**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not implement comprehensive person-centered care plan approaches for 1 of 1 sampled resident (R), (R46) by ensuring fall intervention approaches were in place to meet a resident's medical, nursing, and psychosocial needs which are identified. This is evidenced by: The facility policy, titled Falls and Fall Risk, managing policy statement states, Based on previous evaluations and current data, the staff will identify interventions related to the residents from falling and to try to minimize complications from falling. 6. Staff will identify and implement relevant interventions .to try to minimize serious consequences or falling. R46 was admitted to the facility on [DATE] and has diagnoses of unspecified dementia, mild, with psychotic disturbance with delirium and adult failure to thrive. R46's admission Minimum Data Set (MDS) assessment, dated 01/25/25, indicated a Brief Interview for Mental Status (BIMS) score of 9/15 (mildly impaired) and had a fall in the last month prior to admission and the last 2-6 months prior to admission. R46's fall risk care plan, dated 01/22/25, with a target date of 04/22/25, has interventions approaches dated 01/23/25 of Call don't fall sign placed in room and on 04/14/25 added autolocking brakes to wheelchair. On 05/13/25 at 11:42 AM, Surveyor observed no Call before you fall sign or autolocking brakes on wheelchair for R46. On 05/14/25 at 10:03 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G regarding fall interventions for R46 of signage and brakes. CNA G pulled a CNA care card out of uniform pocket and confirmed that R46 is supposed to have a Call don't fall sign and autolocking brakes on wheelchair to prevent falls. On 05/14/25 at 11:00 AM, Surveyor interviewed Director of Nursing (DON) B regarding fall interventions for R46. DON B stated the sign was found in the resident's drawer and believes R46 does not have usual wheelchair and is investigating on what may have happened.

Based on observation, interview and record review, the facility did not ensure it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 residents (R), (R20, R53) included in the medication pass task, which resulted in an error rate of 6.9%. -R5's prescribed topical medication was used for R20. -R53's lidocaine patch was not removed after 12 hours, as ordered. Findings: Example 1 The facility's policy, Administering Medications read in part, 3. Medications must be administered in accordance with the orders. The licensed nurse shall follow the five Rights for medication pass: Right Resident, Right Medication, Right Time, Right Dose, Right Route. 5. The individual administering medications must verify the resident's identity before giving the resident his/her medication. On 05/12/25 at 3:50 PM, Surveyor observed Registered Nurse (RN) F completing medication administration for R20. RN F reported she could not administer R20's prescription topical diclofenac sodium gel to both knees, as the medication was not in the medication cart. RN F stated she would update R20's primary care provider (PCP) and the pharmacy to order more. RN F stated she would make a progress note reflecting these actions. On 05/13/25, Surveyor reviewed R20's progress notes, and noted there was not a record indicating RN F updated PCP and pharmacy of R20's medication being unavailable on 05/12/25. Surveyor reviewed R20's medication administration record (MAR) and noted: -05/12/25 PM shift, RN F documented diclofenac sodium gel was not administered due to medication being unavailable. -05/13/25 AM shift, R20's MAR indicated RN C administered R20's diclofenac sodium gel as ordered. On 05/13/25 at 10:20 AM, Surveyor interviewed RN C. RN C stated she did administer R20's diclofenac sodium gel on this date, as ordered. RN C looked in the medication cart for R20's gel, for several minutes. RN C did locate R20's gel and Surveyor noted the tube of diclofenac sodium gel appeared to be new and the dosing card included did not appear to be used. RN C stated she borrowed R5's Voltaren gel (brand name for diclofenac gel) as she was unable to locate R20's diclofenac gel. RN C acknowledged she should not have used R5's medication for R20, as this was not the right resident. On 05/13/25 at 10:32 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported licensed nursing staff should not use another resident's medication, and she would expect staff to contact the resident's provider for direction. DON B stated she would provide re-education to nursing staff immediately. Example 2 On 05/13/25 at 7:27 AM, Surveyor observed Registered Nurse (RN) C administer medications to R53 which included: Lidocaine 4% Patch (2 patches) on daily to lower back, remove after 12 hours On 5/13/25 at 7:29 AM, Surveyor observed RN C remove one patch from R53's lower back which was left on from previous day and not removed per physician orders. RN C removed glove, performed hand hygiene, put on a new glove, and applied two new patches to R53's lower back. Surveyor reviewed R53's medication administration record (MAR) for Lidocaine patch order which reads: Lidocaine adhesive patch, medicated; 4%; amount: 2 patches; topical Apply daily, remove 12 hours after applying ON AM, OFF HS Surveyor reviewed R53's MAR, which indicated the patches from the previous day had been removed by Licensed Practical Nurse (LPN) Q, who was not available for interview. On 05/14/25 at 12:31 PM, Surveyor interviewed LPN R. LPN R stated if orders indicate lidocaine patches are to be placed one time daily and removed after 12 hours, the MAR would prompt the nurse to remove patch on PM shift. LPN R stated patches are on for 12 hours and off for 12 hours. The facility did not ensure physician order for Lidocaine patch was followed as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident (R) reviewed (R57). - R57's Foley catheter collection bag was observed placed above bladder level allowing backflow which can contribute to infections. On 05/13/25, half of R57's Foley catheter bag was lying on the floor uncovered. This is evidenced by: The facility policy titled, Catheter Care, Urinary indicates the following, . 4. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . 11. Be sure the catheter tubing and drainage bag are kept off the floor. R57 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following surgery on the urinary system, urogenital implants, urinary tract infection, lobulated, fused and horseshoe kidney, sepsis, kidney stones, enlarged prostate with lower urinary tract symptoms, obstructive and reflux uropathy, and feeling of incomplete bladder emptying. R57's care plan, dated 4/2/25, includes the following: Problem: Resident requires an indwelling urinary catheter R/T obstructive and reflux uropathy Approach: Keep catheter system a closed system as much as possible, Position bag below level or the bladder and use a catheter strap. On 05/12/25 at 1:25 PM, Surveyor observed R57 being brought to the dining room by spouse with R57's catheter bag placed on lap above bladder level during lunch. Surveyor asked Licensed Practical Nurse (LPN) E if they see anything concerning with R57. LPN E stated that R57's catheter bag is on his lap and explained R57 just returned from an appointment with the urologist, and no one must have seen it yet. LPN E added LPN E will take care of the catheter right away. Surveyor reviewed the nursing progress note dated 05/12/25 at 12:41 PM, (which was 1 hour and 16 minutes before the observation) stating R57 returned to the facility from his appointment. The note was entered by LPN E. On 05/13/25 at 7:38 AM, Surveyor observed R57's Foley catheter drainage bag clipped to bottom of the wheelchair with 1/2 of the bag uncovered and resting on the floor. Surveyor interviewed Certified Nursing Assistant (CNA) L and asked who provided morning care for R57. CNA L said CNA L and CNA M provided care for R57. Surveyor asked CNA L if CNA L noticed anything wrong with R57's catheter bag. CNA L said, Oh yes. It is supposed to be in the bag on the back of the wheelchair. CNA L immediately sanitized hands, donned gown and gloves, and placed the catheter bag in the privacy bag on the back of R57's wheelchair. On 5/13/25 at 2:49 PM, Surveyor interviewed Infection Preventionist (IP) O and asked what the expectation would be for staff regarding managing Foley catheters. IP O vocalized staff should place the Foley catheter bags below the bladder level to prevent backflow and infection. The catheter bag is to be in privacy bag off the floor, and place resident on Enhanced Barrier Precautions (EBP). Surveyor discussed the observations, and IP O stated she will start providing education right away. On 05/15/25 at 8:20 AM, Surveyor interviewed DON B who said DON B was made aware of the catheter concerns and the facility has already begun educating staff

Based on observation, interview and record review, the facility did not ensure proper food handling practices related to thawing raw meat were followed to prevent the outbreak of foodborne illness for 26 of 82 residents. Facility did not use proper thawing method for frozen pork chops. Policy and procedure titled Food Preparation and Service last revised in August of 2014 reads in part, Submerging the item in cold running water. Guidelines from Agriculture, Trade, and Consumer Protection Subpart 3-501.13 last registered in November 2024, reads in part, Completely submerged under running water .With sufficient water velocity to agitate and float off loose particles in an overflow. The FDA Food Code states the following: 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41oF), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking. On 05/14/25 at 8:23 AM, Surveyor observed pork chops, which appeared to be thawed, in a pan of water placed in the small sink of the prep table. Pork tenderloins were partially red/partially browning in color. Surveyor observed the pork chops sitting in still water, not running water. On 05/14/25 at 8:49 AM, Surveyor observed pork chops in the same water. This was not cold running water. Surveyor interviewed Dietary Manager (DM) S and [NAME] T. DM S stated the pork chops were thawing and had been taken out of the freezer that morning. [NAME] T stated [NAME] T had taken the pork chops out of the freezer when [NAME] T got to work that morning. On 05/15/25 at 7:50 AM, Surveyor interviewed DM S. DM S stated that [NAME] T may have run the pork tenderloins underwater prior to Sureyor's observation but wasn't positive. DM S stated [NAME] T would most likely have rinsed the pork chops before cooking them. [NAME] T reported the pork chops were partially frozen in the middle when he took them out of the still water. The pork chops were then breaded and cooked and served to 26 residents. Cooked internal temp was recorded at 193 degrees. On 05/15/25 at 9:34 AM, Surveyor interviewed Director of Corporate Food Services (DCFS) U. DCFS U stated DCDS U was informed by [NAME] T the water had been running until about 8:00 AM that morning and it was shut off due to [NAME] T leaving the kitchen. At that time the pork was left in the sitting water. Surveyor determined the facility did not follow safe and appropriate thawing methods for frozen pork, which had the potential for contributing to foodborne illness.

Based on observations, interviews and record reviews, the facility did not ensure 1 of 5 residents (R) reviewed (R36) who is unable to carry out activities of daily living independently, receives the necessary services to maintain good nutrition, repopositioning with personal hygiene and oral hygiene. This is evidenced by: R36 has medical diagnoses that include but are not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, aphasia, metabolic encephalopathy, anxiety disorder, depression and encephalomalacia. Surveyor reviewed the most recent Minimum Data Set (MDS) assessment completed for R36, which was a quarterly assessment with an assessment reference date of 3/7/24. According to this assessment, R36 has a Brief Interview of Mental Status (BIMS) of 3/15, indicating severe cognitive dysfunction, no behaviors such as rejection of care, verbal, physical or other actions in response to stimulation directed at self or others. For ADL functions, R36 requires partial to moderate assistance with oral hygiene and ambulation and substantial to maximum assistance with toileting hygiene, dressing of upper and lower body, personal hygiene, rolling right to left in bed, moving from a sitting to lying and a lying to sitting position, moving from a sitting to a standing position and transfers. R36 requires supervision and touch assistance with eating. Positioning/pesonal hygiene: Care Plan 1. At risk for impaired skin integrity related to decreased mobility. (Start date 12/11/23) Interventions for this plan included: - Encourage physical activity, mobility and range of motion to maximal potential. (Start date 12/11/23) - Reposition every 2-3 hours and as needed (Start date 12/11/23) Observation On 4/2/24 from 6:26 AM - 7:12 AM, Surveyor observed care provision for R36 by Certified Nursing Assistant (CNA) N. R36 has no current pressure injuries. Once cares were completed, at 7:12 a.m., CNA N left R36's room with R36 positioned in the wheelchair in front of the television. R36 remained in the room until 8:10 AM, when she was propelled to the dining room for the morning meal. R36 remained in the dining room until 8:44 AM, when staff propelled R36 to a small activity room/television room in preparation for activity of nail care. Nail care started at 9:18 AM by Activity Aide (AA) O and Activity Director (AD) P. R36 was placed at a table away from the nail care table. R36 was noted to be sitting up straight but slightly leaned to the right side. Both legs were off the footrests and positioned on the floor. At 10:43 AM, a strong odor of feces was noted emanating from R36. At 10:57 AM, AA O began nail care for R36. The nail care was completed at 11:30 AM, at which time AA O noted the feces odor and propelled R36 to the resident's room and alerted staff of the toileting need. This was at 11:30 AM. At 11:31 AM, CNA N assisted R36 to the bed and provided the incontinence cleansing. Surveyor verified with CNA N at this time that no further cares were completed following the earlier morning ADL cares. When asked why no cares were provided after meal service, CNA N stated, I did her cares then she went to breakfast and then she was in an activity. I didn't do anything, but now I am going to change her. Surveyor asked CNA N what the repositioning schedule was for R36. CNA N stated, I think it's every two hours. This was a time period of 4 hours 19 minutes in which no staff approached to offer or encourage repositioning or personal hygiene for R36. At 4:40 PM, Surveyor interviewed CNA J and CNA K regarding ADL provision on the evening shifts. When asked about R36's repositioning and toileting needs, both staff stated R36 was to be repositioned and checked for toileting needs every two hours. On 04/02/24 at 4:54 PM, Surveyor interviewed Director of Nursing (DON) B regarding R36's care needs and asked what the expectation of repositioning and toileting and personal hygiene was for R36. DON B stated R36 was to be repositioned or cued to reposition every 2-3 hours. At that time personal hygiene would be provided if R36 was incontinent. On 4/3/24 at 7:46 AM, Surveyor approached CNA G and interviewed regarding the needs of R36. CNA G is a primary dayshift caregiver for R36. CNA G stated they are to reposition and offer toileting to R36 every two hours. On 4/3/24 at 8:07 AM, Surveyor approached CNA F and interviewed her regarding R36's Restorative Nursing Program (RNP) for ADLs. CNA F is another primary caregiver for R36 on the dayshift. CNA F stated that repositioning and toileting with personal hygiene should be offered to R36 every two hours. On 4/3/24 at 8:18 AM, Surveyor interviewed Unit Manager (UM) M regarding her expectation of staff in regard to R36's needs. When asked about R36's repositioning needs, UM M stated her expectation is that R36 be repositioned every 2-3 hours. Oral care ST completed a Dietary/Staff Communication Guide dated 12/11/23 and again on 1/5/24. According to these, R36 was to take small bites with 1-2 swallows with each bite. Staff were to encourage to clear throat, cough and re-swallow as needed and to check for pocketing. Staff were also to complete oral cares following meals. On 4/1/24 at 12:00 PM, Surveyor observed initial entrance meal service for R36 for the noon meal. R36 was seated at a table with five other residents with two staff assisting these four others. From 12:12 PM - 12:36 PM, Surveyor observed R36's noon meal. At 12:44 PM, AA O noticed that R36 hadn't eaten anything. AA O pulled up a chair to R36's right side, sat down and began to feed R36 the meal. AA O offered R36 a beverage with R36 choosing cranberry juice. AA O fed R36 the meal, finishing at 1:18 PM and accepting approximately 25% of the meal. There was no oral care provided following this meal. On 4/2/24, Surveyor observed the morning meal service. R36 was propelled into the dining room and placed at the table with four other residents at 8:10 AM. R36 remained in the room until 8:10 AM, at which time R36 was propelled to the dining room for the morning meal. R36 was in the dining room until 8:44 AM, at which time was propelled to the small activity room across from the dining room, for an activity of nail care. Surveyors continued to observe R36 in this activity. There was no oral care provided following the meal to clear potential food from the pockets of R36's cheeks, as directed. Surveyor observed meal service on 4/2/24 for the noon meal. R36 was propelled into the dining room at 12:22 PM and positioned at the table with the same four residents noted on earlier observations. R36 was served the meal at 12:23 PM. R36 completed the meal at 1:06 PM, at which time, staff assisted to lay down for a nap. No oral care was provided following this meal. Meal Assist According to the Comprehensive Care Plan developed for R36, the following plans were noted by Surveyor: 2. Nutritional Status: At nutrition risk related to therapeutic, mechanically altered diet due to hypertension and dysphagia. (Start date 12/11/23, last revised 3/18/21) The goal for this problem was No significant weight loss from 130 pounds. Consume 50% or more most meals and tolerate least restrictive diet. Interventions included: - Beverages in mugs with lids (Start date 2/21/24) - Assisted devices: lipped plate and built up utensils (start date 2/20/24) - House supplements three times daily with meals (Start date 12/11/23) - Per ST: Direct supervision, 1-2 swallows per small bite, alternate solids/liquids, clear throat/cough, then re-swallow, oral cares after meals, clear mouth between bites, verbal and physical cues to eat slowly. (Start date 12/11/23) CNA care card (last updated 4/2/24) identified R36 as requiring the following (not all-inclusive): - dining: built up utensils, all beverages in mugs with lids and straws. House supplement three times daily - encourage to participate in activities/meals Observation 1 On 4/1/24 at 12:00 PM, Surveyor observed initial entrance meal service for R36 for the noon meal. R36 was seated at a table with five other residents with two staff assisting these four others. R36 received her meal at 12:12 PM by AD P, which consisted of pasta with marinara sauce, ground chicken, peas, garlic bread and a brownie. There were no beverages served to R36 at that time. R36 was served the main entree on a lipped plate with regular, standard utensils. There were two staff also at the table; Nurse Manager (NM) D was assisting R44 and R12 and CNA C was assisting R32 and R17. R32 was directly to R36's right side and R17 was directly across the table from R36. From 12:12 PM - 12:36 PM, R36 repeatedly looked around the room and around the table at the other residents eating and being assisted. R36 made no attempts to feed self. Still, no beverages were supplied during this time. Neither staff seated at the table prompted, cued or encouraged R36 to eat. At 12:44 PM, AA (Activity Aide) O noticed that R36 hadn't eaten anything. AA O pulled up a chair to R36's right side, sat down and began to feed R36 the meal. R36 observed to sit unassisted with meal for 32 minutes with no staff interaction or encouragement to eat. There was no encouragement or cues given to R36 to eat independently. Observation 2: On 4/2/24, Surveyor observed the morning meal service. R36 was propelled into the dining room and placed at the table with four other residents at 8:10 AM. These four other residents were the same as noted at the noon observation 4/1/24. At 8:15 AM, R36 was given 8 ounces of cranberry juice, served in a regular beverage glass. Two staff assisted the four other residents at the table; NM D was assisting R44 and R12 and CNA E sat between R32 and R36 and assisted R32 with the meal. At 8:22 AM, R36 was served the meal on a lipped plate with regular/standard utensils. The meal served with this observation was biscuits and gravy and oatmeal with brown sugar. R36 made few attempts to feed herself during this meal, frequently looking around at the table at other residents being assisted by staff. R36 also picked up the glass of juice twice and took sips. At 8:28 AM, CNA E finished assisting R32 and began to assist R36, as CNA E noted R36 was not making attempts to feed herself. R36 finished her meal at 8:44 AM, being fed by CNA E. R36 was not encouraged or cued in self-feeding. Observation 3: Surveyor observed meal service on 4/2/24 for the noon meal. R36 was propelled into the dining room at 12:22 PM and positioned at the table with the same four residents noted on earlier observations. R36 was served the meal at 12:23 PM which consisted of chopped chicken fried steak, mashed potatoes with gravy, mixed vegetables, a slice of bread and a marshmallow fluff for dessert. R36 was given 8 ounces of apple juice served in a sippy cup. R36 made no attempts to eat the meal but did occasionally pick up the sippy cup and take a drink of the juice. No staff encouraged or offered assistance until 12:46 PM, when NM D sat beside R36 to assist with the meal. This was 23 minutes in which no cues or encouragement were given to R36 to eat independently. On 4/2/24 at 4:04 PM, Surveyor interviewed Staff H, who is the director of rehabilitation. Speech Therapy (ST) Q was not on duty on this date. Staff H spoke with ST Q on the telephone and reviewed ST documentation. Staff H stated R36 was seen by ST 12/1/23 - 12/8/23 and then again 12/11/23- 1/19/24 and made recommendations for R36 to be on mechanically soft diet with thin liquids, served in a covered mug with a straw on 2/20/24. Staff H stated there were directions of supervision with the meal and directives on swallowing. Staff H stated the RNP was to be implemented 1/25/24. On 4/3/24 at 10:39 AM, Surveyor interviewed ST Q regarding the plan that was to be implemented for meal service. ST Q stated that she recommended the oral care after meals as R36 was a relatively new stroke patient and impulsive, so required cues to slow down with eating and staff to provide oral cares, as she could be pocketing food and didn't want R36 to be laid down and then risk choking on any food that may still be in the mouth. ST Q stated the food was to be cut into bite sized pieces and R36 was to be cued to alter solids and liquids and swallow as needed. R36 required direct supervision with the meal. ST Q stated this plan was to be implemented as of 1/25/24. The ADL assistance was not offered in relation to assistance with meals with the recommended tools for self-feeding, oral cares following meals, and assistance with repositioning and toileting needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview and policy review, the facility failed to ensure 1 of 3 residents (R) R36 reviewed for limited mobility, received restorative services as needed to address limited mobility, to maintain or improve mobility for the goal to reach the maximum practicable independence. R36 has medical diagnoses that include but are not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, aphasia, metabolic encephalopathy, anxiety disorder, depression and encephalomalacia. Surveyor reviewed the most recent Minimum Data Set (MDS) assessment completed for R36, which was a quarterly assessment with an assessment reference date of 3/7/24. According to this assessment, R36 has a Brief Interview of Mental Status (BIMS) of 3/15, indicating severe cognitive dysfunction, no behaviors such as rejection of care were noted. R36 was identified as having impaired visual function and moderate difficulty with hearing. R36 has unclear speech but usually understands others and is usually understood. R36 has limited range of motion for both upper and lower extremities that affect the right side of the body. R36 has limited range of motion for both upper and lower extremities that affect the right side of the body. For activities of daily living (ADL) functions, R36 requires partial to moderate assistance with oral hygiene and ambulation and substantial to maximum assistance with toileting hygiene, dressing of upper and lower body, personal hygiene, rolling right to left in bed, moving from a sitting to lying and a lying to sitting position, moving from a sitting to a standing position and transfers. The MDS documents R36 received restorative in dressing and grooming during the seven days of the assessment observation. R36 was seen by Physical Therapy (PT) 12/11/23-1/25/24. On 1/24/24, PT initiated a Restorative Nursing Program (RNP) to be carried out by nursing staff that directed care giving staff on the following: 1. Ambulation: Ambulate twice daily in 400 hallway with FWW (full wheeled walker), assist of 1 (contact guard assist) and w/c (wheel chair) directly behind. Give cues/assist as needed for maintaining straight path. Ambulate from her room to beauty salon, give seated rest break, then ambulate from beauty salon back to her room. 2. Dressing/Grooming: Resident to complete grooming tasks while seated in w/c in front of sink with setup of supplies and verbal cues. Complete UB (upper body) dressing with maximum assist. Encourage resident to assist with ADL's as much as possible. R36 was seen by Occupational Therapy (OT) 12/12/23-1/25/24. The most recent RNP developed by OT was dated 2/20/24 and directed staff .patient able to manage standard mug; nosey cup and sippy cup no longer needed . According to the comprehensive care plan developed for R36, the following plans were noted by Surveyor: 1. Restorative: Self-Care Deficit related to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side. The goal written for this problem was Resident will maintain current level of function with grooming and UB (upper body) dressing to reduce risk of functional decline. (Start date 12/11/23, last revised on 3/21/24). Interventions for this plan included: - Dressing per RNP: Complete UB dressing with maximum assistance while seated in wheel chair in front of sink with supplies set up in front of her. (Start date of 1/27/24) - Provide verbal cues to initiate task and encourage her to be as independent as possible. Assist as needed. (Start date of 1/27/24) - Dressing and grooming per therapy recommendations. (Start date 12/11/23) 3. Restorative: Impaired physical mobility with risk for falls related to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side. (Start date 12/11/23, last revised on 3/21/24) Surveyor then reviewed restorative documentation completed monthly for R36 and noted the following: - 02/25/2024 . Restorative: Resident admitted [DATE] . Had new RNP established 1/24/23 for ambulation and dressing/grooming. Goal is to maintain ambulation distances and ability to walk with FWW to reduce risk of functional decline. She is very inconsistent with ambulation. Transfers and ambulation with 1 A (assist) ww (wheeled walker). WC (wheel chair) following during ambulation. She needs cueing to maintain straight walking path . Has met goal only sporadically since being implemented . Had 2 falls in January which did not impact her ability to participate in ambulation. Will initiate nursing documentation on how she is tolerating and if refusing why? Dressing/grooming goal is to maintain current level of function with grooming and UB dressing to reduce risk of functional decline. Staff must anticipate needs. ADLS are completed while seated in WC in front of sink with supplies set up within her reach. Needs verbal cueing and encouragement for her to assist as much as she is able to. Has met goal daily. POC (plan of care) updated. - 02/26/2024 Staff reports that resident is difficult to stand up. Needing 2A to ambulate. Resident did ambulate short distance within her room this shift. - 03/24/2024 Restorative: Resident has RNP for ambulation and dressing/grooming. Goal is to maintain ambulation distances and ability to walk with FWW to reduce risk of functional decline. She is very inconsistent with ambulation. Transfers and ambulation with 1 A ww. WC following during ambulation. She needs cueing to maintain straight walking path. Dressing/grooming goal is to maintain current level of function with grooming and UB dressing to reduce risk of functional decline. Staff must anticipate needs. ADLS are completed while seated in WC in front of sink with supplies set up within her reach. Needs verbal cueing and encouragement for her to assist as much as she is able to. Has met goal daily. ADL goal has been met 5-7 days and ambulation has improved and been more consistent this past month. POC Reviewed. Surveyor reviewed ambulation documentation for the hours of awake for the past three months and noted the following: - January 25-31st (RNP was to be implemented 1/25/24): Attempts made for ambulation were 3 times, all other times were documented as refused. This was 7 days with twice daily ambulation orders or 14 opportunities. - February 1-29th: 29 days or 58 opportunities Ambulation completed 24 times, several entries documented as refusals or not observed and one time documented as combative. - March 1-31st: 31 days or 62 opportunities: Ambulation completed 24 times, with 22 refusals documented. There also were unknown documented x1, not observed documented x 2, unavailable documented x2 and no information documented x1. The following observations were made by Surveyor: Restorative Services On 4/2/24 at 6:13 AM, Surveyor observed R36 in bed with the room dark. At 6:26 AM, Surveyor observed Certifiied Nursing Assistant (CNA) N enter R36's room to provide ADL cares. CNA N stated she has worked for the facility for two weeks but has been a CNA for a long time. The following was noted: - Upon entrance to the room, Surveyor noted R36 to be in bed as noted above. No staff have entered the room prior to this. - CNA N gently awakened R36 and explained that she was going to assist her to get up for the day. - CNA proceeded to wash R36's face, removed the pajama top and completed washing of the hands, arms, chest and arm pits. CNA N then proceeded to catheter and perineal cleansing. - Following the bathing, CNA N dressed R36 all while R36 was still in the bed. During the bathing and dressing, R36 followed directions with ease for rolling right and left in the bed. - CNA N then assisted R36 to sit on the side of the bed and placed a gait belt around the resident's waist and pivot transferred her to the wheelchair. No full wheeled walker was used with this transfer. - Once R36 was positioned in the wheelchair, CNA N brushed R36's hair and completed oral care, brushing R36's teeth. These tasks were not completed by the sink. Instead, they were completed for R36 by the bed. - CNA N then positioned R36 in front of the television in the room. CNA N attached the call light over the resident's right side lap and then left the room at 7:12 AM. Of concern with this observation is that R36 was not encouraged or directed to participate in the ADL cares, as OT and PT recommended to maintain or maximize functional abilities. Instead, CNA N performed all the cares for R36, not allowing for some independence by the resident. Also, no ambulation was offered or attempted with this observation. R36 was not given the opportunity to refuse. At 9:18 AM, Surveyor interviewed CNA N regarding care provision of R36. Surveyor asked CNA N if R36 was to be ambulated. CNA N stated, It depends on the day. Sometimes she will but sometimes she gets anxious and won't. [R36] uses the walker and generally just walks in the room. We pivot her from the bed to the chair, but that's about all. [R36] will tell you if she doesn't want to do it. Surveyor asked if there is a restorative plan to encourage R36 to be as independent and functional as able. CNA N stated that she wasn't sure if there was a plan, stating, . We just do everything for her. Surveyors continued to observe R36 to observe for ambulation opportunities. R36 was assisted to the morning meal at 8:10 AM. Following the meal, R36 was placed into a small activity room in which nail care was in progress. R36 remained in this activity until 11:30 AM, at which time was propelled to her room, assisted with incontinence care and placed into bed for a nap. R36 was assisted up into the wheelchair for the noon meal at 12:20 and propelled in the wheelchair to the main dining room. R36 remained at the meal until 1:06 PM, at which time, was placed into bed for a nap. At 4:04 PM, Surveyor interviewed staff H, who is the Director of Rehabilitation, and Certified Occupational Therapy Assistant (COTA) I regarding R36's ADL RNPs. Both indicated that RNPs were written for R36 to ambulate twice daily in 400 hallway with wheeled walker and to provide dressing and grooming tasks in the wheelchair, set up at the sink and to be given verbal cues for self-care. COTA I stated that she worked with R36 to ambulate in the room, while PT worked with walking in the hallway. R36 was still in bed napping at 4:40 PM. At 4:40 PM, Surveyor approached CNA J and CNA K regarding restorative services on the evening shifts. CNA J and CNA K had no knowledge that they were to ambulate R36. CNA I did indicate that on occasion, she places R36 at the sink to do some cares. Both staff stated R36 was to be repositioned every 2 hours. Together, CNA I and Surveyor went to check the computer kiosk for what was written for R36's ADLs. CNA I verified they were to ambulate R36 and set her up at the sink for provision of self-grooming tasks. At 4:54 PM, Surveyor interviewed Director of Nursing (DON) B regarding the carrying out of RNPs written by therapies for resident functional maintenance and maximizing individual abilities. DON B stated the CNAs should follow the programs if it related to ADLs, sometimes the nurses implement them. The staff should follow the plan, but if a resident refuses, the staff should notify the nurse, who then would implement charting. If the refusals continue, a referral back to therapy would be completed. Of concern is staff did not offer or encourage R36 to ambulate as directed in the RNP. On 4/3/24 at 7:46 AM, Surveyor approached CNA G and interviewed regarding the needs of R36. CNA G is a primary dayshift caregiver for R36. CNA G also stated that she does not ambulate R36. CNA G stated she wasn't aware that they were to ambulate R36 until last week. CNA G stated she felt it was a little scary to try to ambulate R36, that even pivot transfers can be scary at times. CNA G stated she informed therapy of this but was told they are to encourage R36 to ambulate, that the resident is able and needs verbal cues. CNA G also stated that she does not place R36 at the sink to conduct self-grooming tasks, stating, . we do all her grooming . At 8:07 AM, Surveyor approached CNA F and interviewed her regarding R36's RNP for ADLs. CNA F is another primary caregiver for R36 on the dayshift. CNA F stated it is sometimes hard to ambulate R36 in the hallway but does ambulate R36 to the bathroom. CNA F stated that R36 will often refuse to walk in the hallway but are to encourage R36 to do so. CNA F also stated that she has never placed R36 at the sink to conduct self-grooming tasks and that she has to do all the grooming for the resident. On 4/3/24 at 8:18 AM, Surveyor interviewed Unit Manager (UM) M regarding her expectation of staff in regard to implementing ADL RNPs completed by therapies. UM M is the manager of the 400 hall, in which R36 resides. UM M stated the process is that a resident is evaluated and treated by therapies. Therapies then writes RNPs for floor staff to implement. The plan is communicated to floor staff onto bright green sheets that are placed on a white board, which is hanging behind the nursing desk. All staff are aware of these boards and are expected to read the RNPs prior to shift to be aware of any potential changes with any residents. UM M stated her expectation is that staff implement the plans written.

Based on observations, interviews and record reviews, the facility did not ensure hand hygiene was conducted appropriately for 1 of 1 care observations (R36). This is evidenced by: The CDC had outlined the following indications for hand washing and the wearing of gloves: A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water. B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items. C. Decontaminate hands before having direct contact with patients . F. Decontaminate hands after contact with a patient's intact skin. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves . The CDC continues to direct healthcare workers with the technique of hand hygiene: . E. Change gloves during patient care if moving from a contaminated body site to a clean body site . R36 has medical diagnoses that include but are not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, aphasia, metabolic encephalopathy, anxiety disorder, depression and encephalomalacia. On 4/2/24 at 6:13 AM, Surveyor observed R36 in bed with the room dark. At 6:26 AM, Surveyor observed Certified Nursing Assistant (CNA) N enter R36's room to provide ADL cares. The following was noted: - CNA N gently awakened R36 and explained that she was going to assist her to get up for the day. - CNA N sanitized her hands and donned a pair of gloves. CNA N washed R36's upper body and underarms. - R36 was then directed to roll onto her right side. CNA N removed the pajama bottoms and proceeded to complete catheter care then front perineal cleansing. CNA N then directed R36 to roll onto the right side and CNA N provided buttock and anal cleansing. R36 was then directed onto the back. CNA N removed the gloves, and without sanitizing or washing her hands, donned a fresh pair of gloves. CNA N then proceeded with the following: - put socks, a clean brief and slacks on R36; - rolled R36 right and left to pull up and adjust the slacks; - emptied the two basins of water in the bathroom toilet and rinsed them in the sink; and - placed all the soiled linens into a plastic bag. CNA N then removed the gloves and again, without sanitizing or washing her hands, proceeded with the following: - adjusted the bed level to low; elevated the head of the bed to 60 degrees; - opened the closet door and put away clothing hangers; - opened the dresser drawer in search of a gait belt; - pulled the wheelchair up to the side of the bed and locked the brakes; - assisted R36 to sit up on the side of the bed, guiding the resident's arms and back in the process and holding R36's hands to assist her to sit up straight; - placed the gait belt around R36's waist and tightened the buckle; - lowered the bed height more so that R36's feet were on the floor; - placed her arms around R36's waist/back area and assisted R36 to a stand, then pivot transferred R36 to the wheelchair; - placed the indwelling Foley catheter drainage bag into a protective pouch located under the wheelchair seat; - placed the foot pedals of the wheelchair onto the chair and then placed each of R36's legs/feet onto these for support; and - moved the wheelchair by the arm rests away from the bed. CNA N then removed the gloves. CNA N still did not sanitize or wash her hands. CNA N entered the bathroom closet to retrieve a comb, not finding it, went to the nightstand and opened the top drawer and removed a brush. CNA N then proceeded to brush R36's hair. CNA N then donned a pair of gloves and picked up a tube of Cere Ve moisturizing lotion and lotioned R36's face. CNA N removed the gloves, and without sanitizing or washing her hands, donned a fresh pair of gloves. - CNA N then removed soiled linens from the bed and made up R36's bed. - CNA N then entered the bathroom and set up a toothbrush with toothpaste, approached R36 and covered the resident's chest with a towel and proceeded to brush R36's teeth, gave R36 a sip of water to rinse and spit into an emesis basin. CNA N then removed the gloves, placed the towel that was over R36's chest into the plastic bag of linens and then without washing or sanitizing, donned another new pair of gloves and placed hearing aids into each of R36's ears. CNA N then wiped off R36's eyeglasses and placed them on the face. CNA N then positioned R36 in the wheelchair in front of the television and set up the over-the-bed table to R36's right side. On this table, CNA N placed a box of kleenex, a covered mug with water, the remote control for the television and a small bag of cookies. CNA N placed the call light cord over R36's lap. CNA N then removed the gloves and sanitized her hands and left the room at 7:12 AM. On this same date at 9:18 AM, Surveyor interviewed CNA N regarding the above procedure and techniques. Surveyor asked CNA N what knowledge she had regarding hand hygiene. CNA N replied that hand hygiene was the best way to keep germs away and she should wash hands frequently, sanitize or wash her hands after removing gloves. The observation was explained to CNA N with no sanitizing or washing her hands with the removal of the gloves, especially following perineal and buttock cleansing. CNA N stated, Yeah, I should have after I took off the gloves. Yeah, so all tasks afterwards were considered dirty. OK. On 4/3/24 at 8:18 AM, Surveyor interviewed Unit Manager (UM) M regarding various topics including the expected practice of hand hygiene with cares. UM M stated, I would expect them [staff] to sanitize and glove when entering the room, and with cares, whenever doing something like peri-care, take off the gloves and sanitize their hands. Surveyor explained the observation made on 4/2/24 with CNA N. UM M stated, Yeah, she should have sanitized her hands after pericare and put on new gloves .

Based on observation, interview and record review, the facility did not ensure proper hand hygiene with food handling in accordance with professional standards for food service safety. This has the potential to affect all 24 residents in the south dining room out of 64 residents residing in the facility. The dietary aide touched multiple contaminated surfaces with gloved hands, did not remove her gloves or wash her hands, and used her gloved hands to serve garlic bread on resident plates. Findings: The facility policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, states in part . 7. Employees must wash their hands: d. Before coming in contact with any food surfaces; f. After handling soiled equipment or utensils; h. After engaging in other activities that contaminate the hands. 10. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. 12. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves dies not substitute for proper handwashing. On 04/01/24 at 12:05 PM, Surveyor observed [NAME] R serving meals in the south dining room. Surveyor observed [NAME] R wearing single-use disposable gloves. Surveyor observed [NAME] R, with gloved hands, touch serving utensils, plates, counter top, meal tickets, and plate lids, and with gloved hands pick up garlic bread and place on a resident plate to be served. Surveyor observed [NAME] R did not remove gloves or wash her hands. Surveyor observed [NAME] R, with same gloved hands, walk to the cooler located at the back of the kitchen, open the cooler door, obtain a can of soda, walk to the steam table, place can of soda on tray, and with gloved hands pick up garlic bread and place on a resident plate to be served. Surveyor observed [NAME] R did not remove gloves or wash her hands. Surveyor observed [NAME] R, with same gloved hands walk to the cooler located at the back of the kitchen, open the cooler door and obtain a plastic container with food, walk to the steam table, open a drawer and obtain a serving utensil, place items on the countertop, and with gloved hands pick up garlic bread and place on a resident plate to be served. Surveyor observed [NAME] R did not remove gloves or wash her hands. Surveyor observed [NAME] R, with same gloved hands continue to plate garlic bread with gloved hands without changing gloves or washing her hands, on four plates. On 04/01/24 at 12:25 PM, Surveyor interviewed [NAME] R. [NAME] R stated it is her normal practice to pick up food items with gloved hands, But I have been touching things, so I shouldn't. Surveyor observed [NAME] R remove her gloves and wash her hands. [NAME] R donned new gloves. On 04/01/24 at 12:27 PM, Surveyor interviewed Corporate Food Service Director S. Corporate Food Service Director S confirmed using contaminated gloves to pick up food items is not the facility's practice, and usually utensils, such as tongs, are used.