**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to notify the family of a resident's significant weight gain for 1 of 3 (Resident #3) sampled residents reviewed for change in condition and failed to notify the resident's responsible party, Nurse Practitioner and Medical Director of a fall for 1 of 3 (Resident #6) sampled residents reviewed for falls. The findings included: 1. Review of the facility's policy titled Notification of Change, revised 11/30/2017, revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies the resident's representative, consistent with his or her authority when there is a change requiring notification .Circumstances requiring notification include .Accidents .resulting in injury .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health .exacerbation of a chronic condition . 2. Medical record review revealed Resident #3 was admitted on [DATE] with a diagnosis of Diabetes, Peripheral Vascular Disease, Heart Failure, End Stage Renal Disease, Congestive Heart Failure, and Malignant Neoplasm of Kidney. Review of Patient Weight Report revealed Resident #3 weighed 275 lbs on 9/1/2022, the day of admission to the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 15 indicating he was cognitively intact, weighed 294 pounds (lbs), and had no weight gain. Review of Patient Weight Report revealed Resident #3 revealed on 9/6/2022 the resident weighed 293.80 lbs five (5) days after admission to the facility. Review of the FULL NUTRITIONAL ASSESSMENT, dated 9/6/2022, revealed .Date admitted .9/1/2022 .Diet Order .Fluid Restriction .1000 [mililiters (ml)] .Weight Gain Comments .[blank] .WEIGHT (in pounds) 293.80 .Edema .No .Resident admitted to the facility on [DATE]. Admit wt .293.8 lbs [the resident's admission weight was actually 275 lbs] .1000 ml fluid restriction ordered .Staff to monitor weekly weights x 4 and wound healing . Resident #3 had an 6.39 % weight gain from admission of 9/1/2022 to 9/6/2022 resulting in a 18. 8 pound weight gain in 5 days. The Nutrition assessment failed to capture Resident #3's admission weight of 275 pounds. During a telephone interview on 12/28/2022 at 8:27 AM and on 2/21/2023 at 8:08 AM, the daughter was asked if she was Resident #3's responsible party (RP) and should the facility notify her of changes. The daughter confirmed she was Resident #3's RP. Resident #3's daughter also confirmed the facility did not notify her when Resident #3 had an changes in his condition. During an interview on 2/15/2023 at 5:21 PM, the Director of Nursing confirmed the responsible party and the Medical director or Nurse Practitioner should be notified with all falls and any changes in condition. During a telephone interview on 2/21/2023 at 2:55 PM, the Medical Director was asked if a resident had an 18.8 pound weight gain what would he expect the staff to do. The Medical Director stated, .normally if that is the case .they let us know if there is a big change . The Medical Director confirmed the nursing staff should follow the orders for fluid restriction and if the resident is noncompliant, he would expect to see documentation in the chart. 3. Medical record review revealed Resident #6 was admitted on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension, Lower Back Pain, Anxiety Disorder, Edema, Hemiplegia, Diabetes, and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) of 11 indicating the resident was moderately impaired and required physical help with transfer. Review of the Clinical Notes Report dated 1/19/2023 at 11:53 AM revealed, .Resident reported to this nurse she had a fall last week and she has been hurting on her left side since then. Resident daughter was present when resident reported this to this nurse [Licensed Practical Nurse [LPN #1]. Resident stated CNA [Certified Nursing Assistant #1] dropped her when transferring her to chair from bed. Resident also stated CNA stated she reported fall to UM [Unit Manager #1]. Resident stated UM never came. Resident also stated she reported pain to her left side and fall yesterday to therapy. Therapy informed resident pain and fall was reported to UM. Today daughter stated she was very upset she was not notified and tx [treatment] was not provided to her mother. This nurse reported concerns and complaints to DON [Director of Nursing], and NP [Nurse Practitioner]. Awaiting instructions from NP. This nurse administered scheduled PRN [as needed] medication to resident for pain. Resident stated pain is 10 out of ten to her whole left side. Resident stated upper arm does not hurt. This nurse assessed resident for bruising, and injury. None noted. No swelling noted .Xray [Radiology] of affected extremity . Review of the Clinical Notes Report dated 1/19/2023 at 2:50 PM revealed, .Therapy staff member notified this nurse that resident did not want to participate in therapy. Therapy informed this nurse that resident stated her left arm was sore because resident had a fall, last week. Therapy further stated the resident did not want to tell her who was with her when she fell. This nurse informed therapy I would speak with resident. This nurse went to resident's room to inquire about fall and when it happened. Resident stated the CNA [Certified Nursing Assistant] was helping her transfer from wheelchair to bed when her leg gave out. Resident further stated the cna [CNA]: helped her to the floor. Resident state they [she and the the CNA] were able to get her up by pushing up on bed and using the arm of wheelchair. Whem [when] this nurse inquired who was the cna, resident reluctantly stated CNA's name. This nurse Immediately spoke with ADON [Assistant Director of Nursing] for instructions. Event not [note] completed regarding resident's self-reporting and interventions . Review of the GRIEVANCE RECORD dated 1/19/2023 revealed .RP [responsible party] was informed today by resident of an assisted fall that occurred one week ago and she [the resident's responsible party] is upset that she did not receive notification from staff nor f/u [follow-up] x-ray were ordered .event was not reported until today [1/19/2023] . During a telephone interview on 2/13/2023 at 11:55 AM, Daughter #1 was asked when was she notified by the facilty of Resident #6's fall, she stated .when she [Resident #6] called me on the 18th she was in pain and let her fall she reported to therapy .they reported it to [Named unit manager #1] . During an interview on 2/13/2023 at 12:06 PM, Resident #6 was asked what happened when she fell in the facility. Resident #6 stated .the girl let me fall .that how everything got started .[Named CNA #1] .said she reported it to [Named Unit Manger #1] .it was in the day time .they were getting me ready for therapy .she was trying to get me out the bed .she told them she placed me on the floor .but she did not .she let me fall .I hurt my back .she tried to get me up herself .I was trying to help her .she put the wheelchair behind me .she had my arm pulling me up off the floor .she got me back to the wheelchair .I helped her . During an interview on 2/15/2023 at 10:54 AM, Unit Manager #1 was asked how she found out Resident #6 had fallen. Unit Manager #1 stated .therapy came to me one afternoon .I was at nursing station .[therapy] told me the patient said she had a fall the week before .she did not want to do therapy, her arm was sore .she didn't fall by herself .someone was with her .she did not want to get her in trouble .went to the patient room .asked her what happen .where .how did she fall .she stated beside her bed .did someone help you .she said [Named CNA #1] .was with me .I asked her what was going on .she said she was trying to help her with transfer .her leg gave out .I was supposed to write event note on the 18th .I just forgot to complete the note .I had a lot going .I honestly forgot to do it .the next day I put it in as a self-reported fall .resident reported to me . Unit Manager #1 was asked if she notified the responsible party. The Unit Manager stated .No .I was writing up because I did not call the daughter to notify her .not sure with the self-report I was to notify the daughter . In reviewing the event note the Unit Manager was asked how she determined the resident did not have any injuries. The Unit Manager stated .No .I Can't .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided during meal services for 1 of 4 (Resident #6) sampled residents reviewed for ADL care. The findings include: 1. Review of the facility's policy titled Resident rights and Resident Responsibilities revised 10/24/2022 revealed, .The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . Review of the facility's policy titled Activities of Daily Living (ADLs), Revised 3/9/2022 revealed, .The facility shall, based on the resident's comprehensive assessment and consisted with the resident's needs and choices, ensure a resident's abilities in activities of daily living (ADL) do not deteriorate unless .Eating include meals and snacks .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition . 2. Medical record review revealed Resident #6 was admitted on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension, Lower Back Pain, Anxiety Disorder, Edema, Hemiplegia, Diabetes, and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) of 11 indicating she was moderately impaired. Resident #6 required physical help with transfer. Review of the Meal Times revealed .Dinner .500-600 Hall Cart .5:10 PM . This is the hall Resident #6 resided. Review of the GRIEVANCE RECORD dated 2/1/2023 revealed .RP [responsible party] informs that resident contacted her late evening on 1/31/23 [2023] and reported that she did not receive her supper tray . During an interview on 2/13/2023 at 11:17 AM, the Director of Nursing (DON) was asked should the residents receive their meal trays timely. The DON stated .Yes . During a telephone interview on 2/13/2023 at 11:55 AM, the complainant confirmed her mother did not get her meal tray till 10:00 PM on 1/31/2023. During a telephone interview on 2/22/2023 at 7:45 AM, Certified Nursing Assistant (CNA) #2 was asked about Resident #6 missing a meal. CNA #2 stated .I did not pass her tray that day .I had a cart myself .other people were giving her tray .she got her breakfast and lunch tray .during dinner that night someone had went home .I passed the 700 and 800 Hall trays .someone passed 500 .no one came to me and told I was responsible for passing her tray .someone had done it for breakfast and lunch that day . CNA #2 was asked if she was assigned to Resident #6 that day. CNA #2 stated .Yes .they gave me her . CNA #2 was asked who had passed the breakfast and lunch tray to Resident #6. CNA #2 stated .I'm sure the .nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to provide treatment and care as ordered by the physician when orders for fluid restrictions, intravenous medications, and wound care treatments were not provided for 1 of 3 (Resident #3) sampled residents reviewed for fluid restriction and wound care. The findings included: 1. Review of the facility's policy titled Medication Administration revised 1/2021 revealed, .Medications will be administered by Licensed medical or nursing personnel .While administering medication the nurse will observe the 8 Rights of Medication Administration .Right Time - Check to ensure the medication is given within the time constraints of the order . Review of the facility's policy titled Physician's Verbal Orders revised 5/24/2021 revealed, Physician orders may be received by telephone, by a licensed nurse .The physician should sign the order on his/her next visit to the facility .Follow through with orders by making appropriate contact or notification .Verbal orders are those given to the nurse by the physician in person or by telephone, however, are not written by the physician in the medical records . Review of the facility's policy titled Pressure Injury Prevention and Non-Pressure Ulcer Management revised 10/15/2021 revealed, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. It is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure ulcers/injury present, and to promote wound healing of various types of wounds in accordance with current standard of practice and Physicians orders .Diabetic ulcer refers to ulcers caused by the neuropathic and small blood vessel complications areas of Diabetes. They typically occurs over the planter (bottom) surface of the foot on load bearing areas such as the ball of the foot .Surgical wound refers to any healing and non-healing, open or closed surgical incision .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factor, monitor the impact of the interventions, and modify the interventions as appropriate .Evidenced-based treatment in accordance with current standards of practice will be provided for all residents who have a pressure injury, non-pressure ulcer or other skin damage .Pressure injuries will be differentiated form non-pressure ulcers/injuries, such as arterial, venous, diabetic, surgical . 2. Medical record review revealed Resident #3 was admitted on [DATE] with a diagnosis of Diabetes, Peripheral Vascular Disease, Heart Failure, End Stage Renal Disease, Congestive Heart Failure, and Malignant Neoplasm of Kidney. Review of Patient Weight Report revealed Resident #3 weighed 275 pounds (lbs) on 9/1/2022, the day of admission to the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 15 indicating he was cognitively intact, weighed 294 pounds, and had no weight gain. (This was a 19 lb weight gain since admission on [DATE]). Review of Physician's Orders dated 9/1/2022 revealed the following: .CEFAZOLIN FOR INJECTION 1 GM [gram] (1gm/NS [normal saline] 100 ml [mililiters]) .Three Times Daily for Nine Days . Intake and Output (I & O) Two Times Daily . Wound Care Consult .Wound Care .(R) [right] foot Wash with Betadine Sol [solution], & [and] rinse there after each time with NACL [sodium chloride] sol. For irrigation. Blot dry with 4 x 4 [4 inches wide and 4 inches long] gauzes, Apply a thin film of Iodosorb 0.9 % [percent] topical gel ointment to the wound. Cover with DSG [dressing] bid [twice a day] & PRN [as needed] .Two Times Daily . (L) [left] foot Wash wound with Betadine Sol, & rinse there after each time with NACL sol [solution].for irrigation Blot dry with 4x4 gauzes, Apply a thin film of Iodosorb 0.9 % topical gel ointment to the wound. Cover with DSG bid & PRN .Two Times Daily . Review of Physician's Orders dated 9/2/2022, revealed .Wound Care Every 1 Day .(L) pinky toe Wash wound with Betadine Sol, & rinse there after each time with NACL sol for irrigation. Blot dry with 4x4 gauzes, Apply a thin film of iodosorb 0.9 % topical gel ointment to the wound. Cover with DSG bid & PRN . Review of Physician's Orders dated 9/8/2022 revealed .Wound Care Every 1 Day (R) foot Wash with Betadine Sol, & rinse there after each time with NACL sol. for irrigation. Blot dry with 4x4 gauzes, Apply a thin film of iodosorb 0.9 % topical gel ointment to the wound. Cover with DSG bid & PRN .Two Times Daily . (L) foot Wash wound with Betadine Sol, & rinse there after each time with NACL sol. for irrigation. Blot dry with 4x4 gauzes, Apply a thin film of Iodosorb 0.9 % topical gel ointment to the wound. Cover with DSG bid & PRN .Two Times Daily . Review of the Treatment Administration Record (TAR) for the month of SEPTEMBER 2022 revealed the resident's fluid intakes: on 9/2/2022 the resident's intake was 2000 ml, 1000 ml above restriction; on 9/7/2022 the resident's intake was 1100 ml, 100 ml above restriction; on 9/8/2022 the resident's intake was 1030 ml, 30 ml above restriction, and on 9/11/2022 the resident's intake was 1200 ml, 200 ml above restriction. Review of the TARecord for the month of SEPTEMBER 2022 revealed the following treatments were missed on the resident's right foot: 9/2/2022 on the 7pm-7am shift; 9/3/2022 on the 7am-7pm shift; 9/4/2022 on the 7pm-7am shift; 9/5/2022 on the 7pm-7am shift; 9/6/2022 on the 7am-7pm shift, and 9/7/2022 on the 7pm-7am shift. Review of the TARecord for the month of SEPTEMBER 2022 revealed the following treatments were missed on the resident's left foot: 9/2/2022 on the 7pm-7am shift; 9/3/2022 on the 7am-7pm shift; 9/4/2022 on the 7pm-7am shift; 9/5/2022 on the 7pm-7am shift; 9/6/2022 on the 7am-7pm shift, and 9/7/2022 on the 7pm-7am shift. Review of the TARecord for the month of SEPTEMBER 2022 revealed the following treatments were missed on the resident's pinky toe: 9/2/2022; 9/3/2022; 9/4/2022; 9/5/2022; 9/6/2022, and 9/7/2022. Review of the Medication Administration Records date SEPTEMBER 2022 revealed the resident missed the following doses of Cefazolin 1 gm: 9/6/2022 at 8:00 AM, 9/6/2022 at 4:00 PM, 9/9/2022 at 12:00 AM, 9/9/2022 at 4:00 PM, and 9/10/2022 at 4:00 PM. During an interview on 2/15/2023 at 5:17 PM, the Director of Nursing (DON) was asked should the nursing staff follow doctors' orders. The DON confirmed the staff should follow the doctors' orders. During a telephone interview on 2/21/2023 at 2:55 PM, the Medical Director was asked should the nursing staff follow doctors' orders. The Medical Director confirmed the nursing staff should follow the doctors' orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure the residents were free of accidents and ensure assistive devices were in good working order for 3 of 4 (Resident #6, 8, and 12) residents reviewed for falls. The findings included: 1. Review of the facility's policy titled Fall Risk - Fall Prevention revised 2/20/2020 revealed .To provide a coordinated system to identify Resident at risk for falls and develop an individual interdisciplinary plan of care to reduce the risk of falls and subsequently injury .The fall risk assessment will be completed by a licensed nurse . upon admission/readmission to the facility .After a fall .Maintenance Director or designee will ensure equipment used by the resident is in working order . Review of the facility's policy titled Occurrence Reporting revised 12/1/2022 revealed, .Our facility shall strive to provide a safe environment with methods to reduce accidents and methods to minimize injury form accidents .The following are examples accidents/incidents are events/occurrences that require the completion of a Nurse event note .Falls .All observed, reported, or other acquired knowledge of and occurrence shall be reported to the charge nurse or DON [Director of Nursing] by the employee who finds or witnesses the incident .The charge Nurse shall initiate the investigation by interviewing and gathering witness statements .from staff, resident .to determine the root cause . 2. Medical record review revealed Resident #6 was admitted on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension, Lower Back Pain, Anxiety Disorder, Edema, Hemiplegia, Diabetes, and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment, and required physical help with transfer. Review of the Physician's Orders dated 12/12/2022 revealed, .Transfer .Dependent w/ use of Mechanical Hoyer lift x 2 person . Review of the Care Plan dated 12/12/2022 revealed, .At Risk For Falls R/T [related to] left side deficits .1/18/2023 fall .intervention - repair locks on wheelchair .Remind .to call for assistance before moving from bed-to-chair and from chair-to-bed . Review of Physical Therapy Notes dated 12/12/2022 revealed .Comments .Min A [minimal assist] . Review of the Occupational Therapy Note dated 1/18/2023 revealed Precautions .fall risk .left side weakness .Pt stated her left side hurts today, no weight exercised done on that side. Nursing was informed of pain . Review of the Interdisciplinary Team Occurrence Investigation Worksheet, revealed .Date of incident .1/18/2023 (reported) .if yes, what type of injury .L [left]-side pain .medical treatment .x-ray .possible contributing factors .other w/c .Physical Function problems that may have contributed to the fall .Gait disturbance .Muscle Weakness .Loss of balance .Intervention(s) put in place .replacement of defective equipment . Review of the NURSE'S EVENT NOTE dated 1/19/2023 (no time documented) revealed .Resident stated she had fallen, last week in her room. CNA [Certified Nursing Assistant] was assisting her with transfer from wheelchair to bed. Resident stated her leg gave out and CNA assisted her to sitting position on floor. Resident further stated she did not hurt herself .Observed fall .Injury No apparent injury .1/19/2023 .13:40 [1:40 PM] .Resident reported to therapy staff member that her left arm was hurting and she did not want to participate. Resident reported to therapist that she had a fall sometime last week. This nurse inquired of resident regarding fall. Resident stated she was being assisted from her wheelchair to her bed, by a CNA, when her leg gave out and she fell to floor with CNA's assistance. She further stated she and the CNA were able to get her into bed. Stated she did not have any pain at the time . Review of the Clinical Notes Report dated 1/19/2023 at 11:53 AM revealed .Resident reported to this nurse she had a fall last week and she has been hurting on her left side since then. Resident daughter was present when resident reported this to this nurse [Licensed Practical Nurse (LPN #1)]. Resident stated CNA #1 dropped her when transferring her to chair from bed. Resident also stated CNA #1 stated she reported fall to UM [Unit Manager (#1)]. Resident stated UM never came. Resident also stated she reported pain to her left side and fall yesterday to therapy. Therapy informed resident pain and fall was reported to UM. Today daughter stated she was very upset she was not notified and tx [treatment] was not provided to her mother. This nurse reported concerns and complaints to DON [Director of Nursing], and NP [Nurse Practitioner]. Awaiting instructions from NP. This nurse administered scheduled PRN [as needed] medication to resident for pain. Resident stated pain is 10 out of ten to her whole left side. Resident stated upper arm does not hurt. This nurse assessed resident for bruising, and injury. None noted. No swelling noted .Xray [Radiology] of affected extremity . Review of the Clinical Notes Report dated 1/19/2023 at 2:50 PM revealed .Therapy staff member notified this nurse that resident did not want to participate in therapy. Therapy informed this nurse that resident stated her left arm was sore because resident had a fall last week. Therapy further stated the resident did not want to tell her who was with her when she fell. This nurse informed therapy I would speak with resident. This nurse went to resident's room to inquire about fall and when it happened. Resident stated 'the CNA was helping her transfer from wheelchair to bed when her 'leg gave out.' Resident further stated 'the cna helped her to the floor.' Resident stated 'they [she and the CNA] were able to get her up by pushing up on bed and using the arm of wheelchair.' Whem [when] this nurse inquired who was the cna, resident reluctantly stated CNA's name. This nurse Immediately spoke with ADON [Assistant Director of Nursing] for instructions. Event not [note] completed regarding resident's self-reporting and interventions . Review of the Interdisciplinary Team Occurrence Investigation Worksheet revealed, .Date of incident .1/18/2023 (reported) .if yes, what type of injury .L [left]-side pain .medical treatment .x-ray .possible contributing factors .other w/c .Physical Function problems that may have contributed to the fall .Gait disturbance .Muscle Weakness .Loss of balance .Intervention(s) put in place .replacement of defective equipment . During an interview on 2/13/2023 at 12:06 PM, Resident #6 was asked what happened when she fell in the facility. Resident #6 stated .the girl let me fall .that's how everything got started .[Named CNA #1] .said she reported it to [Named Unit Manger #1] .it was in the day time . getting me ready for therapy .she was trying to get me out the bed .she told them she placed me on the floor .but she did not .she let me fall .I hurt my back .she tried to get me up herself .I was trying to help her .she put the wheelchair behind me .she had my arm pulling me up off the floor .she got me back to the wheelchair .I helped her . During an interview on 2/13/2023 at 3:47 PM, the Assistant Director of Nursing (ADON) was asked when she was notified of Resident #6's fall. The ADON stated .on the 18th [1/18/2023] from [Named Unit Manager (UM) #1] .therapy reported to her [UM #1] the resident did not want to participate due to a fall one week ago . The ADON was asked if Resident #6 was assessed, an event note completed, and the family notified. The ADON stated .No .on the 19th [Named Licensed Practical Nurse [LPN #1] .informed me [Named Complainant] .wanted to speak to management . her mom had a fall she was unaware of .went and talked to the patient .tell me about that [the fall] .what happened .one time she said she was dropped .one time she said she was assisted with the fall .assessed her pain .we did order x-ray .they were clear no fractures .told her if she was in pain, she had prn [as needed] hydrocodone .I would get it scheduled .I did .I told the charge nurse to give her a pain medication . The ADON was asked if she knew the wheelchair was malfunctioning. The ADON stated .yes .I checked it out .assessed the wheelchair .it was still not working .it would not lock on the left side the wheelchair .it still moved . The ADON was asked should the staff member do with a malfunctioning wheelchair. The ADON stated .the nurse or the aide should put it in TELS [a building management platform that replaces logbooks and helps track preventative maintenance and any issues] . The ADON was asked should CNA #1 have moved the resident during the fall. The ADON stated .the aide should not move the resident .leave them there .report it .so the nurse can come assess the resident .help get them up off the floor .complete event note .write statements . The ADON was asked should the CNA #1 have written a statement the day of the fall. The ADON confirmed the staff members should have written statements the day of the fall and given to the charge nurse. During an interview on 2/14/2023 at 9:00 AM, CNA #1 was asked if she knew the wheelchair was malfunctioning and if she reported it to anyone. CNA #1 stated .Yes .ma'am .the Assistant Maintenance man .he said you still going to use the chair .she had 2 chairs in her room .one was to tight and uncomfortable .so I used her old one that was not working good .I was trying to get her up for therapy .get her up .she is a stand pivot .she holds with one hand .the side was not locking and the chair moved back away from us .I sat her on the floor .I asked her if she was comfortable with me getting her in the chair .took her arm and pants and moved her in the chair .I had her grab the side that locked .moved her to the wheelchair . CNA #1 was asked what is the process when you witness a fall. CNA #1 stated .with the fall assist to the ground .go get help .don't get them up .get the nurse come back and assess them .we lift them off the floor .report to the nurse and write a statement . CNA #1 was asked if she wrote a statement. CNA #1 stated .No .I should have .no ma'am I did not . CNA #1 was asked if she reported the fall. CNA #1 stated .I had been saying something about her wheelchair for the longest .when I told them chair messing up .nurse was charting and did not get up . CNA #1 was asked if she knew how to put things into TELS. CNA #1 stated .No .I don't know how to use TELS . During an interview on 2/14/2023 at 3:44 PM, LPN #2 was asked if she was informed by CNA #1 Resident #6 had a fall on 1/11/2023. LPN #2 stated .the [Named CNA #1] walked up and stated that [Named Resident #6] something was wrong with her wheelchair .she got her to the floor .she assisted her in the bed without help .I did move. It was not my resident . LPN #2 was asked if LPN #1 went to check on the resident. LPN #2 stated .I don't know if she looked at her or not .she said ok .I don't feel like I should go down and check on her resident when she was sitting there with me . LPN #2 was asked what is the process when aide report a resident has fallen. LPN #2 stated .If CNA comes to me I'm going straight to the resident room and assess them . LPN #2 was asked if she worked the 500 hall. LPN #2 stated .Yes .I pick up extra I have the 500 hall . LPN #2 was asked if she remembered getting in report Resident #6 had a fall. LPN #2 stated .did not remember get in report she had a fall .no .no one mention until she came back from therapy . LPN #2 was asked if she knew Resident #6 had a fall should she have completed follow-up note. LPN #2 stated .Yes . During a telephone interview on 2/15/2023 at 8:47 AM, LPN #1 was asked to tell me about Resident #6's fall. LPN #1 stated .all I know is one day went in to give medication .the daughter was in there .she said called the state .[going to] sue this place, her mother fell in the room .complained of pain to her left side .so then I went to the resident .talked to her asked what happened .she said [Named CNA #1] dropped her trying to transfer her from the bed to the wheelchair .dropped her on the floor . LPN #1 was asked what day was this on. LPN #1 stated .the 19th [1/19/2023], she told me the day before she reported to therapy .they reported it to the unit manager .I was on the hall passing meds [medication] .when I came in the room .that is when the daughter started to tell me what was said .then I asked the resident what happen .after [resident] told what happen .I asked why didn't she report it to me .I did not report because [Named CNA #1] .said she reported .who did she report it to .the lady with short hair and glasses . LPN #1 was asked if she remembered CNA #1 coming to the nursing station and report it to you and LPN #2. LPN #1 stated .she never reported to me .I told the DON if I dropped the ball .I would be professional to admit I dropped the ball .but to my knowledge, she never told me she had a fall or was attempting to fall .DON stated that she looked at the camera and [Named CNA #1] said LPN #2 .Assistant Maintenance Director was standing there .she did see the picture on the video .she said she do believe [Named CNA #1] did tell me .she wrote me up for not properly handling the fall .I did not agree to the write up .I'm no long working there .told her if woman called state .I will tell them what occurred when they call me . During an interview on 2/15/2023 at 9:54 AM, the Therapy Director was asked if Resident #6 received therapy and what type(s) of therapy. The Therapy Director stated .Yes .OT [Occupational Therapy] .upper body strength, dressing, and grooming . The Therapy Director was asked how did Resident #6 get to the therapy gym. The Therapy Director stated .the CNAs get her ready in her wheelchair .we would bring her to the gym . The Therapy Director was asked if Resident #6 had reported a fall. The Therapy Director stated .Yes .at the end of her treatment she [Resident #6] complained her left side was hurt .she [Resident #6] could not tell the day .she [Resident #6] said a few days ago . I asked .did it happen yesterday or the day before .she [Resident #6] said I don't recall the date .it was during the transfer .It did not go well .the CNA placed her [the resident] on the floor . The Therapy Director confirmed she reported it to Unit Manager #1. Therapy Director was asked if she knew the wheelchair was malfunctioning. The Therapy Director stated .I assisted her up in her chair .yes ma'am .I know one day when she was here .her wheelchair was not locking .I switched her chair out .I moved it out of the way .I do remember doing that . The Therapy Director was asked if she should have taken it to maintenance, put it into TELS, and documented the chair was malfunctioning. The Therapy Director stated .Yes .I probably should have .I did not put it into TELS .I just got busy .I did not document the wheelchair was not working in my notes . During an interview on 2/15/2023 at 10:54 AM, the Unit Manager #1 was asked how she found out Resident #6 had fallen. The Unit Manager #1 stated .therapy came to me one after noon .I was at nursing station .told me the patient said she had a fall the week before .she did not want to do therapy, her arm was sore .she didn't fall by herself .someone was with her .she did not want to get her in trouble .went to the PT [physical therapy] room .asked her [Resident #6] what happened .where .how did she fall .she [Resident #6] stated beside her bed . [asked resident] did someone help you .she [Resident #6] said [Named CNA #1] .was with me .I [UM #1] asked her [Resident #6] what was going on .she [Resident #6] said she [CNA] was trying to help her [Resident #6] with transfer .her leg gave out .did not fall she [CNA] helped me [Resident #6] down to the floor .asked the day she [Resident #6] fell if she was hurt .she said no .when I [UM #1]talked with her .she [Resident #6] said she hurt her arm .arm was sore .she [Therapy Director] told me on the 18th [1/18/2023] .I was supposed to write event note on the 18 th .I just forgot to complete the note .I had a lot going .I honestly forgot to do it .the next day I put it in as a self-reported fall .resident reported to me . The Unit Manager #1 was asked if she notified the responsible party. The Unit Manager stated .No .I was writing up because I did not call the daughter to notify her .not sure with the self-report I was to notify the daughter . In reviewing the event note the Unit Manager was asked how she determined the resident did not have any injuries. The Unit Manager stated .No .I Can't . During a telephone interview on 2/16/2023 at 4:35 PM, the Administrator was asked what is the process for reporting a wheelchair is malfunctioning. The Administrator stated .If have equipment not working .staff should put it in the TELS system for repair .tell staff equipment not working .when identified not working .chair unstable .that is the standard . The Administrator was asked what should the therapy staff do if notice a wheelchair not working. The Administrator stated .if she [resident] was in therapy .and the chair was not working .they [therapy] should have changed out the wheelchair .there should be some note she [resident] received a different chair .they [therapy] should have all the chairs numbered to identify the wheelchairs .when last time serviced . The Administrator was asked who is responsible for updating the order when there is a change in transfer. The Administrator confirmed the lead therapist/therapy manager should have made the changes. The Administrator was asked what should happen when a nurse finds out the resident had a fall. The Administrator stated .anytime reported there is a fall .she [nurse] should have done an assessment .gathered the staff statements .anyone else involved .try to get a picture of what occurred .that is part of the event note process .notify the medical doctor [MD] .responsible party .follow up on the fall .the MD may give order, for some labs .may send them out for an evaluation . The Administrator was asked should the MD/NP [Nurse Practitioner] come assess the resident after the fall. The Administrator state .Yes .If they are notified .they look at the resident .may not do it the same day .the Nurse Practitioner here more regular .when notified .she should have some type of intervention with the resident that they were notified and followed up . 3 Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with a diagnosis of Dementia, Hypertension, Dysphagia, Anxiety Disorder, and Gastroesophageal Reflux. Review of the quarterly MDS assessment dated [DATE] revealed Resident #8 had a BIMS of 3, indicating she was had severe cognitive impairment and required physical help with activity of daily living (ADL). The MDS documented Resident #8 had no history of falls. Review of the Occurrence dated 2/2/2023 revealed, .Location of the occurrence .Residents room .How was the Resident positioned when you observed them .laying of floor beside bed laying on her left side . Review of the NURSE'S EVENT NOTE dated 2/2/2023 revealed, .Location .Patient Room .Occurrence .Unobserved Fall .Injury Swelling .Indicate area of injury large lump on left side of forehead over left eye . There was no documentation on the event note that identified the laceration/skin tear above the residents right eye. Review of Initial skin assessment dated [DATE] revealed the resident had an injury to .Head .Top of Head .Left .Front .Distal . However, there was no description of the type of injury and did not indicate the skin tear above the right eye. The facility failed to complete an accurately skin assessment for Resident #8 after her fall and on returned to the facility from the hospital. Review of the Clinical Notes Report dated 2/2/2023 at 6:56 PM revealed, .This nurse was called to resident room to find resident laying on her stomach with her face down with bed in lowest position, this nurse assessed resident and resident could not explain what happened resident was place in the bed and VS are as following BP 129/71, 73,18, 96 % [percent], 98.0, UPON ASSESSMENT resident has large knot to left side of forehead above left eye, resident has no other skin issues or areas of concern. FNP [Family Nurse Practitioner] notified with new orders to send to hospital. Resident RP [Named daughter #2] notified with request to sent [send] to [Named Hospital] . Review of the Interdisciplinary Team Occurrence Investigation Worksheet dated 2/2/2023 .was medical treatment provided .transfer to ER .the root cause of occurrence poor safety awareness .Intervention(s) put in place .apply bed bolsters to bed to define bed parameters . Review of the [Named Hospital Records] dated 2/2/2023 revealed .EMS [emergency medical services] reported that they thought she had fallen but according to the staff they think that something fell off the shelf above her head hitting her on the left side of her face .She is stating that something fell of the shelf next to her bed as well .Skin .small 1 cm [centimeter] v shape skin tear to right face .PROCEDURE .cleaned patient's right temporal skin tear and applied Dermabond for closure .visible hematoma over her left eyebrow .Diagnosis .Head injury .facial hematoma .possible neck injury given patient's age and frailty despite her denying pain on exam .IMPRESSION .Facial hematoma .Facial laceration .PATIENT EDUCATION .Hematoma .Laceration Care .Follow up with primary care provider .Within 305 days .Laceration Care .Wash area with soap and water . Review of the Clinical Notes Report dated 2/3/2023 at 1:58 AM revealed, .Resident returned back to facility via ambulance on stretcher no s/s [signs and symptoms] of distress resident a [alert]x [times]2 has large hematoma to left eye, eye lid is swollen shut. Resident vs [vital signs] wnl [within normal limits] denies pain at this time will notify np [nurse practitioner] and md [medical director] and rp [responsible party] of resident's return . Review of the NURSE'S EVENT NOTE dated 2/14/2023 (12 days after the fall incident) revealed, .Location Incident Occurred .Patient Room .Injury Skin Tear .Indicate area of injury right side of head (near right temple) .This nurse was notified of area to resident right side of head .area has adhesive glue applied at hospital at time of resident LOA [leave of absent]. Area dry with sight scab noted. Resident shows no s/s [signs and symptoms] of pain or discomfort r/t [related to] area .Treatment nurse notified .RP [responsible party] advised this nurse she was aware and it was treated at the hospital . During a telephone interview on 2/14/2023 at 12:49 PM, Daughter #2 was asked about the incident when Resident #8 had a fall. Daughter #2 stated .Incident report was not filed till the next day and it seem incomplete .she scooted to the end of the bed .fell hit her forehead .found by [Named CNA #3] told the LPN [Named Unit Manager #2] .got off floor placed in bed [Named Unit Manager #2] called at 6:30 PM on 2/2/2023 .said she had fallen out of bed . spoke to NP .transfer to ER for CT [Computerized Tomography - scan to reveal abnormalities of the head/brain] .scan, [Name Hospital] .I met her there .my sister went to the nursing home .to talk to [Named Unit Manager #2] and the CNA had left for the day .she wanted to speak to them .light in the room was out, the power was out when talked to [named Unit Manager] the day she fell the power was out, she took photos and the fall mat not in front of bed was on the side .bed was low as it could go .1 foot off the floor .she had a skin tear on the right forehead .the DON said she examine [Resident #8] that morning .she had bruise on her left arm . During an observation and interview in the resident room on 2/15/2023 at 5:21 PM the DON was asked during a fall should the staff complete a head-to-toe assessment and skin assessment. The DON stated .when I assessed her .I saw the bruise on her left arm, the bruising on her cheeks and the knot over her the left eye .because she always wears a turban or a hat .I did take the hat off .no .I did not remove the hat .I was more concern about the knot to the left side of her face .She [the nurse] documents the bruising .the knot but not the laceration on the right forehead . The DON was asked to remove the black hat off the resident head. Observation on the right side of face above the right eye was a wound with Dermabond intact. The DON confirmed the nursing staff should complete a head-to-toe skin assessment. 4. Review of the medical record revealed Resident #12 was admitted on [DATE] with a diagnosis of Hypertension, Anxiety Disorder, Dementia, Esophagitis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had a BIMS of 13, indicating she was cognitively intact. Resident #12 required physical help with activity of daily living (ADL) and had no history of falls. Review of the Care plan dated 1/22/2023 revealed .Interventions .Keep bed in lowest position .dycem to w/c [wheelchair] .Bed alarm in place .chair alarm .Footware will fit properly .have non-skid soles . Observation in the resident's room on 2/15/2023 at 5:17 PM with the Director of Nursing (DON) revealed Resident #12 did not have a bed alarm on her bed. During an interview in the resident's room on 2/15/2023 at 5:17 PM the DON was asked if Resident #12 should have a bed alarm as documented on the care plan, the DON stated, .yes .it should have been on her bed .staff should follow the care plan .resident care need should be followed .I'm the one who update the care need .I put the interventions in place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to maintain equipment in good repair in 1 of 1 (Resident #6) sampled residents reviewed for wheelchair function. The findings included: 1. The facility's INSTRUCTIONS DIRECT SUPPLY TELS [a building management platform that replaces logbooks and helps track preventative maintenance and any issues], dated 2/25/2023 revealed, .Inspect wheelchairs for damaged or missing components .check wheelchair for proper operation .Ensure wheelchair is tagged with resident's name .Items identified as poor condition should be removed from service . 2. Medical record review revealed Resident #6 was admitted on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension, Lower Back Pain, Anxiety Disorder, Edema, Hemiplegia, Diabetes, and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) of 11 indicating she was moderately impaired and required physical help with transfer. Review of the Work Orders dated 1/1/2022 - 2/13/2023 revealed there were no work orders documented in TELS (TELS is a building management platform that replaces logbooks and helps track repairs) for the repair of any wheelchairs in the facility. During an interview on 2/15/2023 at 11:39 AM, Certified Nursing Assistant (CNA) #1 was asked how long was Resident #6's wheelchair not working properly. CNA #1 stated .I'm going to be honest .about a week before she fell .I know it was not working . CNA #1 was asked if she ever notice her having a different wheelchair. CNA #1 stated .No .not when I got her up . During an interview on 2/15/2023 at 5:17 PM, The Director of Nursing (DON) was asked to how long was the wheelchair malfunctioning. The DON stated .I was told the wheelchair was changed out by [Named CNA #1] .I was told the chair was in disrepair the week prior to the fall .on 1/18/2023 .ADON [Assistant Director of Nursing] went to her room and found she had the same chair .it would not lock the chair continued to move . The DON confirmed the wheelchair should have been removed. During an interview on 2/21/2023 at 1:23 PM, when the Maintenance Director was asked the process when staff identify malfunctioning equipment, he stated .anytime have problem with equipment .everything has to go thorough TELS .once it's put in TELS .we get to it .fix it .I make note in TELS .I put in a comment .I have them put it in TELS so we can track it .and know if there is something else needs to be done . Observation in the Therapy Gym on 2/21/2023 at 1:45 PM, with the Maintenance Director and the Therapy Director, revealed in the right side of the gym was a oversized and a high back wheelchair that was unlabeled. During an interview on 2/21/2023 at 1:45 PM, the Therapy Director and the Maintenance Director were asked the procedure for assigning and tracking a wheelchair when issued to a resident. The Therapy Director stated .our system is when we have a patient .we find an appropriate wheelchair .we don't have a system to track the wheelchairs . The Maintenance Director was asked if he completed preventive maintenance on a wheelchair when the resident is discharged . The Maintenance Director confirmed that he would just clean the wheelchair and return them back to therapy. The facility had no system in place to track the equipment when assigned to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the residents' status for 1 or 1 sampled residents (Resident #95) reviewed for tracheostomy care. The findings include: Review of the medical record, revealed Resident #95 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Person Injured in Motor Vehicle Accident. Traumatic Brain Injury, Tracheostomy, Gastrostomy, Depression, and Pulmonary Embolism. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #95 was not coded as receiving tracheostomy care. Review of the Physician Order Sheet dated 4/2022, revealed .Tracheostomy cannula care .One Time Daily Starting 1/27/2022 . During an interview on 4/21/2022 at 10:47 AM, the Director of Nursing confirmed Resident #95 should have been coded as receiving tracheostomy care on the MDS dated [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure residents were assisted with Activities of Daily Living (ADLs) for 2 of 3 sampled residents (Resident #11 and #45) reviewed for ADLs. The findings include: Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Acute Respiratory Failure, Dysphagia, Gastrostomy, and Chronic Obstructive Pulmonary Disorder. Review of the comprehensive Care Plan revised 10/11/2021, revealed .Self care deficit .bathing .hygiene .Bathing - Bath/Shower .3x[times]week/prn [as needed] as tolerated alternating days with bed baths . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #11 was severely impaired cognitively, and was dependent on staff for ADL's. Review of the of the ADL Verification Worksheet dated 4/1/2022 - 4/21/202, revealed Resident #11 received no baths or showers. The facility was unable to provide documentation of Resident #11's baths or showers. Observation in the resident's room on 4/18/2022 at 10:16 AM and 4/18/22 at 5:09 PM, revealed Resident #11 had large amount of dry flaky skin on his face and forehead, and a large amount of white flakes in his hair. During an interview on 4/21/2022 at 3:29 PM, the Director of Nursing (DON) confirmed the ADL sheet should be completed daily and Resident #11 should have received a bath or shower 3 times a week. During an interview on 4/21/2022 at 7:17 PM, Certified Nursing Assistant (CNA) #3 stated .most of them [residents] are not getting shower/baths .there are some that are vocal .if they complain .they will get one [shower/bath], we have scheduled shower day .residents are not going as shower schedule .we document the showers or bath on the kiosk [computer for daily documentation of ADLs] .if not documented .they did not get it .I know the rule if not documented it was not done .we have had multiple meeting about the showers . CNA #3 confirmed Resident #11 has not had baths or showers three times a week. Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disorder, Hemiplegia, and Peripheral Vascular Disease. Review of the Care Plan dated 12/17/2021, revealed .Self care deficit R/T [related to] ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers .Bathing - Bath/Shower .3xweek and as needed or requested . Review of the ADL Verification Worksheet dated 2/2/2022-4/14/2022, revealed Resident #45 received a shower on 2/3/2022, and bed baths on 2/2/2022, 2/8/2022, 2/11/2022, 2/13/2022, 2/18/2022, 3/2/2022, 3/8/2022, 4/5/2022, 4/8/2022, and 4/14/2022. Review of the ADL Flow Sheets for 2/1/2022-4/19/2022, revealed Resident #45 received showers on 2/15/2022, 2/21/2022, 2/25/2022, 3/3/2022, 3/10/2022, 3/17/2022, 3/20/2022, and 4/9/2022. Review of the facility's ADL bath and shower documentation revealed the following: Resident #45 was documented as having received 2 baths or showers the weeks of 2/6/2022-2/11/2022, 2/20/2022-2/26/2022, 2/27/2022-3/5/2022, and 3/6/2022-3/12/2022. Resident #45 was documented as having received 1 bath or shower the weeks of 3/13/2022-3/19/2022, 3/20/2022-3/26/2022, and 4/10/2022-4/16/2022. Resident #45 was not documented as having received a bath or shower the week of 3/27/2022-4/2/2022. During an interview on 4/19/2022 at 6:50 PM, the Director of Nursing (DON) confirmed baths and showers should be documented on days they are given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide care and services for residents with enteral feedings when residents received the incorrect enteral feeding and enteral feedings were administered at the incorrect rate for 2 of 3 sampled residents (Resident #11 and #80) reviewed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. The findings include: Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Acute Respiratory Failure with Hypoxia, Dysphagia, Gastrostomy, and Chronic Obstructive Pulmonary Disorder. Review of the Physician Order Sheet dated 4/2022, revealed an order for a bolus feeding (a set amount of enteral feeding administered at one time, without a feeding pump) of Two Cal (Calorie) HN (High Nitrogen) 240 milliliters (ml) every 6 hours. Observation in the resident's room on 4/19/2022 at 11:16 AM, revealed LPN #4 administered a bolus tube feeding to Resident #11. LPN #4 donned gloves, placed an enteral feeding syringe in the feeding tube port, checked for stomach residual, and administered a bolus feeding of strawberry ensure plus through Resident #11's feeding tube. During an interview on 4/21/2022 at 11:34 AM, the Director of Nursing (DON) confirmed Resident #11 had an order for Two Cal HN and staff should administer the bolus feedings as ordered. Review of the medical record, revealed Resident #80 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia, Dysphagia, Gastrostomy, and Aphasia. Review of the Physician Order Sheet dated 4/2022, revealed an order for Jevity 1.5 at 55 ml per hour for 22 hours daily. Observation in the resident's room on 4/18/2022 at 11:51 AM, 2:20 PM and 3:38 PM, 4/19/2022 at 11:42 AM and 4:12 PM, and on 4/20/2022 at 8:14 AM, revealed an enteral feeding pump administering Jevity 1.5 at 50 ml an hour to Resident #80. During an interview on 4/21/2022 at 10:38 AM, the DON confirmed the Physician's Order and that the enteral feeding should be administered at 55 ml per hour.

Based on medical record review, observation, and interview, the facility failed to follow professional standards of practice for a Midline Catheter for 1 of 1 sampled residents (Resident #75) reviewed for a Midline Catheter. The findings include: Review of the medical record, revealed Resident #75 was admitted to to the facility on 6/11/2021 with diagnoses of Dementia, Atherosclerosis, Chronic Kidney Disease, Heart Failure, and Diabetes. Review of the Physician Orders dated 4/15/2022, revealed .Insert Midline Catheter per MD [Medical Doctor] order . There were no orders for monitoring or care of the Midline catheter. Review of the 4/2022 Medication Administration Record, revealed no documentation for monitoring or care of the Midline Catheter until 4/19/2022. Observation in the resident's room on 4/18/2022 at 9:45 AM, revealed Resident #75 was sitting in his wheelchair, with a Midline Catheter to his upper right arm with a dressing dated 4/16/2022. During an interview on 4/19/2022 at 6:20 PM, the Director of Nursing (DON) confirmed the Midline Catheter was inserted on 4/16/2022, and there were no Physician's Orders for the monitoring and care of the Midline Catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to obtain orders for oxygen for 2 of 2 sampled residents (Resident #11 and Resident #95) reviewed for Respiratory Care. The findings include: Review of the facility's policy titled, Oxygen Concentrator and Oxygen Storage, with a revision date of 12/2021, revealed .Obtain Physician's orders for the rate of flow and route of administration of oxygen ( .nasal cannula .) . Review of the medical record, revealed Resident #11 was admitted on [DATE] with diagnoses of Encephalopathy, Acute Respiratory Failure, Dysphagia, Gastrostomy, and Chronic Obstructive Pulmonary Disorder. Review of the Physician's Order Sheet dated 4/2022, revealed Resident #11 did not have an order for oxygen therapy. Review of the Treatment Administration Record dated 3/2022 and 4/2022, revealed no documentation of the oxygen therapy. The facility was unable to provide orders for oxygen therapy. Observation in the resident's room on 4/18/2022 at 10:16 AM, 4/19/2022 at 8:33 AM, 4/20/2022 at 7:59 AM, 4/20/2022 at 2:04 PM, and on 4/21/2022 at 10:40 AM, revealed Resident #11 was receiving 2 liters of oxygen binasal cannula (BNC). During an interview on 4/21/2022 at 11:34 AM, the Director of Nursing (DON) confirmed that Resident #11 did not have an order for oxygen therapy. Review of the medical record, revealed Resident #95 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Traumatic Brain Injury, Tracheostomy, Gastrostomy, Depression, and Pulmonary Embolism. Review of the Physician Order Sheet dated 4/2022, revealed .Oxygen .at ( .liters/[per]minute .) . There was not a rate of administration for the oxygen. Observation in the resident's room on 4/18/2022 at 10:28 AM and 2:50 PM, 4/19/2022 at 5:33 PM, and 4/20/2022 at 8:12 AM and 5:20 PM, revealed Resident #95 was receiving oxygen at 2 liters per minute through a tracheostomy mask. During an interview on 4/21/2022 at 10:47 AM, the DON confirmed oxygen orders should include the rate of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the policy review, medical record review, and interview, the facility failed to communicate with Dialysis for 1 of 1 sampled residents (Resident #67) reviewed for Dialysis. The findings include: Review of the facility's policy Dialysis, dated 10/18/2021, revealed .The facility will communicate, coordinate, and collaborate relevant information with the dialysis clinic to ensure safe, continuous care of the resident .communication .which is sent to dialysis .dialysis clinic will communicate .by returning the completed .form to the facility .Documentation will include assessment of the resident's condition before and after dialysis .pre and post dialysis weights .skin integrity .nutrition/hydration .evidence of infection, bleeding .complications . Review of the medical record, revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Acute Kidney Failure, Diabetes, Anxiety and Dependence on Renal Dialysis. Review of the Physician's Orders dated 3/28/2022, revealed .Dialysis Monday-Wednesday-Friday .[Named Dialysis Facility] . Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #67 was assessed for receiving dialysis services. Review of the medical record, revealed the Dialysis Communication Forms were completed on 3/31/2022, 4/5/2022, and 4/7/2022. Review of the medical record, revealed Resident #67 also went to the dialysis on 4/2/2022, 4/9/2022, 4/12/2022, 4/14/2022, 4/16/2022, and 4/19/2022. The facility was unable to provide communication sheets for each dialysis visit. During an interview on 4/21/2022 at 4:02 PM, the Director of Nursing (DON) confirmed the communication sheets should be completed with each dialysis visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration rate of less than 5% (percent) when 2 of 4 nurses (Licensed Practical Nurse (LPN) #2 and #3) failed to properly administer medications for 2 of 5 sampled residents (Resident #80 and #95) observed during medication administration. This resulted in a medication administration error rate of 7.41%. The findings include: Review of the facility's policy titled Medication Administration, with a revision date of 2/9/2022, revealed .Medications administered via [by way of] feeding tube .Prior to administering medication, check for patency by administering a fluid flush as ordered .Each medication should be administered separately .Flush between medication . Review of the medical record, revealed Resident #95 was admitted to the facility on on 12/14/2021 with diagnoses of Respiratory Failure, Motor Vehicle Accident. Traumatic Brain Injury, Tracheostomy, Gastrostomy, Depression, and Pulmonary Embolism. Review of the Physician Order Sheet dated 4/2022, revealed orders for the following medications to be administered by enteral feeding tube: Vitamin D3 50 mcg (micrograms) capsule daily, Prevacid (a stomach medication)15 milligrams (mg) daily, Docusate Sodium 50mg per 5ml (milliliters) give 10 ml 2 times daily, Lorazepam (an antianxiety medication) 0.5 mg tablet (tab) 2 times daily, Lamictal (an anticonvulsant medication) 200 mg tablet 2 times daily, Levetiracetam (an anticonvulsant medication) 100 mg per ml give 15 ml 2 times daily, Acetazolamide (a diuretic medication) 250 mg tablet 2 times daily, Propranolol (a blood pressure medication) 20 mg 1 tablet 2 times daily, Eliquis (a blood thinner) 5 mg 1 tablet 2 times daily, water flush 30 ml 6 times daily, and to crush medications. The facility was unable to provide an order to cocktail (mix and administer together) Resident #95's medications. Observation in the 100 Hall on 4/19/2022 at 9:47 AM, revealed LPN #2 prepared the following medications for administration to Resident #95: a. Acetazolamide 250 mg 1 tablet b. Eliquis 5 mg 1 tablet c. Lamotrigine (generic Lamictal) 200 mg 1 tablet d. Lorazepam 0.5 mg 1 tablet e. Propranolol 20 mg 1 tablet f. Vitamin D3 50 mcg 1 capsule g. Prevacid 15 mg 1 tablet h. docusate 10 ml liquid i. Levetiracetam 15 ml liquid LPN #2 put on (donned) gloves, opened the medications, placed them in individual medication cups, and placed them on a tray. LPN #2 then placed the 5 tablets, except the Vitamin D3 and Prevacid into 1 medication cup, crushed the combined tablets, and placed the cup of cocktailed medications back on the tray. LPN #2 entered Resident #95's room with the medications on the tray, and placed it on the over bed table. LPN #2 entered the bathroom and obtained 200 ml of water in a plastic cup, poured 10 ml of water into each of the cups with the Vitamin D3, Prevacid, and the cocktail medications, and placed the cup of water on the tray with the medications. LPN #2 connected the enteral feeding syringe to the enteral tube and verified placement. LPN #2 poured 15 ml of water into the syringe, poured the cocktailed medications into the syringe, administered the medication by gravity, poured 30 ml of water into the syringe, poured the remaining liquid and dissolved medications into the syringe one at a time, failed to flush between the medications, and poured the remainder of the water into the syringe. The failure to administer each medication separately to Resident #95 resulted in medication error #1. Review of the medical record, revealed Resident #80 was admitted on [DATE], with diagnoses of Cerebral Infarction, Right side Hemiplegia, Dysphagia, Gastrostomy, and Aphasia. Review of the Physician Order Sheet dated 4/2022, revealed orders for the following medications to be administered by enteral feeding tube: Aspirin 81 mg 1 tab daily, Clopidogrel (an antiplatelet medication) 75 mg 1 tab daily, Docusate Sodium (a stool softener) 50 mg per 5 ml give 10 ml 2 times daily, Famotidine (an antihistamine) 40mg per 5ml oral suspension give 1.25 ml 2 times daily, Famotidine 40 mg give 1 tab 2 times daily, Multivitamin tablet 1 daily, Polyethylene Glycol (a laxative) 17 grams daily, a water flush 30 ml with medications, and to crush medications. The facility was unable to provide an order to cocktail Resident #80's medications. Observation in the 700 Hall on 4/20/2022 at 9:11 AM, revealed LPN #3 prepared the following medications for administration to Resident #80. a. Aspirin 81 mg 1 tablet. b. Multivitamin 1 tablet c. Clopidogrel 75 mg 1 tablet d. Famotidine 40 mg 1 tablet e. Famotidine 1.25 ml liquid f. Polyethylene Glycol 17 grams powder LPN #3 placed the tablets and liquid in individual medication cups, crushed the tablets individually, took the medication into Resident #80's room and placed them on a barrier on the over bed table. LPN #3 entered Resident #80's room, washed her hands, obtained a cup of water from the sink, diluted the medications with 15 ml of water, and placed the cup of water on the barrier with the medications. LPN #3 donned gloves, disconnected a feeding from Resident #80's feeding tube, and verified placement of the tube with an enteral feeding syringe. Then, without flushing the enteral tube, LPN #3 poured 2 cups of crushed medication, 1 at a time, into the syringe. When the medications did not flow through the tube by gravity, LPN #3 poured an unmeasured amount of water into the syringe. LPN #3 placed the plunger onto the syringe an applied light pressure, the medication did not go through the feeding tube. LPN #3 then poured the 2 medications mixed with water, from the syringe into a cup and flushed the enteral tube with 15 ml of water. LPN #3 poured the cocktailed medications into the syringe and administered them by gravity. LPN #3 poured the other cups of medications into the syringe,1 at a time, failing to flush between the medications, and flushed the enteral tube with 45 ml of water. The failure to administer each medication separately to Resident #80 resulted in medication error #2. During an interview on 4/21/2022 at 10:44 AM, the Director of Nursing (DON) confirmed medications should not be cocktailed without an order and staff should flush enteral feeding tubes prior to administering medications and between medication administration.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 10 medication storage areas (the 200 Hall Medication Cart and the Treatment Cart) were observed unlocked, unsecured, and unattended. The findings include: Review of the facility's policy titled, Medication Administration: medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, revised 9/20/2021, revealed .all drugs and biologicals will be stored in locked compartments .( .medication carts .) . Observation on the 200 Hall on 4/19/2022 at 11:10 AM, revealed the 200 Hall Medication Cart was opened, unattended, and unlocked in the hallway in front of room Resident #11's room with the door closed. During an interview on 4/19/2022 at 11:13 AM, Licensed Practical Nurse (LPN) #3 confirmed that she should not leave the medication cart unlocked, unsecured, and unattended. Observation on the 300 Hall on 4/20/2022 at 2:20 PM, revealed the Treatment Cart was opened, unlocked, unsecured and unattended, in the hallway in front of Resident #57's room with the door closed. During an interview on 4/20/2022 at 2:22 PM, the Wound Care Nurse confirmed that he should not leave his Treatment Cart unlocked and unattended. During an interview on 4/21/2022 at 1:50 PM, the Director of Nursing (DON) confirmed that the medication and treatment carts should not be unlocked, unsecured, and unattended.

Based on observation and interview, the facility failed to ensure that waste was properly contained and maintained in a sanitary condition to prevent the harborage and feeding of pests when 2 of 2 dumpsters (Dumpster #1 and #2) were observed open with a large amount of garbage lying in front and around the bases. The findings include: Observation of the dumpsters on 4/20/2022 at 7:15 AM, revealed the dumpsters' doors were open, with a large amount of trash and debris lying in front of the dumpster, with meal tickets, paper cups, Styrofoam boxes, and other debris. Observation of the dumpsters on 4/20/2022 at 8:17 AM, with the Director of Nutrition Services, revealed Dumpster #1 had a large amount of trash in front of the dumpster, including plastic straws, cups, Styrofoam cartons, ketchup packets, sugar packets, water bottles, salt and pepper packets, meal tickets, surgical masks, plastic wear, pudding cups, and mustard packets. Dumpster #2 had paper cups, straws, gloves, and Styrofoam cartons lying around the base of the dumpster. During an interview on 4/20/2022 at 8:17 AM, the Director of Nutrition Services confirmed the dumpster doors should stay closed and trash should not be lying on the ground around the dumpsters. During an interview on 4/20/2022 at 10:54 AM, the Dietary Manager confirmed the dumpster area should be cleaned daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain accurate medical records related to dietary intake and weights on 2 of 5 sampled residents (Resident #39 and #70) reviewed for Nutrition. The findings include: Review of the medical record, revealed Resident #39 was admitted to the facility on [DATE] with diagnoses of Dementia, Convulsions, Muscle Weakness and Insomnia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #39 required extensive assist with eating. Review of the Activity of Daily Living (ADL) Verification Worksheet dated 4/1/2022 - 4/20/2022 revealed incomplete documentation of the dietary intake for the following days: 4/2/2022 no documentation for dinner. 4/3/2022 no documentation for lunch or dinner. 4/4/2022 no documentation for breakfast or lunch. 4/6/2022 no documentation for dinner. 4/7/2022 no documentation for lunch and dinner. 4/12/2022 no documentation for lunch and dinner. 4/17/2022 no documentation for dinner. 4/20/2022 no documentaion for dinner. No meal percentages were recorded for the entire day on 4/1/2022, 4/5/2022, 4/9/2022-4/11/2022, 4/13/2022-4/16/2022, 4/18/2022 and 4/19/2022. During an interview on 4/21/2022, the Director of Nursing (DON) confirmed the ADL Verification Worksheet were incomplete. Review of the medical record, revealed Resident #70 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Chronic Obstructive Pulmonary Disorder, Hemiplegia, and Peripheral Vascular Disease. Review of the ADL Verification Report dated 3/31/2022-4/16/2022 revealed Resident #70 consumed 75% of supper on 4/4/2022. No other meal percentages were recorded. Review of the Patient Vital Sign Report dated 3/28/2022-4/20/2022 revealed the following weights: a. 3/28/2022 - 222.00 pounds (lbs) b. 3/29/2022 -199.00 lbs. c. 3/30/2022 - 73.00 lbs. d. 3/31/2022 - 74.00 lbs. e. 3/31/2022 - 189.00 lbs. f. 4/1/2022 and 4/2/2022 -199.00 lbs. g. 4/3/2022 - 222.00 lbs. h. 4/4/2022 - 224.00 lbs. i. 4/5/2022 - 216.00 lbs. j. 4/6/2022 - 199.00 lbs. k. 4/7/2022 - 75.00 lbs. l. 4/8/2022 and 4/9/2022 - 222.00 lbs. m. 4/10/2022 - 220.00 lbs. n. 4/11/2022 - 221.00 lbs. o. 4/12/2022 - 201.00 lbs. p. 4/13/2022 - 217.00 lbs. q. 4/14/2022 - 216.00 lbs. r. 4/14/2022 - 246.00 lbs. s. 4/15/2022 - 245.00 lbs. t. 4/16/2022 and 4/17/2022 -199.00 lbs. u. 4/18/2022, 4/19/2022 and 4/21/2022 - 200.00 lbs. v. 4/20/2022 - 228.00 lbs. During an interview on 4/20/2022 at 2:50 PM, the Restorative Certified Nursing Assistant (CNA) confirmed she has been trained to do weights and she does the weekly and monthly weights in the facility. The Restorative CNA confirmed she was not aware Resident #70 was on daily weights and did not know who had been weighing the resident. Observation in the 100-300 Hall Common Area on 4/20/2022 at 3:02 PM, revealed the Restorative CNA zeroed the wheelchair scales and weighed Resident #70. Resident #70 weighed 271.8 lbs. The Restorative CNA deducted the weight written on the back of the wheelchair, 43.4 lbs, and confirmed Resident #70 weighed 228.4 lbs. During an interview on 4/20/2022 at 3:20 PM, the DON confirmed Resident #70's weights were not recorded accurately. During an interview on 4/21/2022 at 10:44 AM, the DON confirmed meal percentages should be recorded on the ADL Verification Record and should not have blanks.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by carbon build-up on the pots and pans, dirty storage racks, pink substance build-up on the water curtain of the ice machines, dirty floors, a dirty dish machine, dirty utility carts and a dirty prep (prepare and make ready) table. The facility had a census of 93 with 85 of those residents receiving a tray from the Kitchen. The findings include: Review of the CLEANING SCHEDULE, revealed .Carts - Spray and wipe down outside Friday AM [morning] Aide .Kitchen Floors - Sweep Daily AM Aide . Review of the [Named] Department of Health and Human Services/Food Inspection and Safety, dated 2005, revealed .What exactly is slime .It is a type of mold or fungus that accumulates from bacterial growth on surfaces that are constantly exposed to clinging water droplets and warm temperatures. Water residuals may be present on these surfaces due to machine construction or the presence of scouring utensils such as steel wool or scouring pads. If the residuals are left exposed and not wiped clean or the machine is not sanitized regularly, you will then see bacteria and mold growths in the moist, cool environment of your ice machine. Most times, slime will take on a pinkish tone; if left untreated, the pink will turn to red, green, brown and even black ropes of slime hanging from the freezer panels inside the machine after a while . Observation in the Kitchen on 4/18/2022 at 9:25 AM and 4/20/2022 at 8:13 AM, revealed a large pot sitting on the 6-eye burner with carbon build-up coating over half of the pot on the outside. Observation in the Kitchen on 4/18/2022 at 9:28 AM and 4/20/2022 at 8:14 AM, revealed a large storage rack with white and brown crumbs and 5 sheet pans with large amount of carbon build-up. Observation in the Kitchen on 4/18/2022 at 9:31 AM, revealed the water curtain in the ice machine with a large amount of pink substance along the bottom of the water curtain. The water curtain was dripping into the ice machine. Observation in the Kitchen on 4/18/2022 at 9:33 AM, revealed at the hand sink, the floor had a large amount of dark stains that extended under the hand sink and the 3-compartment sink. Observation in the Kitchen on 4/18/2022 at 9:34 AM and 4/20/2022 at 8:40 AM, revealed the top of the dish machine had large amount of dried food particles and dark brown stains covering the top. Observation in the Kitchen on 4/18/2022 at 9:34 AM and 4/20/2022 at 8:42 AM, revealed 10 sheet pans, 2 sauce pots and 2 large skillets with a large amount of carbon build-up on a drying rack in the dish room. Observation in the Kitchen on 4/18/2022 at 9:37 AM and 4/20/2022 at 8:32 AM, revealed 6 utility carts with a large of amount of food substance and brown stains on the outside of the utility carts in the clean area of the kitchen. Observation in the Kitchen on 4/18/2022 at 9:39 AM and 4/20/2022 at 8:31 AM, revealed a prep table with a large amount of dark dried substance and white particles on the top and the middle shelves. Observation in the Kitchen on 4/20/2022 at 8:37 AM, revealed in the dish room there was a utility cart with a large of amount of brown stains on the inside and outside of the cart, with a large amount of food particles and a used medication cup, with several clean cups, bowls, plates, and divided plates. During an interview on 4/20/2022 at 8:48 AM, the Director of Nutrition Services confirmed the ice machines should not have pink substance on the water curtain, and the Kitchen should not have carbon build-up on the pots and pans. The Director of Nutrition Services confirmed the Kitchen should not have dirty utility carts, dirty prep tables, dirty equipment, and dirty floors. Observation in the 400 Hall Nourishment Room on 4/20/2022 at 10:57 AM, revealed along the bottom of the water curtain was a thin line of pink substance and a white dried substance on the inside ledge of the ice machine. During an interview on 4/20/2022 at 11:25 AM, the Dietary Manager (DM) confirmed that the ice machines should be checked daily and completely emptied and cleaned monthly. During an interview on 4/21/2022 at 5:06 PM, the DM confirmed that he is responsible for monitoring the dietary staff and the cleaning of the Kitchen. The DM confirmed the pots and pans should not have carbon build-up, should not have pink substance build-up in the ice machines, should not have dirty utility carts, dirty prep tables, dirty equipment, and dirty floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Centers for Disease Control and Prevention (CDC) guidelines, Employee Screening Logs, Employee Schedules, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 11 of 93 staff members (Certified Nursing Assistant (CNA) #1 and #2, Licensed Practical Nurse (LPN) #1 and #2, Dietary Staff #1, #2, #3, and #4, Housekeeping Staff #1, Business Office Staff #1, and admission Nurse #1) failed to complete screenings for the prevention and detection of COVID-19 prior to working for 3 of 4 days (4/8/2022, 4/9/2022, and 4/11/2022) reviewed and when 4 of 4 staff members (CNA #3, #4, #5, and #6) failed to perform appropriate hand hygiene and appropriate infection control practices during perineal care. The facility had a census of 89. The findings include: Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to) : individual screening on arrival at the facility . Review of the Facility's Policy and Protocol Booklet titled, Coronavirus 2019 (COVID-19) Response Plan . revised 2/3/2022, revealed .pg. 18. All staff .are required to sign in the Screening Log at the receptionist desk .They will be screened for .presence of active signs and symptoms of respiratory illness . Review of the facility's undated policy titled, PERINEAL CARE FOR A FEMALE WITH HAND WASHING REQUIRED, revealed .Perform hand hygiene .Separate labia .Clean both sides of labia from front to back .Clean the middle of the labia from front to back using a clean portion of the washcloth with each single stroke .Rinse both side of labia from front to back .Rinse middle of labia from front to back .Pat dry .Scrub/wash hands together for at least twenty (20) seconds with soap .Rinse hands thoroughly .Dry hands .turn off faucet with a clean, dry paper towel . Review of the Employees Schedules and Employee Screening Logs from 4/6/2022 - 4/11/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 4/8/2022- CNA #1, #2, Dietary Staff #1, and Business Office Staff #1 b. 4/9/2022- LPN #1, Dietary Staff #2, #3, and #4. c. 4/11/2022 LPN #2, Dietary Staff #1, Housekeeping Staff #1, Business Office Staff #1, and admission Nurse #1. During an interview on 4/21/2022 at 8:25 PM, the Director of Nursing (DON) confirmed all staff should be screened for COVID-19 upon entering the facility and prior to beginning work. Review of the medical record, revealed Resident #57 was admitted to the facility on [DATE] with a diagnoses of Acute Kidney Failure, Urinary Catheter, Multiple Sclerosis, Depression, and Pressure Ulcer. Review of the Physician's Orders dated 2/1/2022, revealed .maintain indwelling catheter .Catheter site care . Observation in the resident's room on 4/20/2022 at 2:39 PM, revealed CNA #3 and #4 entered Resident #57's room and entered the bathroom. CNA #3 washed his hands for 8 seconds and CNA #4 washed her hands for 6 seconds. CNA #3 filled a basin with water, donned (put on) his gloves, and positioned Resident #57 on her left side. Resident #57's catheter was not secured. CNA #3 moistened the washcloth and applied soap, cleaned from back to front on each side of the labia, and cleaned from back to the front and down the middle of the labia. CNA #3 dried the area from the back to the front of the labia and failed to rinse each area. Observation in the resident's room on 4/21/2022 at 3:39 PM, CNA #5 and CNA #6 entered Resident #57's room, placed down a barrier on the over bed table, entered the bathroom and filled a basin with water. CNA #5 and #6 donned their gloves and failed to perform hand hygiene. CNA #5 applied soap to a washcloth, cleaned in a downward motion from front to back on each side of the labia and dried the area. CNA #5 failed to rinse the area. During an interview on 4/21/2022 at 4:01 PM, the DON confirmed that the catheter should be secured. The DON confirmed the staff should wash, rinse, then dry, and wipe from front to back when performing perineal care. The DON confirmed that the staff should wash their hands for 20 seconds.

Based on policy review, observation, and interview, that the facility failed to maintain or enhance respect and dignity when 1 of 7 (Registered Nurse (RN) #1) nurses did not provide privacy during medication administration. The findings include: The facility's Promoting/Maintaining Resident Dignity policy revised 11/2017 documented, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .care for each resident in a manner .that maintains or enhances resident's quality of life .Maintain resident privacy . Observations in Resident #32's room on 5/21/19 at 9:25 AM, revealed RN #1 entered the room for medication administration and did not close the door. RN #1 exposed Resident #32's left breast and applied medicated powder, while the door remained open, exposing Resident #32's breast to the hallway. Interview with the Director of Nursing (DON) on 5/21/19 at 10:23 AM, in the Chapel, the DON was asked if it was acceptable for a resident's door to be left open when applying medication under the breast, exposing the breast. The DON stated, No, Ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to report timely an allegation of abuse for 1 of 5 (Resident #237) Facility Reported Incidents reviewed. The findings include: Review of the facility's Abuse Prohibition Plan dated 05/2019 documented, .The investigation and conclusion regarding all reported allegations/incidents of abuse will be reported to the State Agency by way of the web-based Incident Reporting System (IRS) within 5 calendar days of the initial report of the abuse, incident or allegation . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with diagnoses of Hypertension, Neuromuscular Dysfunction, Depression, and Anxiety. The Grievance Record dated 3/6/19 documented, .On 3/6/2019 myself [Activities Director], [Resident #237] .in the activity room when [Named Maintenance Personnel] came in to bring me a ball back that I had asked him to fill with air for me. As [Named Maintenance Personnel] begin [began] to leave [Resident #237] asked him was he not speaking. [Named Maintenance Personnel] turned back around and stated to [Resident #237] that he was not obligated to speak to him! [Resident #237] then told [Named Maintenance Personnel] that's its [it is] ok and that's when [Named Maintenance Personnel] got closer in [Resident #237] face and asked him who the hell do you think you're [you are]. that's when I got up and said ok that's enough. So [Named Maintenance Personnel] turned and left out of the Activity Room and I proceeded behind him into the hall and I stopped him and asked him why did he do that and that he needed to apologize and he told me that he wasn't doing a MF [expletive] thing that [Resident #237] needs to stay out of his business and that he doesn't have to speak to him if he didn't want to . The Grievance Record dated 3/6/19 documented, .Person investigating complaint/grievance: [Named Administrator] .Corrective Action .met with [Resident #237] & [and] [Named Maintenance Personnel] we cleared the air and shook hands, resolved like gentlemen . Review of the facility's investigation regarding the alleged verbal abuse revealed the allegation of verbal abuse had not been reported to the State Agency. Interview with Resident #237 on 5/19/19 at 8:05 AM, in Resident #237's room, Resident #237 was asked to describe the incident with the Maintenance personnel. Resident #237 stated, .[Named Maintenance Personnel] got verbally loud with me in the activity room for no reason . Interview with the Regional Nurse Consultant (RNC) on 5/20/19 at 9:02 AM, in the Chapel, the RNC was asked why the allegation of verbal abuse was not reported to the State Agency. The RNC stated, .The facility had been through several changes in the administration since the first of the year so I [RNC] came in to QA [Quality Assurance] and I look at the grievance log during that process and found this grievance dated 3/6/19 regarding the verbal abuse and felt that it needed to be further investigated and reported to the State at that time. The RNC was asked if the incident had been reported timely according to state regulations. The RNC stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure nail care was provided for 1 of 2 (Resident #3) sampled residents reviewed for activities of daily living (ADL) care. The findings include: 1. The facility's Shower Schedule 2018 updated 2/20/19 documented, .Clipping Nails .Are All Part of The Daily ADL Care . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Hypertension, Dementia, Alzheimer's Disease, Schizophrenia, Dysphagia, and Depressive Disorder. The annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status score of 3, which indicated severe cognitive impairment and required extensive assistance for personal hygiene and bathing. Review of the Care Plan dated 2/27/19 revealed Resident #3 required extensive assistance with bathing. Observations in Resident #3's room on 5/19/19 at 10:13 AM and 3:55 PM, and 5/20/19 at 3:46 PM and 4:44 PM, revealed Resident #3 was lying in bed asleep with long, unkept nails with a thick, dark brown, dried substance underneath the nails. Observations in the 100 Hall Assisted Dining Room on 5/19/19 at 12:23 PM and on 5/20/19 at 7:40 AM, revealed Resident #3 seated in a wheelchair asleep with long, unkept nails with a thick, dark brown, dried substance underneath the nails. Interview with Certified Nursing Assistant (CNA) #1 on 5/20/19 at 3:51 PM, in Resident #3's room, CNA #1 was asked to observe Resident #3's nails and if they were acceptable. CNA #1 stated, .nails are long and they need cleaning . Interview with Assistant Director of Nursing (ADON) on 5/20/19 at 4:08 PM, in Resident #3's room, the ADON was asked what was underneath Resident #3's nails. The ADON stated, .lunch or something that doesn't belong there and nails are really long. The ADON was asked if this was acceptable. The ADON stated, The length and gunk under nails is not. The ADON was asked if Resident #3's nails had been clipped and cleaned. The ADON stated, No. Interview with the Director of Nursing (DON) on 5/21/19 at 10:28 AM, in the Chapel, the DON was asked if long, unkept nails with a thick, dark brown, substance underneath the nails were appropriate. The DON stated, No, Ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide appropriate oxygen therapy for 1 of 1 (Resident #21) sampled residents reviewed for oxygen therapy. The finding include: 1. The facility's Oxygen Concentrator policy revised 11/2017 documented, .To administer oxygen for the treatment of certain disease or conditions .Oxygen should be administered .under orders of the attending physician .attach oxygen delivery device ordered by the physician to the concentrator (mask, nasal cannula .) . 2. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses of Acute on Chronic Congestive Heart Failure, Atrial Fibrillation, and Anxiety Disorder. The physician's order dated 5/12/18 documented .Oxygen at 2L [liters] / [per] NC [nasal cannula] . Observations in Resident #21's room on 5/20/19 at 8:05 AM and 9:24 AM, revealed Resident #21's oxygen tubing was on her face but was not connected to the oxygen concentrator. Interview with Licensed Practical Nurse (LPN) #1 on 5/20/19 at 9:27 AM, in Resident #21's room, LPN #1 was asked if Resident #21 was receiving the oxygen. LPN #1 stated, It was unhooked. LPN #1 was asked if the tubing should be connected to the concentrator. LPN #1 stated, Yes, she is on continuous [oxygen therapy]. Interview with the Director of Nursing (DON) on 5/20/19 at 5:42 PM, in the Chapel, the DON was asked if the resident's oxygen tubing should be connected to the oxygen concentrator machine. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow the facility policy for abuse and failed to thoroughly investigate an allegation of abuse for 4 of 5 (Resident #38, #237, #238, and #239) Facility Reported Incidences reviewed. The findings include: 1. Review of the facility's Abuse Prohibition Plan dated 05/2019 documented, .Investigation of Misappropriation of Resident Property includes, but is not limited to .e. An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident .Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Diabetes Mellitus, Chronic Kidney Disease, Hypertension, and Chronic Pain. The Grievance Record dated 4/15/19 documented, .Resident [Resident #38] reports when he woke up his rollator was in the bathroom, when he went to sleep it was at the foot of the bed. Reports his wallet was in his pants that was on the rollator. Reports he checked his wallet his $150 was missing .Contact resident daughter who is his RP [Responsible Party] [Named RP] who verified resident did have money. Interviewed staff who cared for resident, unable to identify removal of money . Review of the facility's investigation revealed the facility obtained statements only from the staff on the 100 Hall. Interview with the Director of Nursing (DON) on 5/20/19 beginning at 12:44 PM, in the Chapel, the DON was asked which staff was interviewed regarding Resident #38's missing money. The DON stated, .all statements were taken on the 100 Hall . The DON was asked if other staff could have possibly wandered into Resident #38's room and taken his money out of his wallet. The DON stated, .Yes Ma'am, you are right .I didn't ask any of the other staff that was here . The DON was asked if she considered the investigation of Resident #38's missing money to be a thorough investigation. The DON stated, No. 3. Medical record review revealed Resident #237 was admitted to the facility on [DATE] with diagnoses of Hypertension, Neuromuscular Dysfunction, Depression, and Anxiety. The Grievance Record dated 3/6/19 documented, .On 3/6/2019 myself [Activities Director], [Resident #237] .in the activity room when [Named Maintenance Personnel] came in to bring me a ball back that I had asked him to fill with air for me. As [Named Maintenance Personnel] begin [began] to leave [Resident #237] asked him was he not speaking. [Named Maintenance Personnel] turned back around and stated to [Resident #237] that he was not obligated to speak to him! [Resident #237] then told [Named Maintenance Personnel] that's its [it is] ok and that's when [Named Maintenance Personnel] got closer in [Resident #237] face and asked him who the hell do you think you're [you are]. that's when I got up and said ok that's enough. So [Named Maintenance Personnel] turned and left out of the Activity Room and I proceeded behind him into the hall and I stopped him and asked him why did he do that and that he needed to apologize and he told me that he wasn't doing a MF [expletive] thing that [Resident #237] needs to stay out of his business and that he doesn't have to speak to him if he didn't want to . The Grievance Record dated 3/6/19 documented, .Person investigating complaint/grievance: [Named Administrator] .Corrective Action .met with [Resident #237] & [and] [Named Maintenance Personnel] we cleared the air and shook hands, resolved like gentlemen . Review of the facility's investigation revealed the maintenance personal accused of verbal abuse had not been suspended after the alleged incident pending the investigation. Interview with Resident #237 on 5/19/19 at 8:05 AM, in Resident #237's room, Resident #237 was asked to describe the incident with the Maintenance personnel. Resident #237 stated, .[Named Maintenance Personnel] got verbally loud with me in the activity room for no reason . Interview with the Regional Nurse Consultant (RNC) on 5/20/19 at 9:02 AM, in the Chapel, the RNC was asked if the facility had followed facility policy regarding the alleged allegation by not suspending the accused staff member. The RNC stated, No. 4. Medical record review revealed Resident #238 was admitted to the facility on [DATE] with diagnoses of Bradycardia, Respiratory Arrest, Heart Failure, Hypertension, Diabetes Mellitus, and Viral Hepatitis. The Grievance Record dated 3/27/19 documented, .Resident [Resident #238] stated she had $11 in wallet but there are only $4 left. She also stated her insurance cards were missing. After calling [Named daughter], she stated that she had the resident's insurance cards, but she did give her mom $11 last night .Interviewed day shift nursing staff, unable to determine presence of 11 dollars. Resident at dialysis, waited on return from dialysis. Resident does not recount spending any money not taking money with her to dialysis . Review of the facility's investigation regarding the alleged misappropriation revealed only the direct care staff had been interviewed. Interview with the DON on 5/19/19 at 8:20 AM, in the Chapel, the DON was asked who she interviewed regarding Resident #238's missing money. The DON stated, .I just interviewed the people that directly took care of her . The DON was asked if any staff or visitors that were in the building could have wandered into her room and taken the money. The DON stated, Yes and confirmed she had not completed a thorough investigation. 5. Medical record review revealed Resident #239 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Anxiety Disorder, Hypertension, Diabetes Mellitus, and Hyperlipidemia. The Grievance Record dated 3/28/19 documented, .Resident [Resident #239] states her purse was in cabinet and asked [Certified Nursing Assistant (CNA) #2] .to get it for her. She was looking for her money was missing. She stated, someone stoled [stole] my $80.00. Lock box broken c [with] current wrk [work] order entered .Resident present in room & [and] resident sister reports that a check was written to niece [niece] for $100.00. Reports items such as denture supplies & equal sugar was bought with approximately 15 dollars being spent. Resident reports the money wasn't counted and there is no receipt for items purchased. Reports she removed $20.00 dollars .the receptionist desk Reports receiving five 1.00 bills, a five dollar bill and a ten dollar bill. Used the one dollar bills & five dollar for snacks & replaced the $10.00 bill. Reports money was there at that time but does not recall how long that has been. Went to amoire [armoire] to get money out of purse and noted money not there .Requested patient to obtain copy of cancelled check, attempt to locate receipt & facility to give resident money to replace missing . Review of the facility's investigation regarding the alleged misappropriations revealed only a direct care CNA and Registered Nurse (RN) were interviewed. Interview with the Director of Nursing (DON) on 5/20/19 beginning at 12:44 PM, in the Chapel, the DON was asked who she interviewed regarding Resident #239's accusation of missing money. The DON stated, .I just got a statement from [Named CNA #2] and [Named RN #3] who wrote the statement . The DON was asked if the other staff should have been interviewed. The DON stated, .Yes, Ma'am .investigation was not thorough .

Based on review of Mosby's Pocket Guide To Nursing Skills & Procedures, policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 2 (Assistant Director of Nursing (ADON) and RN #2) did not maintain a sterile technique during a sterile dressing change and 2 of 4 (Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1) nurses did not perform hand hygiene, contaminated medications, and did not rinse a nebulizer cup after a nebulizer treatment during medication administration. The findings include: 1. The Mosby's Pocket Guide To Nursing Skills & Procedures, Seventh Edition, provided by the facility documented, .Sterile Gloving .Gloves help prevent the transmission of pathogens by direct and indirect contact .If glove's outer surface touches hand or wrist, it is contaminated . 2. Observations at the medication cart on the 600 Hall on 5/20/19 at 5:31 PM, revealed the ADON took a peripheral central line dressing kit into Resident #72's room and opened the dressing kit, removed the sterile barrier from the kit, and placed it on the bedside table. The open package was placed on top of the sterile barrier and the ADON touched the contents inside the sterile kit with her nonsterile gloves. The ADON donned sterile gloves after performing hand hygiene. The ADON then removed the tape from the residents arm, touched the inside of the sterile dressing kit after she touched the intravenous (IV) anchor and the bed covers with her sterile gloves. RN #2 entered the room to assist the ADON and attempted to don a sterile glove on her left hand, but was unsuccessful and placed the glove back on the sterile package. RN #2 donned a sterile glove on her right hand and then picked up the soiled glove she previously laid on the sterile field. RN #2 touched the resident and then touched the sterile field. Interview with the Director of Nursing (DON) on 5/21/19 at 10:23 AM, in the Chapel, the DON was asked if a peripheral central line dressing change was considered a sterile procedure. The DON stated, Yes, Ma'am. The DON was asked if it was appropriate to touch the resident's bed, the old dressing, and go back and forth from a sterile field to a nonsterile field. The DON stated, No, Ma'am. Interview with the Regional Administrator on 5/21/19 at 10:23 AM, in the Chapel, The Regional Administrator confirmed the facility uses Mosby's Pocket Guide To Nursing Skills & Procedures, Seventh Edition and a copy was provided to the surveyor. 3. The facility's Hand Hygiene policy revised 4/2018 documented, .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection .Hand Hygiene .Between resident contacts .Before applying and after removing .gloves . The facility's Nebulizer Treatment policy revised 2/2018 documented, .12. Rinse nebulizer cup with warm, tap water, shake off excess water, allow to air dry . Observations at the medication cart on the 300 Hall on 5/21/19 at 8:32 AM, revealed LPN #2 was preparing medications. LPN #2 dropped Resident #30's Lortab on top of the medication cart, picked up the tablet with her bare hand, and placed the tablet into a medication cup. LPN #2 then prepared 3 additional medication cups with Resident #30's medications and stacked the cups on top of each other. LPN #2 entered Resident #30's room and administered these oral medications. LPN #2 donned gloves without performing hand hygiene and administered Resident #30's eye drops. LPN #2 removed her gloves, donned a clean pair of gloves without performing hand hygiene, and administered Resident #30's nasal spray. LPN #2 removed her gloves, donned a clean pair of gloves without performing hand hygiene, auscultated Resident #30's lungs with a stethoscope, and administered Resident #30's nebulizer treatment. After the nebulizer treatment was completed, LPN #2 placed a barrier on the bedside table, placed the nebulizer cup on the barrier without rinsing the nebulizer cup, wiped the nebulizer mask with a Kleenex, and placed the mask into a plastic bag. Interview with LPN #2 on 5/21/19 at 9:08 AM, in the 300 Hall, LPN #2 was asked what should be done between glove changes. LPN #2 stated, Hand hygiene. LPN #2 was asked what she should have done with the tablet that fell on top of the medication cart. LPN #2 stated, Throw it away . LPN #2 was asked if she contaminated the resident's oral medications when she stacked the medication cups. LPN #2 stated, Yes. Observations at the 700 Hall medication cart on 5/21/19 at 9:25 AM, revealed RN #1 removed Resident #32's Instating powder from the medication cart, entered Resident #32's room, donned gloves, and applied the medicated powder under Resident #32's breast. RN #1 removed her gloves, returned to her medication cart, picked up her blood pressure cuff, and started to enter another resident's room. RN #1 did not perform hand hygiene after removing her gloves. Interview with RN #1 on 5/21/19 at 9:33 AM, at the 700 Hall medication cart, RN #1 was asked what should be done after removing gloves. RN #1 stated, Wash my hands. Interview with the DON on 5/21/19 at 10:23 AM, in the Chapel, the DON was asked what she expected staff to do between glove changes. The DON stated, Wash your hands. The DON was asked if it was appropriate to administer medications that had been contaminated by bare hands or the stacking of medication cups. The DON stated, No, Ma'am. The DON was asked if it was appropriate to clean the nebulizer mask with a Kleenex and place it back into a plastic bag. The DON stated, No, Ma'am, that is inappropriate. The DON was asked if the nebulizer medication cup should be allowed to air dry on a barrier without being rinsed. The DON stated, We should have washed it out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 7 (Resident #75 and 85) sampled residents reviewed for baseline care plans. The findings included: 1. Medical record review revealed Resident #75 was admitted on [DATE] with diagnoses of Chronic Respiratory Failure, Bronchitis, Morbid Obesity with Alveolar Hypoventilation, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Tracheostomy, Hypertensive Heart and Kidney Failure, Sleep Apnea, and Anemia. Interview with the Minimum Data Set (MDS) Coordinator on 7/25/18 at 10:50 AM, in the MDS office, the MDS Coordinator was asked if a 48 hour care plan was developed for Resident #75. The MDS Coordinator stated, They did not do it upon admission .I checked and checked and couldn't find a baseline care plan. The facility was unable to provide documentation that a 48 hour care plan had been developed or had been provided to the resident or family within 48 hours of admission. 2. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Colon, Ileostomy Status, Anemia, Malignant Neoplasm of Prostate, Insomnia, Diseases of Stomach and Duodenum, Pressure Ulcer of Sacral Area, Cerebrovascular Disease, and History of Venous Thrombosis and Embolism. Interview with the MDS Coordinator on 07/25/18 at 11:24 AM, in the MDS office, the MDS Coordinator was asked if Resident #85 had a 48 hour base line care plan. The MDS Coordinator stated, No. The facility was unable to provide documentation that a 48 hour care plan had been developed or had been provided to the resident or family within 48 hours of admission.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 17 (Certified Nursing Assistant (CNA) #1) staff members failed to perform proper hand hygiene during dining, and 2 of 5 (Licensed Practical Nurse (LPN) #1 and 2) nurses failed to perform proper hand hygiene during medication administration. The findings included: The facility's Hand Hygiene policy dated 8/2010 documented, Hand hygiene is the simplest, most effective means of infection control .Effective hand hygiene is achieved through handwashing with soap and water or hand decontamination with the use of a waterless antiseptic agent .Hand hygiene must be performed at a minimum .Before and after each patient contact .Before donning gloves and after removing gloves . Observations in the 600 and 500 hallways on 7/23/18 beginning at 5:44 PM, revealed CNA #1 served Resident #26's meal tray, raised the head of the bed, did not perform hand hygiene, then touched the resident's hamburger bare handed, while cutting it in half, and left the room without performing hand hygiene. CNA #1 then served Resident #84's meal tray and did not perform hand hygiene. CNA #1 then served Resident #42's meal tray, touched her hamburger bare handed, while cutting it in half, raised the head of the bed and left the room without performing hand hygiene. CNA #1 served Resident #86's meal tray, moved the overbed table, turned the light on and left the room without performing hand hygiene. CNA #1 served Resident #30's meal tray after touching the door and did not perform hand hygiene. CNA #1 then served Resident #244's meal tray without performing hand hygiene. Interview with the Director of Nursing (DON) on 7/25/18 at 5:15 PM, in the Harbor Club Room, the DON was asked when it was appropriate to wash hands during dining. The DON stated, Prior to serving . The DON confirmed that it was not appropriate to touch articles in the room and then touch a resident's food. The DON was asked if staff should sanitize their hands between resident rooms. The DON stated, Absolutely. Observations in Resident #3's room on 7/24/18 at 8:24 AM, revealed LPN #1 donned gloves, administered an eye drop in Resident #3's left eye, removed gloves, and without performing hand hygiene donned new gloves and administered an eye drop in Resident #3's right eye. Observations on the 700 hallway on 7/24/18 at 5:49 PM, revealed LPN #2 donned gloves, performed blood glucose monitoring on Resident #56, removed gloves, and without performing hand hygiene donned new gloves, cleaned the blood glucose monitor, removed gloves and without performing hand hygiene, then prepared and administered medications to Resident #58. Interview with the DON on 7/25/18 at 6:00 PM, in the DON office, the DON was asked if he expected nurses to wash their hands when changing gloves. The DON stated Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to safely transfer a resident with 2 people assisting the resident, and failed to perform neurological (neuro) checks after a fall as required by the facility's policy, for 2 of 3 (Resident #32 and #143) sampled residents. The findings included: 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Fracture of Right Femur, Age-Related Osteoporosis, Hypertension, Chronic Pulmonary Embolism, Gastroesophageal Reflux Disease, Hallucinations, and Dementia. The significant change Minimum Data Set (MDS) dated [DATE] and the admission MDS dated [DATE] documented Resident #32 had moderate cognitive impairment, required extensive assistance with activities of daily living, and had functional limitations in range of motion with impairment in a lower extremity. The care plan dated 1/16/18 last reviewed 5/17/18 documented, .Transfers .[Named Resident] requires extensive assistance . The Nursing Note dated 5/2/18 documented, .Orders received from [Named Nurse Practitioner] to transfer resident to hospital due to abnormal knee xray . The Nursing Note dated 5/5/18 documented, .Resident returned to facility .Brace noted on right leg due to femoral fracture . The Physician's Progress Note dated 5/8/18 documented, .ASSESSMENT: 1. Status post new compression fracture, right femur, probably pathologic, with old right hip fracture, non-healing . Interview with the Assistant Director of Nursing (ADON) on 7/25/18 at 12:52 PM, in the Harbor Club Room, the ADON was asked how Resident #32 was to be transferred. The ADON stated, .she was supposed to be transferred with 2 person assist . Interview with Certified Nursing Assistant (CNA) #2 on 7/25/18 at 2:28 PM, in the Harbor Club Room, CNA #2 was asked how resident #32 was to be transferred. CNA #2 stated, .I have transferred her just me. That was not the way she [Resident #32] was supposed to be transferred .she is a 2 person assist .I did not check her orders in the kiosk . 2. The facility's Neurological Check policy dated 7/2014 documented, .Falls that occur and a patient hits their head or if the fall was unobserved and the possibility is there that a patient may have hit their head, a neurological assessment must be conducted .The checks must be done according to the guidelines at the top of the form . Medical record review revealed Resident #143 was admitted to the facility on [DATE] with diagnoses of Epilepsy, Acute Respiratory Failure, Encephalopathy, Hypovolemia, Diabetes Mellitus, Hypertension, and Dysphagia. The care plan dated 4/5/18 documented Resident #143 was at risk for non-compliance with requesting assistance. The Nursing Note dated 5/8/18 at 5:30 PM, documented, .Pt [patient] had an unwitnessed fall in her room found on left side with left arm extended. Pt states that she fell attempting to go to bathroom. Pt states that she hit her head but has no feel any pain [had no pain] to her head area. Pt complains of left arm and shoulder pain. Pt assessed for other injuries and alertness. Pt is alert and oriented able to communicate all concerns. B/P [blood pressure] 200/106 HRT [heart rate] 86 O2 [oxygen saturation] 99 [percent] respirations 20. Family called .FNP [Family Nurse Practitioner] notified ordered Xray of left humerus and left shoulder also ortho-static vitals in one hour. Will monitor pt for changes . The Nursing Note dated 5/8/18 at 6:45 PM, documented, .Pt found lying in bed with large amount of vomit in the floor near her head and a small amount in the bed. Pt breathing was labored and she soiled her brief with urine and feces. Pt was able to make eye contact but could not speak. Pts B/P was 178/102 HRT 89 Temp 97.6 sat [oxygen saturation] 98 [percent] . FNP notified of Pt's condition and ordered be sent ER [Emergency Room] for evaluation . Interview with the ADON on 7/24/18 at 2:40 PM, in the Harbor Club Room, the ADON was asked what the facility's policy was when a resident had an unwitnessed fall. The ADON stated, .perform neuro checks . The ADON was asked if neuro checks had been performed after Resident #143 fell. The ADON stated, .I didn't notice the neuro checks were performed . Interview with the Regional Nurse Consultant (RNC) on 7/24/18 at 3:26 PM, the RNC was asked if neuro checks had been performed on Resident #143 after her unwitnessed fall. The RNC shook her head indicating no.

Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by a dusty fan, food particles on clean dishes, a dirty deep fat fryer, nourishment refrigerator temperatures recorded above 41 degrees, and an incorrect acceptable temperature range on the facility's refrigerator logs. The facility had a census of 87, with 85 of those residents receiving a meal tray from the kitchen. The finding included: Review of the facility's Food Storage policy dated 11/28/17 documented, .All perishable food will be stored at proper temperatures .Refrigerated food items at or below 41 [degrees] F [fahrenheit] . Observations in the kitchen on 7/25/18 at 10:13 AM, revealed a large fan with dust on the front and the back of the fan screen, with the air blowing in the direction of uncovered food. The Regional Dietician (RD) took a towel and rubbed the front of the fan and removed a gray colored dust. The RD stated, Just a little dust. Interview with the RD on 7/25/18 at 10:13 AM, in the kitchen, the RD was asked if the dust on the the fan was acceptable. The RD stated, No, ma'am . Observations in the ware washer room on 5/25/18 at 10:27 AM, revealed 3 stock pots with food particles on them, on the drying rack with clean dishes. Interview with the RD on 7/25/18 at 10:27 AM, in the ware washer room, the RD was asked if it was acceptable to have food particles on pans placed on the drying rack with clean dishes. The RD stated, No, ma'am. Observations in the kitchen on 7/25/18 at 10:30 AM, revealed the deep fat fryer with black and brown colored grease build up around the top of the fryer and on the fryer baskets. Interview with the RD on 7/25/18 at 10:30 AM, in the kitchen, the RD was asked if it was acceptable to have brown and black build up on the fryer and fryer baskets. The RD stated, No, ma'am . The facility's REFRIGERATOR/FREEZER TEMPERATURE RECORD DIETARY DEPARTMENT log for July 2018 documented, ACCEPTABLE REFRIGERATOR 35-46. The facility's REFRIGERATOR/FREEZER TEMPERATURE RECORD DIETARY DEPARTMENT log documented the following: a. July 5 .temperature .46 .marked acceptable. b. July 9 .the temperature . 44 .marked acceptable. c. July 16 .the temperature .42 .marked acceptable. d. July 20 .the temperature .44 .marked acceptable. e. July 22 .the temperature .42 .marked acceptable. The facility's temperature's do not meet the Food Storage requirement. Interview with the RD in the Harbor Club Room, on 7/25/18 at 4:27 PM, in the Harbor Club Room, the RD was asked what is the maximum acceptable temperature for the nutrition refrigerators. The RD stated, Through 41. The RD was asked if she was aware the temperatures had been over 41 degrees. The RD stated, No, ma'am. Interview with the Director of Nursing (DON) on 7/25/18 at 4:35 PM, in the DON office, the DON was asked to review the form. The DON stated the temperatures should be below 41 . The DON was asked if the ranges were acceptable on the log. The DON stated .ranges are not acceptable according to the Federal Regulations .