**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) was accurate for two sampled residents (Resident #1 and #2) out of 14 sampled residents. The facility census was 43 residents. Review of the facility's policy titled MDS Completion and Submission Timeframes dated July 2017 showed the MDS Coordinator or designee was responsible for ensuring that resident assessments were submitted in accordance with current federal and state guidelines. 1. Review of Resident #2's face sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD-a disease process that decreases the ability of the lungs to perform ventilation). -Chronic Ischemic Heart Disease (heart problems caused by narrowed heart arteries that supply blood to the heart). -Sleep Apnea (a sleep disorder in which breathing repeatedly stops and starts). -Acute Respiratory Failure (impairment of gas exchange between the lungs). Review of the resident's quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -The resident was not on oxygen therapy. Review of the resident's Physician Order Sheet (POS) dated September 2024 showed an order for the charge nurse to check the placement of oxygen at 3 liters (L the measured amount of the flow of oxygen) per minute by nasal cannula (a device that delivers extra oxygen through a tube and into your nose) at night to ensure the resident was wearing to keep oxygen saturation (the amount of oxygen in the blood with normal levels between 96-100 percent or typically for people with COPD 88-92 percent) about 90 percent while in bed/sleeping. Review of the resident's care plan dated 9/16/24 showed the resident wore oxygen Pro Re Nata (PRN- as needed). During an interview on 9/17/24 at 12:53 P.M. the resident said he/she wore his/her oxygen every night at 3 L per minute. During an interview on 9/19/24 at 8:39 A.M. Licensed Practical Nurse (LPN) A said: -The MDS Coordinator completed the MDS assessments. -The nurses would occasionally help with the MDS assessments by reviewing care with the MDS Coordinator. -The resident's MDS assessment should indicate that the resident wore oxygen at night. During an interview on 9/19/24 at 10:03 A.M. the MDS Coordinator said: -The MDS assessment should indicate if a resident used oxygen therapy. -He/She was unsure if the resident's most recent MDS assessment indicated the resident was on oxygen therapy. During an interview on 9/19/24 at 11:17 A.M. the Director of Nursing (DON) said: -He/She expected the MDS assessments to be accurate. -Any resident who received oxygen therapy should have that indicated in their MDS assessment. 2. Review of Resident #1's Face Sheet showed he/she was admitted on [DATE], with diagnoses including COPD, heart failure, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Anemia (low iron), Vitamin D deficiency, Dysphagia (difficulty swallowing), need for assistance with personal care and deficiency of other vitamins. Review of the resident's Nutrition/Dietary Note dated 4/23/24 showed: -The Registered Dietician (RD) documented he/she reviewed the resident's weights and it showed the resident's weight in April was 128 pounds (down 2 pounds in one month, down 3 pounds in 3 months, and down 13 pounds in 6 months). The resident's appetite varied. He/She ordered 2 cal (a protein and calorie supplement) 60 milliliters (ml) twice daily. The Registered Dietician recommended changing the order to health shakes three times daily due to the resident's weight loss trend. Review of the resident's Nursing Notes showed on 6/4/24, the resident was having episodes of choking at meals more frequently and choking while drinking thin liquids. The resident started a 3 day trial of nectar thickened liquids (liquids were easily pourable and were comparable to heavy syrup found in canned fruit). Dietary and the resident's responsible party were notified. Review of the resident's Care Plan dated 6/26/24, showed: -The resident had a self-care performance deficit related to left sided weakness from a previous stroke. -The resident ate independently with set up assistance from staff. -The resident was on a restorative eating and swallowing program (this was not defined nor were there any additional interventions showing how staff was supporting the resident in this area) Review of the resident's Nursing Notes showed: -On 7/12/24, the resident was sent to the hospital due to increased weakness, persistent pneumonia, crackles throughout the lungs, and irregular heartbeats. -On 7/19/24, the resident was re-admitted to the facility and would receive skilled rehabilitative services (physical, occupational and speech therapies). The resident was now on a pureed diet. He/She did not like it and preferred to chew foods. Review of the resident's daily Skilled Nursing Notes showed: -On 7/20/24, Nutrition: the resident had difficulty swallowing at times. Fluids encouraged. Complaints of thirst: No. Mucous membranes were moist. -From 7/21/24 to 7/24/24, the nursing staff documented the resident was taking nutrition and hydration orally. He/She had no complaints of thirst. There were no signs/symptoms of a swallowing disorder. His/Her mucous membranes were moist. Review of the resident's Nursing Note dated 7/24/24 at 9:43 A.M., showed: -The resident began coughing uncontrollably at breakfast after taking a drink of nectar thick water. -The resident had extensive nasal dripping. -This nurse changed the resident to a 3-day trial of Honey thickened liquids (liquids are similar to honey or a milkshake) at this time. -This nurse spoke to the resident regarding the change and the resident agreed to try Honey thickened liquids. Review of the resident's Nursing Note dated 7/24/24 at 10:22 A.M., showed: -The resident was in the facility for COPD with exacerbation and diabetes. -The resident was alert and oriented with occasional confusion but was easily redirectable. -The resident had difficulties in the hospital and his/her diet was changed to pureed with nectar thickened liquids. -The resident was recently observed to have coughing and difficulty swallowing at times. -The Speech Therapist evaluated the resident for oropharyngeal strengthening (a major method of swallowing training) and appropriate diet. The resident was started on a 3 day trial of honey thickened liquids as of this date. -The resident's lungs were diminished throughout and had occasional coughing following oral intake. Review of the resident's Nursing Note dated 7/25/24 showed the resident continued monitoring for 3-day trial of Honey thickened liquids. The resident had no episodes of coughing at breakfast and he/she tolerated increased thickened liquids well. No nasal dripping was noted. Review of the resident's quarterly MDS dated [DATE] (Assessment Reference Date (ARD) 7/24/24) showed: -The resident did not have any chewing or swallowing issues during the 7 day lookback period. -The resident had no choking or coughing during meals during the 7 day lookback period. Observation on 9/17/24 at 12:38 P.M., showed the resident was sitting in his/her wheelchair in the dining room waiting to be served lunch. He/She received a mechanical soft diet of ground turkey with gravy, mashed potatoes with gravy, broccoli, chocolate cake with water, a red beverage, and tea. The resident's meal was served in a divided plate. He/She was able to independently feed himself/herself and began eating and drinking without assistance. He/she did not receive a supplement at this meal. During an interview on 9/19/24 at 9:33 A.M., Certified Nursing Assistant (CNA) E said: -The facility staff had concerns with his/her weights and he/she had past weight loss and choking issues. -They were still observing him/her during meals due to his/her past weight loss history and low intake at meals. -The resident fed himself/herself and tended to eat about the same amount at each meal, but he/she was eating better. During an interview on 9/19/24 at 10:03 A.M., the MDS Coordinator said: -He/She was responsible for completing the MDS and would update regarding significant change, annuals and quarterlies. -The resident had swallowing/choking issues and weight concerns when he/she came into the facility. -He/She updated the care plans quarterly. -He/she tried to update any significant changes as soon as they occurred, but he/she did not always get to all of them. During an interview on 9/19/24 at 11:16 A.M., the DON said: -He/She would expect the MDS to reflect the resident's nutritional status within the 7 day lookback period. -If the nurse documented the resident had chewing or swallowing problems or if the resident had indications of being treated for choking or swallowing issues, it should be indicated on the MDS and care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a person-centered, individualized care plan describing care and services furnished by the facility to treat a resident for edema (swelling due to the retention of fluid) was developed for one sampled resident (Resident #8)and failed to complete a comprehensive care plan that included nutritional status for one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 43 residents. 1. Review of Resident #8's care plan, dated 2/1/24, showed: -A focus of decreased cardiac output related to congestive heart failure (a disease in which the heart functions at a reduced capacity). -An intervention to evaluate the resident for edema with no specific schedule on when to do so. -No information regarding the resident's active edema including interventions or goals. -No information regarding the resident's orders for compression pumps or compression wraps. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 8/4/24, showed: -Diagnoses including non-traumatic brain dysfunction (damage to the brain by internal factors, such as a lack of oxygen, exposure to toxins, or pressure from a tumor) and Congestive Heart Failure (CHF a serious condition that occurs when the heart is unable to pump blood efficiently, resulting in fluid buildup in the body). -The resident needed moderate assistance with lower body dressing. Review of the resident's Physician Order Sheet (POS) dated 9/18/24, showed orders for: -Compression pumps to both legs for one hour twice per day for edema. -Compression wraps applied to both legs each morning and removed each evening for edema. During an interview on 9/18/24 at 12:29 P.M., the MDS Coordinator said: -He/She was responsible for creating care plans for residents that reflected the care and services they were provided by the facility. -Orders for compression pumps and wraps should have been reflected in the resident's care plan, otherwise staff may not have known how to operate the devices or why the devices were in place. 2. Review of Resident #1's Face Sheet showed he/she was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD a group of lung diseases that block airflow and make it difficult to breathe), CHF, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Anemia (low iron), Vitamin D deficiency, Dysphagia (difficulty swallowing), need for assistance with personal care and deficiency of other vitamins. Review of the resident's Nutrition/Dietary Note dated 4/23/24 showed: -The Registered Dietician (RD) documented he/she reviewed the resident's weights and they showed the resident's weight in April was 128 pounds (down 2 pounds in one month, down 3 pounds in 3 months, and down 13 pounds in 6 months). The resident's appetite varied. -He/She ordered 2 cal (a protein and calorie supplement) 60 milliliters (ml), twice daily. -The Registered Dietician recommended changing the order to health shakes three times daily due to the resident's weight loss trend. Review of the resident's Nursing Notes showed on 6/4/24, the resident was having episodes of choking at meals more frequently and choking while drinking thin liquids. The resident started a 3 day trial of nectar thickened liquids (liquids are easily pourable and are comparable to heavy syrup found in canned fruit). Dietary and the resident's responsible party was notified. Review of the resident's Comprehensive Care Plan dated 6/26/24, showed: -The resident had a self-care performance deficit related to left sided weakness from a previous stroke. -The resident ate independently with set up assistance from staff. -The resident was on a restorative eating and swallowing program (this was not defined nor were there any additional interventions showing how staff was supporting the resident in this area). -There was no documentation showing the resident had a problem area regarding his/her nutritional status to include the resident's history of weight loss, chewing and swallowing difficulties, diet, and it did not show any nutritional interventions that were implemented to address his/her dysphagia and weight loss concerns. Review of the resident's Mini Nutrition assessment dated [DATE], showed: -The resident had no decrease in food intake in the last 3 months and had no weight loss in the last 3 months. --This assessment was incorrect according to the RD's evaluation. -The resident was able to get out of bed/chair but did not go out. -The resident had not suffered psychological stress or acute disease in the past 3 months. -The resident had mild dementia. -The resident's Mini Nutrition Score was 9.0 (a score of 9.0 meant the resident was at risk for malnutrition). Review of the resident's daily Skilled Nursing Notes showed: -On 7/20/24, Nutrition: The resident had difficulty swallowing at times. Fluids encouraged. Complaints of thirst: No. Mucous membranes are moist. -From 7/21/24 to 7/24/24, Nutrition: The resident was taking nutrition and hydration orally. No complaints of thirst. No signs / symptoms of a swallowing disorder. Mucous membranes moist. Review of the resident's Nursing Note dated 7/24/24 at 9:43 A.M., showed: -The resident began coughing uncontrollably at breakfast after taking a drink of nectar thick water. -The resident had extensive nasal dripping. -This nurse changed the resident to a 3-day trial of Honey thick liquids at this time. -This nurse spoke to the resident regarding change and the resident agreed to try Honey thick liquids. Review of the resident's Nursing Note dated 7/24/24 at 10:22 A.M., showed: -The resident was in the facility for COPD with exacerbation and diabetes. -The resident was alert and oriented with occasional confusion but was easily redirectable. -The resident had difficulties in the hospital and his/her diet was changed to pureed with nectar thickened liquids. -The resident was recently observed to have coughing and difficulty swallowing at times. -The Speech Therapist evaluated the resident for oropharyngeal strengthening (a major method of swallowing training) and appropriate diet. The resident was started on a 3 day trial of honey thickened liquids as of this date. -The resident's lungs were diminished throughout and had occasional coughing following oral intake. -The resident was pleasant and cooperative with cares and able to voice needs/wants most of the time. Review of the resident's Physician's Telephone Order showed the following: -On 8/27/24 a Speech Therapy clarification order to re-certify skilled Speech Therapy 10 times in 30 days for dysphagia, to include oral exercises, therapeutic feedings, diet texture analysis, develop and train compensatory techniques. -On 8/29/24 a physician's order to upgrade the resident's diet to Mechanical Soft (soft foods with ground meat) and to continue with nectar thickened liquids. Review of the resident's POS dated [DATE], showed a physician's order for a Mechanical Soft diet with nectar thickened liquids dated 8/9/24. Review of the resident's Nutrition/Dietary Note dated 8/31/24, showed: -The RD completed another nutrition evaluation (due to a recent hospitalization readmission). -The RD documented the resident was receiving a consistent carbohydrate diet that was Mechanical Soft in texture, with nectar thickened liquids and 2 cal supplement twice daily. -The resident ate between 50 to 100 percent at meals and required staff supervision. -The resident was still slightly underweight. -The recommendation was to continue the current plan of care and Speech Therapy was to make recommendations for texture advancement. Monitoring would continue as needed. Observation on 9/17/24 at 12:38 P.M., showed the resident was sitting in his/her wheelchair in the dining room waiting to be served lunch. He/She received a mechanical soft diet of ground turkey with gravy, mashed potatoes with gravy, broccoli, chocolate cake with water, a red beverage, and tea. The resident's meal was served in a divided plate. He/She was able to independently feed himself/herself and began eating and drinking without assistance. He/she did not receive a supplement at this meal. Observation on 9/18/24 at 10:38 A.M., showed the resident was sitting in his/her wheelchair in the dining room. He/She was served oatmeal for breakfast (at his/her request) and beverages. The resident also received a 2 cal supplement. He/She was able to eat and drink independently without assistance. No issues were noted. During an interview on 9/19/24 at 9:28 A.M., Certified Nursing Assistant (CNA) E said: -The facility staff had concerns with his/her weights, past weight loss and choking issues. -They were still observing him/her during meals due to his/her past weight loss history and low intake at meals. -The resident received 2 cal supplements for weight loss. -The resident fed himself/herself and usually ate about the same amount at each meal, but he/she was eating better. -Usually they were informed about any changes in the resident's cares through the nurse. They did not have access to the resident's care plan. -The MDS Coordinator or the nurse completed and updated the resident's care plan. 3. During an interview on 9/19/24 at 9:48 A.M., The Assistant Director of Nursing (ADON) said: -They normally left notes for the MDS Coordinator to update the care plan as needed. -If they had an immediate intervention they needed to implement for a resident, they could update the care plan in those instances, but then they would also communicate with the MDS Coordinator. -Every shift had a matrix that was updated daily and all of the CNA staff were required to sign it as did the Charge Nurse. -The matrix was a form with all of the resident's primary information on it (diet, continence level, ambulation level, if they are on oxygen or any specialized equipment and what it is used for) that informed them of how the staff was to take care of the resident and it was updated per shift as needed. During an interview on 9/19/24 at 10:03 A.M., the MDS Coordinator said: -He/She was responsible for completing the MDS and care plans. -The resident had swallowing/choking issues and weight concerns when he/she came into the facility. -He/She updated the care plans quarterly. -Sometimes the Charge Nurses updated care plans with interventions, and notified him/her, but he/she tried to get the care plans updated as needed within a week of new interventions being implemented. -Sometimes he/she did not get to them in a week and tried to at least update them within a 30 day period. -Any new interventions were updated on the resident matrix for the CNA staff at the time the intervention was implemented. He/She said the matrix was updated daily. -He/she tried to update any significant changes as soon as they occurred, but he/she did not always get to all of them. During an interview on 9/19/24 at 11:16 A.M., the Director of Nursing (DON) said: -Comprehensive care plans should show the current care needs of the resident. -The care plan should be updated as the resident's condition changed. -He/She would expect the care plan to include the nutritional status of a resident with nutritional concerns, weight loss, swallowing or chewing problems and interventions related to it. -He/She would expect a resident with any concerns with chewing, swallowing and weight loss to be on the resident's care plan. -Compression hose and wraps should be reflected on the resident's care plan.

Based on interview and record review, the facility failed to complete a thorough investigation to determine the root cause and fall follow-up report of a resident's fall, failed to update the resident's care plan with appropriate interventions and monitor the effectiveness of interventions to prevent additional falls for one sampled resident (Resident #33) out of 14 sampled residents. The facility census was 43 residents. Review of the facility's Fall Assessing and their Cause revised 10/2010 showed: -The purpose of this procedure was to provide guidelines for assessing after a fall and to assist staff in identifying causes of the fall. -Incident report must be completed for resident falls; The incident report form should be completed by nursing supervisor on duty at the time and submitted to the Director of Nursing Services no later than 24 hours after the fall occurs. -Within 24 hours of the fall, the nursing staff will begin to identify possible likely cause of the incident. They will refer to resident -specific evidence including medical history, known functional impairment, etc -When a resident had fallen the following documentation should be recorded in the resident's medical record to include not limited to appropriate interventions taken to prevent future falls, completion of a fall risk assessment. Review of the facility's Fall Clinical Protocol revised 9/2012 showed: -Cause (root cause) refers to factors that are associated with or that directly result in a fall. -For an individual who has fallen, staff will attempt to define possible cause with in 24 hours of the fall -The staff with physician guidance, will follow-up on any falls associated injury until the resident stable and delayed complication such subdural hematoma (swelling or bleeding under skin) have been ruled out or resolved. -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address risk of serious consequences of falling. -If intervention have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed in fall prevention. 1. Review of Resident #33's admission Face-Sheet showed he/she had diagnoses of: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Major Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of the resident's Care Plan dated 7/1/24 showed he/she had: -Had impaired cognitive function/dementia or impaired thought processes. -At risk for Harm related to Self- Directed or Other-Directed due to diagnosis of Dementia. -At risk for unilateral neglect with poor safety awareness at times, related to not using call light for assistance with transfers. -Nursing care staff were to ensure a safe environment for the resident. Review of the resident's most recent Fall Risk Evaluation dated as completed on 7/8/24 showed he/she was at risk for falls. Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 7/9/24, showed the resident had: -Diagnoses including Dementia and Depression. -Moderate cognitive impairment. -Disorganized thinking that changed in severity. Review of the resident's Fall incident/investigation dated 8/24/24 at 1:38 A.M., showed: -The resident had an unwitnessed fall in his/her room. -Nursing description of the incident: The resident was found by care staff sitting on the floor beside his/her bed. He/she was bleeding from his/her head. -The resident's description of the incident: The resident said he/she was attempting to close his/her door, due to the light in hallway and on the way back to bed he/she slipped and fell. -Immediate Action taken by facility staff was the resident was assessed, vital signs taken, and a towel was applied to the area that was bleeding. The facility staff had contacted the Assistant Director of Nursing (ADON) and then 911 was called. The resident was taken to the hospital for evaluation and treatment. -Injuries observed at the time of the incident was a hematoma (bleeding) on top of his/her scalp (head). -His/her reported pain level was 8 out of 10 on a scale of 1 to 10 with 10 being the worst pain. The resident was alert and ambulatory without staff assistance. -Predisposing factors included poor lighting, gait imbalance, and ambulated without assistance from staff members. -Documented under other information: the resident was not wearing non-skid socks, or shoes and the resident was not using a walker. -The facility had contacted the resident's family emergency contact on 8/24/24 at 1:14 A.M. and the resident's physician at 1:40 A.M. -NOTE: The report did not have documentation related to the root cause and any interventions in place prior to fall and put into place after the fall. The facility did not provide Registered Nurse post fall follow-up investigation with findings and additional interventions put in place after the resident injury fall. Review of the resident's Transfer to Hospital Summary note dated 8/24/24 at 2:04 A.M., showed: -The resident was found by staff around 1:05 A.M., on the floor beside his/her bed surrounded by blood. -The resident had fallen and hit his/her head on an unknown item while attempting to self-transfer back into bed, after shutting his/her bedroom door. -The resident said the light from the hallway was too bright and he/she wanted to close the door. -The resident was found by Certified Nursing Assistant (CNA) staff and was quickly assessed by Licensed Nursing staff. -The resident was bleeding a large amount of blood from his/her head. -The nurse applied a towel to the resident's head to help stop the bleeding. -After assessment the decision was made to send the resident out to the hospital for evaluation and treatment. -The ADON was notified at 1:05 A.M., the resident's family member was notified at 1:15 A.M., and the resident's primary care physician was called and made aware of the resident's fall at 1:40 A.M., -The resident was taken to the hospital via ambulance. Review of the resident's Nursing Note dated 8/24/24 at 5:28 A.M. showed: -The resident returned from hospital via his/her family member. -The resident was given a discharge packet stating that he/she had been seen for a fall with head injury. -The resident was given a Computed Tomography scan (CT scan, is a medical imaging technique used to obtain detailed internal images of the body) of his/her head and spine without contrast with no abnormal findings noted while at the hospital. -The resident had one staple placed on the back side of his/her head, with instructions to have it removed by his/her primary care physician in 10-14 days. -The resident's vital signs were taken upon his/her return from the hospital. -The resident was awake and sitting in his/her recliner. -NOTE: no indication or documentation of any new fall prevention interventions were put in place after fall injury on 8/24/24. Review of the resident's medical record under the assessment tab showed there was no updated Fall Risk Evaluation completed after his/her fall on 8/24/24. Review of the resident's Fall Care Plan showed: -There was no documentation related to the fall on 8/24/24. -There were no new interventions put in place after fall on 8/24/24. During an interview on 9/16/24 at 11:34 A.M., the resident said: -He/she had a recent fall and hit his/her head. -The night shift staff left the door open and he/she went to shut the door and had fallen trying to shut the door. -He/she was able to transfer himself/herself and used a wheeling walker. During an interview on 9/17/24 at 2:55 P.M., Agency Certified Nursing Assistant (CNA) A said: -He/she has been at the facility for the past week. -The facility provided CNA's with resident care cards on how to transfer a resident and any fall prevention measures. -He/she was not aware of any fall prevention measures for the resident. During an interview on 9/17/24 at 3:01 P.M., CNA B said: -He/she was not aware of any recent fall precautions for the resident. -Nursing staff would be responsible for completing any documentation related to the resident fall. During an interview on 9/18/24 at 11:55 P.M., Licensed Practical Nurse (LPN) A said: -When a resident was found on the floor, the CNA's would alert the nurse. Nursing would assess the resident to include vital signs, neuro check, if there were any injuries nursing would send the resident out for evaluation and treatment of the injury. -He/she would ask the resident what happened if the resident was able to answer and obtain witness statements if it was an observed fall. -Nursing staff would complete the fall risk assessment, fall incident report/risk management report and notify the Administrator, physician, families and Assistant Director of Nursing and the Director of Nursing. -He/she was not aware of the RN follow-up fall investigation. -He/She was not working when the resident fell. -He/she was not aware if the care plan was updated. -Fall interventions would have been reviewed and updated as part of the nursing morning meetings. -The MDS Coordinator would be responsible to ensure the resident's fall care plan was reviewed and updated. During an interview on 9/18/24 12:32 P.M., the ADON said: -The nurse assessed the resident who had fallen to include vital signs, neuro checks if possible, head injury unwitnessed fall or witness fall hit head. -Nursing staff would complete the fall risk report and notified the physician, Administrator, ADON, DON and the resident's family member. -Nursing would document and complete monitoring assessment of the resident every shift for 72 hours. -He/she was not aware if the fall risk report or the follow-up by the RN included interventions and the root cause of fall. -The fall incident report would be discussed during the morning meeting and final review during the monthly interdisciplinary team (IDT) meetings for any root cause for the resident fall and fall interventions needed. -RN staff would be part of the IDT monthly meeting and sometimes the morning meeting. -The MDS coordinator would be responsible for any care plan updates. -He/she was not sure if Resident #33's fall care plan was updated after the fall on 8/24/24. -Resident #33's fall plan was discussed to have night care staff check on the resident often, to ensure his/her door was closed at night and to ensure the resident had shoes on when up in his/her room. -The facility had not documented the proposed plan in the medical records at that time. -The resident did have Dementia and was forgetful at times, he/she required reminders. -The root cause of the resident's fall was he/she ambulated without shoes. -RN review -not sure if he/she had access to fall follow-up reports. -Resident falls were reviewed during the monthly IDT meeting. -The facility had not had an IDT meeting yet to review Resident #33's fall on 8/24/24, the IDT had not completed the final review to include final fall care plan and any potential root cause. During an interview on 9/19/24 at 10:03 A.M. the MDS Coordinator said: -He/she was responsible for updating and reviewing the residents care plans every 3 months and as needed. -Nursing staff were able to update care plans when needed, such as after a fall for immediate interventions that were put in place. -He/she would expect the fall care plan to have been updated as soon as possible. -He/she was not sure if he/she had updated the resident care plan after the fall on 8/24/24. During an interview 9/19/24 at 11:16 A.M., the Interim DON said: -Care plans should be comprehensive and show the current needs of the resident. -As resident needs changed, he/she would expect those needs to be added to the care plan. -He/she would expect the resident care plans to be updated or reviewed for new preventive fall interventions. -He/she would expect the care plan to be updated after a fall within 48 hours or less, -He/she would expect immediate fall interventions put in place by nursing staff and documented in nursing notes or on the fall risk incident report. -The fall investigation/incident or risk reports should be reviewed by a RN or the DON after completed. -He/she would expect the root cause to be included in the fall investigation. -He/she would expect nursing documentation every shift, for 72 hours, to include fall follow-up, root cause and any interventions that were put in place. -He/she attended daily morning meetings and monthly IDT meetings. -Falls and other incidents were reviewed at both daily morning meetings and monthly IDT meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #37's face sheet showed he/she admitted to the facility with the following diagnoses: -Congestive Heart Failure (CHF disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). -COPD. Review of the resident's TAR dated August 2024 showed: -Oxygen at 2 liters per minute as needed for Shortness Of Air (SOA). -Obtain pulse oximeter (SPO2 measures the amount of oxygen in the blood and the pulse) every shift for SOA. Review of the resident's current physician orders dated September 2024 showed: -Obtain SPO2 every shift for SOA. -Oxygen at 2 L per minute as needed for SOA. Review of the resident's TAR dated September 2024 showed: -Obtain SPO2 every shift for SOA. -Oxygen at 2 L per minute as needed for SOA. Review of the resident's care plan dated September 2024 showed: -The resident was at risk for impaired gas exchange. -The resident would not require continuous or as needed oxygen use during the review period. -Staff were to monitor the resident's respiratory rate and effort. -Staff were to monitor for changes in the resident's respiratory rate or shallow breathing. Observation on 9/16/24 at 12:02 P.M. showed the resident: -Had an oxygen concentrator in his/her room unplugged with a water bottle dated 7/31/24. -Had oxygen tubing bagged and dated 7/31/24. Observation on 9/16/24 at 12:45 P.M. showed the resident: -Was awake sitting in his/her recliner watching television with a blanket on. -Was not wearing oxygen. Observation on 9/17/24 at 9:10 A.M. showed the resident: -Had an oxygen concentrator in his/her room unplugged with the water bottle dated 7/31/24. -Had oxygen tubing bagged and dated 7/31/24. Observation on 9/17/24 at 9:22 A.M. showed the resident: -Was sitting in a recliner with no oxygen. -Had no difficulty breathing and no respiratory distress noted. Observation on 9/17/24 at 12:55 P.M. showed the resident: -Had an oxygen concentrator in his/her room unplugged with the water bottle dated 7/31/24. -Had oxygen tubing bagged and dated 7/31/24. Observation on 9/18/24 at 8:52 A.M. showed the resident: -Was sitting in his/her wheelchair, appropriately dressed for the weather he/she was not wearing oxygen. -Had an oxygen concentrator in his/her room unplugged with the water bottle dated 7/31/24. -Had oxygen tubing bagged and dated 7/31/24. During an interview on 9/19/24 at 9:15 A.M. CNA C said: -The night shift CNA's usually changed the oxygen water bottles and the oxygen tubing at the first of every month. -All shifts would change the water bottle if it was empty. -Oxygen tubing was changed if it became dirty or hit the floor. -Resident #37 used oxygen as needed. -Resident #37 had an oxygen concentrator in his/her room. -Resident #37 slept in the recliner in the main common area. -The staff would bring out the oxygen concentrator if needed. -The facility had two different kinds of water bottles available for oxygen concentrators. -He/she believed the resident had the refillable bottle. -The oxygen tubing and the disposable water bottle should have been changed at least twice since the 7/31/24 date on the tubing and water bottle. During an interview on 9/19/24 at 9:30 A.M. CNA D said: -The CNA's, CMT's, and Nurses were responsible for changing the oxygen water bottle and tubing. -Oxygen tubing was changed weekly. -The oxygen water bottles were changed when empty. -Resident #37 did not use oxygen. -Resident #37 had an oxygen concentrator in his/her room. -Resident #37 was very rarely in his/her room and that oxygen tubing and water bottle could easily be missed. -The oxygen tubing and water bottle should have been changed since 7/31/24. During an interview on 9/19/24 at 9:44 A.M. LPN A said: -The CNA's were responsible for changing the oxygen tubing and water bottles on Saturday night shift. -The oxygen water bottle should be changed when it was empty or monthly. -The oxygen tubing should be changed weekly and as needed. -Resident #37 used oxygen as needed but had not used it recently. -Resident #37 had an oxygen concentrator in his/her room. -The staff kept an oxygen concentrator in his/her room to know where it was when needed. -He/she was told today the oxygen tubing and water bottle needed to be changed and he/she changed it. -The oxygen tubing and water bottle should have been changed well before today. -The tubing should have been changed and dated for Saturday. During an interview on 9/19/24 at 10:30 A.M. the ADON said: -He/she expected all oxygen tubing and water bottles to be changed weekly on night shift by the licensed nurses. -He/she expected the resident's Medication Administration Record (MAR) or the TAR to be marked when the oxygen tubing and water bottles were changed. -He/she expected the residents who used oxygen as needed consistently to have the oxygen tubing and water bottle set up and ready to go. -He/she expected the residents who did not use oxygen consistently to have the oxygen tubing and water bottle available with the concentrator in his/her room. -Resident #37 did not use oxygen consistently, he/she should have the oxygen tubing and water bottle available in his/her room unopened and not dated. -Staff should bag and date all open oxygen tubing and date water bottles that were connected to the oxygen concentrator. -The oxygen tubing and water bottle were attached to the concentrator so they should have been changed and dated later than 7/31/24. -The oxygen tubing and water bottle should have been dated 9/16/24. During an interview on 9/19/24 at 11:16 A.M. the DON said: -The night shift charge nurses were responsible, but the CNA's could change the oxygen tubing and water bottles and then notify the nurses. -Oxygen tubing and water bottles should be dated when they were changed. -Resident #37's oxygen tubing and water bottle should not have been dated 7/31/24. It should have been dated in September. -Staff should have noticed the oxygen tubing and water bottle were out dated for Resident #37. 2. Review of Resident #40's face sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Asthma (when a person's airways become inflamed, narrow, swell, and produce extra mucus, which makes it difficult to breathe. -Coronary Artery Disease (CAD-plaque build-up in the wall of arteries that supply blood to the heart). Review of the resident's quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -The resident did not use any type of oxygen therapy. Review of the resident's POS dated September 2024 showed an order for oxygen at 2 liters per minute via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person) at night for low oxygen. Review of the resident's care plan dated 9/17/24 showed no focus, goal, or intervention related to the use of oxygen therapy. Observation on 9/16/24 at 11:13 A.M. showed: -The resident's oxygen tubing was wrapped around his/her bed rail. -The resident's oxygen tubing was dated 8/2/24. During an interview on 9/17/24 at 9:38 A.M. the resident said he/she wore oxygen at night. Observation on 9/17/24 at 9:40 A.M. showed: -The resident's oxygen tubing was wrapped around his/her bed rail. -The resident's oxygen tubing was dated 8/2/24. Observation on 9/18/24 at 8:09 A.M. showed: -The resident's oxygen tubing was wrapped around his/her bed rail. -The resident's oxygen tubing was dated 8/2/24. Observation on 9/19/24 at 8:44 A.M. showed: -The resident's oxygen tubing was wrapped around his/her bed rail. -The resident's oxygen tubing was dated 8/2/24. During an interview on 9/18/24 at 12:39 P.M. CNA A said: -Oxygen tubing should be stored in a bag when not in use. -He/She thought the night shift changed out the oxygen tubing weekly. -If he/she were to walk into Resident #40's room and find oxygen tubing wrapped around the bed rail, then he/she would put the oxygen tubing in a bag or get new oxygen tubing. -If he/she saw oxygen tubing labeled 8/2/24 he/she would double check with the nurse that it would need to be changed out. -He/She was unaware that the resident's oxygen tubing was dated 8/2/24 and that it should have been changed out by that point in time. -The MDS Coordinator was in charge of the care plans. -He/She did not look at care plans but would ask the nurse if he/she had questions about a resident's care. During an interview on 9/19/24 at 8:40 A.M. Licensed Practical Nurse (LPN) A said: -Oxygen should be stored in a labeled bag when not in use. -Resident #40 only wore oxygen at night. -Resident #40 was usually up and out of bed before starting his/her shift, so he/she thought night shift would be responsible for the residents oxygen tubing storage. -If he/she were to walk into the resident's room and saw tubing wrapped around the bed rail or dated 8/2/24, then he/she would get new oxygen tubing and a new bag for the tubing to be stored in. -He/She was unaware that the resident's oxygen tubing was dated 8/2/24. -The oxygen tubing should have been changed out by that point in time. During an interview on 9/19/24 at 11:16 A.M. the DON said: -Resident #40's oxygen tubing should not have been wrapped around the bed rail. -The staff should have noticed that the resident's tubing was dated 8/2/24 and it should have been changed before that point in time. -Resident #40's care plans should include the use of oxygen therapy and include the orders of the oxygen use. Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored and changed using proper infection control practices when not in use and in a timely manner for three sampled residents (Resident #1, #40,and #37) out of 14 sampled residents. The census was 43 residents. Review of the facility's policy titled Oxygen Administration dated 1/1/24 showed: -The resident's care plan should identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: --The type of oxygen delivery system. --When to administer, such as continuous or intermittent and/or when to discontinue. --Equipment setting for the prescribed flow rates. --Monitoring of oxygen saturation levels (the amount of oxygen in the blood with a normal range of 96% to 100%) and/or vital signs as ordered. --Monitoring for complications associated with the use of oxygen. -Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. -Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. -Keep delivery devices covered in plastic bag when not in use. 1. Review of Resident #1's Face Sheet showed the resident was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD a group of lung diseases that block airflow and make it difficult to breathe), heart failure, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's Care Plan dated 6/26/24 showed the resident had oxygen therapy related to respiratory failure and wore continuous oxygen at 2 liters via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). The resident ambulated to the restroom in his/her room and required longer oxygen tubing. Interventions showed staff would: -Change oxygen tubing and water concentrator per facility protocols. -Review the resident's Treatment Administration Record (TAR) for the most up to date physician's orders. -Keep extra oxygen tubing up and out of the resident's way during ambulation. -Monitor for signs and symptoms of respiratory distress and report to the physician as needed. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning), dated 7/26/24 showed the resident: -Was alert with confusion. -Needed moderate assistance with bathing, dressing, toileting, transfers and used a wheelchair for mobility. -Received oxygen therapy. Review of the resident's Physician's Order Sheet (POS) dated September 2024, showed physician's orders for continuous oxygen at 2 liters per minute (via nasal cannula) for COPD. Observation on 9/16/24 at 2:11 P.M., showed the resident was sitting in his/her recliner, dressed for the weather without odor, with glasses on and oxygen on reclined with a newspaper in his/her lap. He/She was wearing oxygen via nasal cannula that was connected to his/her oxygen concentrator (a medical device that gives you extra oxygen). His/Her eyes were closed and he/she was resting comfortably. There was a portable oxygen tank sitting across from the resident by the closet and the oxygen tubing was coiled around the top of it and was not in a plastic bag/covering. Observation on 9/17/24 at 9:33 A.M., showed the resident was sitting in his/her recliner with oxygen on via nasal cannula that was connected to his/her oxygen concentrator. The portable oxygen tank was on the back of his/her wheelchair which was sitting across from him/her and the oxygen tubing was coiled up and around the portable tank without a plastic storage bag or covering. Observation on 9/17/24 at 10:01 A.M., showed the resident was in his/her wheelchair in the dining room participating in a large group exercise activity. He/She was wearing his/her portable oxygen via nasal cannula. During an interview on 9/18/24 at 11:59 A.M., Certified Medication Technician (CMT) A said: -When oxygen nasal cannulas, tubing and facemasks were not in use they were supposed to be stored in plastic bag and labeled with the resident's name and date. -The night shift nursing staff was supposed to provide the bags and they also were responsible for changing out the tubing and humidifier bottles. -He/She was not sure how often the tubing and other oxygen supplies were supposed to be replaced. During an interview on 9/19/24 at 9:28 AM Certified Nursing Assistant (CNA) E said: -The resident's oxygen equipment (nasal cannulas, face masks and tubing) was supposed to be stored in a plastic bag when not in use. -The CNA staff provided the bags for storage. -They were supposed to check to ensure the oxygen nasal cannulas and face masks were stored every time they completed cares due to some residents removing the nasal cannulas themselves. -The CNA staff were responsible for dating the tubing and humidifier bottles and were supposed to change them out every week. During an interview on 9/19/24 at 9:45 A.M., the Assistant Director of Nursing (ADON) said: -They normally kept the oxygen equipment (nasal cannulas, face masks mouth pieces) in bags when not in use and they were changed weekly -Humidifier bottles and tubing were also changed weekly or as needed. The CNA's can change the humidifier bottles. The weekly change was done on the night shift by the nurses. During an interview on 9/19/24 at 10:21 A.M., the MDS Coordinator said: -Oxygen tubing should be stored in plastic bags when not in use. -Night staff were responsible for providing the bags, but there was a period where the bags were being thrown away. -The night shift CNA staff were responsible for changing the oxygen tubing and oxygen equipment weekly and as needed. They also labeled the humidifier bottles. -The charge nurses were responsible for following up to ensure it was completed. -Nasal cannulas and tubing should not be coiled around the portable oxygen tank. -She/he did expect the oxygen orders to be on the physician's order sheets and the Medication Administration Record (MAR) and Treatment Administration Record (TAR), but not the care plans. During an interview on 9/19/24 at 11:16 A.M., the Director of Nursing (DON) said: -There should be an order for oxygen on the POS and it should be documented on the MAR/TAR. -The oxygen tubing and humidifier should be changed every week by the nurses. -He/She expected oxygen equipment to be labeled/dated at the time it was changed out. -Oxygen tubing should not be coiled around concentrators, canisters and the tubing should be stored in a plastic bag when not in use.

Based on observation, interview and record review, the facility failed to ensure safe secure storage of cleaning chemicals including liquid laundry soap and a liquid bleach bottle for one sampled resident (Resident #33) out of 14 sampled residents. The facility census was 43 residents. Review of the facility's undated Chemical Storage policy showed: -Chemicals should never be left within reach of a resident and must always be properly stored. -Residents may not have personal chemicals stored in their rooms. Review of the facility's undated Important information for residents and families showed items that cannot be brought into the nursing home due to State and Federal regulations included but was not limited to: Bleach and Laundry detergents provided by facility. 1. Review of Resident #33's face-sheet showed he/she had diagnoses of: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Major Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of the resident's Care Plan dated 7/1/24 showed he/she was: -At risk for harm: self directed or other-directed related to diagnosis of Dementia. -At risk for increased Depression with current diagnosis of Depression. -At risk for unilateral neglect with poor safety awareness at times. -The facility staff were to ensure a safe environment. Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 7/9/24, showed the resident had: -Diagnoses including Dementia and Depression. -Moderate cognitive impairment. -Disorganized thinking that changed in severity. Observation on 9/16/24 at 11:39 A.M., of the resident's room showed: -There was a plastic wash basin under the sink with a medium sized bottle of bleach and a green bottle of laundry soap. -The resident was in the room sitting in a recliner and did not have roommates at that time. Observation on 9/16/24 at 11:34 A.M., showed: -The resident was able to ambulate with a rolling walker throughout the facility. -The resident went to his/her closet to get his/her laundry. During an interview on 9/16/24 at 11:34 A.M., the resident said: -The facility did his/her laundry. -He/she was not sure why he/she had laundry soap and bleach in his/her room other than just in case they were needed. Observation on 9/17/24 at 9:18 A.M. of the resident's room showed: -He/she had a plastic wash basin under the sink with a medium sized bottle of bleach half full and a green bottle of laundry soap. -The resident was in the room in a recliner with his/her eyes closed. During interview on 9/17/24 at 9:29 A.M., Certified Medication Technician (CMT) B said: -The resident provided most of his/her own care, staff assisted with bathing. -He/she was not aware the resident had laundry soap or bleach in his/her room. -He/she was not aware of any reason why the resident would have chemicals in his/her room. -The resident should not have any cleaning chemicals including laundry soap and bleach in his/her room. During an interview on 9/17/24 at 9:36 A.M., CMT A said: -He/she was not aware the resident had cleaning chemicals in his/her room. -If staff found the chemicals they should have removed them from the resident's room and taken them to the charge nurse. During an interview on 9/17/24 at 9:41 A.M., Housekeeper A said: -He/she had seen the bleach and laundry soap under the sink in the resident's room. -He/she thought all care staff knew about the chemicals in the resident's room. -He/she did not notify nursing staff or his/her supervisor of the chemicals in the resident's room. -Normally resident's would not keep cleaning supplies stored in their room. During interview on 9/17/24 at 9:46 A.M., Laundry Aid A said: -The resident did not require any special laundry soap. -He/she was not aware of the resident having laundry soap and bleach in his/her room. -The facility provided laundry services for the resident. During an interview on 9/17/24 at 10:18 A.M., Licensed Practical Nurse (LPN) A said: -He/she was not aware the resident had laundry soap and bleach stored under his/her sink. -He/she would expect all staff to monitor for safety hazards when providing cares and when entering and exiting the resident room. -He/she would expect care staff and housekeeping staff to remove the chemicals from the resident room, give them to the charge nurse to lock up and then talk with the resident's family about bringing laundry and cleaning products into the facility. During an interview on 9/18/24 at 12:00 P.M., the Assistant Director of Nursing (ADON)/LPN said: -He/she was not aware the resident had laundry soap and bleach stored under his/her sink. -The resident was not allowed to keep cleaning chemicals in his/her room. During an interview on 9/19/24 at 8:54 A.M., Interim Director of Nursing (DON) said: -He/she would not expect any cleaning chemicals to be left in the resident's room. -If cleaning chemicals were found, they should have been removed from the resident's room immediately. -He/she would expect staff to monitor the resident rooms for any safety concerns or hazards to include cleaning supplies when entering a resident room. -All cleaning supplies and other chemicals should be stored in a secure locked storage area, not accessible to residents.

Based on interview and record review, the facility failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week and failed to ensure a Director of Nursing (DON) or interim DON was onsite full -time 8 hours a day for a minimum of 40 hours a per week. The facility census was 43 residents. Review of the facility Policy for Nursing Services-RN revised 1/1/24 showed: -It is the intent of the facility to comply with RN staffing requirements. -The facility will utilize the services of a RN for at least 8 consecutive hours per day, seven days a week. -The facility will designate a RN to serve as the DON on a fulltime basis. -The DON may serve as a charge nurse only when the facility has a average daily occupancy of 60 or fewer residents. -The facility was responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ staffing data submitted to Center of Medicare & Medicaid services by long term care facilities)) system. Review of the facility's policy for DON Services revised on 8/2006 showed: -The DON manages the nursing services department at the facility. -The DON is a RN, in licensed in state employed. -The DON is employed full-time (40-hours per week). 1. Review of the Facility Assessment for staffing revised on 1/6/24 showed the facility: -Was to have one DON, RN full time during the weekdays (Monday -Friday). -One RN staffed during the dayshift on the weekends (Saturday and Sunday). -Two licensed nursing staff, a RN and/or Licensed Practical Nurse (LPN) as the charge nurse for the day shift and two licensed staff for the evening shift. -One LPN staffed for night shift. -One RN instructor onsite three days a week. Review of the facility's PBJ, report for the Fiscal Year (FY) 2024 for Quarter 3 from 4/1/24 to 6/30/24 showed the facility PBJ report RN hours triggered due to four or more days within the quarter with no RN hours reported. Review of facility's RN's and Interim DON time sheet from 4/1/24 to 5/31/24 showed: -On 4/27/24, 4/28/24 and 5/4/24 had no time recorded for the facility RN on those days. -The facility documented on the time sheet that the corporate nurse had worked those days, but was not included in the PBJ report submitted for that quarter. Review of the Interim DON's time sheet dated 9/1/24 to 9/15/24 showed a total of 52 hours in the two week pay period. During an entrance conference interview on 9/16/24 at 8:50 A.M., the Administrator said: -The facility had an interim DON, (who also was the training nurse) who was working less than 38 hours a during the week. -The facility Corporate RN assisted with RN and DON duties. During an interview on 9/17/24 at 9:29 A.M., Certified Medication Technician (CMT) B said: -The facility did not have a full time DON for over a year. -He/she would report any concerns to the Assistant Director of Nursing (ADON). During an interview on 9/17/24 at 9:36 A.M., CMT A said: -The facility normally had a RN onsite during the weekday on the dayshift. -The facility corporate nurse was onsite at the facility when needed. -The ADON had been acting DON with oversight by the facility RN staff. During an interview on 9/17/24 at 9:48 A.M., Certified Nursing Assistant (CNA) B said: -The facility did not have a DON at that time, only a ADON/LPN for at least 6 months. -He/she would report to the ADON and RN trainer with any issue or concerns. During an interview on 9/17/24 at 10:18 A.M., Licensed Practical Nurse (LPN) A said the acting DON, was normally at the facility during the dayshift for 8 hours or less a day, it would depend on the day. During an interview on 9/18/24 at 10:45 A.M., the Staffing Coordinator/Human Resource staff said: -He/she completed the daily staffing sheet and ensured there was coverage needed. -The Administrator would ensure there was licensed nurse coverage for that shift or day. -The facility last hired a full time 40 hours a week DON on 9/22/23 and his/her last day of work was 11/22/23. -The ADON/LPN assisted with the DON duties. -The interim DON normally worked less than 40 hours a week. -The facility ADON had been acting as DON with oversight by the RN staff. -The Corporate RN would also assist in weekend RN staffing coverage and as acting DON when needed. -He/she did not track or obtain the Corporate RN hours. -The Corporate RN hours would not be included in PBJ reports. -On 4/27/24, 4/28/24 and 5/4/24 the corporate RN was listed as scheduled that day. He/she would not report those RN hours in PBJ reports. During an interview on 9/18/24 at 11:27 A.M., the Administrator said: -The facility did not have waiver for DON or RN coverage currently. -The facility Interim DON worked four days a week, not full time at 40 hours week. -The ADON/LPN was in the office as acting DON, with RN oversight one day a week or as needed. -The facility Corporate RN had been assisting with onsite RN coverage for weekends and when the Interim DON was not available for fulltime 40-hour a week. -The RN weekend staffing, was normally covered by the Corporate RN and some of the facility RN staff. -The facility should have a RN working at least eight consecutive hours every day. During an interview on 9/18/24 at 12:00 P.M., the ADON/LPN said: -He/she worked as a charge nurse four days a week and in his/her office one day a week. -He/she was the ADON with DON assigned tasks under the supervision of a RN, to include infection control, shower sheet review, quarterly assessments, and as weekend nurse on-call every weekend. -The facility did not always have RN coverage for 8 hours a day, 7 days a week. -The facility did not always have a RN on site on weekends. The RN could be reach by phone on weekends. -The facility was having difficulty maintaining RN and DON coverage/staff. During the Quality Assurance (QA) interview on 9/18/24 at 1:30 P.M., the Administrator said: -The corporate office reviewed the PBJ reports and they had not communicated the results to him/her. -It was possible that the information the corporate office had input regarding staffing was not correct. -He/she was aware of an instance where the information regarding their staffing did not get pulled over correctly into the PBJ. -He/she did not look at PBJ reports. -The facility was having a challenge with maintaining the DON position. -He/she had not been documenting the corporate nursing hours. -The HR staff would be responsible and should have documented the hours of the Corporate Nurse (the facility doesn't pay Corporate Nurse directly). -The corporate office said they were trying to assist the facility in getting a full time DON. -The ADON was a semester away from becoming a RN so they were supporting the ADON in his/her education process. During an interview on 9/19/24 at 8:54 A.M., Interim DON said: -He/she was currently the interim DON and was teaching the CNA class. -He/she did not always work a full 40 hours per week. -He/she was normally at the facility for four days a week, hours varied during the week. -The facility did not always have RN coverage each day, but thought the Corporate RN filled in as RN when RN hours were short or would be acting DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #1), out of 7 sampled residents, was free from resident to resident abuse. On 7/30/23 around 1:00 A.M., Resident #2 entered Resident #1's room and was found with his/her hand under Resident #1's shirt, touching his/her breast. The facility census was 50 residents. Review of the facility's Abuse and Neglect - Clinical Protocol policy dated July 2017 showed: -Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. -Instances of abuse of all residents, irrespective of any mental or physical condition, could cause physical harm, pain or mental anguish. -It included verbal abuse, sexual abuse, physical abuse and mental abuse. -Sexual abuse was defined as non-consensual sexual contact of any type with a resident. 1. Review of Resident #1's admission face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Unspecified dementia without behavioral, psychotic or mood disturbance, (a decline in cognitive function severe enough to interfere with a person's daily life). -Anxiety disorder, (a mental health condition characterized by excessive and persistent feelings of worry, fear or apprehension). -Cognitive communication deficit, (difficulty in the ability to process, comprehend and express information though language and communication). -Unspecified symptoms and signs involving cognitive functions and awareness, (symptoms involving mental processes that involve perception, memory, reasoning, problem solving and decision making). Review of Resident #1's Care Plan dated 3/15/23 showed: -The resident had impaired physical mobility requiring a Hoyer lift, (a mechanical device used in healthcare settings to assist with lifting and transferring individuals with limited mobility or physical disabilities), for all transfers, with the intervention of encouraging times of rest and relaxation between care activities. -The resident had the potential risk for harm, either self-directed or other-directed, so the resident would be free of non-aggressive behaviors, with the interventions of allowing the resident personal space, if safe and utilizing calm touch. Review of Resident #1's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 6/12/23, showed he/she had a Brief Interview for Mental Status (BIMS) score of 0 indicating he/she was not able to answer questions and was cognitively impaired. Review of Resident #2's admission face sheet showed he/she was admitted to the facility on [DATE] with the a diagnosis of Insomnia, unspecified, (a sleep disorder characterized by difficulty falling asleep, staying asleep or experiencing poor quality sleep). Review of Resident #2's admission MDS dated [DATE], showed: -The resident exhibited behaviors and wandering. -He/she had a BIMS score of 3 indicating he/she was not able to answer the questions and was cognitively impaired. -The resident had delusions, (misconceptions or beliefs that were firmly held, contrary to reality). -The resident's behaviors intruded on others. Review of Resident #2's Care Plan dated 7/25/23 showed: -The resident had a behavior of making sexually inappropriate comments and requests to staff and others. Interventions included redirection when he/she made inappropriate comments; 1:1 supervision; the charge nurse would be notified promptly, praise and encouragement would be given to the resident for appropriate interactions. -The resident had impaired social interaction related to dementia and preferred to sleep most of the day and was up a lot during the night, as he was formerly a night shift police officer. Interventions included encouraging the resident to participate in recreational activities. -The resident was at risk for harm, self-directed or at others. Interventions included administration of medications as prescribed; staff should encourage the resident to verbalize cause for aggression; the resident should be allowed personal space; if wandering or pacing, visual supervision should be initiated; reorientation to the situation should be provided; diversion techniques should be used as needed. -The resident had a behavior problem of wandering in the hallways at night and in other resident rooms. The resident was a police officer previously, and tended to do rounds on other residents and wake them up to ask if they were okay. Interventions included giving medications as ordered; intervention as necessary to protect the rights and safety of others; the resident should be approached calmly and attention diverted; the resident should be removed from the situation and taken to an alternative location. promptly and praise and encouragement of appropriate interactions. Review of Resident #2's Progress Note dated 7/30/23 at 1:15 A.M. showed: -Certified Nursing Assistant (CNA) A advised the nurse that she/she had found the resident in Resident #1's room. -Resident #2's door was closed. -Resident #2 had entered Resident #1's room through the bathroom joining their rooms. -CNA A stated he/she found Resident #2 with his/her hand under Resident #1's shirt. -Resident #2 was immediately removed from the room and directed to sit in the main common area. -Resident #2 insisted on returning to his/her room. -The nurse went to check on Resident #2 one minute later and found him/her ambulating through the bathroom into Resident #1's room again. -Resident #2 was removed from the room again. Review of the facility Investigation Summary Form dated 7/30/23 showed: -The event was discovered at 1:00 A.M. by CNA A, who was doing resident checks. -CNA A reported the event. -Resident #2 was found in Resident #1's room with his/her hand inside Resident # 1's shirt. During an interview on 7/31/23 at 11:35 A.M., CNA B said: -He/she was doing 1:1 observation of Resident #2 that day. -Resident #2 had made remarks inviting him/her into his/her bed or shower. -He/she would respond that he/she worked at the facility and that was not his/her job. During an interview on 7/31/23 at 11:57 A.M., the social worker said: -The first inquiry for Resident #2's potential admission to the facility was by his/her Family Member B. -This family member stated Resident #2 had tried to get into bed with him/her. -This was a red flag, and he/she told Family Member B that he/she felt Resident #2 was not appropriate for this facility. -At that time, they did not have a referral from the hospital for Resident #2, nor did they know the resident's name. -When they received the hospital paperwork, there was no mention of any behaviors. -The facility took Resident #2 based on the hospital paperwork. -He/she asked Family Member A point blank about what Family Member B had said, and Family Member A got angry and denied it. -Since Family Member A was the resident's Durable Power of Attorney (DPOA), they felt he/she would know Resident #2 behavior, so the facility went ahead and accepted the resident. During an interview on 7/31/23 at 12:20 P.M., Resident #2 said: -He/she did not recall going in Resident #1's room or who he/she was. -He/she denied putting his/her hand under Resident #1's shirt, because he/she was a gentleman and a policeman for over 40 years. -He/she would get up and walk around at night, but did not talk to anyone. -He/she did not go in any resident rooms. There would be no reason to, since he/she did not know anyone. Review of Licensed Practical Nurse (LPN) A's statement dated 7/30/23 showed: -On 7/30/23 at approximately 1:00 A.M., CNA A was noted to be walking up the north hall with Resident #2. -CNA A stated he/she found Resident #2 with his/her hand down Resident #1's shirt, moving it around. -CNA A stated he/she had asked the resident to follow him/her out of Resident #1's room, to which he/she complied. -He/she asked Resident #2 what happened and he/she stated, I am a police officer! I know what is wrong and right! -He/she asked the resident to sit in the main area with him/her. -The resident refused, stating he/she wanted to go back to his/her room. -The resident went back in his/her room and closed the door. -He/she returned to Resident #1's room to see if Resident #2 would attempt to go back in Resident #1's room. -After about a minute, he/she noted the bathroom door to be opening. -Resident #2 became startled and said he/she was just checking on Resident #1. -Resident #2 was escorted back to his/her room and told he/she could not go in other residents' rooms. -Resident #2 said he knew that and got into bed. During an interview on 7/31/23 at 12:45 P.M., LPN A said: -The CNA found Resident #2 in Resident #1's room. He/she escorted the resident out. -He/she did not actually see Resident #2 in Resident #1's room. -There was a bathroom between the two residents' rooms that was kept locked. -That bathroom door had always been locked, to his/her knowledge. -After report, he/she waited in Resident #1's room to see if Resident #2 would attempt to come in again. -Resident #2 came back in the room almost immediately. -Resident #2 was redirected back to his/her room and he/she laid down. -He/she blocked the bathroom door with a chair, and Resident #2 tried to reenter Resident #1's room through the front door. -He/she was taken back to his/her room and placed on 1:1 observation. Review of CNA A's statement dated 7/31/23 showed: -He/she was doing 1:00 A.M. rounds and opened Resident #1's door to his/her room. -As he/she went in, he/she found Resident #2 sitting on Resident #1's bed, leaning over his/her legs, with his/her right hand on Resident #1's breast. -He/she immediately escorted Resident #2 to his/her room. During an interview on 7/31/23 at 1:20 P.M., CNA A said: -He/she was doing rounds and heard talking in Resident #1's room. -Resident #1 typically kept her door open, and at this time, it was shut, so he/she opened it and went in. -He/she found Resident #2 in the room. -Resident #2 was sitting on the side of Resident #1's bed with his/her hand up Resident #1's shirt. -It appeared Resident #2 was touching Resident #1's breast. -When he/she went in the room, Resident #2 said, What's wrong? I have my badge on me. -Resident #1 was awake, but not very alert at the time. -He/she covered Resident #1, because his/her shirt was up, and redirected Resident #2 out of the room. -He/she found Resident #2 had gotten in the room through the bathroom between the residents' rooms. -There had been a chair in front of the bathroom door, and Resident #2 had been able to push it aside. -Afterward, both he/she and LPN A caught Resident #2 trying to re-enter Resident #1's room. During a telephone interview on 8/1/23 at 10:55 A.M., Resident #2's Family Member A said: -Resident #2's Family Member B went to see the facility prior to his/her referral by the hospital. -Family Member B spoke with the social worker when he/she visited. -Resident #2 lived in his/her own home, and moved to Family Member A's home. -He/she said Resident #2 asked if he/she could get into bed with him/her. -He/she told Resident #2 it was inappropriate and he/she could not do that. -He/she let the facility know this information in the beginning about the resident's behaviors and medications. -At the facility, the staff allowed the resident to sleep in a recliner in the dining room, where they could keep a closer eye on him/her. -At the facility, he/she asked Resident #2 not be placed with a roommate, or near residents of the opposite gender. -He/she was aware Resident #2 shared a bathroom with a resident of the opposite gender. -He/she believed the staff at the facility were aware of his behavior. During a telephone interview on 8/1/23 at 12:00 P.M., the MDS Coordinator A said: -He/she went through every referral with the social worker and the Administrator before accepting a resident. -When Resident #2's Family Member B came to visit and tour the facility, and inquire about the admission process, the family member did not indicate the resident's name. -Family Member B mentioned Resident #2 had a behavior of trying to get into bed with his/her household members. -The day Resident #2 was accepted for admission to the facility, the resident's Family Member A and Family Member B came to the facility. -The social worker and MDS coordinator recognized Family Member B and realized Resident #2 was the same person he/she spoke of when she/she initially visited the facility. -At that time, the social worker asked Family Member A about Resident #2 trying to get into bed with other household residents, and Family Member A went ballistic, and stated absolutely not. -Since Family Member A was who the resident had been living with, and he/she was the resident's DPOA, they believed him/her. During an interview on 8/1/23 at 1:20 P.M., Resident #2's Family Member B said: -He/she told the facility social worker the resident had been making sexual remarks and tried to get in bed with Family member A. -He/she and Family Member A had been caring for the resident since 5/1/23. -The resident tried to get in bed with Family Member A once. -They had the resident placed on a mood stabilizer and a sleeping pill. During an interview on 8/1/23 at 1:40 P.M., Resident #1's Family Member C said: -He/she was aware of the incident and felt the facility was doing the best they could, since both residents had dementia. -He/she said Resident #1 did not remember any of it. -He/she was aware that Resident #2 had been placed on 1:1 observation and moved to a different room. -The bathroom door was supposed to be locked and the staff did not know how it became unlocked. -His/her expectation was that Resident #1 would not have another resident come in his/her room at night. During an interview on 8/1/23 at 2:30 P.M, the Administrator said: -Resident #2's Family Member B had told the social worker that he/she had tried to get into bed with a family member, and that he wandered. -Resident #2's Family Member A said that this was not true, that he/she had been on medications and slept through the night. -Resident #2 had been at the facility about a week and a half without issues, except comments to the staff. -On around 7/25/23 the resident started wandering, and he/she was told he/she had been trying to get into other resident rooms, but without any sexual activity. -It was determined these activities were happening primarily at night, so a nurse was placed at the back nursing station where Resident #2's room was in direct line of sight. -Female residents have the right to be free of non-consensual touching by other residents. MO00222231

Based on interview and record review, the facility failed to ensure two sampled residents (Resident #1 and #18) were treated with dignity and respect. Agency Licensed Practical Nurse (LPN) A was inconsiderate and raised his/her voice when speaking to a cognitively impaired sampled resident (Resident #1); and became argumentative and raised his/her voice to one sampled resident (Resident #18) on 1/21/23, out of 13 sampled residents. The facility census was 53 residents. 1. Record review of Resident #1's Face sheet showed he/she had diagnoses of: -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Alzheimer's disease (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Borderline Personality (BPD-a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 1/20/23, showed: -The Brief Interview for Mental Status (BIMS) should be conducted. -Had a BIMS score of 3 out of 15 which indicated severe cognitive impairment. -Was able to understand others and was able to make his/her needs known. -Was independent with ambulation and transfers. Record review of the resident's nursing note dated 1/21/23 at 11:35 A.M. by Agency LPN A showed: -During the morning medication pass Resident #1 came up to this nurse and told him/her that someone needed to do something with his/her bed. The bed sheets were slick. -Agency LPN A said he/she would have to go to laundry and get linens that would fit the bed, Resident #1 said yeah OK. -Resident #1 immediately got upset and walked away from the nurses cart. -Resident #1 came back while Agency LPN A's back was turned and tried to get close to the nurse to hit him/her. -Agency LPN A moved out of the way. -The second time Resident #1 came up to the cart, he/she took the box of Kleenex saying they were his/hers Kleenex and that the nurse had taken them. -NOTE: There was no documentation related to the resident actually hitting Agency LPN A. Record review of the resident's medical record showed there was no additional documentation related to Agency LPN A being allegedly inconsiderate and having a disagreement with residents on 1/21/23. Record review of the resident's Care Plan for Impaired Coping dated 1/23/23 showed: -He/she was at risk for harm directed toward to others and or himself/herself. -The resident would be free of verbally aggressive behaviors. -Interventions included: --Administer medications as prescribed. --Encourage the resident to verbalize cause for aggression. --If the resident posed a potential threat to injure himself/herself or others staff were to notify the physician. --If safe, allow the resident personal space. --Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors. --Monitor for signs/symptoms of agitation. --Provide clear, simple instructions, provide reorientation to the situation. --Provide verbal feedback to the resident regarding his/her behavior and utilize diversion techniques as needed. Record review of the resident's medical record with the MDS Coordinator on 2/9/23 showed no additional documentation found related to the incident with the Agency LPN A. During an interview on 2/8/23 at 10:17 A.M., Resident #1 said: -Sometimes staff members have good and bad days. (related to moods) -He/she could kind of remember Agency LPN A being rude to him/her. -He/she was not fearful, and he/she loved being at the facility. Observation on 2/8/23 at 10:17 A.M. showed the resident was able to make his/her basic care needs known. 2. Record Review of Resident #18's admission face sheet showed he/she had a diagnosis of Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Was his/her own responsible person. During an interview on 2/10/23 at 10:23 A.M., the resident said: -Resident #1 came up to Agency LPN A and was requesting items from him/her. -Resident #1 was following Agency LPN A around and he/she finally got agitated with Resident #1 and told him/her to get out of his/her space. -He/she tried to explain to Agency LPN A that Resident #1 was forgetful, he/she did not remember asking for items or assistance. -Agency LPN A got upset with him/her also. -Agency LPN A was agitated and short and spoke to him/her and other residents on the unit with a loud voice. 3. Record review the facility staffing sheet for January 2023 showed: -On 1/21/23 during the day shift Agency LPN A was scheduled to work the back hallway on the day shift. -Had LE by his/her name which indicated he/she left early. Record review of a witness statement by Certified Nurses Aide (CNA) B dated 1/21/23 showed: -Agency LPN A seemed very frustrated that morning. -He/she saw Resident #1 go over to Agency LPN A. -Agency LPN A said you better get out of my space. I will call the doctor to evaluate you. -Resident #1 flipped Agency LPN A off and walked away. That was around breakfast time, maybe 8:30 A.M., he/she really did not remember. -Around 10:00 A.M. he/she heard Agency LPN A yelling at Resident #18 during the activity saying; you all are rude and I do not even care anymore. I am trying to do my job. During an interview on 2/8/23 at 9:30 A.M., the Housekeeping Supervisor said: -On 1/21/23 Resident #1 was coming down the hall and seemed upset. -He/she asked Resident #1 what was wrong and he/she had pointed back to Agency LPN A and said that thing back there. -Resident #1 said he/she was told by Agency LPN A don't ever touch me and don't get in my bubble. -Resident #1 said he/she was only wanting his/her sheets changed. -Resident #1 said he/she had tapped Agency LPN A on the shoulder. -He/she was informed that was three or four CNA's who had witnessed Agency LPN A yelling, belittling Resident #1 and residents who were playing bingo saying they were to loud. -He/she called the Administrator, who came to the facility and started a full investigation. -Agency LPN A was asked to leave the facility. -Administration had obtained witness statements from facility staff. -He/she was unaware that he/she was able to ask the Agency LPN A to leave the building. During an interview on 2/8/23 at 11:15 A.M., Certified Medication Technician (CMT) B said: -On 1/21/23, he/she was coming off the south back hallway, when he/she heard and saw Agency LPN A and Resident #1 exchanging words. -Agency LPN A said that Resident #1 had struck him/her in the neck. -The resident was wanting a box of tissues. -Agency LPN A was trying to pass medication while Resident #1 was around the medication cart. -Resident #1 was agitated, so he/she escorted Resident #1 to get a soda and back to his/her bedroom to change the linens on his/her bed. -He/she could hear Agency LPN A arguing with another resident who was trying to explain that Resident #1 had dementia and forgot easily. -Another staff member had already contacted and reported Agency LPN A's behaviors to the charge nurse and the Administrator. -The facility HR staffing coordinator and Administrator arrived at the facility and started the investigation which included obtaining witness statements. -The Administrator asked Agency LPN A to leave the facility. During an interview on 2/8/23 at 11:55 A.M. Agency Human Resources (HR) said; -He/she had verified the information reported to them by the facility Administrator on 1/21/23. -Agency LPN A had been placed on leave of absence until the investigation was completed. -The agency provided training to agency staff related to resident rights and respect. During an interview on 2/10/23 at 9:30 A.M., CMT D said Resident #1 could be cranky at times, he/she did not like crowds or noise. During an interview on 2/10/23 at 11:43 A.M., the Administrator said: -The Housekeeping Supervisor called late morning on 1/21/23 said Agency LPN A was not acting right toward the residents. -A resident was upset and facility staff felt uncomfortable with Agency LPN A in the building. -He/she called and talked with the agency HR to have them remove Agency LPN A from the building. -When he/she called back to the building Agency LPN A was still in the building. --He/she called the agency again. -He/she arrived at the building with the facility Human Resource Director, and went to the back hallway to find Agency LPN A. -He/she asked Agency LPN A to leave the building and Agency LPN A became argumentative. -He/she asked the facility Human Resource Director to call the police to escort Agency LPN A out of the building. Agency LPN A then left the building. -He/she called and gave more details of the incident to the agency supervisor and placed Agency LPN A on the no call back list. During an interview on 2/10/23 at 12:40 P.M. Director of Nursing (DON) said: -He/she thought the disagreement happened during the evening shift. -He/she would expect the notifications to be documented in the residents nursing notes. -Resident #1 could be grouchy at times and difficult to care for. -He/she would expect nursing staff to document any behavior in the resident nursing notes. -He/she expected agency staff to complete a facility orientation related to the facility policy and the care of the resident. -He/she would expect agency staff to ask questions of facility staff on how to handle difficult resident behaviors. During a phone interview on 2/15/23 at 10:17 A.M., Agency LPN A said on 1/21/23 during morning medication pass: -Resident #1 came to the medication cart and requested his/her bed be made. -He/she informed the resident that he/she would have to check the laundry to get the right sheet. -The resident had walked away upset and said ok. -Resident #1 was pacing the floor walking back and forth in front of the medication cart and Agency LPN A. -Resident #1 had Dementia and Schizophrenia and could get upset easily. -He/she was getting medications and Resident #1 was passing by, he/she asked Resident #1 if he/she would like his/her medications. -The resident was given his/he medications. -He/she was getting tissues for another resident to administer eye drops. -Resident #1 snatched the box of tissues and hit Agency LPN A in the throat with the box and then called Agency LPN A a bad name. -He/she informed Resident #1, he/she was not to hit him/her again. -Resident #1 was cursing and yelling derogatory racial slurs toward him/her. -He/she told Resident #1 that's okay (related to slurs), but if he/she hit him/her again he/she would call 911. -Resident #1 started going toward him/her. -CMT B intervened and took Resident #1 to the front of the building for about 15-20 minutes. -When Resident #1 returned to the unit, he/she was pacing back in forth in front of him/her while cursing and was attempting come toward him/her. -He/she stepped back away from Resident #1. -Residents were getting upset about not getting their medication due to Resident #1's behaviors of attempting to hit and get into his/her personal space. -He/she informed his/her co-worker if Resident #1 did not stay out of his/her space, he/she would have to to call the doctor to have Resident #1 evaluated for his/her out of control behaviors toward him/her. -Resident #1 was showing signs of aggressive behaviors toward him/her and Resident #1's behavior had the potential of affecting other residents and other staff members. -He/she said another resident (Resident #18) who was playing bingo informed him/her that Resident #1 had Dementia. -He/she informed Resident #18, that Resident #1 still did not have the right to be up in his/her personal space or to hit him/her. -He/she had raised his/her voice after Resident #1 had hit him/her in the throat and did inform Resident #1 do not get into his/her personal space and not to hit him/her again. -He/she did not call the resident any names. -He/she tried to redirect and inform Resident #1 several times that morning that his/her behaviors and actions were not appropriate. -He/she went on break around 11:00 A.M. and noticed that he/she had missed calls from his/her agency supervisor. -When he/she called the agency supervisor back, he/she was informed to leave the facility immediately. -He/she felt these were false allegations against him/her. -He/she completed the documentation in Resident #1's nursing notes related to the resident's behavior and then left the facility.

Based on interview and record review, the facility failed to ensure vaccinations were offered for one sampled resident (Resident #156) out of 13 sampled residents, and one supplemental resident (Resident #33) out of eight supplemental residents. The facility census was 53 residents. Record review of the facility's policy, dated August 2016, titled Influenza Vaccine showed: -All residents were to be offered the influenza vaccine annually. -Residents that received the vaccine were to have the date given, expiration date, lot number, person that administered, and the site of the vaccine documented in their medical record. -A resident that refused the vaccine was to have the refusal documented in their medical record. -The Infection Control Preventionist (ICP) were to monitor vaccinations. Record review of the facility's policy, dated August 2016, titled Pneumococcal Vaccine showed: -Staff were to assess each resident's pneumococcal vaccination status within five working days of the resident's admission. -Staff were to offer the vaccine to any resident that was eligible. -Residents that received the vaccine were to have the date given, expiration date, lot number, person that administered, and the site of the vaccine documented in their medical record. -A resident that refused the vaccine was to have the refusal documented in their medical record. 1. Record review of Resident #156's Face Sheet showed he/she was admitted with a diagnosis of nausea and vomiting. 2. Record review of Resident #33's Quarterly Minimum Data Set (MDS-a federally mandated program to assist in care planning), dated 9/22/22, showed the resident was admitted with a diagnosis of cellulitis (inflammation of subcutaneous connective tissue). 3. Record review of the facility's Immunization List, dated 12/27/22, showed: -Resident #156 was not on the list. -Resident #33 had no information listed for the pneumococcal vaccine. During an interview on 2/8/23 at 11:10 A.M., the ICP said he/she was not sure where the vaccine records were kept. During an interview on 2/10/23 at 12:40 P.M., the Director of Nursing (DON) said: -All residents were to be offered the pneumococcal and influenza vaccine and their response was to be documented in the resident's medical record. -The ICP was responsible for making sure all resident vaccinations were up to date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the windows in the rooms of two sampled residents (Resident #31 and #19) operated properly so they could open and close at the resident's convenience; and to ensure the area under the vending machine was free from a buildup of dust and grime. This practice potentially affected at least two residents. The facility census was 53 residents. 1. Record review of Resident #31's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 1/13/23, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident ' s attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.) of 15. During an interview on 2/6/23 at 2:27 P.M., the resident said: - He/she could not open the windows because the window in his/her room, did not shut all the way. - The staff had to go outside to close them. Observation with the Housekeeping Supervisor on 2/7/23 at 11:19 A.M., showed one of the windows in Resident #31's room would open, but it did not close because the lever which brought the window to a closed position came loose which caused the window not close. During an interview on 2/7/23 at 11:27 A.M., the resident said the window worked last summer, when he/she could have opened it, but as of lately the window would not shut. During an interview on 2/10/23 at 10:26 A.M. the resident said: - It was terrible that he/she could not open his/her window especially because they could not get his/her air conditioner to work right. - He/she was hot and he/she really wanted the window open so he/she could cool down on some hot days in the spring and summer. 2. Record review of Resident #19's quarterly MDS dated [DATE], showed he/she was cognitively intact with a BIMS of 12 out of 15. Observation with the Housekeeping Supervisor on 2/7/23 at 2:14 P.M., showed the window in Resident #19's room was difficult to close. During an interview on 2/9/23 at 10:34 A.M., the Housekeeping Supervisor said the Maintenance Person is supposed to fix the windows, if they were not working. During an interview on 2/9/23 at 10:38 A.M., the Administrator said that the Maintenance Person would repair the windows, if there was a Maintenance Person at the facility currently. During an interview on 2/10/23 at 9:05 A.M., the resident said he/she would like the windows to open and he/she wanted to feel the breeze. 3. Observation with the Housekeeping Supervisor on 2/7/23 at 11:59 A.M., showed a buildup of dust and grime under the vending machine in the vending machine area. During an interview on 2/7/23 at 12:01 P.M., the Housekeeping Supervisor said the housekeeping staff had a difficult time getting under the vending machine.

Based on observation, interview and record review, the facility failed to maintain Resident #31's wheelchair in a clean manner and without clumps of hair on the wheels; to prevent the storage of trash that was contaminated with human waste, in two shower rooms located on the [NAME] North and [NAME] South Halls; to maintain the [NAME] South Hall shower room in good repair; and to maintain ceiling fans in offices (the Social Service Designee (SSD), the business office and the Administrator's office) where residents would potentially go into. This practice potentially affected at least 40 residents who resided in or used those areas. The facility census was 53 residents. 1. Record review of Resident #31's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 1/13/23, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident ' s attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.) of 15 out of 15 indicating he/she was cognitively intact. Observation with the Housekeeping Supervisor on 2/7/23 at 11:16 A.M., showed a buildup of dirt and clumps of hair on the resident's wheelchair. During an interview on 2/7/23 at 11:17 A.M., the resident said: - He/she used that wheelchair to go to the beauty shop at times. - He/she was not sure how often the wheelchair was cleaned. During an interview on 2/9/23 at 11:00 A.M., Certified Medication Technician (CMT) A said the wheelchairs were supposed to be cleaned on the overnight shift, but he/she was unsure about the wheelchair cleaning schedule for overnights. During an interview on 2/9/23 at 11:02 A.M., Certified Nurse's Assistant (CNA) B said the night shift cleaned the wheelchairs and he/she had been told to use bleach wipes to clean the wheelchairs, if he/she was assigned to clean wheelchairs. During an interview on 2/9/23 at 11:03 A.M., the Director of Nursing (DON) said: - The night shift staff should be cleaning the wheelchairs. - Wheelchairs should be cleaned once per week or once every two weeks. - Facility staff need to look at the wheelchairs every time they take a resident out of the wheelchair. Record review of the wheelchair cleaning schedule showed wheel chairs for the hall which the resident resided on, were last documented as being cleaned on 1/8/23, but the rooms of which wheelchairs were not specified. 2. Record review of the facility's Policy entitled Soiled Linen and Trash Containers, copyright 2022, showed: - Soiled linen and trash collection receptacles shall not exceed 32 gallons in capacity and shall meet all Life Safety Code requirements. - Soiled Utility Rooms shall be used for storing soiled linen and trash. These rooms shall be identified as hazardous areas with the appropriate protections (i.e. signage, sprinklers, self-closing doors, clear path of entrance/egress into room). - Staff shall wear appropriate personal protective equipment handling soiled linen or trash. Observation with the Housekeeping Supervisor on 2/7/23 at 11:39 A.M., showed the presence of container with two bags of contaminated trash which were full, in the [NAME] North Hall Shower room. During an interview on 2/7/23 at 11:41 A.M., CNA A said some of the trash was from that morning and several residents on that hall had episodes of diarrhea and vomited earlier that day. During an interview on 2/7/23 at 12:56 A.M. the Administrator said the facility has kept trash in the shower rooms for at least two years. During an interview on 2/8/23 at 10:00 A.M., the Infection Preventionist said: - He/she has worked at the facility for 13 years and contaminated trash had always been stored in the shower rooms during that time. - The facility only used red bags for items contaminated with blood, not regular human wastes. - He/she had not discussed the state regulation which stated that that there shall be a separate area designated as a dirty utility area and that area shall not be located in a bathroom, with facility staff. - The facility staff just moved the trash containers out of the [NAME] South and [NAME] North shower rooms on 2/7/23. During an interview on 2/8/23 at 10:10 A.M., the Corporate Nurse said he/she had not discussed the proper storage of soiled items within the shower rooms, with the facility staff. 3. Observation with the Housekeeping Supervisor on 2/7/23 at 11:41 A.M., showed a 17 inch (in.) long crack in tile of the floor of the [NAME] North shower room. During an interview on 2/7/23 at 11:42 A.M., CNA A said the floor has been damaged for as long as he/she has worked at the facility. During an interview on 2/7/23 at 11:44 A.M., the Housekeeping Supervisor said that crack has been on the floor of the [NAME] North Shower room for many years and he/she had worked at the facility since the early 2000's. 4. Observations with the Housekeeping Supervisor on 2/7/23, showed: - At 1:18 P.M., a heavy buildup of dust was present on the ceiling fan in the SSD's office. - At 1:58 P.M., a heavy buildup of dust was present on the ceiling fan in the business office. - At 2:00 P.M., a heavy buildup of dust was present on the ceiling fan in the Administrator's office. During an interview on 2/7/23 at 1:19 P.M., the SSD said it has been several months since the fan in his/her office has been cleaned. During an interview on 2/7/23 at 1:58 P.M., the Housekeeping Supervisor said he/she cleaned the fan in the business office, four months ago. During an interview on 2/7/23 at 2:01 P.M., the Administrator said he/she cleaned the fan in his/her office in August 2021, when he/she started as the Administrator at the facility. During an interview on 2/9/ 23 at 10:32 A.M., the Housekeeping Supervisor said: -The vents and fans should be cleaned once per month and - He/she and Former Maintenance Person A used to clean the ceiling fans and the ceiling vents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #7's undated face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Chronic Pulmonary Obstructive Disorder (COPD-a disease process that decreases the ability of the lungs to perform ventilation). -Chronic Atrial Fibrillation (a long lasting abnormal heart rhythm). -Heart Failure (a disease process that impairs the ability if the heart to fill or pump a sufficient amount of blood throughout the body). -Peripheral Vascular Disease (PVD- an inadequate flow of blood to the extremities). Observation on 2/7/23 at 11:15 A.M. with LPN A showed the resident had an open wound on his/her right lower leg. Observation on 2/7/23 at 11:31 A.M. the DON showed the resident had a Stage II pressure ulcer to the resident's coccyx. Record review of the resident's care plan dated 2/8/23 showed: -There was no care plan that addressed impaired skin integrity. -There was no care plan that addressed pressure ulcers. -There was no care plan that addressed Hospice. During an interview on 2/10/23 at 8:45 A.M. CNA C said: -He/she knew about care plans and thought they would be in the resident's chart. -He/she had not checked in the resident's chart to check if the care plan was in the chart. During an interview on 2/10/23 at 9:18 A.M. the MDS Coordinator said: -A resident who was on Hospice should be reflected in the care plan. -The nurses, DON, and MDS Coordinator were responsible for updating care plans. During an interview on 12/10/23 at 10:12 A.M. the MDS Coordinator said all care plans should be up to date and reflect the resident's current condition. 3. Record review of Resident's #8's baseline care plan, dated 1/2/23, showed the resident was admitted with diagnoses that included: -Anemia. -Cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue). Record review of the resident's outside provider Hospice (end of life care) Care Plan Report, dated 1/3/23, showed staff documented: -The resident was at risk for pressure sores. -The resident was at risk for impaired mobility (disability that affects movement ranging from gross motor skills, such as walking, to fine motor movement, involving manipulation of objects by hand). Record review of the resident's Incident Report, dated 1/21/23, showed: -The resident fell on 1/21/23. -The resident had a gait imbalance. -The resident had not been wearing appropriate footwear. Record review of the resident's Incident Report, dated 1/26/23, showed: -The resident fell on 1/26/23. -Staff noted a predisposing factor to the fall as ambulating without assistance. Record review of the resident's outside Hospice providers Skin Issue Notification Sheet From Hospice Aide, dated 1/27/23 showed: -The resident had a red open sore on his/her intergluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum). -The resident had multiple bandages on both arms. Record review of the resident's outside Hospice providers Skin Issue Notification Sheet From Hospice Aide, dated 2/3/23 showed the resident had a small pink open sore on his/her intergluteal cleft. Record review of the resident's Weekly Skin Assessment, dated 2/7/23, showed: -Staff documented a Stage II Pressure Ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister) that measured 0.8 (unit of measure not documented) by 0.3 by 0.1. -Staff documented no other skin issues. During an interview on 2/7/23 at 9:28 A.M., the resident's family member said: -Staff called him/her each time the resident fell. -He/she was aware the resident had fallen often. -He/she was told by the resident that he/she had a sore on his/her bottom. -He/she believed it was because the resident could not move around as well anymore. Record review of the resident's Comprehensive Care Plan, dated 2/8/23, showed: -There was no care plan that addressed falls. -There was no care plan that addressed the resident's wounds. -There was no care plan that addressed the resident's risk of skin breakdown. Record review of the resident's Order Summary Report, dated 2/8/23, showed: -An order for wound care on the resident's coccyx (a small triangular bone at the base of the spinal column). -An order for wound care to the resident's right and left forearm. -An order for physical therapy and occupational therapy. During an interview on 2/9/23 at 11:14 A.M., CMT A said: -Care plans were completed by the MDS Coordinator. -He/she did not know what was in the care plan because he/she didn't know where they were kept. During an interview on 2/9/23 at 11:26 A.M., CMT C said: -He/she did not know who was responsible for care plans. -He/she did not know what was in the care plan because he/she didn't know where they were kept. During an interview on 2/9/23 at 12:22 P.M., Licensed Practical Nurse (LPN) B said: -He/she was not sure who was responsible for care plans. -He/she believed care plans were in the residents' electronic health record and a copy in the paper chart. -He/she thought the care plan should be updated if a resident fell. During an interview on 2/10/22 at 9:19 A.M., the MDS Coordinator said: -He/she was responsible for care plans. -The nurses and DON could also update the care plans if needed. -The DON was responsible for auditing care plans but was new to the role and had not started this process. -He/she expected to see interventions specific to falls if a resident had fallen. -Staff were to review care plans through the electronic health record. -He/she used to keep paper copies of the care plans at the nurse's stations but had removed them as they were not being utilized. -He/she knew he/she did not put any interventions on the care plan after the resident's falls. -He/she knew he/she should have put interventions on the care plan after the resident's falls. 5. Record review of Resident #14's admission Face sheet showed he/she was on Hospice services and had diagnoses that included: -Dementia. -Vitamin deficiency. -History of abnormal weight loss. Record review of the resident's personalized care plan dated 9/6/22 and 9/11/22 showed the resident did not have a facility documented for Hospice comprehensive care plan. Record review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively impaired and had a history of short and long term memory loss. -Was on Hospice services. Record review of the resident's Hospice binder showed a Hospice care plan and other Hospice documentation noted. 6. Record review of Resident #16's admission Face Sheet showed the resident was on Hospice services and had diagnoses that included: -Vitamin deficiency. -Dementia. -Heart disease. Record review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively impaired and had a history of short and long term memory loss. -Was on Hospice services. Record review of the resident's Hospice medical record showed had a Hospice care plan and other Hospice documentation noted. Record review of the resident's personalized care plan dated 2/8/23 showed the resident did not have a facility comprehensive Hospice care plan documented. 7. During an interview and record review on 2/9/23 at 11:45 A.M., the MDS Coordinator said: -Resident #14 did not have a comprehensive Hospice care plan. -Resident #16 did not have a comprehensive Hospice care plan. -He/She and the DON were responsible for monitoring and updating care plans. -Care plans should be comprehensive and include Hospice care. During an interview on 2/10/23 at 12:40 P.M., the Director of Nursing (DON) said: -The resident's care plan should be comprehensive and individualized. -The care plan should reflect the current health status of the resident. -The care plan should be updated to show the changes in the resident's health status. -Pressure ulcers were to be addressed in the care plan, whether they had an active pressure ulcer or risk for pressure ulcers. -If Hospice's care plan addressed skin breakdown, the facility care plan should have also. -Interventions on the care plan should be updated after every resident fall. -He/she, the MDS Coordinator and nurse should be able to update the care plans as needed. -Staff had been trained on using the new computerized system. -The nursing staff was able to review resident care plans in a book at the nursing stations. -The MDS Coordinator should be auditing the care plans at least quarterly. -He/she was ultimately responsible for looking to ensure the care plan was completed and accurate. Based on observation, interview and record review, the facility failed to develop care plans that were comprehensive, individualized and represented the resident's current health status for six sampled residents (Resident's # 43, #53, #8, #7, #14 and #16) out of 13 sampled residents. The facility census was 53 residents. Record review of the facility's undated policy titled Wound Protocol Checklist-(First Discovery of Wound) showed step seven of the protocol was to add the wound to the care plan and put interventions in place. Record review of the facility's policy titled Goals and Objectives, Care Plans , dated April 2009, showed: -Goals and objectives were to be entered on each residents' care plan so that all staff had access to the information. 1. Record review of Resident #43's Face Sheet showed he/she was admitted on [DATE] with diagnoses that included: -Left leg fracture (broken left leg). -Malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). -Vitamin deficiency (a lack of a vitamin or vitamins needed for good health). -Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). -Anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -Pain. -Difficulty walking. -Arthritis (painful inflammation and stiffness of the joints). Record review of the resident's admission Summary showed: -1/12/23 the resident was admitted to the facility. His/Her prior living arrangement was another nursing home where his/her fracture occurred. -The resident was dependent on staff for activities of daily living (ADLs-transfers, bathing, dressing, toileting and mobility). -He/She transferred with a full body mechanical lift with the assistance of two persons. -The resident had dementia and no longer recognized family and was unable to communicate wants and needs due to incoherent speech. -The resident had glasses and did not require dentures. -The resident had no mood or behavior concerns. -The resident was to be a long term placement. Record review of the resident's Fall Risk Evaluation dated 1/12/23 showed: -The resident had intermittent confusion and a history of falls (within the past 3 months). -The resident required assistance with transfers and ambulation and was chair bound. -The resident also had other predisposing factors contributing to falls. -The resident was at high risk for falling. Record review of the resident's Care Plan dated 1/12/23 showed the resident had impaired physical mobility and a knowledge deficit. Interventions showed: -Staff should determine the resident's level of needed assistance based on his/her activities of daily living evaluation, educate the resident on physical restrictions and precautions, encourage the use of prescribed assistive devices, evaluate the resident's ability to perform daily living skills, observe his/her range of motion, educate the resident /representative on fracture precautions, proper food portions, and eating a balanced diet. -The care plan was not individualized to show the resident had dementia, was only alert to self, was no longer able to communicate his/her needs verbally (needs had to be anticipated), was admitted with a broken leg and wore a cast, needed the assistance of two people and a mechanical lift for transfers, mobilized in a wheelchair and needed staff assistance with all ADLs. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/24/23, showed the resident: -Brief Interview for Mental Status (BIMS) showed the resident did not answer any of the questions and showed he/she had a memory problem. -Needed extensive to total assistance with bathing, dressing, mobility, transfers, eating and toileting. Observation on 2/6/23 at 1:14 P.M., showed the resident was in his/her room sitting in his/her wheelchair with glasses on and his/her left leg and foot were in a cast. The resident was alert and pleasant but was not oriented. The resident was groomed without odors. At 1:17 P.M., Certified Nursing Aide (CNA) A brought a tray table with beverages (water, coffee and orange drink, all covered) into the resident's room. He/she set them up, put straws in the cups then assisted the resident to drink. 2. Record review of Resident #53's Face Sheet showed he/she was admitted on [DATE] with diagnoses that included: -Altered mental status (a change in mental function that stems from illnesses, disorders and injuries). -Anxiety disorder. -Anemia (low iron). -Heart failure. -Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). -Pancreas disease (occurs when digestive enzymes become activated while still in the pancreas, irritating the cells of your pancreas and causing inflammation). -Urine retention (a condition in which you are unable to empty all the urine from your bladder.). -Pain. -Abnormal posture. Record review of the resident's admission MDS dated [DATE], showed the resident: -Was alert with a BIMS of 7 meaning the resident had significant memory problems. -Needed extensive assistance with mobility, transfers, bathing, dressing, toileting and eating. -Had a history of falls prior to entering the facility, had no skin issues or wounds. -Had no significant weight loss, chewing or swallowing problems. Record review of the resident's Registered Dietician assessment dated [DATE], showed: -His/Her weight was 135 pounds and the resident received a regular diet with a 2000 milliliter (ml) fluid restriction. -He/she was able to feed himself/herself with set up, but had a poor appetite. -His/her skin was intact, but was fragile. -He/she was at risk for weight loss due to poor appetite and recent illness. -Recommendation was to add one health shake daily. Record review of the resident's Physician Order Sheet (POS) dated 2/2023, showed physician's orders for regular diet, regular texture with a 2000 ml fluid restriction (ordered on 12/27/22). Record review of the resident's Nutrition Note dated 1/31/23 showed: -His/her weight review showed the resident's weight on 1/31/23 was 127 pounds (up four pounds in one month). -He/she was eating between 50 and 100 percent at meals and remained on the 2000 ml fluid restriction per day. -He/she was on daily weights and his/her weight had been stable over the last month. -The admission weight of 135 pounds may have been incorrect or could have been due to fluid loss. Record review of the resident's comprehensive Care Plan dated 2/9/23, showed the resident had increased cardiac output, was at risk for fluid imbalance and malnutrition. Interventions showed: -Staff should monitor for shortness of breath, cough, edema, and evaluate the resident's lung sounds, evaluate for nausea and vomiting. -Interventions also showed staff would educate the resident and responsible party regarding fluid restrictions. -Dietary interventions showed see dietician consult. -There were no interventions showing the resident's abilities regarding transfers, mobility, bathing, dressing, toileting and grooming abilities and what assistance was needed to complete those activities of daily living. -The care plan did not show the resident received a regular diet with thin liquids, was able to feed himself/herself with set up, had a poor appetite or that she was on a 2000 ml fluid restriction and had orders for daily weights. It did not show any interventions for prevention of malnutrition. It did not show that health shake intervention was implemented or that the Registered Dietician had recommended one health shake daily. Observation on 2/7/23 at 1:14 P.M., showed the resident was sitting up in his/her room in a recliner with his/her lunch meal in front of him/her. The resident was alert and was clean, groomed and without odor. He/She was not eating, but a visitor was in the room with him/her encouraging him/her to eat. During an interview on 2/8/23 at 12:01 P.M., Certified Medication Technician (CMT) D said: -The resident needed the assistance of one person to complete all activities of daily living. -The resident transferred with the assistance of one person. -He/she had a poor appetite but ate well at breakfast most of the time and his/her intake varied at other meals. -He/she received a health shake at breakfast but the resident usually would not drink it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review of Resident #7's undated face sheet showed the resident admitted to the facility on [DATE] with the following diagnoses: -Chronic Pulmonary Obstructive Disorder (COPD-a disease process that decreases the ability of the lungs to perform ventilation). -Chronic Atrial Fibrillation (a long lasting abnormal heart rhythm). -Heart Failure (a disease process that impairs the ability if the heart to fill or pump a sufficient amount of blood throughout the body). -Peripheral Vascular Disease (PVD- an inadequate flow of blood to the extremities). Record review of the resident's baseline care plan dated 10/26/22 showed the resident admitted to the facility already on Hospice. Record review of the resident's Hospice book showed the resident was recertified for Hospice from 1/20/23 until 3/30/23 with current orders. Record review of the resident's POS dated February 2023 showed no orders in place indicating that the resident was on Hospice. During an interview on 2/10/23 the MDS Coordinator said Hospice orders should be transcribed into the resident's electronic medical record. During an interview on 2/10/23 at 12:40 P.M., the Director of Nursing (DON) said: -Hospice orders should be transcribed into residents electronic medical record. -He/she would expect the nursing staff to document whatever the Hospice nurses were telling them in the nursing notes. -The Hospice orders should go on a telephone order and include who the Hospice company providing the services was, what services were being provided and the frequency/duration. -Hospice orders should be transcribed onto the resident's POS. -He/she expected to have on-going communication between Hospice staff and facility nursing staff. -He/she expected nursing staff to document notifications made regarding a change of condition to Hospice, family members, and the resident's physician and any orders obtained. -He/she expected facility staff to notify Hospice, family members, and the resident's physician of any change of condition. 2. Record review of Resident #14's admission Face sheet showed he/she was on Hospice services and had diagnoses that included: -Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). -Vitamin deficiency (a lack of a vitamin or vitamins needed for good health). -History of abnormal weight loss. Record review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively impaired and had a history of short and long term memory loss. -Was on Hospice services. Record Review of the resident's hospice binder showed: -The resident was admitted to Hospice care on 9/6/22 -The last Hospice nurse note was dated 1/18/23 and Hospice aide visit was on 1/27/23. -The resident was scheduled for two times a week for nursing visit and for aide visit. Record review of the resident's POS dated 2/2023, showed there was no physician's order documented for Hospice that was comprehensive and included the Hospice was providing service and what services were being provided. Observation on 2/6/23 at 10:10 A.M., showed the resident was in bed with his/her eyes closed. Record review of the resident's nursing note dated 2/6/2023 at 7:33 P.M. showed: -He/she had been quite lethargic today, napping more than normal. -He/she had complaints of nausea in the early afternoon and by 5:00 P.M., the resident had a fever of 100.8 degrees (out of range for age). -He/she had diarrhea at that time. -He/she was given a fever-pain medication. -He/she was placed on a clear liquid diet at that time. -He/she would begin isolation until free of diarrhea and vomiting for 24 hours. -His/her stomach was soft to touch and was non-tender. -Had no documentation of notification to Hospice nurse of the resident's change of condition. 3. Record review of Resident #16's admission Face Sheet showed the resident was on Hospice services and had diagnoses that included: -Vitamin deficiency. -Dementia. -Heart disease. Record review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively impaired and had a history of short and long term memory loss. -Was on Hospice services. Record review of the resident's POS dated 2/2023, showed there was no physician's order for Hospice that was comprehensive and included Hospice was providing service and what services were being provided. Record review of the resident's Hospice medical record showed: -Was admitted to Hospice care on 8/3/22. -The last nursing visit note was dated 2/3/23. -The resident was schedule for weekly nursing visit. Record review of the resident's nursing note dated 2/6/23 at 6:47 A.M. showed: -The resident continued on monitoring for previous episodes of vomiting and diarrhea. -He/she had a temperature of 97.2 degrees which was at normal range for resident. -He/she had one episode of loose stool that shift and no further emesis. -The facility staff were to continue to monitor the resident for signs and symptoms. -No documentation of the Hospice nurse being notified related to the resident's change of condition. Record review of the resident medical record showed: -No documentation of on-going written communication between Hospice staff and facility nursing staff. Record review of the resident nursing note dated 2/8/23 at 12:51 P.M. showed: -The resident continued on isolation and continued to have vomiting. -Occasionally incontinent of bowel and bladder. -The resident is currently in room with call light in reach. -No documentation of the Hospice nurse being notified related to the resident's change of condition. During an interview on 2/14/23 at 2:18 P.M., the Hospice Nurse Supervisor said: -The resident did not have any documentation of a stomach flu-like illness noted in the Hospice notes. -Hospice staff had not received notification of the resident having signs and symptoms of stomach flu. -He/she would expect facility staff to notify the Hospice nurse of any change of condition in the resident. -He/she would expect the facility to coordinate services and to include a facility order for Hospice care. 4. Record review of electronic medical records on 2/9/23 at 11:45 A.M., with the MDS Coordinator showed: -Resident #14 did not have a Hospice care and services order. -Resident #16 did not have a Hospice care and services order. -He/she would expect nursing staff to refer to and verify physicians orders -The administration had not completed auditing and transcribing the resident's physician's orders to the new electronic record. -He/She and the DON were responsible for monitoring POS's. During an interview on 2/10/23 at 9:45 A.M., Certified Medical Technician (CMT) B said -The resident had a Hospice medical record binder that Hospice staff would document their visit and any communication with the facility. -The Hospice nurse would verbally communicate any new orders to facility nursing staff or the DON. -The resident's physician orders were monitored by the DON and the charge nurse. Based on observation, interview and record review, the facility failed to ensure physician's orders for Hospice (end of life care) services were transcribed onto the physician's order sheet (POS), to include the service provider, services provided and frequency for four sampled residents (Resident #156, #14, #16 and #7) out of 13 sampled residents. The facility census was 53 residents. 1. Record review of Resident #156's Face Sheet showed he/she was admitted on [DATE], with diagnoses that included: -Heart disease (A type of disease that affects the heart or blood vessels). -Lung cancer (a disease in which cells in the body grow out of control that is in the lungs). -Brain cancer (a disease in which cells in the body grow out of control that is in the brain). -Seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). -Indigestion (pain or discomfort after eating, while your stomach is digesting). -Anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -Pain. -Depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest ). -High blood pressure. -Nausea. -Vomiting. Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) tracking record showed the resident did not have a MDS completed to date. Record review of the resident's Hospice Records showed a physician's order dated 2/3/23, for admission to the facility for respite care. The diagnoses included lung cancer and a secondary diagnosis of brain cancer. Services included nursing weekly, Certified Nurse Aide (CNA) twice weekly for assistance with daily living (ADL care), comfort care and pain management. The Hospice record included a care plan showing the assistance and services provided by Hospice to the resident while in care at the facility, to include nursing, bath aide, physician services, pain management, Chaplin and social services. Record review of the resident's POS dated 2/2023, showed there was no physician's order for Hospice that was comprehensive and included the Hospice providing service and what services were being provided. Record review of the resident's Baseline Care Plan dated 2/3/23, showed the resident: -Was admitted on [DATE] for respite care and end of life care. His/Her diagnosis was lung cancer. -The resident was dependent for bathing, dressing, grooming, toileting and needed assistance with mobility. -Received Hospice. -The care plan did not show what hospice services the resident received and frequency, or which Hospice provider would be providing services. There were no interventions showing how the facility would assist in providing care in conjunction with Hospice while the resident was residing in the facility. Record review of the resident's Nursing Notes showed: -On 2/4/23 the resident was brought to the facility for a five day respite (short-term, temporary) stay through Hospice for lung and brain cancer on 2/3/23. Staff informed the resident that he/she was in the facility short-term while his/her responsible party recovered from Covid (an infectious respiratory disease caused by SARS-CoV-2 virus) and the resident was okay with this answer. The resident was tested and was negative for Covid. -On 2/5/23 the Hospice company provided extra insight on the resident's condition and behaviors, spoke with Hospice Nurse regarding resident medications and the physician would attempt to get the resident to take his/her medication at this time to calm, distress and relieve some discomfort if any exists. The facility would continue to collaborate with the Hospice team to provide best comfort plan of care for patient at this time. The nurse would call the physician to request medication changes and made the physician aware the resident refused his/her medication today. Observation on 2/7/23 11:42 A.M., showed there was an isolation cart outside of the resident's door. The resident was laying on his/her bed wearing oxygen with his/her eyes closed resting comfortably. During an interview on 2/7/23 at 2:06 P.M., Licensed Practical Nurse (LPN) B said: -The resident came for respite care only and he/she was receiving Hospice services. -The Hospice nurse had come to visit the resident as had the bath aide. -The resident was only going to be a short term stay. -There should be Hospice orders on the POS.

Based on interview and record review, the facility failed to ensure there was a safe medication storage system in place regarding the facility's Cubex system (a smart cabinet that secures different types of medications that can be dispensed when accessed) by not monitoring and reconciling the medications in the Cubex. This deficient practice had the potential to affect all residents who received medications from the Cubex system. The facility census was 53 residents. A policy for the Cubex was requested and was not received at the time of exit. Record review of the facility's pharmacy undated policy titled MEDBANK CUBEX Station Policy and Procedures showed: -Nursing and pharmacy staff will use the MEDBANK Station as an inventory, charging, and information system for the control and distribution of medications for emergency, first-dose use, and other situations where medications are not readily available from the pharmacy until the next scheduled delivery. -All medications removed from the MEDBANK Station will be reviewed and profiled by a pharmacist within 24 hours of removal from the station. -The charge nurse and/or the Director of Nursing (DON) is responsible for generating a discrepancy report before the end of the shift to identify open, unresolved discrepancies and for investigating nursing activity and resolving the discrepancy. -A discrepancy report can be ran by the pharmacy MEDBANK manager upon request. -The DON ant the Medical Director must request in writing any removals or additions of medications contained within the MEDBANK Station to the pharmacy MEDBANK manager. -Each facility should have at least one designated resource nurse on each shift. -A Quick Reference Guide User Guide and Policy and Procedure Binder will be available to assist in the use of the MEDBANK Station. -Sampling of reports included in this procedure are as follows: --Patient Summary Report. --Stock Reorder by Supplier or Inventory by Supplier. --Item Expiration Report. --Discrepancies-Unresolved Report. --Controlled Substance Activity Report. --On-site Facility User Report. --All discrepancies Report. -Additional reports are available, the facility would need to contact the Pharmacy MEDBANK representative for a complete list. 1. During an interview on 2/8/23 at 10:43 A.M. Licensed Practical Nurse (LPN) A said: -He/She had never used the Cubex. -He/She did not know of any processes in place related to the Cubex. During an interview on 2/8/23 at 10:47 A.M. the Director of Nursing (DON) said: -There was not a system in place for Cubex monitoring. -He/She was unsure if the facility had a Cubex policy. -A pharmacist came last month and counted medications. -A pharmacist was in the building yesterday and may have done medication counts at that time. -The Cubex had a glitch last month and that was the initial reason that the pharmacist came into the facility. During an interview on 2/9/23 at 1:43 P.M. Certified Medication Technician (CMT) D said: -CMT's, nurses, the MDS Coordinator and the DON all had access to the Cubex. -When he/she would pull a medication from the Cubex, he/she normally followed the number on the screen for counting purposes. -If he/she had any issues with the Cubex he/she would go tell a nurse and have the nurse come to the Cubex to resolve the issue. During an interview on 2/9/23 at 1:46 P.M. LPN B said: -He/She did not have access to the Cubex. -He/She did not know any procedures or processes related to the Cubex system. During an interview on 2/9/23 at 2:27 P.M. the pharmacy's Automated System Manager for a different area said: -The facility could set up automatic reports to be sent to the facility. -If the facility did not set up the automatic reports the facility would have to contact the pharmacy in order to get those reports. -The facility should have a policy for the Cubex system. -He/She was not sure what reports were currently being sent to the facility because he/she was not the manager for the facility's region. During an interview on 2/9/23 at 2:30 P.M. the pharmacy's Automated System Manager for the facility's area was no longer working for the company and there was no one currently in the position. During an interview on 2/10/23 at 10:15 A.M. the Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) Coordinator said: -He/She would need to ask the DON for any reports received about the Cubex. -He/She thought the pharmacy would give the facility a narcotic discrepancy count report when needed. During an interview on 2/10/23 at 1:39 P.M. the Automated System Manager for a different area said: -The pharmacy and the facility should have a contract related to the Cubex system. -The facility should keep a record of the restock reports and the manifest (what was sent to the facility). -He/She would have to contact the facility's regional pharmacy location regarding any auditing the pharmacy had done for the facility.

Based on observation and interview, the facility failed to ensure the ceiling fan in the dry good storage room and the wall mounted fan in the main kitchen were maintained free of a heavy buildup of dust; to ensure the light fixtures were free from a heavy buildup of dust; to ensure the faucet at the three compartment sink operated properly so it would not continue to leak a stream of water after the valves were turned off; to maintain the floors under the reach in refrigerators and the six burner stove, free of food crumbs and debris; and to maintain the gasket (a piece of rubber or some other material that is used to make a tight seal between two parts that are joined together) of one refrigerator in good repair. This practice potentially affected all residents who ate food from the kitchen. The facility census was 53 residents. 1. Observations on 2/8/23 from 6:40 A.M. through 8:50 A.M., showed: - A heavy buildup of dust on the blades and the grate (the metal covering of an object) of the wall mounted fan in the main kitchen. - A heavy buildup of dust on the ceiling fan in the dry good storage room. - A constant stream of water from the faucet at the three compartment sink. - A buildup of food debris under the six burner stove and the three reach-in refrigerator. - An eight inch (in.) section of the gasket of one of the refrigerator that peeled away from the door of one of the refrigerator. During an interview on 2/8/23 at 6:51 A.M., the Dietary [NAME] said the faucet has been like that for a couple of weeks, but the maintenance person had not gotten to it just yet. During interviews on 2/8/23 at 8:32 A.M., the Dietary Manager (DM) said the wall-mounted fan was last cleaned in January 2023. Record review of an undated list of task posted on the door, showed that cleaning the fans was a listed task, but the list did not mention a specific date. During an interview on 2/8/23 from 8:35 A.M. through 8:50 A.M., the DM said: - The dietary staff are supposed to sweep and mop under the reach-in refrigerators daily. - He/she had not thought about the fan in the dry goods storage room. - He/she depended on the Maintenance Person to clean the light fixtures. - The faucet at the three compartment sink had been leaking like that since about the first week of January 2023. - The dietary staff are supposed to lean under the stoves about once per month. - He/she would have to contact the Maintenance person about the gasket on the refrigerator. During an interview on 2/8/23 at 9:22 A.M., about where the Maintenance person was the Administrator said Maintenance Person A resigned in September 2022 and Maintenance B has had some attendance problem in the last two weeks and had not come in, even though he/she had made phone calls to him/her and at that time, there was not a maintenance person working at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure infection control practices were performed in order to prevent cross contamination and spread of infection by not following their policy when an outbreak had been identified by not educating all staff, notifying visitors, posting signs, identifying exposed residents, and monitoring hand hygiene; failed to implement transmission based precautions and isolation for residents with known signs and symptoms of a norovirus (a group of viruses that cause a sudden onset of severe vomiting and diarrhea). Facility staff failed to ensure the correct Personal Protective Equipment (PPE) was to be utilized while providing personal cares for three sampled resident and handwashing during care (Resident #43, #156, and #31); failed to implement transmission based precautions and failed to ensure hand hygiene was performed and appropriate glove changes were completed while handling respiratory equipment and performing a blood sugar test with Insulin (a hormone produced in the pancreas by the islets of Langerhans, which regulates the amount of glucose in the blood) administration for one sampled resident (Resident #25); failed to ensure hand hygiene was performed and appropriate glove changes were completed while providing wound care for one sampled resident (Resident #7); failed to ensure hand hygiene was performed and appropriate glove changes were completed while performing a transfer for one sampled resident (Resident #7) and one supplemental resident (Resident #52); out of 13 sampled residents and eight supplemental residents. The facility census was 53 residents. 1. Record review of the facility's policy, titled Infection Prevention and Control Manual-Outbreak Management-Outbreak Investigation, dated 2019, showed: -The definition of an outbreak was the occurrence of more cases than was expected, or had serious health implications. -Facilities were not to wait for the definition of outbreak to be met before acting. -All staff were to be educated about the existence of an outbreak, their responsibilities, potential risks to themselves, and methods to prevent transmission. -Staff were to provide information for visitors. -Signs were to be posted with instructions for prevention. -Staff were to identify exposed residents. -The Infection Control Preventionist, supervisors, and managers were to reinforce and monitor compliance with hand hygiene and control measures. -The Infection Control Preventionist, supervisors, and managers were responsible for assuring staff and visitor compliance. Record review of the facility's policy titled Infection Prevention and Control Manual-Transmission Based Precautions and contact precaution isolation, dated 2019, showed: -Communication through verbal reports and signage regarding the particular type of precaution was important. -Pertinent signage regarding type of isolation could help minimize the transmission of infections in the facility. -The facility was to implement Transmission Based Precautions when residents had diarrhea and fecal incontinence. -Norovirus was able to be transmitted through environmental contamination. -PPE was to be worn when staff came in contact with the resident or their environment, and was to include gown, gloves, and eyewear if there was potential for splashing. -The purpose of contact precautions was to prevent transmission of infections that were spread by direct (e.g., person-to-person) or indirect contact with the resident or environment. -Contact precautions required the use of appropriate PPE, including a gown and gloves upon entering the room or making contact with the resident or resident environment. When leaving the room, PPE would be removed and hand hygiene performed -Contact precautions were recommended with known or suspected infections that represent an increased risk for transmission through contact. --Change protective attire and perform hand hygiene between contact with residents in the same room, regardless of whether one or both residents are on contact precautions. -Procedure for contact precautions included. --Hand hygiene with soap and water or waterless alcohol based hand rub (hand sanitizer). --Gloves were to be worn while providing direct care to residents, wear gloves when touching the resident's intact skin or surfaces near the resident, when handling items potentially contaminated by the resident, wearing gloves is not an alternative of hand hygiene. -Gowns were to be worn upon entering a room in contact isolation, and when a resident was incontinent of bowel and/or bladder or has diarrhea, has an ilieostomy or colostomy. -Masks and eye protection should be worn during resident care activities that are likely to generate splashes, or sprays of bodily fluids. -Precautions may be discontinued when signs and symptoms of infection have resolved, when incontinence could be contained or when diarrhea resolved. Record review of the facility's policy titled Standard Precautions dated December 2007 showed: -Standard Precautions were to be used for all residents. -Hands were to be washed with soap and water (no sanitizer) if visibly soiled. -Gloves were to be removed before touching environmental surfaces. -A mask and eye protection or a face shield were required during procedures that may expose employees to body fluids. -Gowns could not be reused. -Staff were to ensure reusable equipment was cleaned before using on another resident. During an interview on 2/6/23 at 8:36 A.M., the Director of Nursing (DON) said: -There was an outbreak of an unknown infection in the facility. -There were about 20 residents who had symptoms of nausea, vomiting, and diarrhea. -Those residents had been placed on isolation as a precaution because they did not know what the infection was. -Flu testing had not been completed. Observation on 2/6/23 at 9:19 A.M., during initial tour showed: -No sign at the entrance notifying visitors of a possible outbreak. -No sign to notify visitors of preventative measures to take while in the facility. -No signage posted at the resident room doors regarding type of precautions or preventative measures to take before entering the room. Observation on 2/6/23 at 9:30 A.M., on initial tour showed: -There were no signs instructing visitors to seek the nurse before entering the rooms where residents were placed on isolation. -There were no isolation carts outside of any rooms to indicate the room was in isolation status. During an interview on 2/6/23 at 9:46 A.M., the DON said: -Two residents had vomiting and diarrhea on 2/1/23. -All residents who had vomiting and diarrhea were on contact precautions. During an interview on 2/6/23 at 10:10 A.M., Certified Nursing Assistant (CNA) D said: -Most of the residents on the back hallway had symptoms of diarrhea and vomiting and were to stay in their rooms. -There were no isolation carts outside of resident's rooms that were exhibiting signs and symptoms. -There was no signage on the doors that indicated to see the nurse before entering the rooms. During an interview on 2/6/23 at 11:52 A.M., Visitor A said: -He/she had not been notified there was a potentially infectious illness in the building. Observation on 2/7/23 at 8:52 A.M., showed: -No sign at the entrance notifying visitors of possible outbreak. -No sign to notify visitors of preventative measures to take while in the facility. During an interview on 2/7/23 at 9:26 A.M., Visitor B said: -He/she was not told about any residents having vomiting or diarrhea. -He/she had talked with the DON on 2/6/23 and the DON had said the facility was having a problem. During an interview on 2/7/23 at 1:26 P.M., the receptionist said: -He/she had heard talk of an outbreak, but had not been told it was confirmed. -He/she had not told visitors of a possible outbreak as nothing had been confirmed. -He/she didn't educate visitors on washing or sanitizing hands as he/she hadn't thought of it. During an interview on 2/7/23 at 1:37 P.M., the DON said: -He/She notified the state Epidemiologist on 2/6/23 about the outbreak in the facility with symptoms of nausea, vomiting, and diarrhea. -The Epidemiologist told him/her that the symptoms he/she described was probably a norovirus spreading in the facility and he/she did not need to notify him/her of this. -The facility received the flu testing supplies this morning and they tested all 10 residents that were having symptoms when they received the supplies. -All of the residents tested were negative for the flu virus. -Staff continued to monitor residents who had symptoms for continued symptoms and all other residents for initial symptoms of nausea, vomiting, and diarrhea. During an interview on 2/7/23 at 1:40 P.M., Certified Medication Technician (CMT) D said: -He/she was aware there was a gastrointestinal illness in the building. -All residents with symptoms of nausea, vomiting, or diarrhea, were in isolation. -He/she knew which residents were on isolation precautions by the isolation cart located outside their door. -If there was no isolation cart outside the door, he/she would have no reason to think he/she needed to take extra precautions. During an interview on 2/8/23 at 9:09 A.M., Nursing Assistant (NA) A said: -He/She usually worked weekends and this past weekend there were only two residents who had vomiting and nausea. -They placed one isolation cart in the hallway for a resident who was newly admitted for quarantine for Covid-19. -When he/she came into work today, the nurse notified him/her that there were several residents who were exhibiting symptoms of nausea, vomiting, and diarrhea, and those residents were placed on isolation, because they did not know what the infection was. -The charge nurse was informing them of what residents were starting to experience symptoms. -Nursing staff were supposed to wash their hands and glove upon entering a resident's room, wash or sanitize their hands each time they would change their gloves, change their gloves each time they complete a dirty task and once their done, wash their hands before leaving the resident's room. -If the resident was on isolation, they were supposed to put on a gown and if there was hand sanitizer on the cart, they are supposed to sanitize their hands then put on gloves prior to entering the resident's room. -If there was no sanitizer on the isolation cart he/she would sometimes glove and then go in to provide care, but he/she would follow the same procedure for changing his/her gloves and washing his/her hands during care and wash his/her hands upon leaving the room. During an interview on 2/8/23 at 9:58 A.M., the DON said: -He/she guessed the gastrointestinal illness was norovirus, but it had not been diagnosed. -All residents who had symptoms of nausea, vomiting, diarrhea were to be placed on contact precautions. During an interview on 2/8/23 at 10:14 A.M., the Infection Control Preventionist said: -He/she believed the outbreak was norovirus, but it was not diagnosed. -The receptionist was responsible for educating the visitors before they entered. During an interview on 2/9/23 at 11:14 A.M., CMT A said: -He/she stopped a visitor from entering a room for a resident that was on isolation. -The visitor didn't know there was a problem and did not put on the appropriate PPE to enter the room. During an interview on 2/9/23 at 11:26 A.M., CMT C said: -He/she knew what residents were on precautions by verbal report from the nurse. -He/she didn't know how non-family visitors would be made aware to take additional precautions when entering rooms of resident's in isolation. -He/she did not know why the precautions and PPE needed to enter each room was not posted on the residents' doors. During an interview on 2/9/23 at 12:22 P.M., Licensed Practical Nurse (LPN) B said: -He/she believed the receptionist notified visitors of any health concerns or precautions to take before the visitors entered the building. -Staff were told verbally which residents were on precautions and what precautions each resident was on at the beginning of their shift. -He/she believed there should be a sign on the resident's door stating what type of precautions to take. Observation on 2/10/22 at 8:44 A.M., showed: -No sign at the entrance notifying visitors of possible outbreak. -No sign to notify visitors of preventative measures to take while in the facility. During an interview on 2/10/23 at 9:18 A.M., Visitor C said: -He/she was not made aware of a contagious illness in the facility. During an interview on 2/10/23 at 9:19 A.M., the Infection Control Preventionist said: -The Medical Director had been notified of the illness in the building but he/she did not know if it had been documented or where it would have been documented. -Staff were verbally educated on hand washing techniques once the gastrointestinal illness began to spread in the facility. -Visitors should have been made aware of the illness in the facility upon entry by the receptionist. -He/she was aware a sign should have been posted on the front door notifying visitors of extra precautions to take. -A sign was not posted on the door to alert anyone coming into the building, because nothing was diagnosed. -He/she was not aware the facility policy said to post a sign. -It was the DON's responsibility to educate staff on isolation precautions. -Contact precautions include a gown, gloves, and eyewear if a chance of splashing could reasonably occur. -Residents should have remained on isolation until they were symptom free for 24 hours, but many residents refused. During an interview on 2/10/23 at 12:40 P.M., DON said: -He/she would expect signage to be posted for those residents on isolation to include the type of isolation and the type of PPE required for care of those residents. --The signage should be placed outside on the door and seen before they go in the resident's room. -He/she would expect signage posted at the front door to be seen before entering the facility regarding the illness in the building. -The Infection Control Preventionist would be responsible for monitoring, tracking and screening residents for contagious disease. -Residents who had nausea, vomiting, and diarrhea would be on isolation for at least 24 hours after the signs and symptoms had stopped. -He/she would expect the CNA's to inform the nurse of any resident having any nausea, vomiting, diarrhea or a fever. 2. Record review of Resident #43's Face Sheet showed the resident was admitted on [DATE] with diagnoses including: -Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning), dated 1/24/23, showed the resident: -Was not able to answer any of the Brief Interview for Mental Status (BIMS) questions and showed he/she had a memory problem. -Needed extensive to total assistance with bathing, dressing, mobility, eating, and toileting. Record review of the resident's Nursing Notes showed: -On 2/4/23 at 8:42 P.M., The resident had two episodes of vomiting at supper this evening. The physician prescribed a new order for Ondansetron (used to prevent nausea and vomiting) 4 milligrams (mg) every six hours as needed, for 7 days, for nausea and vomiting. The resident denied cough, congestion, diarrhea (loose stools), or other signs and symptoms of infection. The resident was currently resting in bed with his/her call light in reach. Staff would continue to monitor. -On 2/5/23 at 3:40 P.M., Nursing staff continued to provide follow up monitoring for nausea, vomiting and diarrhea. There were no reports of vomiting on this shift, he/she continued to have loose stools, orders were in place and were effective, his/her call light was in reach. Staff to encourage fluids, clear liquids and rest. -On 2/6/23 at 6:43 A.M., The resident continued on monitoring for nausea, vomiting and diarrhea. The resident had no signs or symptoms of nausea, vomiting or diarrhea or complaints. He/She appeared to be resting well this shift. Nursing staff would continue to monitor the resident. -On 2/7/23 at 4:57 A.M., The resident continued on monitoring for nausea, vomiting and diarrhea. He/She appeared to be resting well this shift. The resident denied any pain or discomfort. Nurse would continue to monitor. Observation on 2/6/23 at 1:14 P.M., showed: -There was no isolation cart outside of the resident's room and there was no sign on the resident's door directing one to see the nurse prior to entering the room. -There was no sign notifying of what PPE was required prior to entering the resident's room. The resident was in his/her room sitting in his/her wheelchair. -At 1:17 P.M. CNA A, without washing or sanitizing his/her hands, entered the resident's room with a tray table containing covered beverages. He/She was wearing a face mask, but did not obtain gloves or a gown from the isolation cart that was across the hall prior to entering the resident's room. Upon entering the resident's room, CNA A did not wash or sanitize his/her hands or glove. He/she placed the resident's tray in front of him/her, removed the covering from the beverages, placed straws in two of the beverages then he/she assisted the resident to drink coffee, then some water. Without washing or sanitizing his/her hands, CNA A left the resident's room. During an interview on 2/6/23 at 1:22 P.M., CNA A said: -The resident had been exhibiting signs and symptoms of nausea and diarrhea so they placed him/her on isolation and the resident was supposed to eat in his/her room. -The resident was on contact precautions. -He/She did not know why there was no sign on his/her door or why there was no isolation cart by his/her door. -There had been several residents who were placed on isolation due to exhibiting signs and symptoms of diarrhea, nausea and vomiting. -CNA A then sanitized his/her hands. During an interview on 2/10/23 at 11:44 A.M., CNA A said: -Before going into the resident room they were supposed to knock then wash their hands and put on gloves. -He/She would complete resident care then remove his/her gloves and wash his/her hands. -During the care, if his/her gloves became soiled, he/she would clean it up, then remove his/her gloves and wash his/her hands before gloving and finishing the care. -After completing resident care, he/she would remove his/her gloves and wash his/her hands. -If the resident was on isolation, they should gown, and wash or sanitize their hands before putting on gloves, then enter the resident's room. -They should wash or sanitize their hands again before leaving the resident's room or immediately after removing their gown and gloves. During an interview on 2/10/23 at 12:40 P.M. the Administrator and DON said: -They placed the residents who had vomiting, nausea, and diarrhea symptoms on isolation because they did not know what the infection was. -Resident #43 was one of the residents who had exhibited nausea, vomiting, and diarrhea, he/she should have had an isolation cart outside his/her door and signage on his/her door alerting staff and visitors of the required PPE to be worn. -They did not follow their protocol and have orders for isolation, notify staff of what PPE to wear when caring for the resident. 3. Record review of the guidance from Center for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey and Certification Group (QSO) 20-38-NH revised 9/23/22 that the facility was using as part of it's Infection Control Covid-19 policy showed: -New admissions were to be placed in in Transmission Based Precautions. -Residents could be removed from Transmission-Based Precautions after day 7 following the exposure (count the day of exposure as day 0) if they do not develop symptoms and all viral testing for asymptomatic individuals following close contact was negative. Record review of Resident #156's Face Sheet showed the resident was admitted on [DATE], with diagnoses including: -Heart disease. -Lung cancer (a disease in which cells in the body grow out of control in the lungs) -Brain cancer (a disease in which cells in the body grow out of control in the brain) -Seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). -Indigestion (pain, a burning feeling, or discomfort in your upper abdomen). -Pain. -Nausea. -Vomiting. Record review of the resident's Nursing Note, dated 2/4/23, showed the nurse documented: -The resident was brought to the facility for a five day respite (short-term, temporary) stay through Hospice (end of life care) for lung and brain cancer on 2/3/23. -Staff informed the resident that he/she was in the facility short-term while his/her responsible party recovered from Covid-19 and the resident was okay with this answer. -The resident was tested and was negative for Covid-19. Record review of the resident's Hospice records showed documentation, dated 2/3/23, that the resident was admitted to the facility for respite services and was tested negative for Covid-19. Observation on 2/7/23 11:42 A.M., showed: -There was an isolation cart outside of the resident's door that contained gowns, gloves, face masks and bleach wipes. -There was no sign on the resident's door instructing one to stop and see the nurse prior to entering and there was no sign to show what PPE was required prior to entering the resident's room. Observation on 2/7/23 at 11:42 A.M., showed CNA E and CMT A, stopped in front of the resident's door and without washing or sanitizing their hands, they both put on gloves then put on gowns. They knocked on the resident's door then did the following: -They told the resident they were going to complete incontinence care and CNA E raised the resident up in his/her bed. -They rolled the resident to the left side and removed the incontinence pad that was underneath him/her. -CMT A then removed the resident's brief and discarded it into the trash. -CNA E pulled the incontinence wipes and handed them to CMT A who cleaned the resident's front peri-area from front to back and discarded the wipe in the trash. -CNA E rolled the resident to the opposite side and CMT A cleaned the resident's bottom then disposed the wipe in the trash. -Without discarding their gloves and washing or sanitizing their hands, they both assisted with putting a new incontinence pad under the resident. -CNA E and CMT A then removed and discarded their gloves, washed their hands. -CNA E removed the soiled sheet, put it in a bag and removed the trash while CMT A continued to reposition the resident, placed the call light beside him/her and tried to give the resident a drink. -CMT A without washing or sanitizing his/her hands, picked up the soiled laundry bag and trash and left the resident's room. -CNA E removed his/her gloves, washed and dried his/her hands, then re-gloved. -CNA E then took the resident's mouth swab and soaked it in mouthwash then used it to wipe the resident's mouth and teeth. He/She then took a damp face cloth and wiped the resident's mouth. He/She, without washing or sanitizing his/her hands, took a pulse oximeter (a non-invasive device that determines the level of oxygen in the blood) and placed it on the resident's finger then placed a blood pressure cuff on the resident's right wrist. After removing the pulse oximeter and blood pressure cuff, he/she removed and discarded his/her gloves. He/she removed and discarded his/her gown then left the resident's room without washing or sanitizing his/her hands. During an interview on 2/7/23 at 12:05 P.M., CNA E said: -The resident was only going to be at the facility for a few days due to his/her family having Covid. -The resident was exposed, but had been tested at the facility and tested negative for Covid but was on precautions (quarantine). -Nursing staff was supposed to wash or sanitize his/her hands before putting on gloves, between clean and dirty tasks, anytime he/she removed his/her gloves and prior to leaving the resident's room. -He/She thought he/she had washed his/her hands. During an interview on 2/10/23 at 10:07 A.M., CMT B said: -Anytime upon entering a resident room, staff should wash their hands and put on gloves before performing cares. -Depending on what the task was they may have to wash their hands and change gloves during the care. -They should wash their hands before going from a dirty to a clean task, after completing any care of the resident and before leaving the resident's room. -If a resident was on isolation, they should wash or sanitize their hands before gloving, and put on a gown before going into the resident's room. -During care they should sanitize or wash hands after each dirty task. Before leaving the room they should remove their gloves and wash their hands. -If they were removing trash or laundry, they should still remove their gown, remove their gloves, wash their hands, remove the bagged trash or laundry, then wash their hands again after disposing of it. 4. Record review of the facility's Infection Control and Prevention Manual Transmission Based Precautions, dated 2019, showed: -Use contact precautions to prevent the spread of organisms that could be transmitted by direct resident contact (hand or skin-to-skin contact that occurred when performing resident care) or by indirect contact (touching) of environmental surfaces or contaminated resident care equipment. -Contact precautions may be considered for residents who have diarrhea and fecal incontinence, or an ostomy. Record review of Resident #31's face sheet showed he/she was admitted with the following diagnoses: -Ileostomy (where the small bowel [small intestine] is diverted through a surgical opening in the abdomen to allow intestinal waste to be excreted into an attached pouch). During an interview on 2/8/3 at 8:03 A.M., the resident said: -A CNA had told him/her that he/she had what was going around the building. -He/she got sick early in the morning. -He/she did not go to dialysis because he/she was too ill. -NOTE: Resident began vomiting during the interview. Observation on 2/8/23 at 9:24 A.M., showed NA A: -Entered the resident's room and provided the resident incontinence care. -Did not remove the gloves, wash or sanitize his/her hands before leaving the resident's room. -Returned to the resident's room still wearing gloves, removed the gloves, did not wash or sanitize his/her hands and put on new gloves. -Adjusted the resident's air conditioner, did not remove gloves, wash or sanitize his/her hands. -Removed the resident's soiled clothing with the same gloves. -Dressed the resident in clean clothing with the same gloves. -Told the resident he/she could not change the resident's ileostomy, but would get someone who could. Observation on 2/8/23 at 9:46 A.M., showed LPN A: -Entered the resident's room wearing a gown (not closed) and gloves, but no eyewear. -Removed his/her gloves, performed hand hygiene, and put on new gloves. -Removed the dressing surrounding the resident's ileostomy (including the ostomy bag leaking feces) and threw it in the trash, opened the resident's bedside table drawer with the same soiled gloves and removed wipes. -Cleaned the area surrounding the ostomy with the same soiled gloves while the strings of his/her gown hung down and touched the resident's uncovered ostomy. -Removed his/her gloves and put on new gloves without performing hand hygiene and finished changing the ileostomy bag. During an interview on 2/10/23 at 9:19 A.M., the Infection Control Preventionist said: -Hand washing demonstrations were performed by staff once a year. -When changing an ostomy bag, he/she expected staff to wear eyewear due to the high chance of splashing. During an interview on 2/10/23 at 11:44 A.M., CNA C said: -Upon entering the resident's room, nursing staff were supposed to wash their hands and put on gloves. -As they were doing incontinence care, one person did the clean task and the other would perform the care, they would wash the resident's front peri-area, remove their gloves, wash or sanitize their hands, clean the back of the resident then remove their gloves and wash or sanitize their hands before putting a clean brief on the resident. -Once they were done, they should wash their hands before leaving the room. -They would then dispose of the trash and place the soiled linen bag in the laundry room then wash their hands again. 5. Record review of Resident #25's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses that included: -Dementia. Record review of the resident's quarterly MDS, dated [DATE], showed the resident: -Had a BIMS score of 9 with significant confusion. -Needed limited assistance with transfers, locomotion, toileting, dressing, and required extensive assistance with bathing and toileting. Record review of the resident's nursing note, dated 2/6/23, showed: -Nursing staff was monitoring the resident for nausea and vomiting. -He/She was receiving a clear liquid diet and was occasionally incontinent of bowel and bladder. -Nursing staff was to continue to assist the resident with toileting as needed. -The resident was alert to self, but was able to make his/her needs known. During an interview on 2/6/23 at 8:36 A.M., The Administrator and DON said: -The resident was placed on contact precautions isolation over the weekend (February 3 to February 5) due to the resident having symptoms of nausea, vomiting, and diarrhea. Observation and interview on 2/6/23 at 1:13 P.M., showed: -There was no isolation cart outside of the resident's room. -The residents door did not have a sign on it notifying one to see the nurse prior to entering the room and there was no sign showing what PPE should be worn prior to entering the resident's room. During an interview on 2/6/23 at 1:13 P.M. CNA D said: -The resident was on isolation due to having diarrhea and vomiting symptoms on 2/6/23 and was now eating in his/her room. Record review of the resident's nursing note, dated 2/7/23 at 1:08 P.M., showed the nurse documented nursing staff checked on the resident to see how he/she was feeling and the resident said he/she still did not feel well and he/she continued to have diarrhea, but did not have an elevated temperature. Observation on 2/8/23 at 7:17 A.M., showed: -There was no isolation cart in front of the resident's door. -The resident was in his/her bed laying down with his/her eyes closed. -The DON was also in the resident's room and was wearing a face mask, but was not wearing a gown or gloves. -The DON was putting away the resident's Continuous Positive Airway Pressure (CPAP a machine that uses mild air pressure to keep breathing airways open while you sleep) for the day after he/she had used it the previous night and other belongings in the resident's room. -Once the DON was finished, he/she left the resident's room without washing or sanitizing his/her hands. Observation and interview on 2/8/23 at 9:17 A.M., the DON said: -The resident had been placed on contact precaution isolation, because he/she had symptoms of nausea and diarrhea. -The resident was no longer on isolation, but they kept the resident in his/her room because the resident said he/she was not feeling well this morning. -The resident was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper cleaning and storage of a resident Continuous Positive Airway Pressure therapy (CPAP machine, is a machine that treats sleep apnea by delivering a stream of oxygenated air into residents airways through a mask and a tube) mask when not in use for one sampled resident (Resident #250) out of 12 sampled residents and one supplemental resident. The facility census was 47 residents. Record review of the facility's BiPAP/CPAP Administration policy dated 5/13/20 showed: -To clean the face mask with an alcohol prep pad or warm soapy water can be used as needed. Be sure to air dry completely before use if use soap and water. Facility staff were to document in the resident's medical record when cleaned. -Did not indicate how to store a CPAP mask when not in use. 1. Record review of Resident #250's admission Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses of: -Acute bronchitis (is an inflammation of the lining of your bronchial tubes). -Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident's Physician's Order Sheet (POS) dated 3/22/2021 showed he/she had a physician's order for nursing staff to check and re-fill water in CPAP at bedside and to check CPAP machine and settings to be at 0.5 pressure daily at bedtime. Record review of the resident's Electronic Medical Record (EMR) for March 2021 showed no physician order or plan of care indicating how to store the resident's CPAP mask when not in use. Observation on 3/29/21 at 9:20 A.M. of the resident's room showed a CPAP machine on the bedside night stand. The CPAP tubing and face mask was not covered and was laying on the resident's pillow. During an interview and observation on 3/30/21 at 8:20 A.M., showed: - The resident used the CPAP at night. - His/her CPAP mask was observed not covered and laying on the bedside nightstand. Observation on 3/30/21 at 12:20 P.M. of the resident's room showed a CPAP machine on the bedside night stand. The CPAP tubing and face mask was not covered and was laying on the resident's pillow. Observation on 3/31/21 at 8:45 A.M. of the resident's room showed the resident's CPAP mask was laying on his/her pillow and was not stored in a plastic bag. During an interview on 3/31/21 at 9:13 A.M., Certified Medication Technician (CMT) B said: -The facility had three residents with CPAP machines. -The CPAP mask should be stored in a plastic bag when not in use. -The resident was new to the facility and was able to take off the CPAP mask by himself/herself, but staff should ensure the CPAP machine and mask is cleaned and stored properly between use. During interview on 03/31/21 at 10:35 A.M., Certified Nursing Assistant (CNA) A said: -The CPAP masks should be stored in a labeled bag when not in use. -The resident was able to remove and apply his/her CPAP mask. -Facility staff were to ensure that CPAP masks were stored in a plastic bag when not in use. During interview on 3/31/21 at 10:40 A.M., Licensed Practical Nurse (LPN) A said: -CPAP masks should be stored in a plastic bag and labeled with the resident's name when not in use. -Nursing staff were to monitor and check the resident's CPAP machine every shift. During an interview on 3/31/21 at 2:25 P.M., the Director of Nursing (DON) said: -He/She expected CPAP masks to be stored in a plastic bag. -The CPAP tubing and plastic storage bag should be changed weekly. This was currently scheduled for the night shift nurse to complete on Sunday nights, but he/she was looking at changing that task to a day shift nursing duty, as residents were wearing their CPAP masks at night so it was hard to complete that task on the night shift. --CPAP mask storage and changing the storage bag weekly was not documented on the resident's Medication Administration Record (MAR); it was on a cheat sheet for licensed nursing tasks. --The resident's MAR had an order to check and refill the CPAP machine at bedtime. -He/She was responsible for monitoring to ensure CPAP masks were stored correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control protocol was in place to ensure proper hand and glove hygiene during care of one sampled resident (Resident #23) out of 12 sampled residents. The facility census was 47 residents. Record review of the facility's Infection Prevention and Control Manual - Standard Precautions dated 2019 showed: -Standard Precautions Overview: it is the policy of this facility that standard precautions will be implemented. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. -Hand Hygiene: hand hygiene continues to be the primary means of preventing the transmission of infection. -Gloves: --Remove gloves after contact with a patient, bodily fluids/excretions, and the surrounding environment (including medical devices) using proper technique to prevent hand contamination. --Change gloves during patient care if the hand will move from a contaminated body site (e.g. perineal area (surface area between the thighs extending from the pubic bone to the tail bone)) to a clean body site (e.g. face, clothing, etc.). Record review of the facility's Infection Prevention and Control Manual - Standard Precautions: Hand Hygiene dated 2019 showed: -Appropriate hand hygiene is essential in preventing transmission of infectious agents. -Purpose: --To cleanse hands to prevent the spread of potentially deadly infections. --To provide a clean and healthy environment for residents, staff, and visitors. --To reduce the risk to the healthcare provider of colonization or infections acquired from a resident. -Hand hygiene continues to be the primary means of preventing the transmission of infection. -Staff must perform hand hygiene even if gloves are utilized. Record review of the facility's Infection Prevention and Control Manual - General Policies: Glove Technique (Non-Sterile) policy dated 2019 showed: -Apply clean non-sterile gloves when touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and non-intact skin. -Don (put on) clean gloves between tasks and procedures on the same resident after contact with blood, body fluids, secretions, and excretions. -Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. -Perform hand hygiene after the removal of gloves. 1. Record review of Resident #23's Face Sheet showed he/she admitted to the facility on [DATE] and had diagnoses which included: -Chronic Kidney Disease. -Unspecified Skin Changes. -Urinary Incontinence. -Generalized Muscle Weakness. -Lack of Coordination. -Dementia (a chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with Behavioral Disturbance. - Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Record review of the resident's Annual Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/1/21 showed: -Had moderate cognitive impairment. -Was totally dependent upon staff for mobility, transfers, bathing, toileting, and personal hygiene. -Was always incontinent of bowel and bladder. Record review of the resident's care plan dated 2/1/21 showed: -Required staff assistance for all Activities of Daily Living (ADLs). He/She required a mechanical lift (a mechanism that lifts and transfers a person from one place to another using a sling secured to a hydraulic lift) for transfers and toileting. Interventions included: --The resident required assistance of two staff with the mechanical lift for all transfers/toileting. --The resident was incontinent of bowel and bladder; staff provided care to the perineal area every two hours. -Was incontinent of bowel and bladder. He/She was dependent on staff for all perineal area care and most ADLs. Interventions included: --Staff to provide perineal area care for the resident during rounds and as needed. Observation on 3/29/21 at 2:36 P.M. showed: -CNA B and CNA C entered the resident's room with a mechanical lift. -The resident was sitting in his/her wheelchair with a mechanical lift sling under him/her. -CNA B and CNA C washed their hands and donned (put on) clean gloves, then transferred the resident from his/her wheelchair to his/her bed with the mechanical lift. -Both CNA B and CNA C turned the resident onto his/her right side, pulled his/her pants down on the right side, and CNA C unhooked the left side of the resident's brief. Both CNA B and CNA C touched the resident's bare skin on his/her left hip and thigh, then assisted the resident onto his/her back. -Wearing the same gloves, CNA C grabbed the edge of the privacy curtain and pulled it to provide more privacy. CNA C did not remove his/her gloves or sanitize his/her hands, and continued with the resident's care. -Both CNA B and CNA C then turned the resident onto his/her left side, pulled down his/her pants, and unhooked the right tab of the resident's brief. -CNA C removed the lift sling from under the resident and placed it on the resident's wheelchair. -CNA C removed the resident's brief and disposed of it into a lined wastebasket. -While CNA B held the resident on his/her left side, CNA C, with the same gloves, opened a package of cleansing wipes on the table next to the bed and pulled a few wipes out of the package. CNA C used the wipes to cleanse the resident's buttocks. With the same gloves, CNA C touched the resident to assist the resident to his/her back. -Wearing the same gloves, CNA C removed more wipes out of the package and cleaned the resident's front genital area. -CNA B removed the resident's socks and put soft heel-protector boots onto the resident. -When the resident was cleaned and heel-protector boots were applied, CNA C touched the resident's bed linens and covered the resident with the same contaminated gloved hands. -Wearing the same gloves, CNA C removed the lining from the wastebasket that held the resident's brief and wipes used to clean the resident. He/She pulled a new bag up into the wastebasket. -Wearing the same gloves, CNA C lowered the resident's bed with a remote. -CNA C removed his/her gloves. -Without sanitizing his/her hands, CNA C picked up the bed remote and lowered the resident's bed into the lowest position with ungloved hands. -Without washing his/her hands, CNA C put on new gloves and adjusted the resident's oxygen tubing. During an interview on 3/29/21 at 2:45 P.M., CNA B said if he/she would have done anything differently, it would have been to wash his/her hands prior to putting on clean gloves. During an interview on 3/29/21 at 2:45 P.M., CNA C said he/she should have washed his/her hands between glove changes. During an interview on 3/31/21 at 11:55 A.M., CNA E said: -When providing resident care such as a brief change, staff should always wash their hands before the process, then put on gloves. -Glove change was required any time the gloves become soiled, such as with body fluids of any kind. -To change gloves, staff should remove the soiled gloves, wash their hands, put on new gloves, and continue with resident care. -If staff had to touch anything else in the room, such as a mechanical lift, a wheelchair, a bed remote, or the privacy curtain, staff must remove gloves first as they are considered soiled when providing brief care. Then staff should complete whatever task needs to be done, and then wash or sanitize hands, put on new gloves, and continue with care. -When resident care is complete, staff should remove their gloves and wash their hands. -If needed, remove any soiled brief or clothing from the room in a bag, put where it goes, and then staff should wash their hands again. During an interview on 3/31/21 at 12:00 P.M., LPN A said: -His/Her expectation for hand sanitation during resident care was for staff to wash hands immediately before and after care, wear gloves during care, and to wash hands between each glove change during care. -Gloves should be changed after touching anything soiled or dirty, such as any bodily fluids or substances. -If staff had to touch anything in the room such as a chair, a remote, oxygen tubing, or any item not involved in the resident's care, they should first remove their gloves, sanitize their hands, do whatever needed to be done, then wash their hands and put on clean gloves before going back to providing care to the resident. During an interview on 3/31/21 at 12:21 P.M., CNA D said: -Before providing resident care, such as brief change, staff should wash their hands, gather and lay out needed supplies, then wash their hands, and put on gloves. -During perineal area care, staff should: --Take off the resident's pants, undo the brief, then clean the front perineal area. --Remove gloves, wash hands, put on new gloves, return to the resident, and clean the back perineal area. --Remove gloves, wash hands, and put on new gloves. --Return to the resident and put a clean brief on the resident, and re-dress the resident. -Staff should always sanitize hands between glove changes. -Staff should always change gloves immediately if the gloves are soiled and wash their hands before continuing with care. -If staff needed to touch anything in the resident's room such as a bed remote, chair, oxygen tubing, or privacy curtain while providing care, staff must remove their gloves, wash their hands, touch the item/do the needed task, re-wash their hands, put on new gloves, and continue with care. -When finished with resident care, staff should remove their gloves and wash their hands. During an interview on 3/31/21 at 12:24 P.M., the Registered Nurse (RN) said: -During a brief change, the expectation for staff hand sanitation and glove use was: --Wash hands before beginning care, wear gloves during care, and remove gloves and wash hands when care was complete. -Staff should change gloves anytime they are moving from dirty to clean with the care. Dirty meant any kind of body fluid such as urine, feces, other drainage, or blood. -For glove changes, staff should remove gloves, wash or sanitize hands (always wash hands if visibly soiled or if the resident had an infectious disease), then put on new gloves. -If staff needed to lower a resident's bed after care, they should first remove their gloves and wash their hands before touching the bed remote. -If staff needed to adjust a resident's oxygen tubing, they should first remove their gloves and wash their hands before touching the tubing. -If staff had to touch anything in the room during care, they should remove their gloves, wash their hands, do whatever they needed to do, re-wash their hands, and put on new gloves before continuing care. During an interview on 3/31/21 at 2:25 P.M., the Director of Nursing (DON) said: -His/Her general expectation for staff hand sanitation during resident care such as a brief change was: --Staff should wash their hands, wear gloves during care, remove the soiled brief, clean the resident, remove their gloves, wash their hands, put on clean gloves, apply a clean brief, remove their gloves, and wash their hands when the task was done. -Gloves should be used for resident care, and hand sanitation should be done before putting on gloves and after removing gloves. -Gloves should be changed when they are dirty; staff should never go from a dirty area to a clean area without changing gloves. -A glove would be considered dirty after staff performed perineal area care for a resident. -It was not acceptable to touch a privacy curtain with a gloved hand during resident care, or to continue care after touching it without a glove change and hand sanitation. -It was not acceptable to touch a bed remote with a gloved hand during resident care, or to continue care after touching it without a glove change and hand sanitation. -It was not acceptable to touch oxygen tubing with a gloved hand during resident care, or to continue care after touching it without a glove change and hand sanitation. -If staff had to touch any object in the room during resident care, they should remove their gloves, wash their hands, do what needed to be done, wash their hands, put on new gloves, and continue with care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #25's Face Sheet showed he/she: -admitted to the facility on [DATE] and had diagnoses which included: --Repeated Falls. --Pain. --Breast Cancer. --Chronic Kidney Disease (your kidneys are damaged and can't filter blood the way they should). --Disorientation. --Dementia (a chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with Behavioral Disturbance. -Had a court-appointed legal guardian. Record review of the resident's care plan dated 8/11/19 showed he/she: -Was at risk for falls due to being up spontaneously/as he/she desired with a roller walker. He/She had a steady gait with walker use most of the time. He/She did have poor safety awareness. Interventions included: --The resident needed a night light on to help see at night. --Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. --Keep walker within reach at all times. Record review of the resident's Quarterly MDS assessment dated [DATE] showed he/she: -Had moderate cognitive impairment. -Had adequate vision and hearing. -Was usually able to make himself/herself understood, and was usually able to understand others (missed some part/intent of a message but comprehended most conversation). -Exhibited wandering behavior during one to three days during a seven-day lookback period. The impact of the resident's wandering behavior was not documented. -Had no falls since the previous assessment dated [DATE]. -Was independent and required no staff support with bed mobility, transfers, walking in his/her room and the corridor, and locomotion on and off the unit. -Required supervision (oversight, encouragement, or cueing) with setup help only for toileting and personal hygiene tasks. -Was steady at all times with balance during transitions and walking. -Had no limitation in functional range of motion in his/her upper or lower extremities. -Used a walker for mobility. -Received hospice services and had a condition or chronic disease that could result in a life expectancy of less than six months. Record review of the resident's Nursing Notes dated 1/22/21 showed: -At 12:50 A.M. the resident was observed by Certified Nursing Assistants (CNA's) lying on the floor in front of the sink in room. The resident was holding his/her left inner thigh and yelling out in pain. Vital signs were obtained. The resident's left foot was rotated outward and the left lower extremity appeared longer in length. The resident was unable to move without severe pain. There was no bleeding, open areas, swelling, or bruising observed. -At 1:00 A.M. the nurse called 911 for transport of the resident to the hospital for evaluation and treatment. -At 1:05 A.M. Emergency Medical Technicians (EMTs) arrived to transport the resident to the hospital via ambulance. -At 1:10 A.M. the resident left the facility with two EMTs via gurney. -At 1:10 A.M. the nurse called and gave a report to the hospital emergency room (ER) nurse. He/She informed the ER nurse that the resident was a hospice patient and of the resident's current status. -At 1:20 A.M. the nurse called the hospice agency to inform of the resident's fall, complaint of left hip pain, and transfer to the hospital. -At 1:25 A.M. a call was received from the hospice agency stating it was okay the resident was sent to the hospital. -At 1:30 A.M. the nurse called and spoke with the resident's guardian and informed of the resident's fall and complaint of severe left hip pain. -At 1:40 A.M. the nurse called the hospital to ensure hospital staff had the resident's guardian's contact information. -At 3:05 A.M. hospice agency staff called with an update: the resident was being admitted to the hospital with a left hip fracture. Record review of the resident's Incident Report dated 1/22/21 showed: -The resident had an unobserved fall on 1/22/21 at 12:50 A.M. -Narrative: At 12:50 A.M. the resident was observed by CNA's lying on the floor in front of the sink in room. The resident was holding his/her left inner thigh and yelling out in pain. Vital signs were obtained. The resident's left foot was rotated outward and the left lower extremity appeared longer in length. The resident was unable to move without severe pain. There was no bleeding, open areas, swelling, or bruising observed. The resident complained of left hip pain. -Activity at the Time: From bed without assistance. -Immediate Actions Taken: The resident was sent to the emergency room. -Type of Injury: Fracture. -Notifications were documented as follows: --Physician notified on 1/22/21 at 5:00 A.M. --Guardian notified on 1/22/21 at 1:30 A.M. --Hospice notified on 1/22/21 at 1:25 A.M. -Disposition: Hospital admission. -Resident Condition at Time of Incident: --Mobility: [NAME] with wheels. --Mental: Alert/oriented x 2. --Medical Risk Factors Possibly Related to Incident: ---Confusion/Disorientation. ---Breast Cancer. -The report was not signed or dated by the preparer or the reviewer. -The report did not show fall precautions/interventions in place prior to the fall, whether the resident's call light was within reach and/or sounding, if lighting was adequate, trip hazards or other environmental factors that may have contributed to the fall, when staff had last seen the resident, or the last time the resident had toileted. -The report did not show root cause analysis related to the fall, or interventions put into place to prevent future falls. Record review of the resident's Significant Change MDS dated [DATE] showed he/she: -Had moderate cognitive impairment. -Had adequate vision and minimal difficulty with hearing in some environments. -Was usually able to make himself/herself understood, and was usually able to understand others (missed some part/intent of a message but comprehended most conversation). -Exhibited wandering behavior during one to three days during a seven-day lookback period that placed the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). -Had one fall with major injury since the previous assessment dated [DATE]. -Required limited assistance (resident highly involved in the activity; staff provided guided maneuvering of limbs or other non-weight-bearing assistance) of one staff with bed mobility, transfers, walking in his/her room and the corridor, locomotion on and off the unit, and with toilet use. -Required supervision with setup help only for personal hygiene tasks. -Was not steady with balance during transitions and walking, but was able to stabilize without human assistance. -Had limitation on one side of his/her lower extremities in functional range of motion. -Used a walker and a wheelchair for mobility. -Received hospice services and had a condition or chronic disease that could result in a life expectancy of less than six months. Record review of the resident's care plan updated 2/2/21 showed he/she: -Was at risk of falls due to being up spontaneously/as he/she desired with a roller walker. He/She had a steady gait with walker use most of the time. He/She did have poor safety awareness. -Interventions added: --Staff were to check on the resident and assist with toileting every two hours (start date: 1/24/21). --The resident was to wear slipper socks in bed as he/she would tolerate (start date: 2/2/21). Record review of the resident's Nursing Notes dated 2/10/21 showed: -The resident had an unwitnessed fall that morning. -The resident was yelling, help. The nurse found the resident on the floor in his/her room lying on his/her back. -The resident stated he/she slipped on a sugar packet that was on the floor in his/her room. -The resident was alert and oriented x 2 - 3. -The resident had no complaint of pain and denied hitting his/her head. -The resident was assessed by the nurse: his/her range of motion was within normal limits. Vital signs were checked with no abnormalities noted. A neurological check was completed with no abnormality noted. Bowel sounds were active x 4 quadrants, and lungs were clear to auscultation (the act of listening for sounds within the body). -The resident had no visible bruising or redness. -The resident's physician and guardian were notified. -The resident was on neurological checks for 72 hour monitoring. Record review of the resident's Incident Report dated 2/10/21 showed: -The resident had a fall with no head injury on 2/10/21 at 8:15 A.M. -Narrative: The resident was found on the floor in his/her room yelling, help. The resident stated that he/she slipped on a sugar packet in his/her room. No apparent injuries. -Activity at the Time: From chair without assistance. -Immediate Actions Taken: The resident was examined and evaluated. -Type of Injury: None apparent. -Notifications were documented as follows: --Physician notified on 2/10/21 at 8:30 A.M. --Guardian notified on 2/10/21 at 8:40 A.M. -Disposition: Observation. -Resident Condition at Time of Incident: --Bed height: Down. --Medications Taken: Analgesics/Narcotics. --Mobility: No documentation. --Mental: No documentation. --Medical Risk Factors Possibly Related to Incident: Fall History. -The report was not signed or dated by the preparer or the reviewer. -The report did not show fall precautions/interventions in place prior to the fall other than the bed height being down, whether the resident's call light was within reach and/or sounding, if lighting was adequate, when staff had last seen the resident, or the last time the resident had toileted. -The report did not show root cause analysis related to the fall, or interventions put into place to prevent future falls. Record review of the resident's neurological flow sheet dated 2/10/21 - 2/13/21 showed neurological checks were completed as required. Record review of the resident's Nursing Notes dated 2/15/21 showed: -At 3:10 A.M. the resident was heard yelling from his/her room. The resident was observed lying on the floor on his/her back at the foot of the bed. -The resident's walker was by the sink. The resident stated he/she was ambulating without his/her walker and fell. -The resident had shoes on. -The resident was alert to self and place. -The resident complained of right foot, back, and back of head aching. -No visible sign or symptom of injury was observed. -The resident was assessed by the nurse: movement of extremities was within normal limits. Vital signs were checked with no abnormalities noted. A neurological check was completed with no abnormality noted. Respirations were even and unlabored. -The resident was assisted to a standing position with the assistance of two staff with use of a gait belt. -The resident ambulated to the bathroom with his/her walker and staff supervision. No apparent change in gait was noted. The resident had no further complaints of pain while ambulating. -The resident was educated on calling for assistance with ambulation and transfers. -The resident was educated on always ambulating with assistive device - walker. -The resident stated understanding. -The resident was placed on 72 hour monitoring with neurological checks. Record review of the resident's Incident Report dated 2/15/21 showed: -The resident had a fall with no head injury on 2/15/21 at 3:10 A.M. -Narrative: At 3:10 A.M. the resident was heard yelling from his/her room. The resident was observed lying on the floor, on his/her back, at the foot of the bed. The walker was by the sink. The resident stated he/she was ambulating without the walker and fell. The resident had shoes on. The resident appeared to move all extremities within normal limits. Grips are equal and strong. Vital signs were obtained and within normal limits. Respirations were even and unlabored. The resident was alert to self and place. No injury was apparent at that time. The resident complained of right foot, back, and back of head aching. -Activity at the Time: Other. -Immediate Actions Taken: The resident was educated on calling for assistance with ambulation and transfers. Frequent monitoring. -Type of Injury: None apparent. -No notifications were documented. -Disposition: Observation. -Resident Condition at Time of Incident: --Bed Height: Adjustable. --Medications Taken: MS Contin (morphine sulfate extended-release tablets - a strong narcotic pain medication). --Mobility: Ambulated with assistive device. --Mental: Alert/Oriented x 2. --Medical Risk Factors Possibly Related to Incident: ---Fall History. ---Fracture. ---Confusion/Disorientation. ---Bowel and Bladder Urgency. -The report was not signed or dated by the preparer or the reviewer. -The report did not show fall precautions/interventions in place prior to the fall, whether the resident's call light was within reach and/or sounding, if lighting was adequate, trip hazards or other environmental factors that may have contributed to the fall, when staff had last seen the resident, or the last time the resident had toileted. -The report did not show root cause analysis related to the fall, or interventions put into place to prevent future falls. Record review of the resident's Nursing Notes dated 2/16/21 showed: -At 8:00 A.M. the nurse was alerted by housekeeping staff that the resident had fallen. The writer and another nurse entered the resident's room and found the resident lying on his/her back holding his/her hand to the back of his/her head. -A small amount of blood was present. -The resident stated that he/she spilled his/her water cup and then slipped and fell. -The writer applied pressure to the back of the resident's head with gauze. -The resident was assessed: vital signs were check with no abnormalities noted. The resident's respirations were even and unlabored. -The resident was alert and oriented to self per normal. He/She was fully conscious with clear speech. -The other nurse and a CNA assisted the resident using a gait belt to a standing position, then to his/her bed. -Both nurses rinsed the resident's hair. Upon assessment, the resident had a small laceration to the back of his/her head measuring 2.8 centimeters (cm) x 0.5 cm x 0.3 cm. The laceration was cleaned and a small amount of hair was trimmed surrounding it. Wound closure strips were applied. -The resident had no other injuries present at that time. Record review of the resident's Incident Report dated 2/16/21 showed: -The resident had a fall with head injury on 2/16/21 at 8:00 A.M. -Narrative: The resident was found lying on his/her back on the floor holding the back of his/her head; there was a small amount of blood; cleaned the back of his/her head and trimmed hair surrounding the laceration; wound closure strips were applied. The resident had a laceration to the back of his/her head 2.8 cm x 0.5 cm x 0.3 cm. -Activity at the Time: From chair without assistance. -Immediate Actions Taken: Fall protocol; first aid for laceration. -Type of Injury: Laceration - superficial. -Notifications were documented as follows: --Physician notified on 2/16/21. Notification time was not documented. --Guardian notified on 2/16/21. Notification time was not documented. -Disposition: In-house Treatment; Observation. -Resident Condition at Time of Incident: --Mobility: No documentation. --Mental: No documentation. --Medications Taken: Analgesics/Narcotics. --Medical Risk Factors Possibly Related to Incident: ---Fall History. ---Confusion/Disorientation. -The report was not signed or dated by the preparer or the reviewer. -The report did not show fall precautions/interventions in place prior to the fall, whether the resident's call light was within reach and/or sounding, if lighting was adequate, trip hazards or other environmental factors that may have contributed to the fall, when staff had last seen the resident, or the last time the resident had toileted. -The report did not show root cause analysis related to the fall, or interventions put into place to prevent future falls. Record review of the resident's neurological flow sheet dated 2/16/21 - 2/19/21 showed neurological checks were completed as required. Record review of the resident's March 2021 POS showed orders for: -Morphine Sulfate Extended Release 15 milligram (mg) tablet - Administer one tablet by mouth twice a day for pain. -Morphine 20 mg/milliliter (ml) Oral Syringe - Administer 0.25-1 ml by mouth every four hours as needed for pain for pain due to breast cancer. Record review of the resident's care plan updated 3/17/21 showed he/she: -Was at risk of falls due to being up spontaneously/as he/she desired with a roller walker. He/She had a steady gait with walker use most of the time. He/She did have poor safety awareness. -Intervention added 2/17/21: Pharmacy consultant to review medications at least monthly for possible medication interactions warranting an increase in falls. 4. During an interview on 3/30/21 at 2:05 P.M., the DON said: -They reviewed every resident fall with the Interdisciplinary Team (IDT) and they looked at the date and time of the fall, what occurred and what interventions were in place prior to the resident's fall. -They also looked to see if the resident's physician and family were notified and what interventions were implemented or needed to be changed to try to prevent further falls. -They determined new interventions for the resident and reviewed their care plan to see if the current interventions remained effective or not and they changed them as needed. -They tried to determine the causative factors of the resident's fall in order to adequately address it. -They looked at falls overall to try to determine when falls were most often occurring and other related factors to see if they had a systematic problem and then they could put interventions in place to manage it. -They document their discussions in their review book, but they do not document the investigation of each resident's fall. -The documentation of the resident's fall was in nursing notes and on the Incident Report. -The nurses made an initial note showing what occurred and what actions were taken, vital signs, notification of the physician and responsible party and interventions implemented. -They document post fall follow up notes and vital signs for 72 hours after the resident's fall. If the resident was injured they would also document physician's orders and actions taken. -If the fall was unwitnessed or the resident hit their head, they would document neurological checks on the Neurological Check form. During an interview on 3/31/21 at 8:39 A.M., LPN B said: -When a resident had a fall they were supposed to check the resident and complete a full body assessment where they assess for injury, prior to moving the resident and complete vital signs. -They try to determine how the resident fell if it was not witnessed, and interview the resident. -They notify the resident's physician and responsible party of the resident's fall. -If there is a head injury, or if the resident's fall was unwitnessed, they also initiate neuro checks. -They document 72 hour post fall monitoring on all residents who fall. -They document everything about the resident's fall in the nursing notes, complete the incident report and then notify the DON. -The nursing note should show the detailed information regarding the resident's fall to include any immediate interventions they initiated. Long-term interventions should be updated in the resident's care plan. The details of the resident's fall should be in the nursing note and on the incident report. 2. Record review of Resident #15's admission Face-Sheet showed he/she was admitted to the facility on [DATE] with diagnosis including: -History of falls. -Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Mood Disorder. -Lack of coordination and unsteadiness on feet. Record review of resident's Nursing Note in Electronic Medical Record (EMR) dated 12/29/2020 at 5:08 A.M., showed: -At 4:30 A.M. the resident was heard talking to himself/herself and was observed near bathroom door in room. -He/she was lying on his/her right side. -He/she denied and was without any signs and symptoms of pain, discomfort or shortness of air. -His/her respirations were even and unlabored. -He/she was able to move his/her extremities within normal limits (WNL). -His/her grips were strong and equal. Pupils, Equal, Round, Reactive (to), Light, Accommodation. (PERRLA test is one way to assess a person's risk for certain neurological conditions). No injury was apparent at this time. Vital signs were obtained and within normal limits. -His/her bed was in a low position with a fall mat in place. -The resident ambulated back to bed with assist of two staff members and placed on 72 hour fall monitoring with neurological checks (neuro checks monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs). -Nursing staff would continue to monitor the resident. Record review of the resident's Neurological check Sheet dated 12/29/20, showed the nursing staff documented neurological checks on the resident. Record review of the resident's Fall Incident Reports-Action Sheet was not dated or timed when completed showed: -Had documented unknown for date or time of the fall. -The resident had a no head injury/non-witness fall. -Notes section had no date and showed at 5:10 A.M., the resident was observed by aide sitting on bed in another resident's room. -The resident said he/she had fallen. -His/her right knee and shoulder was hurting. -He/she had a small pink abrasion observed to his/her right knee, with an area that appeared to be dried. -Had no bruising, swelling or redness apparent to right shoulder. -The resident ambulated with supervision back to his/her room. He/she had no change in his/her gait apparent and his/her gait was steady. -The resident's vital signs were obtained and within normal limits. -Resident placed on Fall 72 hour monitoring due to being a resident self-reported fall with an injury abrasion to right knee. -The facility action taken was to assist the resident to his/.her room and ensure the resident had shoes on. -He/she was alert and oriented x 2, transfer bed/chair was marked as independent. -Medical reason listed the resident had confusion and was disoriented. -No documentation of date and unsure of the time of the fall happening on 12/29/20. Record review of the resident's EMR showed the resident had no documentation of a completed fall investigation for the resident's fall on 12/29/20. Which would include the root cause of the resident's fall, if able to find cause or if unknown cause and facility's follow-up actions taken to prevent or reduce further incidents. Record review of the resident's Significant change MDS dated [DATE] showed: -The resident had short term and long term memory problems. -Required extensive assist of 1 or 2 staff member for transfer and personal cares. -Had one non-injury fall since last assessment. -Diagnoses include Alzheimer's. Record review of the resident's fall and Activities of Daily Living (ADL) Care Plan was updated on 1/14/2021, showed he/she: -Was at risk for falls due to his/her poor safety awareness, and a diagnosis of dementia. -Had the goal to decreasing the number of falls over the next 90 days. -Interventions included the following; --Was unsteady on his/her feet and required limited assist of one staff member with gait belt for ambulation. --Frequently tried to self-transfer, and needed frequent reminders and cues by facility staff to use call light for assistance. --Was frequently incontinent of urine at night, which increased his/her risk for falls, when and if he/she attempted to self-ambulate. --Certified Nursing Assistants (CNA's) were to toilet/change the resident every two hours. --Staff were to ensure non-skid socks were on while in bed and non-skid shoes were on when up. --Maintain environment free of clutter and safety hazards. --Placed items frequently used within easy reach, to avoid reaching for the items. --Provide with consistent caregiver on all shifts. --Keep call light within reach at all times in room and bathroom. Instruct on use and reinforce the need for use with each contact. Record review of the resident's Physician's Order Sheet (POS) dated March 2021 showed: -He/she had a physician's order for a fall mat to be in place and his/her bed was to be in the lowest position. -The resident had a physician's order to receive Hospice (end of life care) services that had started on 3/2/21 related to a diagnoses of Alzheimer's. Observation on 3/29/21 at 10:30 A.M., of the resident showed: -He/she was laying on his/her left side in bed. -The bed was in the lowest position. -He/she had a fall mat beside his/her bed. -He/she was unable to respond to questions. -He/she had a Broda chair (a specialized wheelchair used for safe and comfortable positioning) in room with a mechanical lift transfer sling in the chair. During an interview 3/30/21 at 11:45 A.M., the DON said: -Staff reviewed the incident log for 12/29/20 and it showed the resident had a fall on 12/29/20 at 4:30 A.M., and he/she had a no head injury fall. -He/she was not aware of the facility having a process in place for completing a formal written investigation form for residents who had fallen. -The licensed nursing staff completed and placed the resident's fall incident report under his/her door and the next day he/she would follow-up by updating the resident care plan. -Nursing staff would notify him/her, the resident's Physician and family of a resident fall. -The fall incident reports and care plans were reviewed during management meeting. -Findings and follow-up action taken that were related to resident's fall, would be documented in the resident's nursing notes and in the morning meeting notes. During an interview on 3/31/21 at 9:13 A.M., Certified Medication Technician (CMT) B said: -He/she would notify the charge nurse of any resident's who had fallen. -The charge nurse would assess the resident and complete any documentation required. -CNA's or CMT's then would get any instruction of the next steps from the charge nurse. During an interview on 3/31/21 at 10:35 A.M., CNA A said: -He/she would notify the charge nurse if he/she found a resident had fallen. -The charge nurse would assess the resident and the CNA would get direction from the charge nurse of any next steps to take. -The charge nurse documented the findings from the fall. Based on observation, interview, and record review, the facility failed to ensure to have a comprehensive fall investigation process in place, to include documentation of a root cause of the resident's fall and final action taken by the facility, as a preventative measure to reduce the incidence of falls for three sampled residents (Resident #41, Resident #15 and Resident #25), out 12 sampled residents. The facility census was 47 residents. Record review of the facility's Falls Clinical Protocol and Policy revised 2018 showed: -The staff will evaluate and document falls that occur while the individual is in the facility: for example, when and where they happen, any observation of the events. -For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. -Often multiple factors contribute to a falling problem. -The staff and physician will continue to collect and evaluate information until either the cause of the fall is identified or it is determined that the cause cannot be found or is not correctable. 1. Record review of Resident #41's Face Sheet showed he/she was admitted on [DATE], with diagnoses including unsteadiness on feet, high blood pressure, history of falling, pain, muscle weakness, diabetes, arthritis, legally blind, difficulty walking, Muscular Dystrophy (a hereditary condition marked by progressive weakening and wasting of the muscles), and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/16/20, showed he/she: -Was alert and oriented without any short-term or long-term memory problems. -Had some sleep disturbance and had no mood or behavioral problems. -Had severely impaired vision. -Needed extensive to total assistance with transfers, locomotion, toileting, bathing, substantial assistance with dressing and did not walk. -Had range of motion impairment in his/her lower extremities and used a wheelchair for mobility. -Had occasional pain and received scheduled, as needed, and non-medicinal pain interventions. -Had no falls since the last assessment (admit/re-entry or prior assessment). -Did not receive any rehabilitation services. Record review of the resident's nursing notes dated 12/19/20, showed: -The nurse found the resident on the floor at 4:45 A.M., and when the nurse asked the resident what happened, the resident said, I need to get in bed. -The resident was not wearing his/her oxygen at the time the nurse found him/her. -The resident said he/she was trying to go to the bathroom. -The resident said he/she hit his/her head, but the resident had no visual injury (bruising, swelling) to his/her head. -The nurse performed an assessment and vital signs (blood pressure, temperature, pulse, respirations and oxygen level) were documented and Neurological checks (neuro checks - neurological checkpoints to monitor: level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) were initiated. -Nursing staff tried to assist the resident up into a standing position and were unsuccessful. -Nursing staff used a mechanical lift with two persons to assist the resident up and into his/her bed, and put his/her call light within reach. -The resident was educated on using his/her call light and continued to tell the nurse to take the call light off of him/her. -The nurse notified the resident's physician. The resident was his/her own responsible party. -Nursing notes showed the resident continued post fall follow up for 72 hours after his/her fall. -The notes did not show how the resident was found (position of his/her body) or the exact location the resident was found in his/her room (bathroom, bedside); it did not show what interventions were in place prior to the resident's fall, whether his/her call light was available and/or sounding, whether there were any environmental factors that may have contributed to his/her fall, when the last time staff had seen the resident and what the resident was doing at that time, or when the resident was last toileted. The report did not show any added interventions to prevent recurrent falls. Record review of the resident's Neurological Checks Sheet dated 12/19/20, showed the nursing staff documented neurological checks on the resident. Record review of the resident's Incident Report showed: -The resident was found on the floor on 12/19/20 at 4:45 A.M. -The resident said he/she was attempting to go to the bathroom. -Imme

Based on interview and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 47 residents. Record review of the facility's Controlled Substances policy dated 2001 and revised on 12/12 showed: -Nursing staff must count controlled medications at the end of each shift. -The nurse coming on duty and the nurse going off duty must make the count together. 1. Record review of the facility's Controlled Drug Count sheet dated March 2021 for the front medication cart showed: -24 out of 85 opportunities were not signed by either the oncoming or off going staff. -Ten of the 85 opportunities were not signed by both the oncoming and the off going staff. -15 out of 85 opportunities did not have the number of narcotic packages documented on the sheet. During an interview on 3/31/21 at 8:12 A.M., Registered Nurse (RN) A said: -The narcotics are counted at the beginning and end of each shift with the oncoming nurse and off going nurse or Certified Medication Technician (CMT). -Both nurses and/or CMT initial the count sheet when the count has been completed to verify the count is correct. -The number of packages or narcotics is to be recorded on the sheet. During an interview on 3/31/21 at 8:15 A.M., the Director of Nursing (DON) said: -The oncoming and off going shifts should count the narcotics and sign the narcotics book each shift. -The number of packages of narcotics is to be recorded in the narcotics count book.