positioning bar. -Order per my PCP, may use positioning bar for bed mobility and transfers. -Positive and negative aspects of positioning bar use have been discussed with resident and/or family and are aware of risks involved with use of positioning bar. -Review of positioning bar use every quarter and with significant status change. Remove bar if no longer appropriate Start Date 04/25/2024 Review of physician's orders, dated 4/23/24, showed the resdient may use positioning bars for bed mobility and transfer. A request for quarterly bedrail assessment was made but not provided. During an interview on 11/21/24 at 10:53 A.M., the resident said the U-shaped rail is really handy. He/she uses it to get up. During an interview on 11/20/24 at 8:15 A.M, Director of Nursing (DON) said: -Facility did complete side rail assessments on residents; -Sometimes residents move in and side rails are already installed on the bed they move into; -Facility must obtain physician's orders prior to installing side rails; -Side rails should be care planned; -Maintenance staff has a guide for entrapment measurements; -Facility switched from side rails to only using u-shaped cane bars and did not view the cane rails as same risk for entrapment; -The Minimum Data Set (MDS) Nurse completed side rail assessments on residents. During an interview on 11/20/24 at 2:39 P.M., Maintenance said: -Facility only used mobility bars (u-shaped cane rails); -Nurse or therapy department will notify him/her to put the side rails on the bed; -He/She completed measurements with the mattresses and side rails using a guide called bed and assist rail maintenance inspection form and bed rail safety assessment; -He/She completed the entrapment assessment with the bed rail safety assessment when resident first comes into facility and with the change of mattress; -He/She did not measure entrapment zones on a monthly basis; -He/She completed a safety assessment monthly to ensure side rails had not come undone; -Does not measure on a monthly basis; -Does do safety assessments; -Side rails will not come out if undone, all have give, there is a deal underneath the clips that go into the side of the bed, will not let you release bars. During an interview on 11/20/24 at 3:05 P.M., Licensed Practical Nurse A said: -Side rails are assessed upon admission of new residents; -He/She would ask resident or family if the side rails were something they preferred or would aide them in getting around and in and out of their bed; -If resident wanted side rails he/she would get a hold of maintenance; -If resident had side rails on their bed they should have a physician's order; -He/She would request a physician's order for the side rail; -MDS coordinator completed quarterly side rail assessments for residents; -Side rails should be included in resident's care plan. During an interview on 11/21/24 at 10:08 A.M., MDS Coordinator said: -Side rails are not already installed on resident's bed; -Side rails are installed when and if a resident requested them; -Facility completed assessments to determine if side rails were appropriate for the resident; -Assessments were done quarterly; -A physician's order for the side rails must be obtained from the physician; -Maintenance or housekeeping would install the side rails; -He/She obtained consents by calling the resident's representative or discussing with resident if they were their own person and obtain consent; -Consent was included under the side rail assessment form; -The initial side rail assessment would show the consent signature of resident or their representative; -Maintenance staff is responsible for measuring dimensions and areas of entrapment; -He/She assumed entrapment zones were measured quarterly but did not know for sure; -A physician's order was required prior to installing side rails; -He/She expected side rails to be care planned; -He/She was responsible for writing care plans. During an interview on 11/21/24 at 12:52 P.M., Administrator said: -Verbal or written consent must be obtained for installation of side rails; -Side rail consents were documented on initial side rail assessment form but were not updated with quarterly assessments; -Entrapment assessments should be completed be completed upon initial installation and quarterly; -He/She expected a physician's order prior to installation of side rails. Based on observation, record review, and interviews, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, failed to review the risk and benefits with the resident or the resident's representative (Resident #5, #45) , failed to obtain informed consent prior to installation (Resident #5 and #45), failed to ensure the bed's dimensions were appropriate for the resident's size and weight (Resident #5 and #45), failed to obtain a physician's order prior to installation of side rails (Resident #5), and failed to complete quarterly safety assessments for residents (Resident #5, #45), and failed to care plan side rails (Resident #5). This included four of 14 residents sampled (Residents #5, #45, #17, and #42). The facility census was 55. Review of facility policy, bed assist bar usage, revised 4/24/24, showed: -Policy to prevent entrapment and other safety hazards associated with bed assist bar use. -Facility leadership will be responsible for completing individual assist bar evaluation on a regular basis; -Providing employees appropriate information, education, training pertaining to general risks and benefits of assist bar use; -Education pertaining to resident-specific risks and care needs associated with bed assist bar use; -Upon admission, readmission or change of conditions residents will be screened to determine level of independence with bed mobility, bed comfort level, if bed meets manufacturers recommendations and specifications pertaining to resident height and weight, and assess the need for special equipment and accessories (assist bars); -Assess the resident to identify appropriate alternative prior to installing assist bars; -Assess the resident for risk of entrapment from assist bar(s) prior to installation; -Facility will document ongoing need for the use of an assist bar; -Review the risks and benefits with resident and resident representative; -Obtain informed consent; -Obtain physician order for medical symptom assessed for need for assist bar use; -Resident care plan will include use of assist bar(s) as assessed); -When installing or maintaining assist bar(s), the maintenance department staff will follow the manufacturer's recommendations and specifications, or provide another bed or appropriate alternative in accordance with individual bed inspections. -Maintenance department will conduct regular annual inspection of all bed frames, mattresses, and quarterly on assist bar(s) as part of a regular maintenance program to identify areas of possible entrapment; 1. Review of admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/22/24, showed: -He/She admitted to facility on 8/12/24; -He/She was cognitively intact; -He/She had clear speech, clear comprehension, and ability to understand others; -He/She had no impairment to upper or lower extremities; -He/She was dependent on a wheelchair; -He/She was independent with mobility, dressing toileting, and personal hygiene; -Diagnoses included diabetes (too much sugar in the blood), heart failure, and high blood pressure. Review of physician's orders, dated 11/18/24, showed no orders for the use of side rail or assist bars. Review of care plan, dated 9/4/24, did not address use of side rails or assist bars. During an interview on 11/18/24 at 2:36 P.M., resident said he/she had side rail so he/she could hold onto it to help position self in bed and assist self when he/she stood up out of his/her bed. Observation on 11/18/24 at 2:36 P.M. showed resident had a u shaped cane rail on right side of bed. Review of electronic medical record showed: -He/She did not have consent for side rails; -He/She did not have side rail assessment; A request for the bed and assist rail maintenance inspection form for the resident was requested and not provided. During an interview on 11/21/24 at 10:08 A.M., MDS Coordinator said: -He/She did not have a side rail assessment completed on the resident; -He/She did not have a physician's ordes for side rails for the resident; -He/She was unsure if resident's side rails were care planned. 2. Review of Resident #45's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and clear comprehension of others; -He/She had impairment of one side of lower extremities; -He/She was dependent on a wheelchair; -He/She required partial to moderate assistance with lying to sitting on side of bed, chair to bed transfers, sit to stand transfers, toilet transfers, and upper body dressing; -He/She required substantial to maximal assistance with lower body dressing, bathing, and applying footwear; -Diagnoses included amputation of left leg below the knee, diabetes, high blood pressure. Review of physician's orders, dated 11/19/24, showed: -Start dated 4/23/24, may use positioning bars for bed mobility and transfers; -Start date 8/13/24, non weight bearing to left leg. Review of care plan, revised 9/4/24, showed: -Resident expressed a desire to use positioning bars to serve as an enabler to promote independence; -He/She had consented to use positioning bars; -Orders per primary care provider, may use positioning bars for bed mobility and transfers; -Positive and negative aspects of positioning bar use have been discussed with resident and/or family and are aware of risks involved with use of positioning bars; -Review of positioning bar use every quarter with significant status change. Remove bars if no longer appropriate; -Resident needed assist with some activities of daily living due to left below knee amputation. During an interview on 11/18/24 at 3:20 P.M., Resident said: -He/She used side rails to pull self up; -The side rails had been on bed ever since he/she had the bed. Observation showed on 11/18/24 at 3:20 P.M. that resident had a u-shaped cane rail on both sides of his/her bed. Review of side rails assessment showed: -9/19/24 he/she was assessed for side rails to use to assist with transfers and bed mobility; -6/20/24 he/she was assessed for side rails to use to assist with transfers and bed mobility. Review of bed and assist rail maintenance inspection form showed: -Bed assessment frequency-If assist bar(s), initally when installed, quarterly, and/or when bed frame, mattress, or other accessories replaced -The Inspection form dated 6/5/24, showed there was no gaps of 4 and 3/4 inches inside the rail, under the rail, between the rail and the matress, or 2 and 3/8 inches between the rail and the headboard or footboard while resident was in his/her bed; -The facility provided no other completed quarterly assessments.

Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent (%). Staff made 6 medication errors out of 31 opportunities for error, which resulted in an error rate of 19.35%. This affected 4 of the 14 sampled residents, (Residents #5, #29, #49, and #50). The facility census was 55. Review of the facility's policy for preparation and administration of oral medications, revised 2/1/24 showed, in part: To ensure the resident receives prescribed medications as ordered by Doctor utilizing the most current nursing practice. Review and verify medication administration records/medication cards with Doctor's order according to facility policy. Check medication record/card and remove the container of medication from the bin. LIQUIDS - Shake liquid (unless medication is not to be shaken) holding label to palm and pour into calibrated cup at eye level. Check the medication record/card and label again. Physician Order to be followed completely. This includes completing medication as ordered. Review of the facility's policy for administration of eye medications, revised 1/31/2024 showed, in part: - POLICY: To ensure resident receives the prescribed medication as ordered by the Doctor utilizing the most current acceptable nursing practice. - (2.) Check the treatment record with the medication label. - (11.) Do not let the dropper tip touch the eye, eyelid, or finger. - (15.) Read label of medication again. 1. Review of Resident #29's Physician order sheet (POS), dated 10/20/2024 - 11/20/2024 showed: - Start date: 10/17/2019 - Artificial Tears (polyvin alc) (polyvinyl alcohol) [OTC] drops; 1.4%; amt: 2 drops each eye; ophthalmic (eye) Three Times A Day; AM 06:00 - 10:00, MD 13:00 - 16:00, PM 19:00 - 22:00. Review of the Resident #29's medication administration record (MAR), dated 11/01/2024 - 11/20/2024 showed: - Artificial Tears (polyvin alc) (polyvinyl alcohol) [OTC] drops; 1.4%; Amount to Administer: 2 drops each eye; ophthalmic (eye) - Documentation shows it was administered three times per day for the past 19 days; Observation and interview on 11/20/24 at 6:06 A.M., showed: - LPN C administered eye drops that were labeled with a different resident's patient sticker. LPN C retrieved a box of artificial tears from the med cart. The box had Resident #29's name written in black marker across the front. The patient sticker on the bottom of the box was labeled with the name of a different resident. LPN C used the bottle of artificial tears from the mislabeled box for administration. - LPN C failed to keep the tip of the applicator bottle from touching the resident's eye lashes during administration. - LPN C reported during interview that the facility regularly has in-service and education related to medications and medication administration. - LPN C stated she was unaware that the sticker on the bottom of the box had another resident's name on it. During an interview with the Director of Nursing (DON) on 11/21/24 at 12:52 P.M. the DON said: - the tip of the eye dropper should not touch the eyelid or eye lashes when administering eye drops. 2. Review of Resident #50's Physician order sheet (POS), dated 10/19/2024 - 11/19/2024 showed: - Start date: 01/22/2024 - House Supplement 120 mL BID for weight loss, advanced age Twice a day; AM 06:00 - 10:00, PM 15:00 - 18:00 Review of Resident #50's medication administration record (MAR), dated 11/01/2024 - 11/19/2024 showed: - House Supplement 120 mL BID d/t weight loss, advanced age. - Documentation shows it was administered twice per day for the past 19 days. Observation and interview on 11/20/24 at 6:24 A.M., showed: - LPN C failed to follow the provider's orders when he/she administered an unknown dose of House Supplement. LPN C retrieved the bottle of House Supplement from the med cart and proceeded to fill a small plastic cup without measuring it and administered the liquid to Resident #50. - LPN C said, that he/she was unaware of how many milliliters (mL) the cup held. During an interview with the DON on 12/2/24 at 10:45 A.M., the DON said: - When preparing liquid medications, staff are expected to measure the liquid in a measuring cup at eye level. - That all liquid medications should be measured before administration. - To his/her knowledge there is no liquid medication used in the facility that would not need to be measured before administration. 3. Review of Resident #49's POS dated November, 2024 showed an order start date for 2/29/24 for Olopatadine drops 0.1 % one drop daily in each affected eye for dry eyes. Review of the resident's MAR dated November, 2024 showed an order for Olopatadine drops 0.1 % one drop daily in each affected eye for dry eyes. Observation on 11/20/24 at 6:45 A.M., showed: - CMT A placed one drop in the resident's left eye and the tip of the eye dropper touched the resident's eye lid and eye lashes and applied lacrimal pressure for 13 seconds; - CMT A placed one drop in the resident's right eye and the tip of the eye dropper touched the resident's eye lid and eye lashes and applied lacrimal pressure for 14 seconds. During an interview on 11/21/24 at 10:21 A.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lid or eye lashes; - Should apply lacrimal pressure for five to ten seconds. During an interview on 11/21/24 at 12:52 P.M., the DON said: - The tip of the eye dropper should not touch the resident's eye lid or eye lashes; - Staff should apply lacrimal pressure for one minute. 4. Review of the facility's policy for nasal medication administration revised 2/1/24, showed, in part: - To ensure resident receives nasal medication per physician's orders according to approved procedures; - Position resident: sitting up for nasal sprays; - Give the resident a tissue and instruct to blow nose to clear nasal passage; - Instruct resident to use finger to close nostril opposite of nostril receiving medication; - Administer the dosage: insert spray nozzle gently into nose and spray; - Wipe away excess medication with tissue; - Instruct resident not to blow nose for a few minutes. Review of the package leaflet for Flonase nasal spray, revised March 2016, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. Review of Resident #5's POS dated November, 2024 showed: - Start date: 11/11/24 - Fluticasone (Flonase) propionate spray, 50 micrograms (mgs.) two sprays in both nostrils daily for chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the residents's MAR, dated November, 2024 showed: - Fluticasone (Flonase) propionate spray, 50 mgs., two sprays in both nostrils daily for COPD. Observation on 11/20/24 at 7:16 A.M., showed: - CMT A did not shake the Flonase bottle; - CMT A did not have the resident blow his/her nose; - CMT A administered two sprays in the resident's right nostril and gave two sprays in the left nostril and did not occlude either side of the nostril. During an interview on 11/21/24 at 10:21 A.M., CMT A said: - He/she should follow the manufacturer's guidelines for administration of Flonase. During an interview on 11/21/24 at 12:52 P.M., the DON said; - She would expect the staff to follow the manufacturer's guidelines for the administration of Flonase.

Based on observation, record review, and interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to utilize proper thawing techniques, failed to ensure garbage cans were kept covered when not in use, failed to properly sanitize all food preparation surfaces in kitchen, failed to store dishes in an inverted position, failed to implement proper hand washing techniques, and failed to ensure proper storage and labeling of foods. The facility census was 55. 1. Review of facility policy, waste disposal, dated April 2011, showed: -All waste must be placed in lined garbage and trash cans and kept covered when not in use. Observation on 11/18/24 9:07 A.M., showed there was no lids on two large trash cans, one in dishwashing area and one towards back of kitchen. Observation on 11/20/24 at 9:21 A.M. showed no lids were on the trash cans in the kitchen. During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -Trash cans in the kitchen should have lids on them at all times. During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -Trash cans in kitchen should have lid. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -Trash cans in kitchen should have lids on them. During an interview on 11/21/24 at 9:00 A.M., Dietary Aide A said: -Trash cans in kitchen should be covered; -The trash cans in the kitchen were not covered. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -He/She expected trash cans in kitchen to be covered at all times unless they are being used. During an interview on 11/21/24 at 12:52 P.M., Administrator said: -He/She expected trash cans in the kitchen to be covered. 2. Review of facility policy, hand washing and glove use dining services, posted 9/5/11, showed: -All residents and staff should be free from contamination by improper hand washing and glove use. -Wash hands after every activity such as eating, drinking, using the restroom, touching a resident or wheelchair, picking up trash, taking out the trash, touching face or hair, bussing tables; -Wash hands before and after glove use; -Wash hands following the instructions located at every hand sink. Review of facility policy, untitled, revised 7/22/14, showed: -Use proper hand washing techniques often and when necessary (hand washing should be done after any activity, such as eating, drinking, using the restroom, smoking, cleaning, touching anything contaminated, and before and after glove use) Review of facility policy, dishwashing, dated April 2011, showed: -Sanitize hands properly before pulling racks from the clean side of the dish machine; -Allow items to thoroughly dry before unloading racks or storing items. During a continuous observation on 11/20/24 from 9:21 A.M.-11:35 A.M., showed: -9:29 A.M., [NAME] B washed his/her hands and then turned faucet off with his/her paper towel, and continued to use same paper towel to dry his/her hands; -9:36 A.M. [NAME] B went from dirty dishes of dishwasher to clean side of dishwasher. He/She removed items from clean side of dishwasher without washing his/her hands; -9:45 A.M., Dietary Aide B washed his/her hands and used bare hands to shut off water faucet handles. He/She then dried hands with paper towel; -10:10 A.M., Dietary Aide B washed his/her hands and used bare hands to turn off faucet handles; -10:23 A.M., Dietary Aide B washed his/her hands and used bare hands to turn off faucet handles; -10:51 A.M., [NAME] B washed his/her hands, used paper towel to turn off faucet, then used same paper towel to dry his/her hands; -11:09 A.M., Dietary Aide B washed his/her hands and used bare hands to turn off faucet handles. Review of facility policy, dishwashing, dated April 2011, showed: -Sanitize hands properly before pulling racks from the clean side of the dish machine. During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -He/She must wash hands any time changing tasks, entering kitchen, and any time he/she contaminates his/her hands; -It was not sanitary to wash his/her hands and then use his/her bare hands to shut off faucet; -It was not sanitary to wash his/her hands, turn off faucet handles with paper towel, and then use same paper towel to dry his/her hands. -He/She should wash hands after loading dirty dishes into dishwasher and before taking clean dishes out of dishwasher. During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -He/She expected frequent hand washing with anytime changing tasks, leave kitchen and returning to kitchen; -It was not sanitary for staff to wash hands and turn faucet off with bare hands; -He/She expected staff to use a different paper towel to shut off faucet after washing hands and should not use same paper towel to dry his/her hands; -He/She expected staff to wash hands between loading dirty dishes and removing items from clean side of dishwasher. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -He/She had to wash hands if went to bathroom, took out trash, wipe off carts, touch his/her face, brush his/her hands, or when entered kitchen; -It was not sanitary for him/her to shut off faucet handles with bare hands after washing his/her hands; -It was not sanitary for him/her to shut off faucet handles with paper towel and use same paper towel to dry his/her hands. -He/She did not know if he/she should wash his/her hands before removing clean dishes from dishwasher During an interview on 11/21/24 at 9:00 A.M., Dietary Aide A said: -He/She should wash hands by running water for 20 seconds, putting on soap, rubbing nails and stuff, rinsing hands off, pull paper towels down, turn off water with paper towel; -It was not sanitary to use his/her bare hand to shut off water faucet; -It was not sanitary to use paper towel to shut off water faucet and then use same paper towel to dry his/her hands. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -He/She expected staff to wash their hands between going to bathroom, smoking, when in and out of the kitchen; -He/She expected staff to turn off faucet handles after washing their hands with a towel; -He/She expected staff to wash their hands before going to clean side of dishwasher and putting dishes away. During an interview on 11/21/24 at 12:52 P.M., Administrator said: -He/She expected dietary staff to wash hands frequently; -He/She expected staff to wash hands and turn faucet off with a paper towel; -He/She did not expect staff to turn off faucet handles with bare hands or use the same paper towel to turn off faucet handles and then dry their hands with same paper towel but expected them to use new paper towel. 3. Review of facilitys food policy, untitled, revised 8/26/11, showed: -Leftovers will be stored and discarded properly; -Put leftovers in appropriate containers; -Label, date, and initial the containers; -Place containers in cooler or freezer. -Max storage for leftovers is 7 days for canned fruits, vegetables, etc. and 3 days for foods prepared with mayor or cooked meats. Review of facility policy, receiving and storage of food, dated April 2011, showed: -Keep all foods in clean, undamaged wrappers or packages; Observation on 11/18/24 at 8:57 A.M. of the walk in cooler in kitchen showed: -Opened, unsealed, and undated bag of soft shell tortillas; -Opened and undated 5 lb shredded Monterey jack cheese; -Opened and undated 5 lb pimento spread; -Three sections of opened and undated American cheese wrapped in clear plastic wrap; -Opened and undated bag of hard boiled eggs; -Opened and undated dough; Observation on 11/18/24 at 9:03 A.M. of dry storage showed: -Undated and opened 5lb egg noodles; -Undated and unsealed 10 oz bag of spaghetti noodles; -Undated bag of mini marshmallows; Observation on 11/18/24 at 9:07 A.M. of spice rack showed: -Outdated 16 oz ground clove, dated 10/11/22 -Opened and undated 16oz chives; -Opened and undated garlic powder had no date; -Opened and undated Italian seasoning; -Opened and undated lemon pepper 20oz; -Opened and undated basil leaves 20 oz; -Opened and undated celery salt 20 oz; -Opened and outdated dill weed, dated 1/10/22; -Opened and outdated rubbed sage 60z dated 10/11/22; -Opened and undated Hungarian paprika 18oz; -Opened and undated 20 oz onion powder; -Opened and undated beef flavor soup base 16 oz; -Opened and undated chicken flavor soup base 16 oz; -Opened and undated iodized table salt 26 oz; -Opened and undated season salt 16 oz; -Opened and undated corn starch 16oz; -Opened and undated cinnamon, 16 oz; -Opened and undated nutmeg 16oz; -Opened and outdated ground ginger 14oz dated 1/17/22. Observation on 11/18/24 at 9:12 A.M. of food preparation table: -Opened and undated sliced white bread; During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -Food should be dated when opened with date opened and three days following; -Spices should be dated; -Spices could be maintained thirty days to one year after opening; -Spices should be thrown out after one year During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -He/She expected a date and label on anything left over from being cooked or that was taken out of a can; -Leftovers could be kept for three days; -He/She expected condiments such as salad dressing to have a written opened date and a disposal date one month after that open date; -Spices should be dated when opened; -Spices should be disposed one year after opened date; -He/She expected staff to dispose of spices after 1 year. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -He/She dated food items when he/she opened them; -Bags should be sealed; -Spices should have a date on them; -He/She did not know how long spices could be maintained in kitchen from date they were opened. During an interview on 11/21/24 at 9:00 A.M., Dietary Aide A said: -He/She dated food items when they were opened; -Items stored in fridge or freezer should be sealed; -Spices should be dated when they were opened. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -He/She expected spices to have dates written on the bottle after they were opened; -Spices could be kept for 1 year after they were opened; -Food items that are opened should have a date on them; -Food items should not be exposed to air; -Everything store should be sealed. During an interview on 11/21/24 at 12:52 P.M., Administrator said: -He/She expected food in kitchen to be dated when opened; -He/She expected opened food to be stored in sealed containers; -He/She expected spices dated 2022 to be discarded. 4. Facility did not provide a policy on storage of dishware. Observation on 11/18/24 at 9:01 A.M. showed bowls and plates are stored upright. Observation on 11/18/24 at 9:18 A.M. showed 17 metal bake pans were stored upright, three bowls sat on top of microwave not in use stored upright; Observation on 11/20/24 at 9:21 A.M. showed plates and bowls were stored face up on counter. Bowls located on top of the microwave were stored up right. Observation on 11/20/24 at 11:08 A.M. showed under the steam table shelf had plastic containers, bowls, with lids were all stored upright. During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -Bowls, plates, cups, pans, pitchers should be stored inverted; During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -Anything that could be stored inverted should be including plates, bowls, pitchers, and bakeware. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -They always stored plates, dishes, bowls upright in the kitchen. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -He/She expected plates when stored at the end of the day to be covered with a blanket and stored up right; -Items that have contact with food should be covered or stored upside down; -Pitchers and bowls should be stored inverted if they were not covered. 5. Facility did not provide a policy on proper unthawaing techniques. Observation on 11/18/24 at 8:57 A.M. of the walk in cooler showed a 5 lb roll of hamburger was unthawing on top of a cardboard box on the bottom shelf; During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: -Meat should be unthawed in fridge prior to when need it; -Hamburger should not be unthawing on top of card board box; During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -He/She expected meat to be unthawed overnight in the refrigerator in a separate container. -Meat could be unthawed under running water below 70 degrees in a pinch, but he/she preferred meat be unthawed in advance. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -Meat should be unthawed in refrigerator or during cooking process; 6. During a continuous observation on 11/20/24 from 9:21 A.M.-11:35 A.M., showed: -9:21 A.M., towels and Dawn dish soap out on counter, [NAME] B used a wash cloth to wipe off food prep surfaces that was not in sanitizer water. -9:24 A.M., [NAME] B tested sanitizer water showed appropriate parts per million (PPM), stated he/she set up the sanitizer water when he/she came into shift that morning; -9:40 A.M., Dietary Aide A used a green towel that was in a gray pale bucket next to dawn dish soap to wipe off 3 tiered cart. During an interview on 11/20/24 at 2:49 P.M., [NAME] A said: Surfaces in kitchen should be sanitized with water we make from our sanitizer out of the machine or 409. During an interview on 11/20/24 at 4:02 P.M., Registered Dietician said: -He/She expected kitchen surfaces to be sanitized with sanitizer solution. During an interview on 11/21/24 at 8:51 A.M., [NAME] B said: -He/She sometimes used dish soap to wash off surfaces in the kitchen; -He/She at times would use dish soap and sanitizer on kitchen surfaces in the kitchen; -He/She did not always use both dish soap and sanitizer and sometimes only sanitized surfaces with dish soap. During an interview on 11/21/24 at 9:00 A.M., Dietary Aide A said: -He/She was using soapy dish water in gray container to wash off kitchen carts; -He/She did not use sanitizer on the 3 tiered carts; -He/She would use towels to dry off coffee cups and silverware; -He/She used dish soap to sanitize surfaces in the kitchen; -He/She also used sanitizer that comes from dishwasher to sanitize surfaces in the kitchen. During an interview on 11/21/24 at 9:09 A.M., Dietary Manager said: -Kitchen prep surfaces should be scrubbed with dish detergent, then expected staff to use 409; -He/She expected sanitizer to be used on food prep surface areas; -Towels were not supposed to be used to dry things and should only be used for carts and stuff; -He/She expected dish soap and sanitizer to be used on carts; During an interview on 11/21/24 at 12:52 P.M., Administrator said: -He/She expected surfaces in kitchen to be cleaned with sanitizer solution and then allowed to dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #24's undated care plan showed: - Resident required Enhanced Barrier Precautions (EBP) related to urinary catheter and wounds. - Staff is expected to wear gloves and gown for the following high-contact resident care activities: Dressing, Bathing/showering, transfering, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care: central line, urinary catheter, feeding tube, tracheostomy; wound care. - Resident was admitted to the facility with stage III pressure ulcers (wounds caused by prolonged pressure on the skin) to his/her back and coccyx (the small, triangular bone at the base of the spine). - Staff is expected to keep linens clean and dry. - Requires help with all ADLs. Review of Physician orders for October 2024., showed: - Wound Care start date: 10/04/2024 Cleanse wounds with wound cleanser, dry. Apply lidocaine 5%/bupivocaine 2%/metronidazole 20% (pixie dust), calcium alginate, and super absorbant dressings to sacral and spinal wounds daily. An observation on 11/18/24 at 2:18 P.M. showed: - Multiple dime-sized dried blood droplets on the Resident's sheet. - A fist-sized blood stain on the bottom sheet under the resident. During an observation and interview on 11/19/24 at 10:08 A.M., showed: - LPN A and LPN D entered Resident's room for wound care. - Staff failed to apply gowns prior to care. - Blood stained top sheet and draw sheet remained untouched on Resident #24's bed. -There was no EHB signage on the door or outside the resident's room. - Two washable EBP gowns were hung on the back of Resident #24's door for staff use. - LPN D said that a resident with a catheter and wounds would require EBP. - LPN D said that they both should have donned gowns prior to wound care. During an interview on 11/21/24 at 12:52 P.M., the DON said staff are expected to wear gowns and gloves during wound care for all residents requiring EBP. Based on observation, interview and record review, the facility failed to follow acceptable infection control practices to reduce the development and spread of infections for three of the 14 sampled residents (Resident #18, #24, and #53), and failed to ensure the urinary catheter drainage bag for Resident #53 did not touch contaminated surfaces. The facility additionally failed to place residents with wounds (Resident #18 and Resident #24) and with urinary catheters (Resident #18 and #53) on enhanced barrier precautions (EBP). The facility census was 55. Review of the facility's Enhanced Barrier Precautions policy, dated August 2022, showed: - EPBs are utilized to prevent the spread multi drug resistant organisms (MDRO) to residents; - EPBs employ targeted gown and glove use during high resident care activities when contact precautions do not otherwise apply; - Gloves and gowns are applied prior to performing the high contact resident care activity; - Examples of high contact resident care activities that require the use of gown and gloves are; - Catheter care or use; - Wound care; - EPBs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling device; -Signs are posted on the door or on the wall outside the resident's room indicating the type of precautions and personal protective equipment (PPE) required. Review of the facility's Catheter Emptying, Urinary Drainage Bag, revised 1/31/24, showed: -Keep the drainage bag and tubing off the floor at all times to prevent contamination. 1. Review of Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/30/24, showed: -No cognitive impairment; -Substantial assistance with showers; -Partial assistance with toileting; -The resident has indwelling urinary catheter; -Frequently incontinent of bowel; -Diagnoses included, kidney failure, and thyroid dysfunction. Review of the resident's care plan dated 11/1/24, showed: -The resident requires the assistance of one staff for Activities of Daily Living (ADLs); -The resident has an indwelling urinary catheter; - Do not allow tubing or any part of the drainage system to touch the floor. Observation on 11/21/24, at 9:36 A.M., showed: -There was a yellow gown for PPE hanging on the back of the resident's door; -Certified Nurses Aide (CNA) D washed his/her hands and applied gloves; -CNA D removed the residents brief; -CNA D lowered catheter drainage bag to the floor by the catheter tubing; -The resident's catheter drainage bag came in contact with the floor; -CNA D drained the urine from the top of the catheter tubing into the drainage bag and hung it on the bed; -CNA D removed the drainage bag from the bed and drained the urine out of the catheter tubing again; -The drainage the bag came in contact with the floor again and with top of the trash can beside the resident's bed; -CNA D failed to keep the catheter drainage bag off the floor; -CNA D failed to keep the catheter drainage bag from touching the trash can; -CNA D did not apply the yellow isolation gown hanging on the back of the resident's door before starting cares on the resident; -No signs were posted on the door or on the wall outside the resident's room indicating the resident was on EBP. During an interview on 11/21/24 at 9:48 A.M., CNA D said: -The catheter drainage bag or tubing should not touch the floor; -The catheter drainage bag or tubing should not touch the trash can; -He/she was not aware that the resident was on EBP. During an interview on 11/21/24 at 9:57 A.M., Registered Nurse (RN) A said: -The catheter drainage bag or tubing should not touch the floor; -The catheter drainage bag or tubing should not touch the trash can; -If a resident has a catheter they should be on EBP; -The resident should have a sign on the door or the wall indicating EBP should be used; -The yellow gown on the back of the residents door is used for EBP. During an interview on 11/21/24 at 12:52 P.M., the Director of Nursing (DON) said: -He/she expects the staff to use EBP when the resident has a catheter or a wound; -He/she expects staff to keep catheter drainage bags from touching the floor or other contaminated surfaces. 2. Review of Resident #18's admission MDS, dated [DATE] showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing and transfers; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel - Diagnoses included anxiety, multiple sclerosis (a disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve and spinal cord, called the myelin sheath), and neuromuscular dysfunction of the bladder (a condition that occurs when the nerves, spinal cord, or brain that control bladder function are damaged). Review of the resident's care plan, revised 11/8/24 showed: - The resident required enhanced barrier precautions related to Suprapubic catheter (a catheter which enters the bladder through the lower abdomen); - Clean hands before entering and when leaving the room; - Do not wear the same gown and gloves for the care of more than one person; - Wear gloves and a gown for the following high-contact resident care activities: dressing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, central line, urinary catheter, feeding tube, tracheostomy (an artificial opening into the wind pipe to aid breathing) and wound care. Review of the resident's physician order sheet (POS) dated November 2024 showed: - Start date: 7/17/24 - Catheter change as needed related to non-function; - Start date: 11/18/24 - Cleanse wound with normal saline, pat dry. Apply skin prep to area where foam dressing will be applied, apply saline moistened prisma (a sterile, freeze-dried wound dressing that's used to help manage wounds and promote healing) to ulcer base and cover with hydrofera blue (a moist antibacterial foam dressing used to treat a variety of wounds) over ulcer and secure with 3 x 3 quadrilobe allevyn foam dressing (a hydrocellular foam dressing with a quadrilobe shape and wide border that's designed to conform to the body's contours) to the area. Change daily every two days or when 3/4 saturated with drainage. Observation on 11/20/24 at 10:36 A.M., showed: - There was a sign outside the resident's room which indicated staff should use enhanced barrier precautions; - There were two reusable gowns hanging on the back of the resident's door; - The resident's drainage bag hung on the side of the resident's bed and did not have a dignity cover over it; - The resident declined to have the surveyor observe catheter care; - Licensed Practical Nurse (LPN) A and LPN B entered the resident's room, washed their hands and applied gloves; - LPN A and LPN B did not apply any gown during the wound care process; - LPN B provided wound care to the resident's right gluteal fold ( the horizontal crease that separates the upper thigh from the buttocks), covered the resident with a blanket and placed the resident's call light in reach; - LPN A and LPN B removed gloves, washed hands and left the room. During an interview on 11/20/24 at 11:03 A.M., LPN B said: - He/she should have worn the gown on the back of the resident's door for EBP; - The drainage bag should have a dignity cover over it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff treated residents in a manner that maintained their dignity when staff stood to assist residents to eat which affected three of 14 sampled residents (Resident #42, #44, and #52). The facility census was 53. Review of the facility's undated policy for assistive dining for the dependent resident showed, in part: - To assist any resident that cannot feed themselves and maintain adequate nutrition as able; - Sit down while feeding the resident. 1. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 1/25/23, showed: - Cognitive skills intact; - Supervision with set up and eating; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), high blood pressure and chronic obstructive pulmonary disease, (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 1/31/23, showed: - The resident was independent in his/her dining choices and had fluid restriction as ordered; - The resident made his/her own menu choices and fed him/herself. 2. Review of Resident #44's quarterly MDS, dated [DATE], showed; - Short-term and long-term memory problems; - Required extensive assistance of one staff for eating; - Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's care plan, revised 3/20/23, showed: - The resident required assistance with activities of daily living (ADLs); - He/she required supervision, cues and at times assistance of one staff with meals. 3. Review of Resident #52's admission MDS, dated [DATE], showed: - Short-term and long-term memory problems; - Dependent on the assistance of one staff with eating; - Diagnoses included dementia and anxiety. Review of the resident's care plan, revised 1/27/23, showed: - The resident received a puree diet and required extensive assistance with eating; - He/she ate in the dining room and required the assistance of one staff to assist with eating. 4. Observation on 4/4/23 at 11:52 A.M., showed: - Residents #42 and #52 sat beside one another at the assist table and Resident #44 sat across from them; - Certified Nurse Aide (CNA) B stood at the table and gave a bite of food to Residents #42 and #52 then stood by Resident #44 and gave him/her a bite; - CNA B continued standing to assist the residents until they had finished eating. Observation on 4/5/23 showed: - At 7:55 A.M., CNA D stood at the assist table and fed Residents #44 and #52 their breakfast; - At 7:59 A.M., Licensed Practical Nurse (LPN) A moved a chair to the table and sat down and assisted Resident #52 to finish his/her breakfast; - CNA D stood and finished feeding Resident #44 his/her breakfast. Observation on 4/5/23 showed: - At 11:35 A.M., CNA D stood to assist Resident #52 to eat; - At 11:38 A.M., LPN A offered CNA D a chair to sit in while he/she assisted Resident #52 to eat. CNA D declined and said he/she could not sit and stood to assist Resident #44 to eat; - At 11:39 A.M., LPN A sat down and assisted Resident #52 to eat. CNA D continued to stand and assist Resident #44 to finish his/her meal. During an interview on 4/7/23 at 9:37 A.M., CNA A said: - The staff usually sit down to assist the residents to eat, but CNA D has leg pain and has to stand. During an interview on 4/7/23 at 10:06 A.M., CNA D said he/she should probably not stand to assist the residents to eat, but he/she has a lot of back and hip pain. The Director of Nursing (DON) was aware of his/her pain. During an interview on 4/7/23 at 10:32 A.M., CNA B said he/she thought that it was alright for the staff to stand when they assisted residents to eat. During an interview on 4/7/23 at 2:58 P.M., the DON said: - Typically, the staff would sit to assist a resident to eat, but some of the Broda chairs (reclining geri chair) were higher so sometimes it is easier to stand; - The facility policy says the staff should sit to assist residents to eat and we should follow our policy; - CNA D does not have a physician's note not to sit when assisting residents to eat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to keep residents' money separated from the facility's operating account. This effected eight additionally sampled residents (Resident #37, #156, #157, #158, #159, #160, #161, and #162). The facility census was 110. Review of the facility policy titled Guidelines for Maintaining the Resident Trust Fund Account, dated [DATE], showed the following: - This facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf. - A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf; - The facility will deposit all funds of the resident in an interest-bearing account that is separate from any of the facility operating accounts and all interest will be credited monthly to the resident fund account with a separate accounting for each resident's share; - Written receipts will be issued for cash received. 1. Review of the facility's aging report (a report used to determine if the facility has residents' funds in the operating account) showed the following residents had money in the facility's operating account: - Resident #37- $1190.88; - Resident #156- $860.06; - Resident #157- $3411.46; - Resident #158- $176.35; - Resident #159- $1899.91; - Resident #160- $140.18; - Resident #161- $4197.40; - Resident #162- $5566.25. During an interview on [DATE] at 1:48 P.M., the Business Office Manager said: - Resident #37's family member keeps paying the room and board amount monthly and she keeps telling him/her not to; - Resident #156 expired in 2018. She has tried to get ahold of family, but she had not been able to make contact; - Resident #157 discharged in 2019. She did not realize the resident had money in the aging report; - Resident #158 discharged in 2020. She could send the money to family; - Resident #159 expired in 2018. She could contact the family; - Resident #160 discharged in 2018. She did not know there was money in the operating account. - She had spoken with Resident #161's family and they wanted the money transferred to the other family member in the facility. She would call them. - She was told by Resident #162's family the money was going to be donated, but will contact family to issue a check to them; - She knew resident funds should not be in the operating account. She ran the report every so often, but it had gotten away from her.

Based on record review and interview, the facility failed to maintain a surety bond sufficient to cover any loss or theft to residents' money held in the facility's Resident Trust Fund (RTF) account which had the potential to affect all eight residents who had money held in their RTF account. The facility census was 53. The facility did not have a policy for surety bonds. 1. Review of the facility's RTF documents showed there were currently eight residents with open RTF accounts in the facility. Review of the facility's approved surety bond, approved on 6/3/1996, showed an approved amount of $10,000.00. Review of the RTF worksheet on 1/12/23, showed: - The average monthly balance for the facility's interest bearing account of $11,923.42; - The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $18,000. During an interview on 4/5/23 at 1:48 P.M., the Business Office Manager said she did not realize the bond amount was not sufficient. She would talk to the Administrator about increasing the amount.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; and for residents with a mental disorder or related disabilities, the mailing, electronic mail (email) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy for Mentally III Individuals Act. This affected three of 14 sampled residents (Resident #7, #8 and #11). The facility census was 53. Review of the facility's policy for discharge/transfer of resident, revised 2/7/23, showed, in part: - The purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Explain the discharge guidelines and reason to resident and give copy of transfer and discharge notice as required. Include representative; - If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible; - Explain and give copy of bed hold form to the resident and/or representative; - Complete transfer form, copy any portion of the medical record necessary for care of resident; - Send original of transfer form and portions of medical record that was copied with the resident; - Notify Business office/Administration of discharge. 1. Review of Resident #8's annual Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/1/23, showed: - Modified independence with communication; - Required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use; - Upper and lower extremity impaired on one side; - Diagnoses included stroke, hemiparesis (muscle weakness on one side of the body) and anxiety. Review of the resident's progress notes, dated 3/6/23 at 7:51 A.M., showed: - The resident had a wet cough and labored breathing and agreed to go to the local hospital via ambulance. Review of the resident's transfer or discharge notice, dated 3/6/23, showed: - The resident was transferred due to labored breathing and a wet cough; - It did not contain the addresses, emails or telephone numbers for the Appeals Unit or the Ombudsman's office. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed: - The resident had short term and long term memory problems; - Required extensive assistance of two staff for transfers, and dressing; - Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Alzheimer's disease. Review of the resident's progress notes dated 3/3/23, showed: - The resident was transferred to the local hospital due to labored breathing and low oxygen saturation (amount of oxygen in the blood). Review of the resident's transfer/discharge notice dated 3/3/23 showed; - The resident was transferred due to labored breathing and low oxygen saturation; - It did not contain the addresses, emails or telephone numbers for the Appeals Unit or the Ombudsman's office. 3. Review of Resident #7's quarterly MDS dated [DATE] showed: - A Brief Interview for Mental Status (BIMS) score of 5, indicating moderate cognitive impairment. - Diagnoses included: Muscle weakness and heart failure. - He/she required the assistance of one staff to reposition him/her while in bed, transfer and use the toilet. Review of the resident's record showed he/she was hospitalized on [DATE] due to low blood pressure and the resident became unresponsive. He/she returned to the facility on [DATE] with hospice services. The facility staff did not document they provided the resident with the hospital transfer documents. 4. During an interview on 4/6/23 at 9:37 A.M., Registered Nurse (RN) said: - When he/she sent a resident to the hospital, the paperwork included the face sheet, physician's order sheet (POS), Out of Hospital Do Not Resuscitate (OHDNR, informs emergency personnel or staff what to do if your heart stops beating or you stop breathing), labs if indicated and recent vital signs. During an interview on 4/7/23 at 2:58 P.M., the Director of Nursing (DON) said: - She thought there was new criteria; - She knew their current form needed to have additional criteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of 14 sampled residents (Residents #28, #29, and #36). The facility census was 53. Review of the perineal care of the female resident policy, dated 2/7/23, showed: - The purpose of perineal care was to provide comfort for the resident and prevent an infection. - The staff was supposed to separate the inner perineal folds and wipe from front to back with a clean wipe. - Wipe from front to back the outer skin folds with a clean wipe. - With a new wet wipe clean the inner thighs. 1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 2/22/23, showed: - Brief Interview for Mental Status (BIMS) score of 0, indicating a severe cognitive deficit. - Diagnoses included: Dementia (a disease of the brain that causes memory loss and impaired reasoning) and muscle weakness; - He/she required the assistance of two staff to reposition while in bed, transfer, personal hygiene, and to get dressed. - He/she was incontinent of bowel and bladder. Review of the resident ADL care plan, dated 6/20/22, showed: - He/she required the staff to provide perineal care for him/her after each incontinent episode. Observation on 4/6/23 at 9:57 A.M., showed Certified Nurses Aide (CNA) C and CNA D: - Entered the resident's room to lay the resident down in bed and provide perineal care. - CNAs C and D used the mechanical lift and laid the resident in bed. - CNA D removed the resident's pants and wet brief. - CNA C cleaned the outer skin folds of the resident with one swipe down each side of the resident's perineal area. He/she used a clean wipe with each swipe. - CNA C did not spread the resident's inner perineal folds and clean the area. During an interview on 4/7/23 at 10:36 A.M., CNA C said: - He/she was trained to separate the inner skin folds to provide perineal care. - He/she did not separate the inner skin folds when he/she provided perineal care to Resident #28. 2. Review of Resident #29's quarterly MDS, dated [DATE], showed: - Short- and long-term memory problems; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and toilet use; - Always incontinent of bowel and bladder; - Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions). Review of the resident's care plan, revised 3/28/23, showed; - The resident had urinary incontinence and dependent with incontinent care; - Provide assistance of two staff with incontinence care. Observation on 4/6/23 at 8:45 A.M., showed: - CNA C wiped down one side of the groin and with the same area of the wipe, wiped down the groin again; - CNA C did not separate and clean all the perineal folds; - CNA C and CNA E turned the resident on his/her side; - CNA C used a new wipe and wiped the buttocks twice with the same area of the wipe. He/she used a new wipe and wiped front to back, folded the same wipe and wiped again from front to back; - CNA C and CNA E turned the resident to the other side; - CNA C used a new wipe and used the same area of the wipe and wiped up and down the buttocks; - CNA E removed the wet paper pad and placed a clean one under the resident. During an interview on 4/7/23 at 10:36 A.M., CNA C said: - He/she should not use the same area of the wipe to clean different areas of the skin; - He/she should not fold the wipe; - He/she should have separated and cleaned all areas of the skin where urine has touched. 3. Review of Resident #36's care plan, revised 2/3/23, showed: - The resident had left sided weakness related to a stroke and required assistance with most activities of daily living (ADLs); - The resident was unable to tell staff when he/she needed to use the bathroom and wore incontinent briefs for dignity; - Required the assistance of two staff with incontinent care. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and toilet use; - Upper and lower extremity impaired on one side; - Always incontinent of bowel and bladder; - Diagnoses included stroke and hemiparesis (muscle weakness on one side of the body) and anxiety. Observation on 4/4/23 at 1:33 P.M., showed: - CNA A and CNA B used the mechanical lift and transferred the resident from his/her wheelchair to the bed; - CNA A and CNA B turned the resident from side to side to remove the lift sling and pulled the resident's pants down; - CNA A unfastened the soiled incontinent brief and turned the resident on his/her side; - CNA B wiped the rectal area three time with fecal material on each new wipe; - CNA B wipe front to back three more times with a new wipe each time; - CNA B removed the soiled and wet incontinent brief; - CNA B used a new wipe and wiped from front to back, folded the wipe and wiped one side of the resident's buttocks, folded the same wipe and wiped the other side of the buttocks; - CNA A placed a clean incontinent brief under the resident and turned him/her on their back; - CNA A used the same area of the wipe and wiped each side of the resident's inner legs and each side of his/her groin; - CNA A did not separate and clean all areas of the skin folds. During an interview on 4/7/23 at 9:37 A.M., CNA A said: - Should not fold the wipes with perineal care; it should be one swipe, one swipe; - He/she should have separated and cleaned all the skin folds where urine or feces had touched; - He/she should not have used the same area of the wipe to clean different areas of the skin. During an interview on 4/7/23 at 10:32 A.M., CNA B said; - He/she thought it was alright to fold the wipes with perineal care; - He/she should make sure to separate and clean all the skin folds where urine or feces has touched; - He/she should not use the same area of the wipe to clean different areas of the skin. 4. During an interview on 4/7/23 at 2:58 P.M., the Director of Nursing (DON) said: - She would not expect staff to use the same area of the wipe to clean different areas of the skin; - Staff should not fold the wipe with perineal care; - Staff should wipe from the inner to outer skin folds and should make sure they separate and clean all areas of the skin where urine or fecal material has touched.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM or to prevent further decrease in ROM. This affected four (Resident #2, #7, #8, and #19) of 14 sampled residents. The facility census was 53. Review of the restorative nursing policy, dated 2/7/23, showed: - The purpose policy was to identify residents that would benefit from restorative nursing services and to maintain the current level of independence. - The therapist will meet with the restorative aide once the resident's skilled therapy has been completed. - The charge nurse will be responsible to obtain an order for restorative services. - The restorative aide will be responsible for documentation of the restorative services provided. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 1/11/23, showed: - He/she had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. - He/she required two staff to help the resident reposition while in bed, transfer and use the toilet. - He/she had an impairment to left side of the upper and lower body. - Diagnoses included: Weakness, hemiplegia (paralysis of one side of the body), and abnormal mobility. Review of the resident's April 2023 physician's order sheet (POS) showed: - 4/4/23 Apply splint to the resident's left hand, on at all times and off only for hygiene. Review of the resident's activities of daily living (ADL) care plan, dated 9/11/20, showed: - He/she required the assistance of one staff to get dressed. - He/she required the assistance of two staff to use the toilet and transfer. - He/she had left-sided body weakness. - His/her hand splint was not addressed. Observation and interview on 4/4/23 at 9:02 A.M., showed and the resident said: - He/she had a stoke in 1999, and has had trouble with his/her left upper and lower extremity weakness. - His/her left hand with fingers curling in to the palm of his her hand. - He/she was not wearing a splint. Observation on 4/4/23 at 11:16 A.M., showed: - He/she had a hand splint on his/her left hand that straightened his/her fingers. During an interview on 4/7/23 at 8:53 A.M., the resident said: - He/she would like to participate in a restorative program to strengthen the his/her hand and straighten his/her fingers. - He/she was afraid if the staff did not work with his/her hand, his/her fingers would curl tighter and he/she would lose even more function of his/her hand. During an interview on 4/7/23 at 9:10 A.M., Certified Nurse Aide (CNA) A said: - He/she ran the Restorative Therapy program in the facility until November of 2022. - He/she stepped down from the Restorative Therapy program and began working on the floor as a CNA because he/she was assigned to work on the floor and he/she was not able to complete his/her Restorative Therapy duties. - There was not a current Restorative Therapy program at the facility. 2. Review of Resident #7's quarterly MDS, dated [DATE], showed: - He/she had a BIMS score of 5, indicating moderate cognitive impairment. - Diagnoses included: Muscle weakness and heart failure. - He/she required the assistance of one staff to reposition him/her while in bed, transfer and use the toilet. Review of the POS, dated April 2023, showed an order to complete hand hygiene twice daily to the right hand due to a contracture. Review of the resident's limited ROM care plan, dated 3/13/23, showed: - He/she had limited ROM to his/her right hand. - He/she had a hand splint for his/her right hand. - He/she often refused to wear the splint and often took it off. Observation on 4/4/23 at 10:48 A.M., showed: - The resident's right hand was closed in a tight fist with his/her fingers digging into his/her palm. - He/she was not wearing a splint. Observation on 4/7/23 at 12:10 P.M., showed the resident had his/her hand splint applied to his/her right hand. The resident did not appear to be in distress. The splint did not fit properly and was not flush against his/her palm. 3. Review of Resident #8's annual MDS, dated [DATE], showed: - Modified independence with cognitive skills; - Required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use; - Upper and lower extremity impaired on one side; - Diagnoses included stroke, anxiety and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 3/22/23, showed: - It did not address restorative therapy. Review of the resident's POS dated April 2023 showed: - Start date: 3/12/23 - restorative care program: perform seated exercises, bilateral lower extremities (BLE) as tolerated for 15 minute sessions, once a day on Monday, Tuesday, Wednesday, Thursday and Friday. Observation of the resident at various times from 4/4/23 through 4/7/23, showed the resident in a wheelchair and had limited range of motion on one side of her body. Review of the resident's medical record showed no RA documentation to indicate staff had completed the RA program with the resident. 4. Review of Resident #29's quarterly MDS, dated [DATE], showed; - Short and long term memory problems; - Dependent on the assistance of two staff for bed mobility, transfers, dressing and toilet use; - Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions). Review of the resident's care plan, revised 3/28/23, showed: - The resident had limited range of motion to left leg and both arms related to contractures and right leg is amputated above the knee; - The care plan did not address any restorative therapy. Observations at various times from 4/4/23 through 4/7/23 showed: - The resident lay in bed with no wash cloths in his/her hands. Review of the resident's medical record showed no documentation regarding the resident's contractures, RA services or passive ROM. 5. During a telephone interview on 4/7/23 at 10:36 A.M., CNA C said: - As far as he/she knew, they did not have anyone doing RA at this time. During an interview on 4/7/23 at 9:37 A.M. the Physical Therapy Director said: - Once the resident completed his/her skilled therapy days, the therapy department develops a Restorative Therapy program for the resident. - The facility staff were then expected to carry out the prescribed program. - The facility had staffing problems and do not currently have a Restorative Therapy program. - The therapy department educated the staff how to apply hand splints to Residents #2 and #7. During an interview on 4/7/23 at 2:59 P.M. the Director of Nursing said: - The facility did not have an active Restorative Therapy program. - The program dissolved in November of 2022 due to staffing. - The facility staff were not providing Restorative Therapy services to the residents. - The nurses and therapy were to educate the staff how to apply hand splints to Resident #2 and #7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to implement the abuse and neglect policy when multiple Certified Nurse Aids (CNA) and a Nurse Aide (NA) failed to report observations of physical abuse of two of four sampled resident's (Resident #1 and #4) and observations of verbal abuse of four of four sampled resident's (Resident #1, #2, #3, #4) to the charge nurse, Director of Nursing (DON) or the Administrator in a timely manner. The staff made the observations during the week of 11/7/22 to 11/11/22 and did not report the observations until 11/14/22 at which time NA A reported his/her observations. During the investigation it was reported to the DON of additional observations of verbal and physical abuse. The facility census was 55. Review of the facility's abuse and neglect policy dated March 2012 showed: - Physical abuse was defined as hitting or slapping a resident. - Verbal abuse was defined as the use of oral language that uses derogatory terms to residents, or within the hearing distance of the resident, or to describe residents. - Training of new staff during orientation to include how to report allegations of abuse and neglect of residents without fear of retaliation, defined abuse, and appropriate interventions when cares were provided to resident with aggressive behaviors. Review of the undated patient bill of rights policy showed: - The residents have the right to be free from abuse. - The residents have the right to be treated with respect and dignity. 1. Review of Resident #1's quarterly Minimum Data Set, (MDS, a federally mandated assessment tool completed by the facility staff) dated 11/23/22 showed: - He/she had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. - Diagnoses included: Alzheimer's disease (a disease of the brain that impairs memory and reasoning) and anxiety. - The resident was dependent on two staff member to reposition while in bed, transfer, get dressed, and use the toilet. - The resident was incontinent of bowel and bladder. - He/she became physically combative at times when cares were provided to him/her. Review of the resident's Physician Order Sheet (POS) dated November 2022 showed: - 5/25/21 Monitor for behaviors each shift. - 8/5/21 Quetiapine 50 mg by mouth one time daily at bedtime to treat his/her behaviors. - 9/17/21 Depakote Sprinkles 125 mg per capsule, give one capsule by mouth one time per day in the morning to treat his/her behaviors. Review of the resident's care plan showed: - 6/7/21 Activities of Daily Living (ADL's), he/she required the assistance of two staff members to transfer using the mechanical lift, use the toilet, get dressed, and reposition while in bed. - 6/7/21- He/she was combative with cares at times. - The staff were to maintain a calm environment. - 11/14/22 The staff were to ensure the resident was safe and return at a later time to complete cares when the resident became combative. 2. Review of Resident #2's annual MDS dated [DATE] showed: - He/she had a BIMS score of 15, indicating no cognitive impairment. - Diagnoses included: Anxiety and a stroke that made his/her left side very weak and difficult to move. - The resident required the assistance of two staff to reposition while in bed, transfer, get dressed, and use the toilet. - The resident was incontinent of bowel and bladder. Review of the resident's care plan showed: - 12/14/20 He/she had left sided weakness and required the assistance of two staff members to get dressed, transfer with the mechanical lift and with incontinent cares. - 12/14/20 He/she had trouble communicating due to he/she had a stroke. The staff were to face the resident when speaking to him/her and speak clearly. During an interview on 11/29/22 at 2:20 P.M. the resident said: - Some of the staff mumble under their breath when they provided cares for him/her and that was bothersome, but he/she could not hear what they said. 3. Review of Resident #3's quarterly MDS dated [DATE] showed: - He/she had a BIMS score of 0, indicating severe cognitive impairment. - Diagnoses include: Alzheimer's disease and combative behaviors. - He/she required the assistance of two staff to reposition while in bed, get dressed, transfer, and using the toilet. - The resident was incontinent of bowel and bladder. Review of the resident's care plan showed: - 12/31/20 He/she had a behavior of yelling at the staff when they provided cares. - The staff were to maintain a calm approach and environment. - 12/31/20 the resident was dependent on two staff to help him/her get dressed, transfer with the mechanical lift, repositioning while in bed, and for incontinence care. - 12/31/20 the resident had memory loss due to Alzheimer's disease, the staff were to allow the resident enough time to process what staff said to him/her before proceeding to the next task. 4. Review of Resident # 4's quarterly MDS dated [DATE] showed: - The resident had a BIMS score of 0, indicating severe cognitive impairment. - Diagnoses included: Dementia, (a chronic disorder of the brain that causes memory loss, personality changes, and impaired reasoning), mood disorder, and anxiety. - He/she required the assistance of two staff to reposition while in bed, transfer, and use the toilet. - He/she required the assistance of one staff to get dressed. - The resident was incontinent of bowel and bladder. Review of the resident's care plan showed: - 11/8/22 He/she had behavioral symptoms hitting the staff when the staff were providing cares to him/her. - The staff were to ensure the resident was safe, stop the task and reproach the resident later. - The staff were not to make the resident do the task when he/she was upset. - The staff were to maintain a calm approach and environment. During an interview on 11/29/22 at 3:28 P.M. NA A said: - He/she worked with CNA A during the week of 11/7/22 through 11/11/22. - During that time NA A witnessed CNA A smack Resident #1's hand when the resident grabbed at him/her during a transfer. CNA A called the resident an asshole. - CNA A turned Resident #3 roughly while in bed and called the resident an asshole and a dick. - NA A and CNA A was getting Resident #4 ready for bed, NA A was in front of the resident getting his/her top half undressed, CNA A was positioned behind the resident. The resident struck NA A, CNA A then struck the resident on the side of his/her head with an open hand. - NA A did not immediately report the observations he/she made to the charge nurse, DON or Administrator because he/she was afraid management would not believe him/her and of peer retaliation. - He/she should have reported the observations of abuse immediately to the charge nurse. - He/she reported his/her observations over the previous week to the DON on 11/14/22. During an interview on 11/29/22 at 4:09 P.M. CNA B said: - He/she worked with CNA A during the week of 11/7/22 to 11/11/22. - He/she and CNA A cleaned Resident #2 in bed after he/she had been incontinent of urine. The resident urinated again while the CNA's were rolling the resident from side to side, the resident said he/she wanted to be cleaned up again. CNA A told the resident to 'shut up, he/she was just changed'. As CNA A was leaving the resident's room, he/she said 'It's probably because you have aids from being a ho'. CNA B was unsure if the resident heard the remark. - He/she and CNA A were cleaning Resident #1 after he/she had been incontinent while in bed, the resident grabbed CNA A's arm during the process. CNA A yelled at the resident 'Do not fucking touch me, you little dicked bitch.' - He/she and CNA A were getting Resident #3 up using the mechanical lift. The resident became agitated and shook his upper body. CNA A said to the resident 'Stop acting like a fucking retard because that is the reason his/her mom never loved him/her.' - CNA B did not report any of the events to the charge nurse when they occurred because he/she thought he/she would not be believed. - CNA B reported the events to the DON on 11/14/22. - He/she knew he/she should have reported each event immediately to the charge nurse. During an interview on 11/29/22 at 4:21 P.M. CNA C said: - He/she worked with CNA A on 11/10/22 and 11/11/22. - He/she observed CNA A being rough with Resident #1 while he/she rolled the resident to clean him/her while in bed. - CNA A told Resident #1 to 'shut up' when the resident made a sound. - CNA C told CNA A that behavior was not very nice. - He/she did not report the incident to the charge nurse and knew that he/she should have. During an interview on 11/30/22 at 10:30 A.M. CNA D said: - He/she had worked with CNA A occasionally and had witnessed CNA A be rough when he/she rolled Residents # 1 and # 3 from side to side. - He/she witnessed CNA A grab Resident #1's and Resident #2's wrist area and jerk them quickly to their side while CNA A provided cares to the residents in bed. - CNA D did not report the incidents to the charge nurse, DON or the Administrator. - He/she had been trained to report the incidents to the charge nurse immediately. During an interview on 11/30/22 at 8:31 A.M. Licensed Practical Nurse (LPN) said: - CNA B reported to him/her that CNA A said inappropriate things to Resident #2 while they provided cares. - LPN A could not recall when CNA B reported this, but CNA B said he/she had reported the incident to the DON. During an interview on 11/30/22 at 9:35 A.M. the Nurse Educator (NE) said: - He/she was the DON when CNA B and NA A reported the allegations of abuse about CNA A. - He/she expected CNA B, CNA C, CNA D, and NA A to report their observations of verbal and physical abuse immediately to the charge nurse. During an interview on 11/30/22 at 11:40 A.M. the DON said: - She expected all staff to report all allegations of abuse to the charge nurse, DON, or Administrator immediately. During an interview on 11/30/22 at 11:30 A.M. the Administrator said: - He expected CNA B, CNA C, CNA D, and NA A to report the allegations of abuse immediately to the charge nurse, DON or the administrator. During an interview on 12/1/22 at 3:27 P.M. the Primary Care Physician (PCP) said: - He expected the staff to report any allegations of abuse to management immediately. MO209888

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to report allegations of a staff member verbally and physically abusing three residents (Resident #1, #3, and #4).The allegations were made on 11/14/22. The staff reported the allegations to the local police department on 12/1/22. This affected four of four sampled residents. The facility census was 55. Review of the abuse and neglect policy dated 3/2012 showed: - The administrator and/or the Director of Nursing (DON) will notify local law enforcement when they believe abuse had occurred. 1. Review of Resident #1's quarterly Minimum Data Set, (MDS, a federally mandated assessment tool completed by the facility staff) dated 11/23/22 showed: - He/she had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. - Diagnoses included: Alzheimer's disease, (a disease of the brain that impairs memory and reasoning), and anxiety. - The resident was dependent on two staff member to reposition while in bed, transfer, get dressed, and use the toilet. - The resident was incontinent of bowel and bladder. - He/she became physically combative at times when cares were provided to him/her. Review of the resident's care plan showed: - 6/7/21 Activities of Daily Living (ADL's), he/she required the assistance of two staff members to transfer using the mechanical lift, use the toilet, get dressed, and reposition while in bed. - 6/7/21- He/she was combative with cares at times. - The staff were to maintain a calm environment. - 11/14/22 The staff were to ensure the resident was safe and return at a later time to complete cares when the resident became combative. 2. Review of Resident #3's quarterly MDS dated [DATE] showed: - He/she had a BIMS score of 0, indicating severe cognitive impairment. - Diagnoses include: Alzheimer's disease and combative behaviors. - He/she required the assistance of two staff to reposition while in bed, get dressed, transfer, and using the toilet. - The resident was incontinent of bowel and bladder. Review of the resident's care plan showed: - 12/31/20 He/she had a behavior of yelling at the staff when they provided cares. - The staff were to maintain a calm approach and environment. - 12/31/20 the resident was dependent on two staff to help him/her get dressed, transfer with the mechanical lift, repositioning while in bed, and for incontinence care. - 12/31/20 the resident had memory loss due to Alzheimer's disease, the staff were to allow the resident enough time to process what said to him/her before proceeding to the next task. 3. Review of Resident # 4's quarterly MDS dated [DATE] showed: - The resident had a BIMS score of 0, indicating severe cognitive impairment. - Diagnoses included: Dementia, (a chronic disorder of the brain that causes memory loss, personality changes, and impaired reasoning), mood disorder, and anxiety. - He/she required the assistance of two staff to reposition while in bed, transfer, and use the toilet. - He/she required the assistance of one staff to get dressed. - The resident was incontinent of bowel and bladder. Review of the resident's care plan showed: - 11/8/22 He/she had behavioral symptoms hitting the staff when the staff were providing cares to him/her. - The staff were to ensure the resident was safe, stop the task and reproach the resident later. - The staff were not to make the resident do the task when he/she was upset. - The staff were to maintain a calm approach and environment. During an interview on 11/30/22 at 11:40 A.M. the DON said: - The expectation was to call the local police department with an allegation of abuse. During an interview on 11/30/22 at 11:30 A.M. the Administrator said: - The expectation was to call the local police department with an allegation of abuse. - He did not report the allegations of abuse to the police department when they were brought to his attention on 11/14/22. - He should have reported the abuse allegations to the police when he was made aware of them on 11/14/22. MO209888

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to implement, develop, maintain and update a plan of care consistent with residents' specific conditions, needs, and risks based on their comprehensive assessments for two of 14 sampled residents (Residents #6 and #9). The facility census was 56. Review of the facility's policy, titled Care Planning, revised July 2018, showed: - The care plan is based on the resident's comprehensive assessment, the interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident; - The policy did not indicate the care plan will be reviewed at least quarterly to evaluate effectiveness and revised and updated as necessary to address resident needs in accordance with the most current assessment. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 7/24/19, showed: - Severe cognitive impairment; - Extensive assist of two staff for for activities of daily living (ADL's); - Received no scheduled pain medication; -Diagnosis included: Dementia. Review of Resident #6's History And Physical, dated 9/25/19, showed: - Neck Contractures. Review of the resident's care plan, revised on 9/20/19, showed: - Goal to maintain adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress; - Monitor non-verbal signs of pain as he/she may be unable to verbalize discomfort related to a diagnosis of dementia; - No interventions related to the resident's neck contractures. Review of the physicians' order sheet (POS) for October 2019, showed: - Start date 2/1/18, Icy Hot gel (used to treat minor aches and pains), apply topically to neck four times daily as needed; - No diagnosis of neck contracture. Review of the resident's Restorative Care Program notes for October 2019, showed: - The resident received restorative services three to five times weekly which include passive range of motion (range of motion with no effort from the resident), (PROM) cervical stretching and massage therapy. Observation and interview on 10/15/19, at 10:44 A.M., the resident did and said the following: - Sat in his/her broda chair (used to assist with positioning and comfort), with his/her head tipped towards his/her left shoulder making it difficult for the resident to move his/her neck, with no pillow or device supporting his/her neck; - Said his/her neck hurt felt like it was run over. Observation and interview on 10/16/19, at 11:06 A.M., the resident and his/her spouse said the following: - Today he/she feels better; - The resident's neck was tipped towards his/her left shoulder making it difficult for the resident to move his/her neck, with a wedged blanket behind the left side of his/her back; - The resident's spouse said he/she removed the curved pillow and rolled a blanket and wedged it behind the resident's neck to assist in supporting his/her neck; - When the resident lay in his/her bed, staff should use a bed pillow and position it on his/her left side. During an interview on 10/16/19, at 9:12 A.M., Registered Nurse (RN) A said: - The resident has torticollis (a fixed or dynamic tilt, rotation, with flexion or extension of the head and/or neck), and he/she had a stroke which also effects the resident's left side; - The resident's spouse is also a resident here; he/she is very attentive to the resident's needs and frequently he/she removes the the cervical pillow; - He/she will roll a blanket to assist in supporting his/her neck. During an interview on 10/16/19, at 11:36 A.M., Restorative Aide (RA) said: - The resident's restorative program includes cervical stretching and massage; - He/she is also on restorative dining; at times he/she has difficulty eating due to his/her neck contracture; - The resident's neck should be supported and he/she has several curved pillows that should be used; - His/her spouse frequently moves the the curved pillows and will roll a blanket to assist in supporting his/her neck. 2. Review of Resident #9's admission MDS, dated [DATE], showed: - No cognitive impairment; - Indwelling catheter; - Diagnoses included: neurogenic bladder (inability to pass urine from the bladder). Review of the Resident #9's care plan, revised on 8/12/19, showed: - Suprapubic catheter (a urinary catheter that is inserted into the abdominal wall and into the bladder) for a diagnosis of neurogenic bladder (inability to pass urine from the bladder); - Do not allow the tubing or any part of the drainage system to touch the floor; - Store collection bag inside a protective dignity pouch; - Staff to monitor for signs and symptoms of infection and report complications of urinary tract infection (UTI); -The care plan did not include who should provide suprapubic catheter care and how often; did not include the cleaning and monitoring of the insertion site. Review of the resident's physicians' order sheet (POS), dated October 2019, showed the following orders: - Change foley catheter every 30 days; start date 10/10/19; - No order for suprapubic catheter care. 3. During an interview on 10/16/19, at 3:47 P.M., the Director of Nursing (DON) said: - The care plan is an individualized plan that directs staff with care; - The care plan should include a history of the resident including their disease process, specific needs, and preferences; - Resident #5's contracted neck should be in his/her plan of care; - Resident #9's care plan should include interventions for his/her suprapubic catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Resident #50's care plan, revised on 9/30/19, showed: - Resident requires hospice related to hypoxemia. - The assessment did not include oxygen therapy. Review of the resident's significant change in status MDS, dated [DATE], showed: - No cognitive impairment; - Required supervision with one person assist with bed mobility and transfer; - No oxygen therapy; - Diagnoses did not include pulmonary disorder or disease. Review of the resident's October 2019 POS showed: - Diagnoses included: wheezing, acute upper respiratory infection, and hypoxemia (an abnormally low level of oxygen in the blood); - Medication orders included: oxygen; titrate (measure) to keep oxygen saturation in the blood greater than or equal to 90%. - Special instructions: Start date 9/28/19, end date was open ended. Review of the resident's October 2019 medication administration record (MAR) and treatment administration record (TAR) showed: - No documentation for assessing oxygen saturation every shift; day shift, night shift. Review of the resident October 2019 vitals showed: - Staff documented an oxygen saturation of 94% on 10/1/19. - Staff did not document the resident's oxygen saturation for each shift daily from 10/2/19 through 10/17/19. Observation on 10/14/19, at 10:00 A.M., showed: - A oxygen concentrator sitting on the floor next to Resident #50's bed and a nebulizer machine sitting on the bed side table. 3. During an interview on 10/16/19, at 3:47 P.M., the Director of Nursing (DON) said: - Resident #9 should have a physician's order for his/her suprapubic catheter and it is unclear why the resident does not; - She previously thought when the resident returned to the facility on [DATE], the order may have been omitted; but she reviewed the resident's medical record and this was not the case; - She was not aware Resident #50 had an order for obtaining daily oxygen saturation vitals; - She expected staff to follow phsycican's orders; - There was not a system in place to ensure order were correct or current. Based on observation, interview and record review, the facility failed to meet professional standards of quality when staff did not follow physician orders for checking a resident's oxygen level for one of 14 sampled residents (Resident #50) and failed to ensure one sampled resident (Resident # 9) with a suprapubic catheter (a urinary catheter that is inserted into the abdominal wall and into the bladder) had a physician's order for the care of the catheter. The facility census was 56. Review of the facility's policy for Physician Orders, revised July 2018, showed: - All medication and treatment regimes will be ordered by a licensed physician authorized to practice medicine in this state and residents must be seen by the physician at least every sixty days; - Treatment orders specify what is to be done, location and frequency, and duration of the treatment; - Catheter care specifies what is to be used or according to facility procedure. 1. Review of the facility's policy on Suprapubic Catheter Care revised on July 2018, showed: - Purpose: To prevent skin irritation around the stoma (insertion site) and to prevent infection of the resident's urinary tract; - Check the physician's order for catheter care; - Assist resident to dorsal recumbent position (on the back) and drape for privacy; - Clean around the catheter well with soap and warm water; - Rinse and dry the area well; - Apply thin film of antiseptic ointment to edges of opening for suprapubic catheter; - Question resident and observe for adverse signs and/or symptoms of infection. Review of Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/3/19, showed: - No cognitive impairment; - Indwelling catheter; - No oxygen therapy; - Diagnoses included: Neurogenic bladder (inability to pass urine from the bladder). Review of the Resident #9's care plan, revised on 8/12/19, showed: - Suprapubic catheter for a diagnosis of Neurogenic bladder; - Do not allow the tubing or any part of the drainage system to touch the floor; - Store collection bag inside a protective dignity pouch; - Staff to monitor for signs and symptoms of infection and report findings. Review of the resident's physicians' order sheet (POS), dated October 2019, showed the following orders: - Change foley catheter every 30 days; start date 10/10/19; - No order for suprapubic catheter care. Observation on 10/15/19, at 3:20 P.M., showed Certified Nurse Aide (CNA) A provided catheter care and the resident's suprapubic catheter insertion site did not contain a dressing. During an interview on 10/15/19, at 3:30 P.M., the resident said: - He/she was recently hospitalized with a UTI and sepsis; - When he/she initially arrived at the facility, nursing staff applied a gauze dressing around his/her suprapubic catheter; - This has not been done for several months.

Based on observation, interview and record review, the facility failed to follow their policy when they failed to ensure catheter tubing did not touch the floor and staff failed to provide catheter care in a manner to prevent urinary tract infections (UTI) for one of 14 sampled residents (Resident #9) with a supra-pubic catheter (a urinary catheter that is inserted into the abdominal wall and into the bladder) and had been recently hospitalized for a UTI and sepsis (a potentially life-threatening condition caused by the body's response to an infection). The facility census was 56. 1. Review of the facility's policy on Suprapubic Catheter Care revised on July 2018, showed: - Purpose: To prevent skin irritation around the stoma ( insertion site) and to prevent infection of the resident's urinary tract; - Check the physician's order for catheter care; - Assist resident to dorsal recumbent position (on the back) and drape for privacy; - Clean around the catheter well with soap and warm water; - Rinse and dry the area well; - Apply thin film of antiseptic ointment to edges of opening for suprapubic catheter; - Question resident and observe for adverse signs and/or symptoms of infection. Review of the facility's policy on Changing and Cleaning Drainage Bag/Leg Bag, revised on July 2018, showed: - NOTE: Drainage bag tubing should NEVER be on the floor; - Wash hands and put gloves on; - After measuring the urine in graduate (device for emptying and measuring), empty urine into the toilet; - Place drainage bag/leg bag in a plastic bag with the resident's name on it and take to the dirty utility room; - In the locked cabinet under the sink is a solution of LD-64 (disinfecting solution); - Pour some LD-64 into the bag and clean the bag; - After cleaning the bag, clean the tip with alcohol and recap; - Place drainage bag/leg bag in a clean plastic bag with the resident's name and return it to the resident's room; - The clean plastic bag may be placed in a dignity bag in the bathroom; - The policy did not indicate how staff should store the graduate; - The policy did not include emptying the urinary drainage bag when the catheter drainage bag is not being changed. Review of Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/3/19, showed: - No cognitive impairment; - Indwelling catheter; - No oxygen therapy; - Diagnoses included: Neurogenic bladder (inability to pass urine from the bladder). Review of the resident's care plan, revised on 8/12/19, showed: - Suprapubic catheter for a diagnosis of neurogenic bladder (inability to pass urine from the bladder); - Do not allow the tubing or any part of the drainage system to touch the floor; - Store collection bag inside a protective dignity pouch; - Staff to monitor for signs and symptoms of infection and report findings. Review of the nurses' notes, dated 10/5/19, at 6:45 A.M., showed: - Nurse called to the resident's room as staff was unable to awaken the resident; - Periods of apnea (cessation of breathing), no response with sternal rub (the application of painful stimulas with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli); - Oxygen variances changing from 66 percent (%) to 85% (readings usually range from 95 to 100%, values under 90% are considered low) on room air oxygen immediately applied at 2 liters (L) via nasal cannula that was placed in the resident's mouth as he/she was mouth breathing. Review of the resident's History and Physical from the hospital, dated 10/5/19, showed: - admission date 10/5/19; - Chief Complaint: Change in mental status, unresponsive; - Sternal rubs were preformed; however, the resident did not respond well and EMS (emergency medical services) were called; - Upon arrival to the emergency room, the resident was found to be confused; - Suprapubic catheter with a positive urinalysis; - It was thought the resident possibly has symptomatic UTI; - Considering the resident's previous history of recurrent UTIs, it is thought he/she would need intravenous antibiotics. Review of the resident's hospital progress note, date 10/7/19, showed: - Chief Medical Problem: UTI with suprapubic catheter; - Positive UTI with culture pending. Review of the resident's physicians' order sheet (POS), dated October 2019, showed the following orders: - Change foley catheter every 30 days; start date 10/10/19; - No order for suprapubic catheter care. Observation on 10/15/19, from 2:22 P.M. to 3:19 P.M., showed: - The resident lay in his/her bed with his/her urinary catheter drainage bag attached to the side of his/her bed setting directly on the floor; - The urinary drainage bag was not in a dignity bag; - The catheter tubing also lay directly on the floor. Observation on 10/15/19, at 3:20 P.M., showed Certified Nurse Aide (CNA) A entered the resident's room as the resident lay in his/her bed and did the following: - Assisted the resident to move in his/her bed as he/she was yelling help; - Repositioned the resident's catheter bag, picking it up from the floor; - Went to the resident's bathroom and obtained a urinal that hung on the railing near the toilet; the urinal was not in a plastic bag; - Without setting a barrier on the floor, he/she set the urinal directly on the floor; - Opened the drain port and drained the urine from the catheter bag into the urinal; - Did not clean the drain tube with an alcohol pad and returned the drain tube to the plastic protective sleeve; - Picked up the urinal from the floor, emptied the urine in the resident's commode, added water to the urinal at the resident's sink, emptied the water in the commode, and hung the urinal on the railing next to the commode in the resident's bathroom; - The resident informed the staff that he/she had a bowel movement and needed assistance with changing his/her brief; - After washing his/her hands and putting on new gloves, he/she assisted the resident to roll onto his/her side, pulled the resident's pants down and removed the soiled brief that contained fecal material; - Changed gloves without washing his/her hands, used disposable wipes to clean fecal material from the resident's buttock and rectum then changed his/her gloves again without washing his/her hands; - Obtained a clean brief and assisted the resident to roll onto his/her back; - The resident did not have a leg strap on and his/her suprapubic catheter was pulled taunt (tight); - The resident informed the staff that his/her catheter was pulling; - CNA A moved the catheter towards the insertion site to prevent the catheter from pulling; - He/she used disposable wipes and cleaned the resident's front perineal folds, removing a small amount of fecal material; - The resident's suprapucic catheter insertion site did not contain a dressing; - Without changing gloves and washing his/her hands, he/she used a disposable wipe and cleaned around the catheter insertion site; held the catheter at the insertion site and wiped the catheter tubing downwards about six inches; During an interview on 10/15/19, at 3:30 P.M., the resident said: - He/she was recently hospitalized with a UTI and sepsis; - After he/she returned from the hospital, facility staff provided a shower and the adhesive catheter leg strap came off; - He/she preferred to have a leg strap on to prevent the catheter from pulling; - When he/she initially arrived at the facility, nursing staff applied a gauze dressing around his/her suprapubic catheter; - This has not been done for several months. During an interview on 10/15/19, at 3:37 P.M., CNA A said: - Staff should clean the drain port with an alcohol pad after emptying a catheter; - Staff should clean the insertion site for a suprapubic catheter with disposable wipes. Observation on 10/16/19, at 9:50 A.M., showed the resident sat in the dining room eating his/her breakfast with his/her catheter bag in a dignity bag tied under his/her wheelchair with his/her catheter tubing on the floor. Observation on 10/16/19, at 10:11 A.M., showed the resident sat in his/her wheelchair in his/her room with his/her catheter bag in a dignity bag tied under his/her wheelchair with his/her catheter tubing on the floor. During an interview on 10/16/19, at 10:15 A.M., Certified Medication Technician (CMT) A entered the resident's room and said: - The resident's catheter tubing should not be on the floor; - The plastic clip on the catheter tubing should be used to keep the catheter tubing from dragging the floor. During an interview on 10/16/19, at 3:47 P.M., the Director of Nursing (DON) said: - The resident was recently admitted to the hospital for sepsis and staff should ensure they use good infection control practices when providing catheter care for residents to prevent UTIs; - She expects the facility's catheter policy to be followed and licensed nursing should be assessing the insertion site once daily, cleansing the insertion site with soap and water, apply an antiseptic to the site, and apply a gauze dressing; - A resident's catheter and or catheter tubing should never be on the floor as the floor is considered dirty; - After emptying a catheter, staff should clean the end of the drain port with an alcohol pad; - A leg strap should be used to prevent a catheter from pulling.

Based on interviews and record review, the facility failed to check the Nurse Aide (NA) Registry for Federal Indicators (individuals with federal indicators cannot work in a certified Medicare/Medicaid long term care facility) which affected five of five sampled and newly hire employees. The facility census was 56. Review of the facility's Employee Screening Guidelines, dated 8/1/17, showed: -It is the purpose of this facility to thoroughly screen potential employees for a history of abuse, neglect, mistreatment of residents, or misappropriation of resident's property; -verify the applicants certification of license. 1. Review of the personnel records for Licensed Practical Nurse (LPN) B showed: - Hire date 5/17/19; - No NA registry check. 2. Review of the personnel records for Housekeeping Aide (HA) A showed: - Hire date 10/1/19; - No NA registry check. 3. Review of the personnel records for Activities personnel (ACT) showed: - Hire date 8/12/19; - No NA registry check. 4. Review of the personnel records for Certified Nursing Aide (CNA) B showed: - Hire date 8/19/19; - No NA registry check. 5. Review of the personnel records for Dietary Aide (DA) A showed: - Hire date 6/20/19; - No NA registry check. 6. During an interview on 10/17/19, at 11:00 A.M., the Administrative Staff said he/she did not know all new hires required NA registry checks, he/she thought they only needed done for CNAs. During an interview on 10/17/19, at 11:30 A.M, the Administrator said NA registry checks should be completed for all new hires. The facility did not have policy or procedure for ensuring pre-screening requirements were completed for all new hires.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood when staff transferred three of 14 sampled residents (Residents #9, #38, and #53) to the hospital. The facility census was 56. Review of the facility's Transfer and Discharge Policy, updated 7/20/18, showed: - Explain transfer, reason to the resident and/or representative and give a copy of signed transfer or discharge notice to the resident and/or representative; - Complete transfer form, copy any portion of the medical record necessary for care of resident; - Send original transfer form and portions of medical record that was copied with the resident. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/18/19, showed: - Moderately impaired cognitively; - Required one assist for bed mobility and transfers; - Diagnoses included: heart failure, diabetes, anxiety, and depression. Review of the nurses' notes showed: - On 5/10/19, at 04:15 A.M.: Resident's low blood sugars not responding to treatment and transferred to hospital; - On 5/14/19: Resident readmitted from the hospital; - On 8/2/19: Resident transferred to hospital for respiratory failure; - On 8/8/19: Resident readmitted from the hospital. Review of the resident's medical record on 10/16/19, showed no letter provided to the resident or his/her responsible party with the reason for transfer/discharge to the hospital. During an interview on 10/17/19, at 12:00 P.M., the resident said: - He/she did not remember receiving any papers; - He/she was not alert and oriented at the time of transfer and only remembers waking up at the hospital. 2. Review of Resident #53's annual MDS, dated [DATE], showed: - Cognitively intact; - Required one assist for activities of daily living (ADLs); - Diagnoses included: heart failure, depression, chronic kidney disease, fibromyalgia (widespread muscle pain and tenderness), and respiratory failure. Review of the nurses' notes showed: - On 5/19/19: Resident's chest x-ray showed right lower lobe pneumonia (infection that inflames air sacs within the lung); received physician order to transfer to the hospital; - On 5/24/19: Resident readmitted from the hospital. Review of the resident's medical record on 10/16/19, showed no letter provided to the resident or his/her responsible party with the reason for transfer/discharge to the hospital. During an interview on 10/17/19, at 12:15 P.M., the resident said: - He/she has been hospitalized multiple times and never recalled receiving any papers. 3. Review of Resident #9's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/19, showed: - No cognitive impairment; - Extensive assistance of two staff for bed mobility, dressing, and transfers; - Diagnoses included: urinary tract infection (UTI) within the last 30 days. Review of the resident's medical record showed: - The resident admitted on [DATE]; - The facility discharged the resident to a local hospital on [DATE]; - The facility readmitted the resident on 10/8/19; - There was no documentation or evidence staff provided the discharge/transfer letter to the resident prior to being sent to the hospital found in the record. During an interview on 10/17/19, at 10:17 A.M., Licensed Practical Nurse (LPN) A said: - He/she did not know that when they transferred a resident to the hospital that the resident and or representative needed written documentation showing the reason for the transfer or discharge. During an interview on 10/17/19, at 12:10 P.M., the resident said: - He/she was sent to the hospital from the facility and was hospitalized for three days. -The facility did not provide any written documentation to him/her for the transfer or discharge to the hospital on [DATE]. 4. During an interview on 10/16/19, at 1:18 P.M., the Director of Nursing (DON) said: - Staff do not currently give the responsible party any transfer summary paper. - Staff notify responsible parties by phone and verbally discuss the transfer reason. - He/she provided a copy of the blank form that should be completed for discharge and transfer. - This form is not currently copied and saved into the chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure they provided written information that specifies the duration of the state bed-hold policy, the reserve bed payment policy, the facility's policy regarding bed-hold periods when staff transferred three of 14 sampled residents (Resident #9, #38, and #53) to the hospital. The facility census was 56. Review of the facility's Transfer and Discharge Policy, updated 7/20/18, showed: - Explain and give copy of bed hold form to the resident and/or representative. The facility did not provide a separate Bed-Hold Policy. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/18/19, showed: - Moderately impaired; - Requires one assist for bed mobility and transfers; - Diagnoses included: heart failure, diabetes, anxiety, and depression. Review of the nurses' notes showed: - On 5/10/19, at 4:15 A.M.: Resident having low blood sugars; not responding to treatment and transferred to hospital; - On 5/14/19: Resident readmitted from the hospital; - On 8/2/19: Resident was transferred to hospital for respiratory failure; - On 8/8/19: Resident readmitted from the hospital. Review of the resident's medical record on 10/16/19, showed no letter provided to the resident or his/her responsible party with the bed-hold policy. During an interview on 10/17/19, at 12:00 P.M., the resident said: - He/she did not remember receiving any papers; - He/she was not alert and oriented at the time of transfer and only remembered waking up at the hospital; - He/she did know what a bed hold policy was. 2. Review of Resident #53's annual MDS, dated [DATE], showed: - Cognitively intact; - Requires one assist for activities of daily living (ADLs); - Diagnoses included: heart failure, depression, chronic kidney disease, fibromyalgia (widespread muscle pain and tenderness), and respiratory failure. Review of the nurses' notes showed: - On 5/19/19: Resident's chest x-ray indicated right lower lobe pneumonia (infection that inflames air sacs within the lung) and received physician order to transfer to the hospital; - On 5/24/19: Resident readmitted from the hospital. Review of the resident's medical record on 10/16/19, showed no letter provided to the resident or his/her responsible party with the bed-hold policy. During an interview on 10/17/19, at 12:15 P.M., the resident said: - He/she had been hospitalized multiple times and never recalled receiving any papers. - He/she did not know what a bed hold policy is. 3. Review of Resident #9's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/19, showed: - No cognitive impairment; - Extensive assistance of two staff for bed mobility, dressing, and transfers; - Diagnoses included: urinary tract infection (UTI) within the last 30 days. Review of the resident's medical record showed: - The resident admitted on [DATE]; - The facility discharged the resident to a local hospital on [DATE]; - The facility readmitted the resident on 10/8/19; - There was no documentation or evidence staff provided a bed hold letter to the resident prior to being sent to the hospital found in the record. During an interview on 10/17/19, at 12:10 P.M., the resident said: - He/she was sent to the hospital from the facility and was hospitalized for three days; - The facility did not provide any written documentation to him/her on the facility's bed hold policy when he/she was sent to the hospital on [DATE]. 4. During an interview on 10/16/19, at 1:18 P.M., the Director of Nursing (DON) said: - Staff notify responsible parties by phone and verbally discuss transfer reasons. - The bed hold policy is not documented when provided. - He/she provided a copy of the form that should be filled out for bed holds upon transfer. - This form is not currently copied and saved into the chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's Hydration policy, dated 7/20/18, showed: - All residents will be well hydrated by evidence of moist mucosal lining and good skin turgor; - Staff should offer a drink to the resident every time they are in the resident's room. Review of Resident #1's quarterly MDS assessment, dated 7/17/19, showed: - Severe Cognitive impairment; - Required extensive assistance with two-person physical assistance for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene; - Diagnoses included: dementia. Review of the resident's care plan, with a review date of 4/29/19, showed: - The resident required assistance with ADLs; - At times, the resident would feed him/herself with set up assistance and supervision. Other he/she needed one person to assist with eating; - Needed two-person assist with gait belt for transfers; - Provide cues, supervision and assistance with ADLs. Observations on 10/14/19 through 10/16/19 at various times throughout the survey showed: - On 10/14/19, at 2:18 P.M., the resident awake laying on his/her right side; the resident's lips were dry; his/her insulated mug of water sat on the counter by the sink across the room from the resident's bed and not within reach. - On 10/14/19, at 2:33 P.M., CNA B passed water on the resident's hall; staff entered the resident's room, picked up the resident's mug, removed the lid, filled the cup with ice, and sat the mug back on the sink without offering the resident a drink. - On 10/15/19, at 1:34 P.M., the resident awake lying in bed on right side; his/her drink sat on the sink across the room from the resident's bed, and the mug felt full of fluid. - On 10/15/19, at 2:44 P.M., CNA B passed water on the resident's hall; staff entered the resident's room, picked up the resident's mug, removed the lid, filled the cup with ice, and sat the mug back on the sink without offering the resident a drink. - On 10/16/19, at 7:55 A.M., the resident sat at the end in the dining room, facing the Restorative Aide (RA), who sat at the opposite end, of the assist-to-dine table with a full glass of juice setting in front of him/her; the RA asked the resident if he/she was going to finish his/her drink; the resident grasped the straw, pulled it out of the cup and sucked the juice out of the end of the straw, and placed the straw back in the glass; the resident used his/her thumb and index finger to grasp the straw and his/her other fingers were folded into a fist. - 10/16/19, at 8:00 A.M., the resident had his/her index finger in the glass and thumb outside the rim of glass and appeared as though he/she was trying to pull the glass closer to him/her. The RA asked the resident if he/she was going to finish his/her drink. The resident stared at the RA then looked at the glass, moved the straw around while continuing to look at RA. - 10/16/19, at 8:08 A.M., the resident had his/her finger in juice and glass tipped on edge; the RA stood up, walked over to the resident and moved the glass closer; the resident removed his/her finger from glass and sucked the juice off of his/her finger. - 10/16/19, at 8:18 A.M., the resident closed his/her eyes; the RA said drink your drink and made drinking motion; the resident looked at the RA and closed his/her eyes again and gave no response. - 10/16/19, at 8:19 A.M., the RA moved the resident to his/her side of the table, opened the resident's hand and place the glass in his/her grasp, placed the glass in her hand, placed the straw in the resident's mouth, and told the resident to drink his/her juice; the resident drank quickly and did not stop until the glass was empty. - On 10/16/19, at 1:37 P.M., the resident awake, laying on his/her back in bed, and his/her drink mug sat on sink across room; the mug felt full. - On 10/16/19, at 2:39 P.M., CNA B and CNA D filled the resident's cup with ice, sat back on counter by the sink, and did not offer the resident a drink before leaving the room. During an interview on 10/16/19, at 8:20 A.M., the RA said Resident #1 needed assistance with grasping his/her drink about 25% of the time. If the resident's drink mug was within reach, he/she would take a drink, and required queuing at times in order to get him/her to drink. During an interview on 10/16/19, at 3:26 P.M., CNA B and CNA D said they fill the residents' cups up multiple times throughout the day, and encourage residents to take a drink. Residents that require assistance with drinking or supervision should have their glass on the bedside table. 4. During an interview on 10/16/19, at 3:47 P.M., the Director of Nursing (DON) said: - She expected staff to assist residents who require full ADL assistance; - Residents' water mug should be within reach, and aides are to offer the resident a drink when filling the cup; - The call light must be placed within easy reach for the residents use; - Residents who do not normally use a call light, should still have it placed within reach; - Resident #9 should have his/her call light placed near his/her right side; - Call lights should be placed on the higher functioning side of the resident; - She was not aware that Resident #26's call light was not on the same wall as his/her bed, and the call light is stretched across the room when the resident is in his/her bed; - All residents should have access to their call lights. Based on observations, interviews, and record reviews, the facility failed to follow their policy to ensure two of 14 sampled residents' (Resident #9 and #26), who were unable to carry out their own activities of daily living (ADLs), call light were within reach and accessible and failed to ensure staff placed the water pitcher within reach for one sampled resident (Resident #1) when staff placed the water pitcher on the sink. The facility census was 56. Review of the facility's policy for titled Call Light, revised July 2018, showed: - To ensure that residents are assisted with needs in a timely manner; - All residents have a call light in their room; - The call light must be placed within easy reach for the resident's use; - Residents who do not normally use a call light, will still have it placed within reach in the event that they do know how to use it; - Call lights will be placed on the higher functioning side of the resident; - Staff will treat a holler for help as if it were a call light; - The staff will seek out where the hollering is coming from and find out what is needed; - The policy did not indicate an acceptable time frame for a call light to be answered. 1. Review of the Resident #9's care plan, revised on 8/12/19, showed: - Pain to left arm related to a fracture; - Goal to maintain level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress, verbalizing satisfaction with level of comfort through the next review date; - At risk for falls related left side weakness; - Keep call light within reach at all times. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/3/19, showed: - No cognitive impairment; - Extensive assistance of two staff for ADLs; - Diagnoses included: Hemeplegia (a condition, caused by a brain injury, that results in a varying degree of weakness, stiffness (spasticity) and lack of control in one side of the body). Observation on 10/15/19, at 2:22 P.M., from the hall showed the following: - The resident lay in his/her bed with his/her feet partially hanging off the right side of his/her bed; - The resident's call light laid on the left side of the bed; - The resident's room was at the end of the hall and the doors at the beginning of the hall were closed as the facility was testing the fire alarm. Observation on 10/15/19, at 3:03 P.M., from the hall showed: - The resident lay in his/her bed with his/her feet partially hanging off the right side of his/her bed; - He/she said to his/her roommate I want to get back in my chair; I need help, then the resident shouted HELP, I want to get back in my chair! Observation and interview on 10/15/19, at 3:04 P.M. the resident did and said the following: - Said Can you help me? My arm is stuck under me; - The resident's call light laid on the left side of the bed and the resident's left lower arm and hand were under his/her left hip; - Said his/her left arm was broken prior to coming to the facility; he/she had a stroke and was unable to move his/her left arm; - Moved his/her right hand and said I can not find my call light; - The surveyor turned on the resident's call light and exited the resident's room. Observation on 10/15/19, at 3:10 P.M., from the hall showed the resident continued to lay in his/her bed with his/her feet partially hanging off the right side of his/her bed with his/her call light sounding and repeatedly shouted I need help! Observation on 10/15/19, at 3:11 P.M., from the hall showed the following: - Two staff enter through the closed doors with an ice chest and started going room to room passing ice to residents at the beginning of the hall; - The resident's call light continued to sound and the resident continued to yell off and on for staff assistance. Observation on 10/15/19, at 3:12 P.M., from the hall showed the resident continued to lay in his/her bed with his/her feet partially hanging off the right side of his/her bed with his/her call light sounding shouting Is somebody out there? I need help! Observation on 10/15/19, at 3:14 P.M., from the hall showed the following: - The resident continued to lay in his/her bed with his/her feet partially hanging off the right side of his/her bed with his/her call light sounding shouting I am on my arm! I can not move, please help! - The same two staff continue to go room to room passing ice. Observation on 10/15/19, at 3:15 P.M., from the hall showed the resident's roommate started shouting nurse! Observation on 10/15/19, at 3:17 P.M., from the hall showed the resident and his/her roommate both started shouting Help! Observation on 10/15/19, at 3:19 P.M., from the hall showed the two staff exited room [ROOM NUMBER]. After being informed by this surveyor that Resident #9 needed assistance, Certified Nurses Aide (CNA) A walked towards the resident's room. CNA A entered the resident's room and assisted the resident, 16 minutes after the resident began yelling for help and the call light was activated and 10 minutes after the two CNAs walked on to the hall. During an interview on 10/15/19, at 3:37 P.M., CNA A said: - The resident is unable to move his/her left arm and staff should ensure the call light is on his/her right side; - He/she did not hear the resident or his/her roommate shouting for help; - He/she did not see the resident's call light on; - Staff should be watching up and down the hall while providing care to check for call lights. 2. Review of Resident #26's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Extensive assistance of two staff for ADLs; - Diagnoses included: dementia. Review of the the resident's care plan, revised on 9/4/19, showed: - Staff assistance with ADLs; - Keep call light within reach at all times. Observation on 10/14/19, at 1:01 P.M., showed the resident in his/her room sitting in his/her wheelchair with his/her call light laying in his/her recliner across the room. Observation on 10/14/19, at 2:07 P.M., showed the resident in his/her room sitting in his/her wheelchair with his/her call light laying in his/her recliner across the room. Observation on 10/16/19, from 1:01 P.M. to 1:56 P.M., showed the following: - The resident lay in bed in his/her room with no call light; - The call light was across the room in his/her recliner. Observation and interview on 10/16/19, at 1:57 P.M., CNA C and Certified Medication Technician (CMT) A entered the resident's room to provide perineal care as the resident lay in his/her bed and they did and said the following: - Said the resident does not use his/her call light but he/she should have his/her call light; - The call light is not on the same wall as the resident's bed; - Picked up the call light from the resident's recliner, stretched it across the room to reach the resident's bed and placed it near the resident.

Based on observations, record review and interviews, the facility failed to discard expired medications and biologicals stored within the medication carts. This had the potential to affect all residents with medications stored in the facility's medication carts. The facility census was 56. Review of the facility policy, Storage of Medications, updated on 7/20/18, showed: - No discontinued, outdated, or deteriorated drugs of biologicals may be retained for use. - All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. 1. Review of the label on the box of Tuberculin purified protein derivative (PPD, used to test for Tuberculosis, an infectious lung disease) showed the medication expires 30 days after opening. Observation and interview of the nurses' medication cart on 10/15/19, at 10:56 A.M., showed and Licensed Practical Nurse (LPN) A said: - Tuberculin purified protein derivative (used to test for Tuberculosis, an infectious lung disease) diluted aplisol 5 transducing (TU)/0.1 millileters (ml); opened on 9/11/19;. - He/she said that should not have been in the cart. 2. Observation and interview of the 300/400 hall medication cart on 10/15/19, at 1:00 P.M., showed and Certified Medication Technician (CMT) A said: - Systane Ulta eye drops (used for dry eyes that may relieve burning, irritation, and discomfort), opened 9/15/19; expired October, 2009; - He/she said he/she did not know where the eye drops came from; - Acetaminophen (used for minor pain and fever) 500 milligrams (mg); expired December 2006; - Ondansetron 4 mg (for nausea and vomiting); expired 6/23/19. - Arthritis relief acetaminophen 650 mg; expired April 2018; - He/she said carts are checked often, at least every week; - He/she did not know how the outdated medications were missed; - He/she said all outdated medications are logged and two nurses destroy. During an interview on 10/16/19, at 1:18 P.M., the Director of Nursing (DON) said: - He/she did not know how often medication carts are checked for outdated medications. - He/she expects staff to check at least weekly. - Staff should log outdated medications. - Two nurses destroy outdated medications two times a week.