PROGRESSIVE CARE CENTER

A complaint survey, prompted by #CO1933144, #CO1933146 and Incident #2603152 was conducted on 9/29/25 to 12/10/25. No deficiencies were cited. The actual survey exit date was 9/29/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider on12/10/25.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

A revisit survey was completed on 12/18/24 for all previous deficiencies cited on 11/7/24. The facility is in compliance with all regulations surveyed.

The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility's general characteristics. The facility is a one-story, Type II (000) structure. The facility is separated from the hospital building by a 2-hour wall located by the chapel. There is a partial basement that is used for support services only. The facility has a fully supervised automatic sprinkler system NFPA 13 automatic fire sprinkler system. The facility was surveyed on November 26th, 2024 for compliance to fire safety requirements using the National Fire Protection Association (NFPA) 2012 Life Safety Code, Chapter 19, Existing Healthcare Occupancy. The facility will meet these requirements when the following deficiencies are corrected. The census for the day was 61.

Through observation during the survey, it was determined that the facility failed to meet the Means of Egress-General requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) In the Dining Room, a gate separated the dining area from the food preparation area. The gate failed to meet the egress and door requirements listed in Chapter 7, and this was witnessed in two areas. 2) Near the nurse station to a stairwell to the basement, there was a gate before the door to the basement. The gate failed to meet the egress and door requirements listed in Chapter 7. This did not meet the requirement of LSC Sections7.1.9 Impediments to Egress. Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress, unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.7.1.10.2.2 No obstruction by railings, barriers, or gates shall divide the means of egress into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment. 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Egress Door requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The exterior door in the therapy room did not open when tested. It is a double door, and the left door leaf did not operate because the mechanism was not operating properly. This did not meet the requirement of LSC Sections4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows:(1)The opening forces for interior side-hinged or pivoted-swinging door leaves without closers shall not exceed 5 lbf (22 N).(2)The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.(3)The opening forces for horizontal-sliding door leaves in detention and correctional occupancies shall be as provided in Chapters 22 and 23.(4)The opening forces for power-operated door leaves shall be as provided in 7.2.1.9.7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Discharge from Exit requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) Through observation, when exiting the 600 Hall exit through the exterior, exit signage need to be along the path taking occupants to public way does not have marking to public way. This did not meet the requirement of LSC Sections7.7.3.2 The exit discharge shall be arranged and marked to make clear the direction of egress travel from the exit discharge to a public way. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Hazardous Area- Enclosure requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The Generator Room had open penetrations in the fire-resistant construction. 2) The Soiled Utility Room does not resist the passage of smoke due to damage to the door. 3) Room used for oxygen storage has penetrations around the plumbing stubouts from the wall that have unprotected space between the pipes and gypsum board. This did not meet the requirement of LSC Sections4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within two smoke compartments. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey and documentation review, it was determined that the facility failed to meet the Kitchen Hood requirements in accordance with NFPA 101, and NFPA 96. This STANDARD is not met, as evidenced by: 1) In the dining room, there is a model VCS 2000 Ventless Cooking System. Through document review it was determined that that the system was not connected to the Fire Alarm Control Panel. 2) In the dining room, there is a model VCS 2000 Ventless Cooking System. The manual activation device is fixed to the unit, so the distances listed in NFPA 96 Section 10.5 Are not met. This did not meet the requirement of LSC Sections19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 96: 10.5.1.1 At least one manual actuation device shall be located a minimum of 3 m (10 ft) and a maximum of 6 m (20 ft) from the protected kitchen appliance(s) within the path of egress. NFPA 96: 10.6.2 Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the automatic fire-extinguishing system shall activate the fire alarm signaling system. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey and documentation review, it was determined that the facility failed to meet the Sprinkler System- Maintenance and Testing requirements in accordance with NFPA 101, and NFPA 25. This STANDARD is not met, as evidenced by: 1) There was no Hydraulic Calculation or General Information sign on the fire riser. 2) Testing documentation indicates that the Back Flow Prevention Device failed the testing. 3) Dry barrel sprinkler heads outside of 700 patio are stamped with a date of 2007,no testing information was provided per NFPA 25 requirements. 4) Testing documentation states that the Control Valve Basement West Mechanical Room Main Side zone two control valve failed. The valve handle broke off of the stem. This did not meet the requirement of LSC Sections19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25: 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. NFPA 25: 5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible. NFPA 25: 5.3.1.1.1.6* Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. NFPA 25: 13.6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer ' s instructions in accordance with the procedure and policies of the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Subdivision of Building Spaced- Smoke Barrier Construction requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) At the occupancy separation from the Skilled Nursing Facility, to the kitchen in the hospital occipany, there are open penetrations in the fire rated assembly above the ceiling. 2) Hall 500 had penetrations in the smoke barrier above the ceiling. 3) Hall 700 had penetrations in the smoke barrier above the ceiling. This did not meet the requirement of LSC Sections19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:(1)This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:(a)Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).(b)Not less than two separate smoke compartments shall be provided on each floor.(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

A recertification survey with complaint #CO36038 and #CO37034 was completed on 11/4/24 to 11/7/24. Seven deficiencies were cited.

An Emergency Preparedness survey was conducted from 11/4/24 to 11/7/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to take steps to prevent abuse for three (#40, #10 and #35) of three residents reviewed for abuse out of 29 sample residents. Specifically, the facility failed to protect Resident #40, Resident #10 and Resident #35 from physical abuse. Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation Prevention policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 11/4/24 at 5:30 p.m. It read in pertinent part, "Our facility prohibits the abuse, mistreatment, neglect, and/or exploitation of residents. We believe that all residents have the right to be free from such actions by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving our community, family members or legal guardians, friends, or any other individuals."The facility will train all employees, through orientation and on-going training sessions (online training and in-services) on issues related to abuse prohibition practices such as what constitutes abuse, neglect, and misappropriation of resident property."As part of our facility's attempt to prevent abuse, neglect, and/or exploitation of our residents, we will provide residents, families, and staff with information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding to concerns that have been expressed."Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident."The individual conducting the investigation will, as a minimum; review the resident's medical record to determine events leading up to the incident."II. Incident of physical abuse involving Resident #10, Resident #40 and Resident #35 on 10/26/24The facility investigation was provided by the NHA on 11/5/24 at 3:30 p.m. The investigation, dated 10/27/24 at 1:15 p.m., documented the following information:Resident #10 said when CNA #1 was changing her bed and rolling her around, CNA #1 was jerking on the sheets. When CNA #1 was finished, Resident #10 said she asked for her pillow back. Resident #10 said CNA #1 hit her with his hand in her right ear while placing the pillow under her head. Resident #10 said she did not report the incident last night (10/26/24) and reported it the next day (10/27/24). Resident #10 was assessed and there was no redness to her ear and she was monitored for any latent bruising. (However, according to the 10/27/24 nursing progress note, the resident had redness to her right ear and right face - see record review below). Resident #10 said she was not afraid of CNA #1. Resident #10 was notified that CNA #1 was suspended pending investigation of the incidents. On 10/28/24 the NHA documented that during the investigation, another resident (Resident #40) alleged the same CNA (CNA #1) had pushed too hard when rolling her causing her to hit her hip on the wall. Resident #40 said CNA #1 had also yelled at her roommate, Resident #35. Resident #40 said CNA #1 was telling Resident #35 to get up and he needed to get Resident #35 changed. Resident #40 said after CNA #1 had gotten Resident #35 up, he left the room and left Resident #35 on the commode. Resident #40 said CNA #1 did not come back into the room and Resident #35 had to get herself changed and dressed. Resident #40 said she was not afraid of CNA #1 and said next time she saw CNA #1 she was going to kick him in the teeth. The police department was notified of the additional information and came to the facility to add to the report and speak with Resident #40. On 10/28/24 the NHA documented that she interviewed Resident #35. Resident #35 said her care was fine. The NHA asked if Resident #35 remembered CNA #1 providing care for her and Resident #35 said she remembered CNA #1. Resident #35 said CNA #1 was a very nice young man. Resident #35 said CNA #1 assisted her to the bedside commode. Resident #35 did not report any other issues. On 10/28/24 interviews were conducted with three other residents and four staff members. None of the additional residents or the staff members had any concerns regarding abuse. On 10/28/24 the NHA documented that she completed a phone interview with CNA #1. CNA #1 said 10/26/24 was his second time working at the facility. The NHA asked CNA #1 if there were any concerns he had with any of the residents. CNA #1 said he felt like his interaction with one of the residents was odd. CNA #1 said the lady three doors down on the left side of the room was saying snarky stuff all night. CNA #1 said the resident was asking him to joke around with her. CNA #1 said he did not say anything back to the resident. The investigation documented CNA #1 said the call light was on in the room about three doors down on the left side of the hall. CNA #1 said when he walked into the room, he asked Resident #40 (on the left side of the room) how he could help. CNA #1 said Resident #40 told him "what the explicit do you think I need help for." CNA #1 said he was caught off guard by the comment, but asked Resident #40 what he could do for her. CNA #1 said Resident #40 requested to go to bed and he assisted her. CNA #1 said during the night he answered Resident #40's call light several times. The investigation documented that CNA #1 said at 4:00 a.m he answered the call light again for Resident #40. CNA #1 said Resident #40 said she needed to be changed. CNA #1 said he asked Resident #40 if she was able to move and she told CNA #1 that he had to roll her. CNA #1 said Resident #40 was incontinent of bladder. CNA #1 said Resident #40 never said ouch or indicated any type of pain. CNA #1 said Resident #40 did not hit the wall when he turned her. The inveestigation documented CNA #1 said after he was done changing Resident #40 he assisted her roommate, Resident #35. CNA #1 said Resident #35 started saying a prayer while he was assisting her. CNA #1 said he asked Resident #35 if he could help get her to the commode and get her changed. CNA #1 said he had to speak loudly to Resident #35 because she was hard of hearing. CNA #1 said Resident #35's roommate, Resident #40, started yelling and said "can' t you see she is doing something." CNA #1 said he told Resident #40 that he was doing his rounds and needed to make sure everyone was clean and dry. CNA #1 said Resident #40 told him that he had an attitude. CNA #1 said when he was assisting Resident #35, Resident #40 would answer for Resident #35. The NHA asked CNA #1 about Resident #10. CNA #1 said when he entered Resident #10's room towards the beginning of his shift, he noticed that Resident #10 was soiled. CNA #1 said he assisted Resident #10 into her bed and changed her. The NHA asked CNA #1 if he had any further interactions with Resident #10 the rest of the night. CNA #1 said he checked on Resident #10 during his rounds and she was dry. CNA #1 said during the 4:00 a.m. rounds he asked Resident #10 if she needed to be changed. CNA #1 asked Resident #10 if he could check her. CNA #1 said he asked Resident #10 if she needed to go to the bathroom and the resident told him yes CNA #1 said Resident #10 was incontinent of bowel and bladder. CNA #1 said he assisted Resident #10 with getting her changed and completed a bed change for the resident. CNA #1 said Resident #10 asked for her pillow, but he let Resident #10 knew that he would need to get her a new pillow since her pillow was soiled. CNA #1 said when he was leaving the room, Resident #10 began yelling at him to give her pillow back. Resident #10 said she wanted her pillow now. CNA #1 said when he came back into the room he set the pillow by Resident #10's head and Resident #10 placed the pillow under her head herself. CNA #1 then told Resident #10 to have a great night. The investigation indicated CNA #1 was suspended pending investigation of the incidents. The conclusion of the internal investigation was unsubstantiated based on the facility's determination that there was no willful acts of physical abuse. -However, Resident #10 was assessed on 10/27/24 and the right side of her face and ear was red (see record review below). III. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on 9/19/23. According to the November 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation (abnormal heart rate), schizoaffective disorder, anxiety disorder and borderline personality disorder (interpersonal relationship instability and distorted sense of self). The 9/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for assistance with toileting hygiene and lower body dressing. She required substantial/maximum assistance with upper body dressing, rolling left and right, sitting to lying and lying to sitting on the side of bed. B. Resident interviewResident #10 was interviewed on 11/4/24 at 2:22 p.m. Resident #10 said last Monday night a male agency CNA (CNA #1) made her feel scared. She said the CNA was rough and he did not want to change her but he did it anyway. She said when she asked for her pillow, CNA #1 purposely hit her ear with his hand while putting the pillow under her arm. She said she reported the incident to the NHA the next day and she called the police. She said the police had talked to her about the incident. She said CNA #1 was not allowed on the premises and had not been back. She said if something was wrong that she would tell someone about it. She said she did not feel afraid and felt safe at the facility. Resident #10 was interviewed again on 11/6/24 1:40 p.m. She said CNA #1 being abusive because of the way he handled her care. She said CNA #1 came into her room with an attitude and it was not accidental that he hit her ear on purpose. She said when he hit her ear she said, "Ouch leave me alone and get out of here." She said she did not see CNA #1 for the rest of the night. Resident #10 said she would not be upset if CNA #1 came back to work at the facility as long as he did not go to her room. She said she would not want him to provide personal care for her. She said she would be fine if he worked down a different hallway. She said she felt comfortable knowing that the facility investigated the abuse right away and called the police. C. Record ReviewThe care plan for mood/behavior, revised on 3/1/24, documented Resident #10 had a history of alteration in mood or exhibition of behavioral symptoms related to schizoaffective disorder. Resident #10 heard voices all the time, such as a group of boys singing. She had a recent increase with Haldol (an antipsychotic medication). She had accused her roommate of stealing her money. Interventions included administering medications as ordered, allowing the resident time to calm down and reapproaching her at a later time, sending the resident to psychological counseling as recommended by the physician, interacting in an empathetic and supportive manner, monitoring and documenting each behavioral event and offering psychosocial support as needed. The 10/27/24 progress note documented when the resident was first assessed, her ear and her face were red on the right side. Resident #10 denied pain to either area. Resident #10 was assessed in the afternoon (on 10/27/24) and all the redness had gone away. No other injury or discoloration was noted to her right ear. IV. Resident #40A. Resident statusResident #40, age greater than 65, was admitted on 5/14/24. According to the November 2024 CPO, diagnoses included chronic respiratory failure with hypoxia, anxiety disorder and adjustment disorder with depressed mood. The 8/20/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for assistance with toileting hygiene, upper and lower body dressing and putting on/taking off footwear. She required substantial/maximal assistance with rolling left and right, sitting to lying and lying to sitting on the side of the bed. B. Resident interviewResident #40 was interviewed on 11/5/24 at 9:24 a.m. Resident #40 said CNA #1 told her to roll to the wall. She said she told CNA #1 that she could not and that he needed to help her. She said CNA #1 grabbed her arm and put a bruise on her arm and then he grabbed her right hip and she banged her head on the wall. She said she did not hit the wall hard. She said CNA #1 had a hold of her bad hip and she told him not to move her bad hip because it hurt. She said CNA #1 ignored her and kept pushing on her bad hip. She said when CNA #1 did not listen to her, it made her mad. She said she did not want to say anything else to CNA #1 because he would have pushed harder on her hip. She said she told CNA #1 that he was not listening to her. She said she did not feel afraid. Resident #40 said she told the NHA on 10/28/24 about the abuse regarding CNA #1. C. Record reviewThe care plan for mood/behavior revised 4/16/24, documented Resident #40 had a history for alteration in mood or exhibition of behavioral symptoms related to anxiety and depression. Interventions included administering medications as ordered;,allowing the resident time to calm down and reapproaching at a later time, continuing to remind the resident of the importance of utilizing the call light and asking for help with cares, evaluating the resident's need and referring to psychological counseling as recommended by physician, interacting in an empathetic and supportive manner, monitoring and documenting each behavioral event, offering one to one interactions as needed, and offering psychosocial support as needed.-Review of Resident #40's EMR revealed there were no progress notes related to the resident's physical abuse allegation with CNA #1 on 10/27/24.-Review of Resident #40's EMR revealed there was no documentation that indicated a skin assessment was completed related to Resident #40's allegation. V. Resident #35A. Resident statusResident #35, age greater than 65, was admitted on 8/8/22. According to the November 2024 CPO, diagnoses included dementia and muscle weakness. The 9/23/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. She required substantial/maximal assistance with toileting hygiene and upper and lower body dressing She required partial/moderate assistance with toilet transferring. B. Record reviewThe care plan for mood/behavior, revised 6/16/24, documented Resident #35 had a history of alteration in mood or exhibition of behavioral symptoms related to dementia. Resident #35 would often use her wash basin to urinate in during the night. Interventions included providing a bedside commode next to bed during the night, interacting in an empathetic and supportive manner, offering one to one interactions as needed and offering psychosocial support as needed.-Review of Resident #35's EMR revealed there were no progress notes related to the resident's physical abuse allegation with CNA #1 on 10/27/24. VI. Staff interviewsCNA #2 was interviewed on 11/6/24 at 8:58 a.m. CNA #2 said when there was an allegation of abuse she would call the police and report it to the director of nursing (DON) and the NHA. CNA #2 said the nurse, the DON, or anybody could document that there was abuse reported. She said she did not have access to write a progress note in the resident's chart. CNA #2 said she did not hear about the abuse regarding CNA #1, Resident #10, Resident #40 and Resident #35. She said she had not seen any behavioral changes in Resident #10, Resident #40 and Resident #35 recently. CNA #2 said she received abuse training when she started working at the facility. She said she had not received any recenteducation or training on abuse. Licensed practical nurse (LPN) #1 was interviewed on 11/6/24 at 9:11 a.m. LPN #1 said when there was an allegation of abuse, she would notify the NHA. She said the NHA was responsible for documenting in the resident's chart regarding the abuse allegation. She said she was not working the night the allegation of abuse occurred with CNA #1. She said she heard about what had happened in the morning report on 10/30/24. She said she had not noticed any changes in Resident #10, Resident #40 or Resident #35's behavior recently. LPN #1 said Resident #10 was monitored for her ear after the incident on 10/26/24 and she had no visual signs of bruising on her ear. She said Resident #10 was on alert charting and monitoring for three days or until it resolved. She said there was no bruising noted to Resident #10 ear. The NHA was interviewed on 11/7/24 at 10:32 a.m. The NHA said she was the abuse investigator for the facility. She said she received a call from LPN #3 on 10/27/24 and said Resident #10 had reported to her that she had issues with CNA #1 last night (10/26/24). The NHA said Resident #10 reported that CNA #1 had hit her on her right ear. The NHA said LPN #3 told her that she had put in orders to monitor Resident #10's ear. The NHA said LPN #3 told her a skin assessment was completed and no redness was reported. She said Resident #10 reported she was not afraid of CNA #1. The NHA said Resident #10 said she was alright and that she did not like CNA #1. The NHA said she talked to Resident #10 over the phone. The NHA said Resident #10 said CNA #1 had hit her in the ear with his left hand. The NHA said when she asked Resident #10 if it was an accident, the resident said no, that CNA #1 had hit her on purpose. The NHA said she told Resident #10 that she was sorry that it happened. The NHA said Resident #10 was asked if she reported the incident right away and Resident #10 said no, that she reported it the next day. The NHA said she told Resident #10 that CNA #1 was going to be suspended. The NHA said she added Resident #10 to alert charting and called the police. The NHA said the police went to the facility and interviewed Resident #10. The NHA said when she came in Monday morning (10/28/24) she started her investigation with the staff and the residents. The NHA said during her investigation, another resident (Resident #40) came forward about having problems with CNA #1. The NHA said Resident #40 reported she did not like CNA #1's demeanor and the way he spoke to her roommate, Resident #35. The NHA said Resident #40 told her to look at her arm and there was discoloration and a line on Resident #40's arm. She said Resident #40 said she had her call light on to be changed. The NHA said Resident #40 said CNA #1 came into her room to change her and when CNA #1 was rolling her on her side, he pushed so hard that she hit her hip on the wall. The NHA said Resident #40 told her about her roommate, Resident #35. The NHA said Resident #40 said CNA #1 was yelling at Resident #35 and telling her that she needed to get up. The NHA said Resident #40 said CNA #1 left Resident #35 on the commode and never came back to get her off. The NHA said Resident #40 said Resident #35 had to get herself off the commode and back into bed by herself. The NHA said she called the police again and asked if she needed to make a new report and the officer said no. The NHA said the same police officer came to the facility and met with Resident #40. The NHA said Resident #40 reported to the officer that she had hit her head while CNA #1 was changing her and not her hip. The NHA said she met with Resident #35 on 10/28/24. The NHA said Resident #35 had dementia and was forgetful. She said she asked Resident #35 if she remembered CNA #1 and she said he was a nice man. The NHA said Resident #35 said CNA #1 had helped to get her on the commode and she had no concerns about him. The NHA said she followed up with all three residents a few days later. She said none of the residents had any changes in their behaviors in regards to eating, sleeping and attending activities. She said she talked to the residents about CNA #1 coming back to work at the facility. She said Resident #10 said she did not care if he came back as long as he did not mess with her pillow. The NHA said Resident #40 said she was fine with him coming back as long as he was not taking care of her. The NHA said Resident #35 said she would not have any issues with CNA #1 coming back. The NHA said all three residents reported feeling safe and not afraid. The NHA said CNA #1 was an agency CNA. She said he had completed the abuse training before working at the facility. She said CNA #1 had not come back to work at the facility yet. The NHA said she documented the investigation by typing up the abuse on the computer and placing the documentation in a file. She said she did not document the abuse incident in the chart. She said it was important for the nursing staff to know what was going on.

Based on record reviews and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#38) of one resident reviewed for PASRR out of 29 sample residents. Specifically, the facility failed to take steps to ensure services were provided as recommended in Resident #38's PASRR Level II report. Findings include:I. Facility policy and procedureThe PASRR policy and procedure, revised June 2023 was received on 11/7/24 at 8:19 a.m., was provided by the nursing home administrator (NHA). It read in pertinent part, "Federal regulations allow seven to nine days for the completion of a PASRR. A hospital should start the PASRR process with a Level 1 screening at admission, or as soon as there is an indication the individual may be discharging to a nursing facility, as this will support timely completion of a Level 2 evaluation, if needed, and determination prior to discharge."If the resident's Level I screening results is positive for specialized mental illness (SMI), intellectual disability (ID)/developmental disability (DD), or resident condition (RC), then a Level 2 evaluation must be completed by an approved state contractor, and a determination made by the appropriate mental illness (MI) or intellectual disability (ID) state authority."II. Resident #38A. Resident statusResident #38, age 74, was admitted on 7/13/23. According to the November 2024 computerized physician orders (CPO), the diagnoses included major depressive disorder, anxiety disorder and post-traumatic stress disorder (PTSD). The 9/25/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required substantial/maximal assistance with showering/bathing. He required supervision or touching assistance with oral hygiene, toileting hygiene, upper and lower body dressing and personal hygiene. B. Record reviewResident #38's PASRR Level II, dated 7/7/23, revealed the resident had a PASRR condition and required specialized services. The specialized services required were psychiatric case consultation. The Level II documented Resident #35 could benefit from neurocognitive testing for his dementia to assess how the facility could best help him. Resident #35 would benefit from a medication evaluation to assess the efficacy of his Effexor (antidepressant medication) dosage, noted to be above the not-to exceed daily limit. The care plan for mood/behavior, revised on 11/14/23, documented Resident #38 had a history of altercation in mood or exhibition of behavioral symptoms related to dementia and PTSD. He had a history of believing there was a secret room at his previous facility, where staff would get together and plan to burn the building down. He experienced delusional thinking related to staff drinking alcohol and partying with other residents. The family reported the resident could become more confused in the afternoons and would fixate on events that had never happened. Interventions included, administering medications as ordered, allowing the resident time to calm down and reapproach at a later time, evaluating for need and referring to psychological counseling as recommended by physician, interacting in an empathetic and supportive manner; monitoring and documenting each behavioral event, offering one to one interaction as needed, and offering psychosocial support as needed.-A review of the comprehensive care plan revealed there was no documentation regarding the resident's PASRR Level II screening and specialized service recommendations.-A review of the electronic medical record (EMR) did not reveal documentation that indicated the resident was receiving case management, psychiatric case consultation or other services recommended on the 7/24/23 PASRR Level II determination.-No social services notes were located regarding PASRR or recommendations. No PASRR progress notes showing communication with the State Mental Health Agency regarding a delay or inability to follow the recommendations were located. C. Staff interviewsThe NHA was interviewed on 11/06/24 at 2:36 p.m. The NHA said she was not able to find notes that the recommendations on Resident #38's were completed. She said Resident #38 was transferred from another nursing facility in July 2023. She said she called the facility and they did not have any documentation that neurocognitive testing was completed. She said Resident #38 had vascular dementia and he did not categorize as a Level II.-However, the facility did not submit an updated PASRR for a qualified mental health professional to determine if the Level II recommendations were still applicable for Resident #38. The NHA said she read Resident #38's PASRR before he was admitted and made sure the facility was able to meet his needs. She said she would resubmit a PASRR and get further recommendations. She acknowledged the recommendations were in place, but did not know how to get psych services. She said they do not have anyone in town, but would look into getting Resident #38 seen.

Based on observations, record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for the resident that met professional standards of quality care for one (#110) of one resident out of 29 sample residents. Specifically, the facility failed to develop and implement within 48 hours of admission a person-centered baseline care plan for Resident #110 that included pertinent healthcare information, specifically related to the resident's hard cervical collar and fractured left wrist, necessary to properly care for the resident. Findings include:I. Facility policy and procedureThe Baseline Care Plan policy, revised March 2022, was provided by the nursing home administrator (NHA) on 11/7/24 at 8:16 a.m. It read in pertinent part, "A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission."The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:-Initial goals based on admission orders and discussion with the resident/representative;-Physician orders;-Dietary orders;-Therapy services;-Social services; and,-PASARR (pre-admission screening and resident review program) recommendations, if applicable."The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed."The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following:-The stated goals and objectives of the resident;-A summary of the resident's medications and dietary instructions;-Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and,-Any updated information based on the details of the comprehensive care plan, as necessary."Provision of the summary to the resident and/or resident representative is documented in the medical record."II. Resident #110A. Resident statusResident #110, age greater than 65, was admitted on 11/2/24 and discharged home per resident request on 11/6/24. According to the November 2024 computerized physician orders (CPO), diagnoses included displaced fracture of the first cervical vertebra (broken neck), nondisplaced fracture of lunate left wrist (broken wrist) and insomnia. The 11/5/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The functional status section of the assessment was not completed and was in progress at the time of the survey. B. Resident observation and interviewOn 11/4/24 at 12:37 p.m. Resident #110 was in bed with his left wrist/forearm in a cast and a hard cervical collar around his neck. Resident #110 said he had been admitted to the facility for rehabilitation. Resident #110 said he had not been informed by the facility when he would see his orthopedic doctor, get an x-ray/CT scan of his neck or wrist, when his neck brace could come off or when his left forearm/wrist brace would be removed. Resident #110 said he had received a shower that day from a certified nursing aide (CNA) and his hard cervical collar had been removed. III. Record review-Review of Resident #110's electronic medical record (EMR), as well as the resident's paper medical record, revealed no evidence that a baseline or comprehensive care plan had been developed to address the needs of the resident, specifically related to the resident's hard cervical collar and fractured left wrist. A nurse progress note dated 11/3/24 documented Resident #110 required daily skilled nursing related to falls at home with a left wrist fracture and C1 (first cervical vertebra) fracture. He was working with physical therapy/occupational therapy (PT/OT) and was cooperative with care. The resident's left wrist had a splint in place and the resident was wearing a cervical collar. -Despite the nurse's progress note, the facility failed to implement a baseline care plan which addressed Resident #110's weight-bearing status of his left wrist, his need for PT/OT or if the resident's hard cervical collar could be removed for skin checks and showers. Cross-reference F684 for failure to ensure residents received treatment and care in accordance with professional standards of practice. IV. Staff interviewsCNA #3 was interviewed on 11/6/24 at 8:55 a.m. CNA #3 said she began working with Resident #110 on 11/3/24. CNA #3 said the care plan was not loaded into the resident's EMR yet so she got Resident #110's care information/report from another CNA who said he had a neck and arm brace. CNA #3 said she gave Resident #110 a shower on 11/4/24 and the resident took off his neck brace and she wrapped his left arm splint so it would not get wet. CNA #3 said not having a baseline care plan put her in a bad position when she did not know important details about a resident. CNA #3 said she did what she could until she knew more about the resident. CNA #3 said the more she knew about a resident, the better care was provided because effective communication was crucial. CNA #3 said she received education on 11/5/24, during the survey, (see facility follow up below) that a new communication book, which included baseline care plans for the residents, was at the nurses station. CNA #3 said she thought the communication book would help make everyone more safe. CNA #3 said did not want to hurt a resident who was here for rehabilitation and the more knowledge she had helped with resident pain control when transferring and providing care. Registered nurse (RN) #1 was interviewed on 11/6/24 at 8:59 a.m. RN #1 said she worked in the rehabilitation hall. RN #1 said she had recently received education about the process for a new baseline care plan notebook (see facility follow up below). RN#1 said she loved the idea of the new baseline care plan book because it was a good quick glance reference for important resident care information. RN #1 said with high resident turnover, care changes with diagnoses and resident progress with therapy, it was good to have the communication binder and it gave her confidence to know what was going on with each resident. RN #1 said the rehabilitation residents were in and out quickly and there was a potential to get things mixed up with all the new residents. RN #1 said not knowing all the details about a resident could put her in a bad position when providing care. RN #1 said it was essential to have a baseline care plan day one because nurses needed to know important healthcare information about each resident. RN #1 said Resident #110 was alert and oriented and could tell the staff some things. The assistant director of nursing (ADON) and the NHA were interviewed together on 11/6/24 at 10:55 a.m. The ADON and the NHA said the facility had not developed baseline care plans for residents but had started developing them today (11/6/24) for all residents. The ADON and the NHA said nurses had previously conducted an admission/readmission evaluation assessment but the assessment did not trigger staff to create a baseline care plan for residents. The ADON said it was important to establish a baseline care plan for residents because it provided a person-centered care service plan for the CNAs to follow for each resident. She said a baseline care plan should provide the minimum healthcare information necessary to properly care for the immediate needs of each resident. The NHA said a baseline care plan was not created until today (11/6/24) for Resident #110. V. Facility follow up On 11/6/24 at 8:40 a.m. the NHA provided documentation via email that baseline care plans for all newly admitted residents were placed in a communication binder for staff to utilize. The newly created baseline care plan for Resident #110 revealed special instructions that the Resident was non-weight bearing on his left wrist and staff was to ensure the resident wore his hard cervical collar and the left wrist brace, but the collar and the wrist brace could be removed for showers and skin checks. The email further provided documentation of education that had been started with the staff on 11/5/24. The education revealed a communication binder would be made available to ensure new residents' needs were communicated to the staff. This would ensure continuity of care was maintained and resident safety measures were met. Information such as weight bearing status, diet, device status, such as braces and casts, including whether it could be removed should be included. Nurses were to familiarize themselves with the communication form and ensure that the information on the form was obtained when they were receiving report from a transferring facility. CNAs were to familiarize themselves with the communication binder, especially on their first day back to work after time off. The education included 23 staff members' signatures.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were provided in order to attain the resident's highest practicable physical, mental and psychological well-being and to provide effective and person-centered care for one (#40) of one resident out of 29 sample residents. Specifically, the facility failed to ensure Resident #40 had a care plan for the use of an anticoagulant medication. Findings include:I. Resident #40A. Resident statusResident #40, age 75, was admitted on 5/14/24. According to the November 2024 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia, atrial fibrillation (irregular heartbeat) and anxiety disorder. The 8/20/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with toileting hygiene, upper and lower body dressing and putting on/taking off footwear. The assessment indicated the resident received an anticoagulant medication daily. B. Record reviewThe November 2024 CPO revealed the resident had a physician's order for Xarelto (a blood thinner) 15 mg (milligrams), give one tablet by mouth one time a day for atrial fibrillation, ordered on 5/15/24.-A review of the comprehensive care plan did not reveal a care plan addressing the use of the anticoagulant medication or its side effects. C. Staff interviewsThe assistant director of nursing (ADON) was interviewed on 11/7/24 at 11:07 a.m. The ADON said if a resident was taking an anticoagulant they should be monitored on every shift for any complications. He said residents who were prescribed an anticoagulant should have a care plan. He said he was responsible for making sure that a care plan was in place. He said he coordinated changes and educated the nurses on any changes made on the plan of care. He said when the order came in for the anticoagulant medication that he missed it.

Based on observations, record review and interviews, the facility failed to ensure one (#110) of one resident out of 29 sample residents received treatment and care in accordance with professional standards of practice. Specifically, for Resident #110, the facility failed to:-Obtain physician's orders which indicated if it was acceptable to remove the resident's hard cervical (neck) collar brace for skin checks and showers;-Obtain physician's orders for the weight bearing status of the resident's fractured left wrist;-Follow up on scheduling the resident's neurosurgeon/orthopedic doctor's appointment and CT (computed tomography) scan appointment; and,-Ensure nursing staff were aware of and informed of pertinent healthcare information related to the resident's hard cervical collar and fractured left wrist. Findings include:I. Resident #110A. Resident statusResident #110, age greater than 65, was admitted on 11/2/24 and discharged home per resident request on 11/6/24. According to the November 2024 computerized physician orders (CPO), diagnoses included displaced fracture of the first cervical vertebra (broken neck), nondisplaced fracture of lunate left wrist (broken wrist) and insomnia. The 11/5/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The functional status section of the assessment was not completed and was in progress at the time of the survey. B. Resident interview and observationOn 11/4/24 at 12:37 p.m. Resident #110 was in bed with his left wrist/forearm in a cast and a hard cervical collar around his neck. Resident #110 said he had been admitted to the facility for rehabilitation. Resident #110 said he had not been informed by the facility when he would see his orthopedic doctor, get an x-ray/CT scan of his neck or wrist, when his neck brace could come off or when his left forearm/wrist brace would be removed. Resident #110 said he had received a shower that day from a certified nursing aide (CNA) and his hard cervical collar had been removed. C. Record reviewReview of Resident #110's 10/15/24 hospital discharge summary and instructions revealed Resident #110 was to follow up with his primary care physician (PCP), neurosurgeon and orthopedic surgeon. The summary revealed the resident's active issues requiring follow up included:-Following up in the neurosurgery clinic in two weeks for a repeat cervical spine CT; and,-Following up with an orthopedic surgeon for the left lunate (wrist) fracture. The summary included the names, addresses and phone numbers for the physicians the resident was to follow up with. A review of a 10/28/24 community PCP visit note revealed Resident #110 was seen for a follow-up appointment following a recent hospital stay. The PCP's note revealed the resident's wife was having difficulties managing the resident's care at home and the resident and his wife agreed to a short-term rehabilitation stay at a skilled nursing facility. Review of the facility's electronic medical record (EMR), as well as the paper medical record, for Resident #110 revealed no evidence that a baseline or comprehensive care plan had been developed upon the resident's admission to the facility on 11/2/24 to address the needs of the resident, specifically related to the resident's hard cervical collar and fractured left wrist. A nurse progress note dated 11/3/24 documented Resident #110 required daily skilled nursing related to falls at home with a left wrist fracture and C1 (first cervical vertebra) fracture. He was working with physical therapy/occupational therapy (PT/OT) and was cooperative with care. The resident's left wrist had a splint in place and the resident was wearing a cervical collar. -Despite the nurse's progress note, the facility failed to implement a baseline care plan which addressed Resident #110's weight-bearing status of his left wrist, his need for PT/OT or if the resident's hard cervical collarcould be removed for skin checks and showers. Cross-reference F655 for failure to develop and implement a baseline care plan within 48 hours of admission in order to provide the minimum healthcare information necessary to properly care for the immediate needs of the resident. Review of Resident #110's November 2024 CPO revealed a physician's order to monitor the skin around the resident's neck brace daily, ordered 11/4/24.-There was no physician's order which indicated if the resident's hard cervical collar could be removed for skin checks or showers.-There was no physician's order for the weight bearing status of the resident's left wrist. The 11/4/24 OT start of care evaluation revealed precautions/contraindications documented by the OT included a non-weight bearing status for Resident #110's left upper extremity. The 11/4/24 PT start of care evaluation revealed precautions/contraindications documented by the PT included the resident was to wear the neck brace at all times and possible weight bearing precautions for the left wrist. The 11/4/24 facility physician's progress note revealed Resident #110 was in the hospital from 10/6/24 to 10/15/24 related to a mechanical fall from standing and the resident had the following injuries: a minimally displaced bilateral anterior and left posterior C1 arch fracture without atlantoaxial/subluxation and a closed non-displaced left lunate fracture. The note documented the hospital neurosurgeon recommended non-operative management of the C1 fracture with a cervical collar and the hospital's orthopedist recommended non-operative management of the left lunate (wrist) fracture with a splint. The resident underwent surgery for a right occipital hematoma which was performed without complication. -However the physician's note did not reveal the recommended weight bearing status of the resident's left wrist or if the cervical collar and the wrist splint could be removed for showers or skin checks.-Review of Resident #110's EMR revealed there were no follow up neurosurgeon/orthopedic doctor's appointments scheduled or follow up CT scan appointments. A nurse progress note dated 11/4/24 documented that Resident #110 had received a shower in the morning. According to the resident's interview on 11/4/24, the CNA removed his cervical collar during the shower on 11/4/24 (see resident interview above). II. Staff interviewsThe nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 11/5/24 at 4:19 p.m. The NHA and the DON said there was no care plan documented in Resident #110's EMR because the resident had just been admitted to the facility on 11/2/24. The NHA and the DON said they completed baseline care plans by day five after a resident's admission. The NHA and the DON said staff communicated verbally to relay important information about a resident's specific care needs until a care plan was developed. The NHA and the DON said they needed to find out when Resident #110 would see his orthopedic doctor and then they could find out when his cervical collar was scheduled to come off. The NHA and the DON said they would follow up in regards to whether or not the resident's cervical collar could be removed for bathing. The NHA and the DON said Resident #110 had a platform walker and was non-weight bearing on his left upper extremity (LUE). The NHA and the DON said since there was no care plan in place, the CNAs knew about the weight-bearing status from a verbal report, however, they said a verbal report was not the most comprehensive way to let the CNAs know about residents' pertinent healthcare information. The NHA and the DON said the residents' care information would usually be included in the CNA tasks in the EMR after the care plan was developed, however, they said the weight bearing status for Resident #110's LUE was not documented in the EMR. The NHA and the DON said they planned to develop a new communication binder that would include a baseline care plan, a communication white board and a temporary individual care service plan for the CNAs to utilize for resident care. The NHA and the DON said they planned to complete a whole house audit to determine any resident limitations, how to transfer, and educate staff on the new communication book until the white boards had arrived. III. Facility follow upOn 11/5/24 at 6:22 p.m. the NHA sent an which indicated Resident #110 had been scheduled for an orthopedic appointment and a CT scan. The email further revealed physician's orders had been obtained which indicated the resident could remove his cervical collar during showers or baths. On 11/6/24 at 8:40 a.m. the NHA provided the following documentation via email: Copies of communication sheets that the facility would be using until the ordered white communication boards. A copy of education that had been started with the staff on 11/5/24. The education revealed a communication binder would be made available to ensure new residents' needs were communicated to the staff. This would ensure continuity of care was maintained and resident safety measures were met. Information such as weight bearing status, diet, device status, such as braces and casts, including whether it could be removed should be included. Nurses were to familiarize themselves with the communication form and ensure that the information on the form was obtained when they were receiving report from a transferring facility. CNAs were to familiarize themselves with the communication binder, especially on their first day back to work after time off. The education included 23 staff members' signatures. The documentation provided by the NHA additionally revealed baseline care plans for all newly admitted residents was placed in a communication binder for staff to utilize. The newly created baseline care plan for Resident #110 revealed special instructions that the Resident was non-weight bearing on his left wrist and staff was to ensure the resident wore his hard cervical collar and the left wrist brace, but the collar and the wrist brace could be removed for showers and skin checks. The email further indicated the following physician's orders were obtained on 11/6/24:-Okay to remove cervical collar during showers or baths;-Okay to remove wrist splint in the shower or bath. NWB to left wrist; and,-Resident has follow-up appointment with orthopedic surgeon and CT scan on 11/21/24.

Based on observations, record review and interviews, the facility failed to ensure residents received the proper treatment and assistive devices to maintain hearing and vision for two (#7 and #40) of two out of 29 sample residents. Specifically, the facility failed to:-Ensure Resident #7 received hearing aids and vision services in timely; and,-Ensure Resident #40 received timely vision services. Findings include:I. Facility policy and procedureThe Ancillary Services policy and procedure, revised October 2023, was provided by the nursing home administrator (NHA) on 11/7/24 at 8:13 a.m. It read in pertinent part,"Residents shall have access to annual vision screenings conducted by qualified professionals."Eyeglasses and corrective devices will be provided in accordance with individual care plans."The facility will provide support for the purchase and maintenance of hearing aids as per the resident needs."A designated staff member (social services director or designee) will oversee coordination of all ancillary services."Documentation of all referrals, services rendered, and follow ups must be maintained in the residents ' health records."II. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on 5/10/17 and readmitted 5/9/21. According to the November 2024 computerized physician orders (CPO), the diagnoses included glaucoma (high eye pressure) and dementia. The 9/25/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. She required supervision with toileting and transfers She required set up assistance with eating, personal hygiene and was independent with bed mobility. The assessment indicated the resident had moderate hearing difficulty and wore hearing aids. It indicated the resident had adequate vision and did not wear corrective lenses or glasses. B. Observations and resident interviewOn 11/4/24 at 2:37 p.m. Resident #7 was sitting in bed with the television on loud. She was not wearing hearing aids and was wearing glasses. Resident #7 said her current hearing aid ear pieces were not the right size and the staff was trying to figure out on getting her a size that would stay in her ear. She said she had great difficulty hearing without hearing aids and people had to speak very loudly to her. She said she was due to see an eye doctor and she needed new glasses. She said her current glasses made it difficult for her to see her television. She said she did not know when or if an appointment was set up for the eye doctor. C. Record reviewThe hearing care plan, initiated on 12/28/18 and revised on 7/31/24, indicated Resident #7 had a hearing deficit and new hearing aids were being ordered and were in the PETI process (post eligibility of treatment income submission request). Interventions included allowing time to respond, repeat as necessary when speaking, turn off the television/radio to reduce environmental noise, wearing headphones when watching television and referring to an audiologist as needed. The vision care plan, initiated on 12/30/18 and revised on 3/23/23, indicated Resident #7 had the potential for visual impairment due to glaucoma and dry eye syndrome. Interventions included arranging visits to the eye doctor, encouraging her to wear her eyeglasses, providing large print, keeping the environment free of clutter and reporting missing/broken glasses to the social service director (SSD). The 5/9/24 care conference summary progress note documented Resident #7 wore glasses and wanted new glasses. It documented that she wore hearing aids and needed to be seen by an audiologist. The 6/12/24 state medical assistance program response to PETI requested benefits for hearing aids documented it was approved. The 6/21/24 email documented from the business office manager (BOM) to the accounts receivable director (ARD) indicated that PETI approval was received for the hearing aids. The 6/21/24 email documented from the ARD to the BOM receipt of notification of approval and requesting further supporting documentation. The 7/18/24 care conference summary progress notes documented Resident #7 wore glasses and requested to get her eyes checked. It documented the SSD would schedule an appointment with vision. It documented Resident #7 was seen by audiology on 5/28/24 and new hearing aids were being ordered through the PETI process.-However, Resident #7 had not received new hearing aids or been seen by the eye doctor. The 10/17/24 care conference summary progress notes documented Resident #7 was seen by audiology on 5/28/24. It documented she wore glasses and was on the list to be seen.-However, Resident #7 had not received new hearing aids or been seen by the eye doctor. A comprehensive review of the electronic medical record (EMR) failed to reveal any further documentation of hearing aids being ordered or received. It failed to reveal a vision appointment for Resident #7. D. Staff interviewsThe NHA and the BOM were interviewed together on 11/6/24 at 10:00 a.m. The NHA said audiology, vision, podiatry and the dentist were all reviewed in the resident's care conference. She said the SSD was in charge and led the care conferences. She said currently the SSD was on leave. The BOM said PETI was the Medicaid process which can be applied for on line through the state portal for residents who needed new hearing aids . She said they were still waiting on the approval process for Resident #7. She said in the meantime they had gotten an amplifier for Resident #7 with the smaller ear buds but they were still too large for her ears. She said she was in the process of trying to find ear buds that would fit. The NHA said she was only able to find documentation that Resident #7 was on the list to be seen by vision services for the evaluation of new glasses. She said she could not find documentation if a vision appointment was made or when vision was coming in to see Resident #7. The BOM was interviewed on 11/6/24 at 10:22 a.m. The BOM said she found email documentation of the PETI approval for Resident #7 for her hearing aides that was dated on 6/12/24. She said she found an email she had sent to the ARD, dated 6/21/24, notifying her that the facility had received the PETI approval. She said she then received an email from the ARD that requested additional supporting documentation. She said she did not have any further documentation of follow up in the ordering or receiving of the hearing aids. She said she would submit the approval letter and the supporting documentation on 11/6/24. III. Resident #40A. Resident statusResident #40, age 75, was admitted on 5/14/24. According to the November 2024 CPO, the diagnoses included chronic respiratory failure with hypoxia, anxiety disorder and adjustment disorder with depressed mood. The 8/20/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for assistance with toileting hygiene, upper and lower body dressing and putting on/taking off footwear. The MDS assessment documented she had corrective lenses. B. Resident interviewResident #40 was interviewed on 11/4/24 at 3:12 p.m. Resident #40 said she had mentioned to a couple of staff that she needed to see someone to get her eyes checked. She said she would like to be seen by the eye doctor because her glasses broke. She said she had worn glasses for years. She said she had not seen the eye doctor since she was admitted to the facility in January 2024. C. Record reviewThe vision care plan, revised on 8/26/24, documented Resident #40 had visual impairment and poor vision. She wore reading glasses at times. Interventions included adapting the environment to the resident's needs to ensure she was able to recognize objects/environment, arranging for visits to eye doctor as needed, ensuring the call light was within reach, ensuring that appropriate visual aids were provided to meet the residents needs, keeping the environment free of clutter, orienting the resident to her surroundings as needed and providing large print reading material, if applicable. The 7/23/24 care conference note documented theSSD would schedule vision appointment. The 10/24/24 care conference note documented the SSD was to schedule an appointment with optometry. The resident had glasses but they were broken prior to admission. The November 2024 CPO revealed a physician's order, may refer to ancillary services as needed for audiologist, dentist, dermatology, ophthalmology and podiatrist ordered on 1/23/24.-Review of Resident #40's EMR did not reveal the resident had been seen by the eye doctor. D. Staff interviewsThe BOM was interviewed on 11/6/24 at 2:00 p.m. The BOM said the social worker was responsible for arranging ancillary appointments for the residents. She said the social worker was out and she was covering for her while she was out. She said she was figuring out which residents needed services. She said the facility had ancillary services that came to the facility to see the residents. She said the residents were given the option to see someone outside the facility or to be seen at the facility. The BOM said she was not sure if Resident #40 wore glasses. She said Resident #40 had a care conference last week. She said Resident #40 told the staff about her broken glasses prior to admission. She said she would make sure that Resident #40 was on the list to be seen by the eye doctor. The BOM said that the resident should have been seen by the eye doctor sooner. She said it has been too long for her not to have been seen. She said she was putting a process in place so that the residents were seen by ancillary services sooner. She said the residents were asked if they would like ancillary services in their first care conference. The NHA was interviewed on 11/6/24 at 2:25 p.m. The NHA said social services was responsible for tracking ancillary appointments. She said the eye doctor came to the facility every other month. She said if the residents needed to be sooner that the facility offered for them to be seen elsewhere. The NHA said in the initial care conference that was held within 48 hours, the residents should be asked if they were having issues or needed to be seen for ancillary services. She said those services should be set up right away especially if the resident was requesting to be seen. The NHA said Resident #40 should have been seen by the eye doctor sooner. She said if residents were having issues that they should be seen immediately. She said residents who requested services should be seen within the first 30 days of admission. She said the eye doctor had not been coming in regularly to see the residents. She said she would call them and arrange for Resident #40 to be seen.

Based on record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for one (#29) of five residents out of 29 sample residents. Specifically, the facility failed to ensure the pharmacist's monthly medication regimen review (MRR) recommendations and the associated physician's orders to discontinue baclofen and guaifenesin for Resident #8 were followed up on in a timely manner, which resulted in the resident receiving additional doses of the medications. Findings include:I. Facility policy and procedureThe Medication Regimen Reviews policy and procedure, revised May 2024, was provided by the nursing home administrator (NHA) on 11/7/24 at 8:19 a.m. It read in pertinent part,"The goal of the medication regimen review (MRR) is to promote positive outcomes while minimizing adverse consequences and potential risk associated with medication."The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities."An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice, is not supported by medical evidence, and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences."II. Resident #8A. Resident statusResident #8, age 79, was admitted on 2/23/23 and readmitted on 5/19/23. According to the November 2024 computerized physician orders (CPO), diagnoses included right humeral (upper arm bone) fracture, bipolar disorder and chronic pain. The 8/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial/maximal assistance with toileting, personal hygiene, bed mobility and transfers and set up assistance with eating. B. Record Review 1. BaclofenThe November 2024 CPO revealed Resident #8 had a physician's order for baclofen (a muscle relaxant medication) 10 milligrams (mg) tablet every eight hours as needed for spasms, ordered 8/16/23. Review of Resident #8's June 2024 MRR revealed the following recommendations from the pharmacist:Baclofen 10 mg. The MRR documented the medication had not been administered to the resident since 4/17/24. The pharmacist's recommendation was to discontinue the medication. The physician responded to the recommendation with an order to discontinue the medication and the order was signed by the physician on 6/28/24.-The June 2024 medication administration record (MAR) documented baclofen 10 mg was administered to Resident #8 on 6/30/24. The July 2024 MAR documented baclofen 10 mg was administered to the resident on 7/1/24, 7/2/24, 7/7/24, 7/8/24, 7/16/24, 7/23/24, 7/30/24 and 7/31/24. The August 2024 MAR documented baclofen 10 mg was administered to the resident on 8/4/24, 8/5/24, 8/11/24, 8/12/24 and 8/27/24. The September 2024 MAR documented baclofen 10 mg was administered to the resident on 9/5/24, 9/7/24, 9/22/24 and 9/29/24. The October 2024 MAR documented baclofen 10 mg was administered to the resident on 10/13/24. A second review of Resident #8's November 2024 CPO revealed a physician's order to discontinue baclofen 10 mg every 8 hours as needed on 11/6/24, during the survey. There were no documented administrations of baclofen in the MAR for November 2024.-Resident #8 received 19 additional doses of baclofen due to the facility's failure to discontinue the medication until more than four months after the pharmacist recommended the discontinuation and the physician signed an order to discontinue the medication on 6/28/24.2. GuaifenesinThe November 2024 CPO revealed Resident #8 had a physician's order for guaifenesin 600 mg every 12 hours as needed for prophylaxis cold symptoms, ordered 4/18/23. Review of Resident #8's September 2024 MRR revealed the following recommendations from the pharmacist:Guaifenesin 600 mg as needed. The MRR documented the medication had not been administered to the resident since 8/5/24. The pharmacist's recommendation was to discontinue the medication. The physician responded to the recommendation with an order to discontinue the medication and the order was signed by the physician on 9/27/24. The October 2024 MAR documented guaifenesin 600 mg was administered on 10/6/24, 10/7/24, 10/9/24 and 10/11/24. A second review of Resident #8's November 2024 CPO revealed a physician's to discontinue guaifenesin 600 mg every 12 hours as needed for prophylaxis cold symptoms on 11/6/24, during the survey. There were no documented administrations of guaifenesin in the MAR for November 2024.-Resident #8 received four additional doses of guaifenesin due to the facility's failure to discontinue the medication until more than one month after the pharmacist recommended the discontinuation and the physician signed an order to discontinue the medication on 9/27/24. III. Staff interviewsThe director of nursing (DON) was interviewed on 11/7/24 at 11:15 a.m. The DON said the assistant director of nursing (ADON) would receive an email from the pharmacy with the pharmacist's recommendations for residents' medications. The DON said the recommendations were reviewed and shared with the physician for review and the physician's signature, if needed.. She said if the pharmacist's recommendations were accepted, the MRR was turned back into the ADON or the DON and the appropriate changes were made to the residents' medical records. The ADON was interviewed on 11/7/24 at 11:35 a.m. The ADON said there was a nurse who was working light duty and had been assisting with the MRR's and pharmacy recommendations. He said the pharmacy recommendations were missed during the time period the nurse was helping. He said the usual check and balances was if the pharmacy did not get a response back from the physician, they would send out another email to the facility regarding the previous recommendations. However, he said the facility did not receive another email from the pharmacy regarding Resident #8's medication recommendations. He said the physician's order to discontinue Resident #8's baclofen and guaifenesin was discovered during survey after the facility pulled the pharmacist's MRRs for the previous six months. The ADON said the medications were discontinued on 11/6/24, during the survey.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection in two of three units. Specifically, the facility failed to:-Ensure resident rooms were cleaned in a sanitary manner;-Ensure manufacturer recommended surface contact times were followed for effective disinfection; and,-Ensure glucometers were cleaned in a sanitary manner. Findings include:I. Failure to clean and sanitize resident rooms appropriatelyA. Professional referenceCenters for Disease Control (CDC). Environment Cleaning Procedures (3/19/24), was retrieved on 11/12/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part,"Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms."Clean patient areas (patient zones) before patient toilets."Proceed in a systematic manner to avoid missing areas. In a multi bed area, clean each patient zone in the same manner."Mop from cleaner to dirtier areas."B. Manufacturer's recommendationsAccording to the Bright Solutions HP202 (hydrogen peroxide) manufacturer guidelines, reviewed 2024, retrieved on 11/12/24 from https://mybrightsolutions.com/wp-content/uploads/046200BSL_Lit.pdf,"For Use as a One Step Cleaner/Disinfectant."Spraysix to eight inches from the surface, making sure to wet surfaces thoroughly. All surfaces must remain visibly wet for 10 minutes."For use as a Virucide. All surfaces must remain visibly wet for five minutes. A one minute contact time is required for HIV (human immunodeficiency virus, the virus that causes AIDS), Influenza Virus type A, SARS Coronavirus 2 (the virus that causes COVID-19)."According to the Clorox Clean Up Disinfectant with Bleach manufacturer guidelines, reviewed 2024, retrieved on 11/12/24 from https://www.cloroxpro.com/products/clorox/clean-up-disinfectant,"Spray four to six inches from the surface until thoroughly wet. Let stand 30 seconds or longer. Wipe with a wet sponge or cloth and rinse with water."For use as a Bactericidal the spray kill time is 30 seconds, for Escherichia coli (E. coli) 0157:H7 and ESBL (extended spectrum beta lactamase) producing E. coli a spray kill time of five minutes."For use as a Virucide (chemical that kills viruses) the spray kill time is 30 seconds, for Norovirus and Poliovirus a spray kill time of one minute."C. Facility policy and procedureThe Cleaning and Disinfecting Resident's Rooms policy and procedure, revised August 2013, was provided by the housekeeping supervisor (HSKS) on 11/7/24 at 11:00 a.m. It read in pertinent part,"Manufacturer's instructions will be followed for proper use of disinfecting (or detergent) products including: Recommended use-dilutions; Material compatibility; Stotowele; Shelf life; and, Safe use and disposal."Use heavy duty gloves (and other personal protective equipment as indicated) for housekeeping tasks."Perform hand hygiene after removing gloves."D. ObservationsOn 11/7/24 at 8:55 a.m. housekeeper (HSK) #1 was cleaning room #811, where two residents resided. HSK #1 put on a glove on her right hand and obtained a saturated towel from the HP202 solution on the housekeeping cart. She started on the A side of the room and wiped the top of the bedside table, top of the overhead light, top of headboard and footboard. She then wiped the table at the foot of the bed. She then wiped the windowsill on the A side of the room. She then disposed of the used towel and removed the glove off her right hand.-HSK #1 failed to wear gloves on both hands during cleaning. Without performing hand hygiene, HSK #1 put on a new glove on her right hand, obtained a new saturated towel and the bottle of Clorox Clean Up disinfectant from the housekeeping cart. She then wiped down the overhead light and bedside table with the saturated towel on the B side of the room. She then spot cleaned a small area with the Clorox bleach and immediately wiped off with the same saturated towel. She then wiped the chair, bedside table, head and footboard of the bed. She then wiped the window sill on the B side of the room. She then disposed of the towel. Without performing hand hygiene HSK #1 placed a new glove on her right hand and obtained a new saturated towel from the housekeeping cart. She wiped the top of the towel dispenser, the top of the mirror and then the top of the vanity. She then wiped down the handrails on the bathroom walls, wiped the toilet handle, sprayed the top of the toilet seat and toilet bowl with the Clorox Clean Up. She then flushed the toilet. She then set the Clorox bottle on the floor of the bathroom. She then immediately wiped down the top of the toilet seat. She leaned on the top of the toilet bowl with her ungloved hand and wiped the top of the toilet bowl. She then proceeded down the sides of the toilet bowl. She then picked up the Clorox spray bottle with ungloved hand and returned to the housekeeping cart. She then disposed of the towel and glove.-HSK #1 failed to perform hand hygiene between tasks and changing gloves. She failed to wear gloves on both hands. She failed to perform hand hygiene after touching a contaminated surface (toilet) and touching clean items (Clorox spray bottle and housekeeping cart). -HSK #1 failed to clean the inside of the toilet bowl.-HSK #1 failed to ensure the bottle of disinfectant/cleaning solution was kept sanitary by keeping it off the floor in the bathroom. HSK #1 without performing hand hygiene obtained a reusable mop head soaking in disinfectant solution on the housekeeping cart. She started on the A side of the room, continued to the B side of the room and continued mopping the bathroom and then through the vanity to the room door.-HSK #1 failed to use separate mop heads for each side of the residents ' joint room and a separate mop head for the bathroom.-HSK #1 failed to ensure the surfaces for HP202 remained visibly wet for the five minute virucidal time and the ten minute total disinfection time and failed to ensure for Clorox remained visibly wet for the one minute virucidal time and the five minute total disinfection time specified by the manufacturer's guidelines (see guidelines above). On 11/7/24 at 9:10 a.m. HSK #1 was observed cleaning room #812. HSK #1 performed hand hygiene and put on a pair of gloves . She obtained a saturated towel from the solution on the housekeeping cart. She sprayed the bedside table with Clorox spray and immediately wiped it down with the towel. She then wiped down overhead lights, bed head and footboard and windowsill. She then disposed of the towel and her gloves. Without performing hand hygiene she put on new gloves, obtained a new towel and wiped vanity lights, sink fixtures, vanity top and inside of the sink. She then disposed of the towel and gloves. Without performing hand hygiene she obtained a fresh mophead from the housekeeping cart and mopped the room.-HSK #1 failed to perform hand hygiene after removing her gloves.-HSK #1 failed to ensure the surfaces for HP202 remained visibly wet for the five minute virucidal time and the ten minute total disinfection time; and failed to ensure for Clorox remained visibly wet for the one minute virucidal time and the five minute total disinfection time specified by the manufacturer's guidelines (see guidelines above). E. Staff interviewsHSK #1 was interviewed on 11/7/24 at 9:30 a.m. HSK #1 said the facility used HP202 (hydrogen peroxide) in the solution for the cleaning towels. She said the disinfection time was ten minutes. She said the Clorox Clean Up disinfection time was either one minute or three minutes but was not sure. She said she should be wearing both gloves while cleaning a room and performing hand hygiene after gloves were removed. She said she should have been wearing gloves while cleaning the toilet and she should not have stored the spray bottle on the floor of the bathroom because it was a dirty area. HSK #1 said she wore only one glove because she was told not to wear gloves out in the hallway. She said when the residents shared a room, each side of the room was cleaned separately. She said when she cleaned a room she started with the high areas before cleaning the lower areas because the lower areas were considered dirty. She said she was taught to mop a room using one mop head and starting from the far side of the room and mopping the bathroom last. The HSKS supervisor was interviewed on 11/7/24 at 10:00 a.m. The HSKS said a shared room should be cleaned like two separate rooms. She said gloves and hand hygiene should be performed after cleaning each side and each side should be mopped separately using a new mop head. She said the bathroom should be mopped last using a new mop head. She said the HP202 had a disinfection time of ten minutes and the Clorox Clean Up with bleach had a disinfection time of three minutes. She said when cleaning a toilet gloves should be used. She said gloves should be changed and hand hygiene performed after cleaning the toilet and touching any clean items. She said the inside of the toilet bowl should also be cleaned. She said she would follow up with the housekeepers regarding the procedure for cleaning rooms, disinfectant time of the chemical used in the cleaning process, and changing gloves and performing hand hygiene after touching a dirty area and before proceeding to a clean area. II. Failure to clean glucometers appropriately A. Professional referenceThe Centers for Disease Control and Prevention (CDC). Considerations for Blood Glucose Monitoring and Insulin Administration (2024), was retrieved on 11/12/24 from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=Unsafe%20practices%20during%20assisted%20monitoring,for%20more%20than%20one%20person. It read in pertinent part,"Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions."Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place."B. Manufacturer guidelinesAccording to the McKesson True Metrix manufacturer guidelines, undated retrieved on 11/12/24 from https://imgcdn.mckesson.com/CumulusWeb/Click_and_learn/True_Metrix_Manual.pdf. It read in pertinent part,"To clean and disinfect the meter: Wash hands thoroughly with soap and water; To Clean make sure the meter is off and a test strip is not inserted. With only PDI Super Sani Cloth Wipes (EPA reg no. 9480-4), rub the entire outside of the meter using three circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter; To disinfect using fresh wipes, make sure that all outside surfaces of the meter remain wet for two minutes."The PDI Super Sani Cloth disinfecting wipes manufacturer guidelines (2024), were retrieved on 11/12/24 from https://pdihc.com/in-service/super-sani-cloth-disinfecting-wipes/. It included the following recommendations in pertinent part,"Bactericidal, Tuberculocidal and Virucidal, effective for 30 microorganisms with a contact time of two minutes."The Metrex CaviWipes manufacturer guidelines, reviewed 2024, retrieved on 11/12/24 from https://www.metrex.com/en-us/caviwipes#kill. It read in pertinent part,"Two minute efficacy against multidrug resistant bacteria MRSA (methicillin resistant staphylococcus aureus), VRE (Vancomycin resistant Enterococcus faecalis), HBV (hepatitis B), HCV (hepatitis C), human immunodeficiency virus (HIV); Three minute efficacy against Mycobacterium tuberculosis, Pseudomonas aeruginosa, Salmonella, Staphylococcus aureus."C. ObservationsOn 11/16/24 at 7:37 a.m. licensed practical nurse (LPN) #1 was wiping a glucometer with an alcohol prep pad (used to disinfect skin prior to an injection) and returning it to its case in the medication cart that was labeled with an unidentified resident's name. -However, according to the manufacturer guidelines LPN #1 should have used the Super Sani Cloth Wipes and allowed the glucometer to remain wet for two minutes. She was then observed removing Resident #17's labeled glucometer to check her morning glucose. She took the glucometer to the resident's room and completed the blood glucose check. She then returned to the medication cart, disposed of the test strip and lancet in the biohazard container. She then wiped down the glucometer with an alcohol prep pad and returned it to its labeled case.-However, according to the manufacturer guidelines LPN #1 should have used the Super Sani Cloth Wipes and allowed the glucometer to remain wet for two minutes. D. Staff interviewsLPN #2 was interviewed on 11/6/24 at 8:53 a.m. LPN #2 said each resident that needed blood glucose checks had their own designated glucometers. She said she used alcohol prep wipes to clean glucometers between uses. She said she was not aware of the manufacturer's recommendations on how to clean blood glucometers. She said the glucometers should be cleaned after every use because of blood borne pathogens. LPN #1 was interviewed on 11/6/24 at 8:55 a.m. LPN #1 said all residents had their own dedicated glucometers and she would clean them with an alcohol wipe after each use. She said she was not aware of the manufacturer recommendations for cleaning and disinfection after use. Registered nurse (RN) #1 was interviewed on 11/6/24 at 8:59 a.m. RN #1 said she used germicidal wipes such as a Cavi Wipe or an alcohol pad to wipe down glucometers after every use. She said she did not know the manufacturer recommendations for cleaning and disinfecting the glucometers. She said she thought the disinfectant time for the Cavi Wipes was two minutes but was not sure. The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 11/6/24 at 9:09 a.m. The DON said glucometers should be wiped with Cavi Wipes after each use and each resident has their own blood glucometers. The DON said they should be allowed to dry one to two minutes according to the recommended dry times but was not sure. The DON said this was to ensure that the blood glucometers were disinfected against blood borne pathogens according to manufacturer recommendations. The DON was interviewed again on 11/6/24 at 3:30 p.m. The DON said she provided education to the nursing staff regarding the appropriate cleaning method for using the germicidal disinfecting wipes on 11/6/24. She said the correct method was to clean with Cavi Wipes and the disinfection time was two minutes after every use.

A revisit survey was completed on 6/29/23 for all previous deficiencies cited on 4/20/23. The facility is in compliance with all regulations surveyed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility's general characteristics. The facility is a one-story, Type II (000) structure. The facility is separated from the hospital building by a 2-hour wall located by the chapel. There is a partial basement that is used for support services only. The facility has a fully supervised automatic sprinkler system NFPA 13 automatic fire sprinkler system. The facility was surveyed on May 10, 2023 for compliance to fire safety requirements using the National Fire Protection Association (NFPA) 2012 Life Safety Code, Chapter 19, Existing Healthcare Occupancy. The facility will meet these requirements when the following deficiencies are corrected.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code Sections 19.7.9.3.1.1. No 90 min test for Emergency lightsNo 90 min test for Exit lightsExit light by room 501 and 700 hallway exit need new batteriesNFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 101, Life Safety Code, Section 19.3.2.1.3. Room 506, Beauty Shop and 700 hallway rooms used as storage need self closers installedNFPA 101, 19.3.2.1.3 Doors. Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 21.2.2.4. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. 2hr fire wall has unprotected penetrations by the chapelNFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to maintain the facility laundry chute in accordance with NFPA 101 and NFPA 82. Laundry chute door assembly did not self close from all open positionsNFPA 101 9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless such installations are approved existing installations, which shall be permitted to be continued in service. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills not performed under varied times NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Through documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No Receptacle Polarity/Retention inspection available at the time of inspection NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

A recertification survey with complaints #CO30643, #CO30966 and #CO31707 was completed from 4/17/23-4/20/23. Twelve deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/17/23 to 4/20/23. No deficiencies were cited.

Based on interviews and record review, the facility failed to ensure one (#19) resident out of 29 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to resolve to a grievance filed by a Resident #19 about her medication not being administered timely. Findings include:I. Facility policy and procedureThe Grievance policy and procedure, revised April 2017, was provided by the nursing home administrator (NHA) on 4/20/23 at 6:22 p.m. It revealed in pertinent part, "Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative."Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint."The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated."The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems." II. Resident #19 A. Resident statusResident #19, age 62, was admitted on 11/9/18. According to the April 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis, epilepsy, peripheral vascular disease, chronic respiratory failure with hypoxia, major depressive disorder and diabetes mellitus type 2 .The 4/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive two-person assistance with bed mobility, transfers, toileting, dressing and bathing. She required a one-person assist with personal hygiene. B. Resident interview Resident #19 was interviewed on 4/20/23 at 9:16 a.m. Resident #19 said that she did not get her medications on time in the evenings on Thursdays through Sundays. She said she did not get her medications until 10:00 p.m. to 11:00 p.m. She said her medications needed to be taken timely due to her diagnosis. The resident said she reported this to the NHA but the issue was not fixed. Resident #19 said she was concerned about all of her medications not being administered timely at night. C. Record reviewResident #19 completed two grievance reports for late medication administration. On 1/31/23 the resident requested that her medication be given by 9:00 p.m. The follow-up revealed a text message was sent to the nurses and passed along on the shift report. It also noted if the concern was not resolved, they would schedule the medications. The director of nursing (DON signed the grievance form, information was reviewed with the resident and marked as resolved. -However, there was no documentation to show if the resident was satisfied with the resolution. On 4/19/23 the resident said she was not receiving her night medications until midnight. The follow-up revealed the administration spoke with the resident and would pull records and look into the matter. The medication administration audit report for 4/13/23 to 4/16/23 revealed the actual time of administration of the resident's medication and was provided by the DON: On 4/13/23 the resident's nine medications scheduled at 7:00 p.m. and her two medications scheduled at 9:00 p.m. -However, all eleven medications were administered between 9:25 p.m. and 9:35 p.m. On 4/14/23 the resident's nine medications scheduled at 7:00 p.m. and her two medications scheduled at 9:00 p.m. were administered between 10:30 p.m. and 10:41 p.m.-However, all eleven medications were administered between 10:30 p.m. and 10:41 p.m. On 4/15/23 the resident's nine medications scheduled at 7:00 p.m. and her two medications scheduled at 9:00 p.m. were administered at 11:01 p.m.-However, all eleven medications were administered between 11:01 p.m. On 4/16/23 the resident's nine medications scheduled at 7:00 p.m. and her two medications scheduled at 9:00 p.m. were administered between 9:01 and 9:08 p.m.-However, all eleven medications were administered between 9:01 and 9:08 p.m.-According the the medication audit report, the resident was not receiving all her medications timely. III. Staff interviewsThe NHA was interviewed on 4/20/23 at 4:03 p.m. The NHA said Resident #19 voiced a concern in January 2023 about her medication being administered late. The administration talked with the nurses and they believed it was resolved since the resident had not voiced any additional concerns until recently. The NHA said grievance reports should be responded to as soon as possible, at least within 72 hours. The DON was interviewed on 4/20/23 at 4:05 p.m. She said medications should be administered within two hours before and two hours after scheduled administration times.

Based on observation, record review, and interviews, the facility failed to ensure residents were free from resident-to-resident abuse for one (#34) resident out of two residents reviewed for abuse out of 29 sample residents. Specifically, the facility failed to ensure effective person-centered interventions were in place to prevent physical abuse by Resident #31 toward Resident #34. Findings include:I. Facility policy and procedureThe Abuse, Neglect, & Exploitation Prevention policy and procedure, revised 10/4/22, documented in pertinent part, "Our facility prohibits the abuse, mistreatment, neglect, and/or exploitation of residents. We believe that all residents have the right to be free from such actions by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving our community, family members or legal guardians, friends, or any other individuals. "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. "Physical abuse includes hitting, slapping, pinching and/or kicking. It also includes controlling behavior through corporal punishment. "II. Resident to resident altercation between Resident #34 and Resident #31 on 1/21/23 based on record review and interviews (see below)Resident #34, with a diagnosis of dementia, had known aggressive and impulsive behaviors towards staff and other residents (cross-reference F744 for dementia care). Resident #31 was sitting in her room when Resident #34 past by in the hallway. Resident #31 waved her hand with a greeting gesture at Resident #34. Resident #34 entered the room and continued towards Resident #31. Resident #31 verbally instructed Resident #34 to not enter the room, when Resident #34 did not comply with request, Resident #31 put her hand forward. Resident #34 responded by doubling up her fist and hitting the right side of Resident #31 ' s jaw, Resident #34 then turned and left the room. III. Resident #34A. Resident statusResident #34, age 84, was admitted on 9/7/21. According to the March 2023 computerized physician orders (CPO), the diagnoses include Alzheimer's disease and depression. The 3/1/23 MDS assessment revealed the resident had severe cognitive impairment and was unable to participate in a brief interview for mental status. She required extensive assistance from one staff member with transfers, dressing, personal hygiene, and toilet use. She used a wheelchair for all mobility and was able to self propel. B. Record review showed the resident had known behaviors to include impulsivity and being territorial, and would hit staff when being redirected. The 1/18/23 progress note revealed Resident #34 had increased behaviors with staff and was hitting staff while being redirected. The 1/21/23 progress note revealed Resident #34 displayed agitation and went into other resident ' s rooms. Resident was medicated for pain per the medical doctor ' s request. The 2/13/23 progress note revealed Resident #34 touched a male caregiver inappropriately and asked him to get into bed with her. The 1/23/23 progress note revealed social services had sent referrals to multiple memory care facilities related to Resident #34 having an increase in behaviors. The 3/20/23 progress note revealed social services had sent referrals to two memory care facilities. The care plan, dated 3/28/23 revealed Resident #34 had a history of alteration in mood and behavioral issues related to a diagnosis of depression. It revealed Resident #34 had an altercation with another resident, when trying to take the other resident's baby doll. It revealed Resident #34 was territorial over personal items, impulsive, and difficult to to redirect related to dementia. The care plan revealed a facility goal of preserving the dignity and quality of life for Resident #34 by minimizing risks for agitation, inappropriate behaviors, and unmet needs. The interventions included one-to-one line of site, administering medications as ordered, interacting in an empathetic and supportive manor, and providing Resident #34 with a baby doll when observed in distress. C. InterviewsThe social services director (SSD) was interviewed on 4/20/23 at 1:45 p.m. The SSD said Resident #34 began displaying aggressive behavior a few months ago, she would shake her fist at people or be verbally rude. She said Resident #34 was territorial and had dementia. She said she did not believe Resident #34 was intentional with her aggression, she said it was related to Resident #34 dementia and impulsivity. She said the facility interventions were providing Resident #34 with two baby dolls, allowing her to have a private room and putting stop signs at the doors of resident ' s rooms that Resident #34 was observed entering. She said she had made referrals to memory care facilities and none had accepted Resident #34. -There were no stop signs in the doorways of the hall Resident #34 resided on (cross-reference F744). The human resources (HR) was interviewed on 4/20/23 at 3:16 p.m. She said Resident #34 occupied common areas of the facility and participated in activities. She said Resident #34 would enter another resident ' s room if the resident gained her attention. Certified nurses aide (CNA) #3 was interviewed on 4/20/23 at 3:23 p.m. She said Resident #34 could become easily upset in the evening. The NHA was interviewed on 4/20/23 at 4:00 p.m. She said Resident #34 entering the room of Resident #31 was an isolated event. She said Resident #34 was territorial of her babies and she did not have her babies on the day of the occurrence. She said Resident #34 ' s mood did not fluctuate and the occurrence of hitting another resident was isolated. She said the SSD had made referrals to memory care facilities, and none have accepted. -However, observations revealed Resident #34 was in an unoccupied resident room (cross-reference F744). IV. Resident #31A. Resident statusResident #31, age 76, was admitted on 12/23/19. According to the February 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, difficulty in walking, muscle weakness and localized edema. The 1/25/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one staff member with transfers and toilet use. Personal hygiene was not assessed. B. Resident interviewResident #31 was interviewed on 4/18/23 at 9:05 a.m. Resident #31 said Resident #34 entered her room and when Resident #31 asked her to leave Resident #34 hit her on the right cheek. Resident #31 said she was sitting in her room and waved and said hello to Resident #34 as Resident #34 passed by in the hallway. Resident #31 said Resident #34 began entering the room and Resident #31 asked Resident #34 to stop. Resident #31 said Resident #34 proceeded to move towards her and she put her hand out to stop the forward movement of Resident #34. Resident #31 said Resident #31 doubled up her fist and made contact with the cheek of Resident #31. Resident #31 was interviewed again on 4/19/23 at 9:50 p.m. She said she felt safe remaining in the facility. She said she saw Resident #34 often because they lived on the same hall. She said this was the only altercation she had with Resident #34. C. Record reviewThe 1/21/23 progress note revealed Resident #31 told a staff member she was hit in the face today by another resident (Resident #34). It revealed Resident #31 had no obvious bruise to the right jaw, no redness, and no tenderness at the time. The 1/21/23 progress note revealed NHA spoke with Resident #31 via phone call, and Resident #31 was educated on the importance of calling for staff to assist with redirecting residents. The following progress notes dated 1/23/23, 1/24/23, and 1/26/23 revealed that Resident #31 ' s jaw had been monitored for injury and Resident #31 had no complaints or bruises. D. InterviewsThe SSD was interviewed on 4/20/23 at 1:45 p.m. She said she provided Resident #31 with continuous support and check-ins. The NHA was interviewed on 4/20/23 at 4:00 p.m. She said Resident #31 skin assessments were conducted by nursing along with emotional support. She said Resident #31 was monitored for several days to determine any changes in mood, appetite or sleep.

Based on observations, record review and interviews the facility failed to comprehensively assess and care plan the continued use of a wheelchair lap tray for one (#36) out of 29 sample residents. Specifically, the facility failed to ensure Resident #36's lap tray was on the comprehensive care plan with a release schedule communicated to staff. Findings include: I. Resident #36A. Resident status Resident #36, age 83, was admitted on 2/9/19 and readmitted on 10/24/22. According to the April 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, frontotemporal (damaged nerves to frontal and temporal lobes of the brain) neurocognitive disorder and major depressive disorder. The 4/14/23 minimum data set (MDS) assessment revealed the resident had a severe cognitiveimpairment and was unable to complete a brief interview for mental status. He required extensive assistance of two-people with bed mobility, and extensive assistance of one-person with transfers, toileting, dressing and personal hygiene. The MDS assessment revealed a chair alarm and a wander guard were used with Resident #36 daily. B. Resident observationsResident #36 was observed on 4/19/23 at 9:01 a.m. in his wheelchair in the television lounge area. The lap tray was attached to the wheelchair and he was busy with items on the tray. At 10:07 a.m. the resident was in his wheelchair while he was moving independently around the nursing station. He was busy with items on his tray. From 10:10 a.m. to 11:14 a.m. the resident was in the activity room. Resident #36 was supervised by activity staff, he was sitting in his wheelchair up at a table without his lap tray. At 11:53 a.m. the resident was in the dining room. Resident #36 was seated at a lunch table without his lap tray. At 2:48 p.m. the resident was in his room with his tray table attached to his wheelchair. At 3:43 p.m. the resident was in his room with his tray table attached to his wheelchair. He appeared to be napping. C. Record reviewThe Safety Device Consent form dated 4/12/23 revealed the following:-the physician ordered the lap tray. -lap tray was considered a restraint/safety device. It was recommended to be re-evaluated every quarter and as needed.-the release and reposition schedule was to be checked every shift. The April 2023 CPO did not include a physician's order for use of the resident's lap tray. The activity care plan, initiated on 3/9/19 and revised on 4/6/23 revealed "the resident enjoys the use of his lap tray so he can have activities available to him during the day." -There were no interventions associated with the resident's lap tray.-The resident's care plan did not identify the use of his lap tray -and how often the lap tray needed to be released throughout the day. D. Staff interviewsCertified nurses aide (CNA) #3 was interviewed on 4/20/23 at 10:03 a.m. CNA #3 said Resident #36 had a new tray that he used for activities. CNA #3 said she was unsure if the resident could remove the tray. She said there was no schedule for the removal of the tray but it was removed when he ate and when he was tired. The nursing home administrator (NHA) was interviewed on 4/20/23 at 3:55 p.m. The NHA said Resident #36's primarily used the tray for activities. She said the resident was a high fall risk so it was important to keep him busy with activities. The NHA said the tray was attached with Velcro and he had removed the tray himself. There was no schedule for the release of the tray. The tray was removed for personal care, meals and when sitting at a table. -However, according to Safety Device Consent, there was supposed to be a release and reposition schedule checked every shift.

Based on observations, interviews and record review, the facility failed to ensure three (#37, #32 and #2) of five residents reviewed out of 29 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to:-Ensure Resident #37 was provided with timely incontinence care; and,-Provide Resident #32 bathing was in accordance with their plan of care; and-Provide Resident #2 received assistance with oral care. Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADL) Care of Residents policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 4/20/23 at 6:22 p.m. It read, in pertinent part, "Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care."II. Resident #37 A. Resident status Resident #37, age 90, was admitted on 3/7/19 with a readmission on 10/14/19. According to the April 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia, age related osteoporosis and muscle weakness. The 3/28/23 minimum data set (MDS) assessment revealed the resident had a cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of one-person with bed mobility, transfers, toileting, dressing and personal care. The MDS also revealed that rejection of care was not exhibited. B. ObservationsOn 4/19/23 a continuous observation from 8:35 a.m. to 4:03 p.m. revealed the resident was observed participating in activities, going to lunch and going to the facility dentist. During this observation, the resident was not brought back to her room and provided with incontinence care. On 4/19/23 at 4:03 p.m. resident was brought to her room and was provided incontinence care. The brief was contained in a plastic bag that was slightly heavy. C. Record reviewThe ADL care plan, initiated on 3/18/19, revealed the resident had a self-care deficit related to decreased cognition. It indicated the resident required a one-person assist for bathing, bed mobility, dressing, toileting and one to two person assist with transfers with a gait belt. For incontinence episodes staff were to provide peri-care after each incontinent episode and utilize disposable incontinent products as needed. Resident #37's bladder incontinence records from 3/21/23 to 4/18/23 documented the resident received incontinence care one to three times a day for a 29 day period.-She received incontinence care one time a day for nine days out of a 29 day period.-She received incontinence care twice a day for fourteen days out of a 29 day period.-She received incontinence care three times a day for six days out of a 29 day period. C. Staff interviewsCertified nurses aide (CNA) #2 was interviewed on 4/19/23 at 4:12 p.m. CNA #2 said when she provided incontinence care at 4:03 p.m. for Resident #37, the resident was a little wet but not heavily wet. CNA#2 said she did not know what the resident's previous bladder incontinence amount was because it was provided by the morning staff when the resident was given a shower that morning. CNA #2 said the resident needed to be asked if she was wet or needed the bathroom because she would not tell the staff. The director of nurses (DON) was interviewed on 4/20/23 at 4:00 p.m. She said the resident should be provided incontinence care before and after meals, after getting up and should be checked for incontinence episodes every two hours. III. Resident #32A. Resident status Resident #32, age 85, was admitted on 7/17/19. According to the April 2023 CPO, the diagnoses included dementia (impaired ability to remember). The 3/25/23 MDS assessment revealed the resident had short-term and long-term memory impairment and required moderate assistance in making decisions about his daily life. She required extensive two-person assistance with bathing, bed mobility, transfers, dressing, toileting and personal hygiene. One person physically assists with eating. The resident did not have behaviors or rejection of care. B. ObservationOn 4/17/23 at 2:04 p.m. Resident #32 was observed in the hallway with hair unkempt, shiny and greasy. On 4/18/23 at 9:35 a.m. Resident #32 was sitting in a wheelchair in the dining room. Her hair was uncombed and greasy in appearance. At 4:34 p.m. the resident was sitting up in a wheelchair with hair slicked back and was stringy, shiny and greasy in appearance. On 4/20/23 at 12:38 p.m. CNA #2 was observed running her fingers through Resident #32 hair in the hallway. CNA #2 then wiped her hands on her clothing. Resident #32 hair appeared stringy, shiny, greasy and remained slicked back after CNA ran her fingers through her hair. C. Record reviewThe resident's record failed to reveal her preference of shower days, frequency and times. According to the shower schedule provided by the NHA on 4/20/23 at 8:30 a.m. Resident #32 was scheduled to receive showers twice a week on Saturdays and Wednesdays. Review of the CNAs electronic task charting in point of care (POC) and shower sheets provided by the NHA on 4/20/23 at 8:30 a.m. revealed the resident had only received the following showers:-January 2023 three showers given and one resident refusal on the shower sheet out of possible eight showers.-February 2023 six showers were recorded out of eight possible showers.-March 2023 nine showers recorded with three refusals documented on shower sheets only.-As of 4/20/23 the resident had only received one shower for the month of April 2023 out of a possible six. Review of nursing progress notes from 1/1/23 to 4/20/23 failed to reveal any documentation for Resident #32 refusal of showers. D. Staff interviewsCNA #1 was interviewed on 4/20/23 at 11:04 a.m. CNA #1 said residents usually got two showers a week but could change based on their preference. CNAs documented showers on the shower sheets and in the point click care task section of the CNA charting system. If a resident refused, CNAs were to try and accommodate the resident at a different time. CNAs were to let the nurse know if a resident refused their shower. CNA #1 was unable to recall Resident #32's shower preferences and she went off the shower sheet assignments. The director of nursing (DON) was interviewed on 4/20/23 at 4:07 p.m. The DON said during admission a new resident was asked how many showers they wanted a week and it was added to the residents' bathing profile/choices. Residents' bathing choices were reviewed at the quarterly care conferences. If a resident refused, staff would try to accommodate them. Refusals were to be documented on the shower sheers and verbal notification given to the assigned nurse by the CNA. The nurse was to attempt to offer a shower to the resident, if the resident continued to refuse the nurse was to document the refusal in the progress notes. IV. Resident #2A. Resident statusResident #2, age 75, was admitted on 5/23/22. According to the April 2023 computerized physician orders (CPO), the diagnoses included lack of coordination, intracranial injury with loss of consciousness, sequelae (traumatic brain injury from disease or injury), intellectual disabilities and contracture of joints and shoulder. The 1/14/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. He required extensive assistance of one staff member with transfers, dressing, eating,toilet use, and personal hygiene. B. Observations and resident interviewOn 4/17/23 at 11:30 a.m. Resident #2 was observed sitting at a common area of the facility, his top teeth observed to have a thick white/tan film prominent at the upper gum line and covering tops of teeth. His lower gums unable to be seen on this observation. On 4/18/23 at 12:51 p.m. Resident #2 was observed sitting at a common area of the facility, his top teeth observed to have a thick white/tan film prominent at the upper gum line and covering tops of teeth. His bottom teeth had a white film at the gum line extending up the sides of teeth. On 4/19/23 at approximately 10:00 a.m. Resident #2 was observed at a common area of the facility, his bottom teeth observed to have white film at the gum line extending up the sides of teeth; his top teeth were not visible. At 10:18 a.m. a staff member was heard informing Resident #2 that he would be receiving dental care from the hygienist in the building on this day. Resident #2 did not oppose. At 11:00 a.m. Resident #2 received oral cleaning by a dental hygienist. Top and bottom teeth were observed to be free of any debris or film, gums observed to be mildly bleeding on bottom. -No mouthwash was observed to be available for Resident #2, no order for mouthwash existed (as indicated in the care plan, see below). On 4/20/23 at approximately 2:00 p.m. Resident #2 was interviewed. He said he did not mind having his teeth cleaned by the hygienist yesterday (4/19/23). He said he accepted help from staff staff for teeth brushing. C. Record reviewThe 2/21/23 dental hygiene treatment chart revealed in pertinent parts Resident #2 was cooperative with activity, he had heavy bleeding, plaque, and calculus (forms from plaque that has not been removed). Oral hygiene for Resident #2 was noted to be poor with severe inflammation. The 3/1/23 care plan revealed Resident #2 refused to brush his teeth or to allow staff to brush his teeth, and that he only uses mouthwash. The care plan goal revealed Resident #2 would accept staff assistance to brush his teeth if he is unable to do so himself. The interventions on the care plan revealed staff is to offer assistance with teeth brushing, praise Resident #2 for accepting assistance, and explain to Resident #2 that mouth wash is not enough to clean teeth. The 4/17/23 nutritional progress note revealed in pertinent part Resident #2 has his own teeth in poor condition. The point of care response history revealed the following for personal hygiene tasks performed by facility staff (personal hygiene tasks can include: combing hair, brushing teeth, shaving, applying makeup,washing/drying face and hands. On 4/17/23 Resident #2 received the physical assistance of one person once on this day. On 4/18/23 Resident #2 received the physical assistance of one person once on this day. On 4/19/23 Resident #2 received the physical assistance of one person once on this day. D. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 4/20/23 at 12:00 p.m. She said she provided oral care for Resident #2 every morning when she worked. She said Resident #2 enjoyed brushing his teeth, washing his face, and being clean. She said Resident #2 was compliant with care. She said she has not assisted with mouthwash. CNA #2 was interviewed on 4/20/23 at 1:00 p.m. She said Resident #2 always refuses oral care. She said she was not aware of Resident #2 using mouthwash. The social services director (SSD) was interviewed on 4/20/23 at 1:45 p.m. She said there was an order for prescription mouthwash for Resident #2 in the past. She said the mouthwash ran out and the dentist recommended discontinuation rather than ordering more. She said she did not know why this was the recommendation of the dentist. She said it was her responsibility to update the care plan for dental needs. She said Resident #2 would accept assistance from particular CNAs. The nursing home administrator (NHA) was interviewed on 4/20/23 at 4:00 p.m. She said oral care assistance for residents was twice a day or whenever teeth were observed to have food in them. She said Resident #2 likes some CNAs better than others and his compliance with teeth brushing depended on which staff was assisting. She said Resident #2 was able to verbalize his needs. The director of nursing (DON) was interviewed on 4/20/23 at 4:00 p.m. She concurred with NHA regarding staff providing oral care assistance with residents. She said that staff always encouraged Resident #2 to brush his teeth.

Based on record review, observations, and interviews, the facility failed to ensure two (#44 and #20) of 29 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to:-Investigate, determine origin and monitor a bruise to Resident #44's forearm; and,-Ensure a treatment for Resident #20 was administered according to physician orders and by a qualified staff member. Findings include:I. Resident #44 A. Resident statusResident #44, age 83, was admitted on 3/16/23. According to the April 2023 computerized physician orders (CPO), the diagnoses included coagulation defects (bleeding disorder), chronic atrial fibrillation (irregular heart rhythm that can lead to blood clots), difficulty in walking, personal history of transient ischemic attack (mini stroke) and weakness. The 4/6/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. She required extensive assistance of two staff members for transfers, dressing, and toileting, and extensive assistance of one staff member for personal hygiene needs. B. Resident interviewOn 4/17/23 at 3:00 p.m. Resident #44 believed the bruise on her left forearm was obtained a month ago. She said she was lying on the floor of her home for three days after a fall. She said the emergency response team had difficulties finding a vein to start an IV (intravenous). She said she could not think of another explanation for the bruise. C. ObservationsOn 4/17/23 at 3:00 p.m. Resident #44 was observed with a bruise on her left forearm. The bruise was located just below the exterior elbow crease, was blue and purple in color, oblong, and approximately an inch in length and a quarter inch wide. On 4/19/23 at 10:11 a.m. the bruise was observed to be green and brown in color, oblong, approximately an inch in length and quarter inch wide. On 4/20/23 at 11:58 a.m. the bruise was observed to have a yellow border with brown speckles inside. It was less than an inch long and less than a quarter inch wide.-No other bruises were observed on the right or left forearms or hands of Resident #44. D. Record reviewThe 3/13/23 new admission report revealed wound vac to right hip and bruises to left arm as significant skin problems. The 3/21/23 skin observation tool revealed the resident had a wound vac (negative pressure wound machine) placed to the right trochanter (upper thigh). -It did not identify any other skin concerns. The 4/4/23 skin observation tool documented a rash to the resident's right trochanter. The 4/10/23 and 4/17/23 skin observation tools revealed no skin issues for Resident #44. The 4/19/23 skin observation tool revealed skin integrity issues for Resident #44 to be a bruise to the left antecubital (region of arm in front of elbow) and a healing surgical incision to the right trochanter. It indicated staples had been removed with some bruising noted. No other skin issues were identified. The 4/19/23 interdisciplinary team review revealed, in pertinent part, "Resident with a BIMS of 15 out of 15 states that the bruise happened when she fell at home stating that her whole left AC antecubital (region of arm in front of elbow) area was bruised (prior to admission). Bruise was noted on new admission report sheet when report was given to nurse from hospital. Resident was admitted after a fall at home where she lay on floor for three days. Resident is on eliquis."-However, according to the 4/6/23 MDS assessment, the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/19/23 at 4:49 p.m. She said she had not noticed a bruise on Resident #44's left forearm. LPN #1 observed the bruise at that time and said it could have been obtained from a routine blood draw. She saidblood draws were done by the overnight nursing staff on Mondays. She said she looked in the resident's medical record and did not find any documentation related to a bruise on the resident's left forearm. She said a skin assessment was conducted for Resident #44 on 4/17/23 and a bruise was not documented. The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 4/20/23 at 4:00 p.m. She said that skin assessments were done weekly. She said all skin assessments were documented in the resident's electronic medical record. She said bruises or other skin abnormalities should be documented, monitored and the physician should be notified. The NHA said she spoke with Resident #44 about the bruise on 4/19/23. She said Resident #44 believed the bruise was from a fall at home a month ago. The NHA said that Resident #44 was cognitively intact. The DON said a bruise that had happened prior to the resdent's admission to the facility would not have been purple and blue in color. She said it would have been fading if it had been sustained in March 2023. II. Resident #20A. Resident statusResident #20, age 90, was admitted on 7/14/2020. According to the April 2023 CPO the diagnoses included chronic obstructive pulmonary disease (air flow blockage), respiratory failure (affects oxygen exchange), chronic kidney disease (decrease in kidney function) and dementia (memory deficit). The 2/7/23 MDS assessment revealed the resident was severely cognitive impairment with a brief interview for mental status score of six out of 15. She required one person physical assistance with bed mobility, transfers, dressing, eating, personal hygiene, and toileting. B. Record reviewAccording to the April 2023 CPO Resident #20 orders revealed an order for: -Antifungal powder to the buttock two times a day;-Zinc oxide cream 6% apply to peri area topically at bedtime for peri genital diaper dermatitis with skin break down. Apply this cream, after Nystatin cream and hydrocortisone cream; and, -Hydrocortisone cream 2.5% apply to affected areas topically every 12 hours as needed for itching and scratching. Review of the CNA point of care (POC) task assignments failed to reveal barrier cream application assigned to the CNA staff. The care plan revealed Resident #20 was at risk for skin break down. Interventions in place were to apply creams and ointments as ordered and as needed. C. Staff InterviewsCNA #2 was interviewed on 4/19/23 at 4:30 p.m. CNA #2 said she used creams that were ordered by the facility/physician. She acknowledged and provided the creams used were Medline Remedy (skin protectant), Renew Protect barrier cream (zinc and dimethicone-based moisture barrier) and an antifungal cream. CNA #2 acknowledged mixing these creams with the antifungal powder and was currently using the mixture for Resident #20. She said a former nurse used this method and that was who she learned it from. LPN #3 was interviewed on 4/19/23 at 6:13 p.m. LPN #3 said nurses were to apply prescription creams to residents. A CNA could apply it if a nurse has educated them and hands the medication to them. Creams were not to be mixed unless ordered to be mixed, but should really come mixed from pharmacy to ensure accuracy and prevent reactions like rashes from happening. LPN #3 acknowledged she was not aware of a CNA mixing multiple barrier creams when asked. The DON was interviewed on 4/20/23 at 11:10 a.m. The DON said antifungals should be applied by the nurse and not passed onto a CNA to administer. CNAs were allowed to apply barrier creams but should not be mixing or adding antifungal to them. An order was needed to mix multiple creams.

Based on record review, observations and interviews the facility failed to provide timely interventions to prevent worsening of a pressure injury for one (#28) of three residents of sampled 29 residents. Specifically, the facility failed to:-Measure and implement treatment orders for Resident #28's left heel pressure injury until five days after her admission; and, -Ensure preventative boots were ordered timely for Resident #28. Findings include:I. Professional ReferenceAccording to the National Pressure Injury Advisory Panel (NPIAP), Prevention and Treatment of Pressure Ulcers/Injuries, Quick Reference Guide (2019). Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia 2/14/18, retrieved on line 5/1/23 from: https://www.internationalguideline.com/static/pdfs/Quick_Reference_Guide-10Mar2019.pdf "Steps to prevent the worsening of existing pressure injuries and to promote healing include: Avoiding positioning that places pressure on the pressure injury, assessment and documentation of the pressure injury when discovered and reassessment and documentation at least weekly. Assessment should include location, category/stage, size, tissue types, color, peri wound (the skin around the wound) condition, wound edges, and evidence of undermining or tunneling, exudate, and odor."The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing:-Positioning that places pressure on the pressure injury should be avoided.-The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented."II. Resident statusResident #28, age 84, was admitted on 12/22/22. According to the April 2023 computerized physician orders (CPO), the diagnoses included hypertension (high blood pressure), left knee prosthesis and dysphagia (difficulty swallowing). The admission minimum data set (MDS) dated 12/27/22 revealed the resident had an unstageable pressure injury. The 3/18/22 MDS assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status score of nine out of 15. She required two-person assistance with transfers, bed mobility, dressing, toileting and personal hygiene. One-person physical assist with eating. Skin had a stage four pressure ulcer with use of pressure reduction devices for bed and chair. III. Record reviewAdmission records from 12/22/22 revealed the resident was admitted with a blister to the left heel covered with foam dressing.-The admission skin assessment failed to reveal measurements of the left heel blister. Initial skin weekly wound tool dated 12/27/22 indicated Resident # 28 was admitted with pressure injury to the left heel measuring 3 centimeters (cm) by 3 cm with no drainage. Special equipment or preventative measures bunny boots (specialized pressure reducing footwear). -This was the first documentation of measurements for the left heel since admission. The December 2022 CPO orders revealed treatment to the left heel wound orders initiated on 12/27/22, five days after admission. Order read Venelex ointment (balsam peru-casteroil specialized wound ointment) to be applied to left heel topical every day shift for wound care to left heel. Cleanse left heel with wound cleanser (saline solution used to clean wounds) pat dry, and apply venelex and cover with island dressing. Review of wound physician notes revealed the following:-Wound physician note from 12/27/22 indicated the wound was an unstageable deep tissue injury to the left heel. Heel measurements were three centimeters (cm) by three cm. The wound had no drainage at the time of physician assessment. Physician note revealed to float heels while in bed, off load wound, EZ boot (specialized boot to keep pressure off the heel) to be worn in bed and chair to off load wound. -Wound physician note dated 1/6/23 indicated the left heel measuring 2.3 cm by 3.3 cm was now draining light serous (body fluid) fluid. Plan of care reviews and addressed continued for floating heels in bed off load wound, EZ boots to be worn in bed and chair to off load wound. -Wound physician note dated 1/10/23 indicated the wound measured 2.5 cm by 2.6 cm by 0.1 cm with light serous drainage with 50% granulation (new tissue) tissue and 50 % dermis (layer of skin) tissue visible. Physician indicated continued use of EZ boot to be worn in bed and chair to off load wound, float heels and off load wound. -Wound physician notes from 1/17/23 indicated wound measurements of 2 cm by 2.5 cm by 0.1 cm with light serous drainage containing 20% slough (yellow debris from inflammation), 30 % granulation and 50 % dermis. Surgical debridement was completed by the physician. Plan of care to continue EZ boot while in bed or chair to off load wound and float heels in bed. -Wound physician note date 2/7/23 indicated the wound to the left heel was categorized as a stage four pressure wound. Measuring 2 cm by 2.5 cm by 0.1 cm with moderate serous drainage, with 20% necrotic (dead tissue) tissue, 10% slough, 60% granulation tissue, and 10 % dermis tissue. Review of Resident #28 treatment administration records (TAR) revealed the following:The December 2022 failed to reveal an order for EZ boots or floating heels while in bed. The January 2023 failed to reveal an order for EZ boots or floating heels while in bed. The February 2023 failed to reveal an order for EZ boots or floating heels while in bed. The March 2023 failed to reveal an order for floating heels while in bed. An order for Bunny boots on at all times was ordered on 3/14/23. Review of the certified nurse aide (CNA) point of care (POC) charting task assignments revealed the following:The December 2022 failed to reveal an order for floating heels or ez boots while in bed or chair. The January 2023 failed to reveal an order for floating heels or EZ boots while in bed or chair. The February 2023 failed to reveal an order for floating heels or EZ boots while in bed or chairThe March 2023 revealed an order for bunny boots on at all times ordered on 3/14/23. Review of progress notes from December 2022 to 3/13/23 revealed:The provider note dated 2/1/23 indicated the resident followed by wound MD and appreciated their recommendations and follow-up. Recent debridement performed to left heel wound which remains about 2 x 2.5 cm in size and use of EZ boot when in bed or chair to offload wound. The wound skin note dated 2/28/23 documented by the assistant director of nursing (ADON) indicated a new order to apply betadine twice daily and EZ boot to be worn in bed and chair to off-load wound. A late entry wound/skin noted dated 3/7/23 by the ADON documented EZ boot to be worn in bed and chair to off-load wound. The resident's care plan revealed bunny boots (specialized boot for offloading pressure on feet) was initiated on the care plan on 12/22/22. -However, the bunny boots did not reflect onto the TAR or POC for staff to apply. IV. Staff interviewsCNA #2 was interviewed on 4/20/23 at 1:53 p.m. CNA #2 said the POC charting told the CNAs who needed special devices like specialty boots or floating heels. CNA #2 said the resident's skin was reviewed during bathing or anytime resident care happened. Staff need to be on look out for new skin and old skin concerns and report to the nurse if there was an issue or something new. CNA #2 said Resident #28 wears bunny boots at all times to protect her feet she has a wound on her heel. Licensed practical nurse (LPN) #3 was interviewed on 4/19/23 at 2:00 p.m. LPN #3 said orders for wound care come from the wound physician who rounded with the ADON weekly. Orders were then to be followed by a nurse or CNA depending on who could apply the treatment/equipment. Bunny boots or EZ boots could be applied by a CNA. These orders would be found in the resident's TAR for nurses or the POC for CNAs. LPN #3 said Resident #28 wore protective boots to her feet at all times to prevent further deterioration of the wound. The director ofnursing (DON) was interviewed on 4/20/23 at 4:07 p.m. The DON said wound care orders coming from the wound physician could be verbal when doing rounds or come in wound documentation that was uploaded into the resident's medical record. The ADON completed rounds with the wound physicians and was responsible to place orders into the resident's chart. When an order was obtained and the facility did not have items needed in stock, staff were to request an alternative and/or request to hold till intervention became available.

Based on observation, record review and interviews, the facility failed to ensure the environment for three (#53, #57 and #36) residents of eight residents reviewed for aciident/hazards out of 29 sample residents remained as free of accident hazards as possible and the residents received adequate supervision to prevent accidents. Specifically the facility failed to:-Ensure medications were not left at the bedside for Resident #53; -Ensure an registered nurse completed an assessment post resident fall for Resident #57 and #36; and,-Ensure Resident #57 did not eloped from the facility. Findings include:I. Failure to ensure medications were not left at the bedsideA. Facility policy and procedureThe Administering Medication policy, revised April 2019, was received from the nursing home administrator (NHA) on 4/20/23 at 6:22 p.m. It revealed in pertinent part, "Medications are administered in a safe and timely manner. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care team, has determined that they have the decision making capacity to do so safely."The Self Administration of Medication policy, revised on February 2021, was received from the NHA on 4/20/23 at 6:22 p.m. it revealed in pertinent part, "Residents have the right to self administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. If the resident is able to safely and securely store teh medications. Any medications found at the bedside that are not authorized for self administration are turned over to the nurse in charge for the return to the family or responsible party."B. Resident #531. Resident status Resident #53, age younger than 65, was admitted on 10/7/22. According to the April 2023 computerized physician orders (CPO), the diagnoses included hyperlipidemia (high fat concentration in blood), hypertension (high blood pressure), anxiety (feeling of fear), epilepsy (nerve cell disorder) and depression. The 4/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required set up assistance with bed mobility, transfers, dressing, eating. One person assistance with personal hygiene and toileting. 2. Observation and resident interviewOn 4/17/23 at 2:59 p.m. a tube of cortisone 1 % cream (anti-itch medication) was observed on the nightstand in Resident #53's room. On 4/19/23 at 3:52 p.m. an albuterol inhaler (used for shortness of breath) and a tube of cortisone cream 1% was observed on the resident's nightstand. Resident #53 stated she needed the inhaler for when she got shortness of breath. She was unable to recall the last time she used the inhaler. She stated she did not need to tell staff if she used it. She said she used the cortisone cream when she got an itchy spot but did not have any spots currently. . She said she kept the medications on her night stand as she did not have anywhere else to safely store them. Resident #53 stated the facility gave her a second night stand with a locking drawer but they never provided the key. A nightstand was noted in the room with a locking mechanism available. 3. Record reviewReview of the April 2023 CPO revealed an order for:-Albuterol sulfate two puff inhalation every six hours as needed for pneumonia.-There was not ordered indicated for the cortisone 1% cream. Review of progress notes revealed the following:Nursing note dated 3/14/23 documented resident #53 wanted to keep her albuterol inhaler at the bedside. Request was discussed with provider, provider denied request stating she can ask for inhaler from the nursing department if she needs it.-Resident #53's assessments failed to reveal if a self administration of medication assessment was completed by nursing home staff. C. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 4/19/23 at 5:10 p.m. LPN #3 saidno residents were allowed to self administer medications at this time. A resident would need to have an assessment completed first for safety. If the resident came from home with medication the nurses took them, put their name on them and placed them in the medication room or in a cart till a responsible person could take them back home. LPN #3 said residents should not have medication in their room. LPN #3 acknowledged Resident #53 had one albuterol inhaler and one tube of cortisone 1% cream at bedside. LPN #3 stated she would not remove them and would talk to the assistant director of nursing (ADON). The ADON was interviewed on 4/19/23 at 5:15 p.m. The ADON said the facility could accommodate medication for residents at bedside in certain situations. A resident had to be evaluated to ensure they were able to safely take the medication along with safely storing the medication in their room. The ADON acknowledged the two medications found in the Resident #53's room. The ADON stated he would speak with Resident #53 about medication and removing them from her room. The ADON acknowledged he was unable to locate a self administration assessment in Resident #53's medical record. The director of nursing (DON) was interviewed on 4/20/23 at 11:10 a.m. The DON said self administration of medications could only occur if a resident had been screened to ensure their safety. Residents needed a way of securing medications from other residents if they were able to keep medications in their room. The facility had residents with dementia who wandered and could encounter medications if left unsecured. The use of stop signs in resident doors helps detour wandering residents but was not always effective. If residents were to get a hold of a medication not prescribed to them it could be harmful to their health. II. Failure to have registered nurse assessment post fallA. Facility policyThe Falls and Fall Risk, Managing policy, revised March 2018, was received from the nursing home administrator (NHA) on 4/20/23 at 6:22 p.m. It revealed in pertinent part, "to prevent the resident from falling and to minimize complications from falling. Unintentionally coming to rest on the ground, floor or other lower level."B. Resident #571. Resident statusResident #57, age 87, was admitted on 2/1/23. According to the April 2023 computerized CPO, the diagnoses included Alzheimer's disease (memory deficit), hypertension (high blood pressure) and hypothyroidism (abnormal thyroid function). The 2/7/23 MDS assessment revealed the resident was severely cognitive impairment with a brief interview for mental status score of six out of 15. She required one-person assistance with bed mobility, transfer, dressing, eating, toileting and personal hygiene. The resident wandered daily. 2. Record reviewRecord review revealed the resident had a fall on 2/5/23. There was no progress note indicating an RN assessment completed. Record review revealed resident had a fall on 2/17/23 which resulted in a bruise to left knee cap, a cut to residents eye brow and a lip laceration requiring an emergency room visit for surgical glue. Progress notes for 2/17/23 were signed by a licensed practical nurse (LPN).-The fall investigation failed to show a registered nurse (RN) completed an assessment post fall. -Record review for a fall on 2/27/23 where Resident #57 eloped out the front door and fell causing a scraped chin, cut to the bridge of nose requiring emergency room visit (see below). -Fall investigation failed to show that the resident was assessed by an RN post fall. C. Resident #361. Resident statusResident #36, age 83, was admitted on 2/9/19 and readmitted on 10/24/22. According to the April 2023 CPO, diagnoses included traumatic subdural hemorrhage with loss of consciousness, unspecified fracture of base of skull, and Alzheimer's disease. The 4/14/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment and was unable to complete a brief interview for mental status. He required extensive assistance of two-people with bed mobility, and extensive assistance of one-person with transfers, toileting, dressing and personal hygiene. Falls were not coded. 2. Record reviewThe fall risk assessment dated 3/20/23 revealed Resident #36 was a moderate risk for falls, and had multiple falls within the past six months. The fall risk care plan, initiated on 2/23/19, revealed the resident was at risk for falls. The intervention initiated on 3/21/23 was ensuring the foot pedals were in place while pushing the resident. The intervention initiated on 3/24/23 was ensuring the wheelchair cushion was available for better positioning. The 3/24/23 incident progress note written by a licensed practical nurse (LPN) #1 documented that Resident #36 fell forward out of his wheelchair when he fell asleep. It revealed he had a new red abrasion on his forehead. She reported his neurological check was at baseline and there were no signs or symptoms of pain. -A review of Resident #36's medical record did not reveal documentation that the resident had been assessed by a RN following the fall on 3/24/23.-The facility was unable to provide additional documentation to show that an RN assessment was completed during the survey process. C. Staff interviewsLPN #2 was interviewed on 4/20/23 at 11:03 a.m. She said if a resident sustained a fall, an RN needed to assess the resident before the resident was moved from the floor. Notification should be made to the director of nursing (DON), the physician and the family. The DON was interviewed on 4/20/23 at 4:07 p.m. The DON said a post fall assessment was to be completed after every fall. A resident must be assessed prior to moving them, assessment included vitals signs, checking for injuries and providing attention to injuries as needed. The DON acknowledged it was out of the LPN's scope to assess a resident after a fall. III. Failed to prevent elopementA. Record reviewThe admission record from 2/2/23 revealed resident was evaluated for elopement and was a high risk for elopement due to Resident #57 wandering behaviors, verbalization to leave the facility and cognitive mental status. Review of Resident #57's record there was an elopement on 2/27/23 where the resident was able to exit the front doors of the facility. This elopement resulted with resident sustaining injuries from a fall requiring an emergency room visit. The care plan revealed Resident #57 was an elopement risk with impaired decision making and exit seeking behavior identified on 2/2/23. The goal was for Resident #57 to not leave the facility unattended. Interventions in place prior to resident elopement on 2/27/223 were: provide structured activities, wander alert/guard was placed on the right wrist, checking placement and function of wander guard, monitor attempts of exiting for pattern, and reorient/redirect as needed. -The care plan failed to indicate any new interventions put in place post the 2/27/23 elopement with injury. B. Staff interviewsThe NHA was interviewed on 4/20/23 at 5:13 p.m. The NHA said residents were assessed on admission for elopement. If they triggered for elopement or had a history of eloping a wander guard was placed with consent from a resident or the resident's power of attorney. When a resident got to a certain point by an exit door the alarm would sound. Facility doors did not lock on alarm so residents could still exit. The facility kept a book with resident pictures for all residents who have a wander guard in place to help staff with residents at risk for elopement. Night shift was responsible for checking the wander guard function nightly by checking the wander guard system and the resident individual devices. Resident #57's picture was observed in the elopement book on 4/20/23 at 3:30 p.m. The NHA acknowledged Resident #57 elopement on 2/27/23 out the front door of the facility and sustained injuries. The NHA said human resources staff was the last staff member who was seen resident prior to elopement by the main dining room. By the time the staff member made it to the nurses station the alarm was going off. A certified nurse aide (CNA) who was walking towards the dining room went to the main door due to an alarm sounding. Resident #57 was on a mission and when CNA found her outside she had already fallen. A second CNA came and then went for a nurse to assess Resident #57. Interventions in place post elopement were one-to-one line of sight supervision and referral to a memory care unit. Line of sight was kept for 72 hours post elopement. The NHA said interventions in place after the elopement were activity involvement, nurses station as Resident #57 believes she was still a nurse, offering resident coffee/snacks and her line of sight of staff.

Based on resident observations, record review, and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#61 and #266) of seven residents reviewed for supplemental oxygen use out of 29 sample residents. Specifically, the facility failed to:-Obtain a physician's order for continuous oxygen use for Resident #61; and,-Administer oxygen by the physician's order for Resident #266. Findings include:I. Resident #61A. Resident statusResident #61, over the age of 65, was admitted on 3/23/23. According to the April 2023 computerized physician's orders (CPO), diagnoses included pulmonary hypertension, unspecified atrial fibrillation and unspecified heart failure. The 3/28/23 minimum data set (MDS) assessment showed the resident had minimal cognitive impairment with a BIMS score of 13 out of 15. The resident required limited assistance with mobility and with personal hygiene. The resident was not coded for oxygen use. B. ObservationOn 4/17/23 at 2:33 p.m. Resident #61 was sitting in a wheelchair watching television in her room. She had a nasal cannula on her connected to a concentrator. The resident's oxygen concentrator was set to three liters per minute (LPM). On 4/18/23 at 09:20 a.m. the resident was up sitting in her wheelchair with oxygen on her. The concentrator was set on three LPM.On 4/19/23 at 1:06 p.m. the resident was assisted from her wheelchair to her bed by a certified nursing assistant (CNA) #4. The resident was resting in bed with the oxygen on her set at three LPM.At 4:00 p.m. the resident was observed working with a physical therapist assisting the resident on a walk. She had a portable oxygen tank on her set at three LPM.At 4:15 p.m. the physical therapist assisted the resident to her room after completing the walk with the resident and set her up in her room for dinner. CNA #4 changed the oxygen from the potable tank to the room concentrator and applied it to the resident. The concentrator was set at three LPM.C. Record reviewThe care plan, initiated on 3/29/23 and revised on 4/18/23, identified the resident was at risk for cardiac/circulatory complications related to heart failure. Interventions included administering oxygen as ordered, monitoring for signs and symptoms of upper respiratory infection, monitoring vital signs, assess respiratory status before, during, and after treatment.-The April 2023 CPO did not include a physician's order for oxygen. D. Staff interviewsCNA #4 was interviewed on 4/19/2 at 4:45 p.m. CNA #4 said Resident #61 has been using oxygen continuously and it was set at three LPM.Licensed practical nurse (LPN) #4 was interviewed on 4/19/23 at 5:15 p.m. She said the resident has been on continuous oxygen set at four LPM beginning of the shift on the room concentrator and three LPM for the portable tank. LPN #4 said there should be an order for oxygen therapy, however, could not locate the order on the resident's medication administration record (MAR). II. Resident #266A. Resident statusResident #266, over the age of 65, was admitted on 3/17/23 and readmitted on 4/12/23. According to the April 2023 CPO, diagnoses included acute and chronic respiratory failure with hypoxia (low blood oxygen) and unspecified chronic obstructive pulmonary disease (COPD). According to the 3/28/23 minimum data set (MDS) assessment, the resident had minimal cognitive impairment with a BIMS score of 12 out of 15. He required limited assistance for bed mobility, transfers, grooming, and toilet use. The resident received oxygen therapy. B. ObservationThe resident was observed in his room on 4/17/23 at 9:00 a.m., laying on his bed. He had a nasal cannula connected to a room concentrator. The room concentrator was set at five and a half LPM.After getting a shower, the resident was observed on 4/18/23 at 1:55 p.m. and was transferred back to his bed in an upright position with oxygen on him. The room concentrator was set at five and a half LPM.The resident was observed in bed on 4/19/23 at 4:25 p.m. with his oxygen on him. The room concentrator was set at six LPM.C. Record reviewThe care plan, initiated on 3/27/23 and revised on 3/27/23, identified the resident as at risk for complications related to a compromised respiratory system related to pneumonia. Interventions include: Administer oxygen as ordered, monitor vital signs as ordered, notify the physician of complaints of difficulty in breathing, and monitor for signs, and symptoms of upper respiratory infection. The April 2023 CPO included an oxygen order dated 4/12/23 for oxygen at three liters per minute (LPM) continuously via nasal cannula every shift. On 4/20/23 at 5:44 p.m. the DON provided a new physician's order obtained for five LPM for Resident #266 after being identified during the survey the resident was not on the correct prescribed liters per minute. D. Staff interviewCNA #4 was interviewed on 4/19/23 at 4:45 p.m. CNA #4 said Resident #266 has been on oxygen, however, was not sure how many liters the resident was supposed to be on. CNA #4 verified the resident's room concentrator and stated it was set at five and a half liters. LPN #4 was interviewed on 4/19/23 at 5:40 p.m. She said Resident #266 had been on six liters of oxygen since the beginning of her shift. LPN #4 verified the physician order on the resident's MAR and stated that the physician order indicated three LPM of oxygen for Resident #266. She said the resident has been on four liters of oxygen and above for several days. LPN #4 said the physician's order should have been followed for the use of oxygen for the resident. The director of nursing (DON) was interviewed on 4/20/23 at 5:00 p.m. The DON said the facility has to obtain a physician order before oxygen therapy begins for each of the residents that required the use of oxygen. The DON said the facility staff should follow the physician's order. She said it was on the resident's care plan if they were receiving oxygen therapy. The DON said it was important to obtain a physician's order for the use of oxygen so the facility staff would know the liters per minute to administer. She said oxygen was considered a medication and could not be administered without a physician's order. The DON said she assisted with the resident's shower on 4/20/23, however, did not notice that the resident was on six LPM of oxygen.

Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#34) of five residents reviewed for dementia care out of 29 sample residents. Specifically, the facility failed to provide personalized interventions to address the Resident #34's behaviors, which caused a resident altercation. Findings include:I. Facility policy and proceduresThe Dementia policy, no date, was provided by the nursing home administrator (NHA) on 4/25/23. It read in pertinent part: "complications related to dementia will be minimized. The staff and physician will review the current physical, functional, and psychosocial status of individuals with dementia to formulate an overview of the individual's condition, related complications, and functional abilities and impairments. The staff and physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and in considering healthcare treatment choices, including life-sustaining treatments. The physician will help staff adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident/patient or family wishes, etc."II.. Resident #34A. Resident statusResident #34, age 84, was admitted on 9/7/21. According to the March 2023 computerized physician orders (CPO), the diagnoses include Alzheimer's disease and depression. The 3/1/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to participate in a brief interview for mental status. She required extensive assistance from one staff member with transfers, dressing, personal hygiene, and toilet use. B. ObservationsOn 4/18/23 at 4:18 p.m. Resident #34, was observed self propelling in her wheelchair holding two baby dolls on a separate hallway than her own, staff engaged in conversation and assisted her to a common area. At 4:28 p.m. Resident #34 was observed in her wheelchair holding two baby dolls and being escorted to dinner by staff. At 5:00 p.m. Resident #34 was observed to be in her wheelchair sitting with staff having dinner. She was holding one baby doll and a second one was on the table within arms reach. On 4/19/23 at 10:56 p.m. Resident #34 was observed to be in her wheelchair, holding two baby dolls and passively engaging in a scheduled activity. At 12:00 p.m. Resident #34 was observed to be in her wheelchair, holding two baby dolls while staff escorted her to lunch. At 1:33 p.m. Resident #34 was observed to be sitting in her wheelchair holding two baby dolls in the common area watching television. At 1:42 p.m. Resident #34 was escorted to a scheduled activity by staff, she was in her wheelchair holding two baby dolls. At approximately 3:30 p.m. Resident #34 was observed in her wheelchair sitting in a room of another resident, she was holding one baby doll and appeared to be sleeping. On 4/19/23 at 3:54 p.m. the NHA was walking past room that Resident #34 was occupying and assisting her to a common area. The room Resident #34 was not occupied by a resident at the time. -There were no stop signs to deter the resident from entering other residents rooms (as indicated in interviews below) and the resident had wandered into an unoccupied resident room. C. Resident altercation 1/21/23Resident #34 was involved in an altercation with another resident. She had wandered into the residents room and hit her in the jaw when she was asked to leave (cross-reference F600 for abuse.)D. Record reviewThe 1/18/23 progress note revealed Resident #34 had increased behaviors with staff and was hitting staff while being redirected. The 1/21/23 progress note revealed Resident #34 displayed agitation and went into other resident's rooms. Resident was medicated for pain per the medical doctor's request. The 1/23/23 progress note revealed social services had sent referrals to multiple memory care facilities related to Resident #34 having an increase in behaviors. The 2/13/23 progress note revealed Resident #34 touched a male caregiver inappropriately and asked him to get into bed with her. The 3/20/23 progress note revealed social services had sent referrals to two memory care facilities. The care plan, dated 3/28/23, revealed Resident #34 had a history of alteration in mood and behavioral issues related to a diagnosis of depression. It revealed Resident #34 had an altercation with another resident, when trying to take the other resident's baby doll. It revealed Resident #34 was territorial over personal items, impulsive, and difficult to redirect related to dementia. The care plan revealed a facility goal of preserving the dignity and quality of life for Resident #34 by minimizing risks for agitation, inappropriate behaviors, and unmet needs. The interventions included one-to-one line of site, administering medications as ordered, interacting in an empathetic and supportive manor, and providing Resident #34 with a baby doll when observed in distress. III. InterviewsThe social services director (SSD) was interviewed on 4/20/23 at 1:45 p.m. She said Resident #34 began displaying aggressive behavior a few months ago, she would shake her fist at people or be verbally rude. She said Resident #34 was territorial and had dementia. She said she did not believe Resident #34 is intentional with her aggression, she said it was related to Resident #34 dementia and impulsivity. She said the facility interventions were providing Resident #34 with two baby dolls, allowing her to have a private room and putting stop signs at the doors of resident's rooms that Resident #34 was observed entering. She said she had made referrals to memory care facilities and none had accepted Resident #34. -There were no stop signs in the doorways or the hall Resident #34 resided on. The human resources (HR) was interviewed on 4/20/23 at 3:16 p.m. She said Resident #34 occupied common areas of the facility and participated in activities. She said Resident #34 would enter another resident's room if the resident gained her attention. Certified nurses aide (CNA) #3 was interviewed on 4/20/23 at 3:23 p.m. She said Resident #34 could become easily upset in the evening. She said she had not witnessed Resident #34 entering other resident rooms. The NHA was interviewed on 4/20/23 at 4:00 p.m. She said Resident #34 entering the room of Resident #31 was an isolated event (cross-reference F600). She said Resident #34 was territorial of her babies, and she did not have her babies on the day of the occurrence. She said Resident #34's mood did not fluctuate and the occurrence of hitting another resident was isolated. She said the SSD has made referrals to memory care facilities, and none have accepted.

Based on record review and interviews, the facility failed to promptly provide, or obtain dental services to meet the residents' needs for one (#53) of one resident out of 29 sample residents. Specifically the facility failed to ensure timely follow up for Resident #53's dentures. Findings include:I. Facility policy and procedureThe Social Service policy, dated September 2021, received from the nursing home administrator (NHA) on 2/20/23 at 6:22 p.m. It revealed in pertinent part, "facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental or psychosocial well-being. Medically-related social services were provided to maintain or improve each resident's ability to control everyday physical needs including equipment for eating. Assist with situations that impede the resident's dignity and sense of control."II. Resident #53A. Resident #53 statusResident #53, age younger than 65, was admitted on 10/7/22. According to the April 2023 computerized physician orders (CPO), the diagnoses included hyperlipidemia (high fat concentration in blood), hypertension (high blood pressure), anxiety (feeling of fear), epilepsy (nerve cell disorder) and depression. The 4/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required set up assistance with bed mobility, transfers, dressing, eating. One person assistance with personal hygiene and toileting. B. Resident interviewResident #53 was interviewed on 4/17/23 at 3:13 p.m. Resident # 53 said she saw a dentist a couple months ago and was told she would get new bottom dentures. Resident #53 said she had not heard anything from anyone on the new dentures or when the dentist would return. Resident #53 said she was hopeful the dentures would help her talk better as currently she was talking with a lisp. Resident #53 was interviewed again on 4/19/23 at 3:44 p.m. Resident #53 said she was unaware of the plan for obtaining new dentures. She said her mouth had not been assessed for an impression to get new ones made. Resident #53 stated she never used to speak with a lisp and she was embarrassed by the way she sounded when speaking. C. Record review The resident's electronic medical record failed to reveal any dental notes or social service progress notes indicating the resident was seen by dental. On 4/20/23 at 1:52 p.m. the social services director (SSD) provided documentation of a dental visit from 1/10/23. The dental note indicated dentures would be made pending approval from insurance. D. Staff interviewsThe social service director (SSD) was interviewed on 4/20/23 at 1:55 p.m. The SSD said dental services were last in the building in January 2023. The SSD indicated Resident #53 was seen by the dentist on 1/10/23 and it was the resident's first visit with the dentist. The SSD said that the dental company prepared a post eligibility treatment of income (PETI) packet for the social services department to give to the business office department to get approval for dentures. The SSD said the process could take weeks. She said the PETI packet had been delivered to the business office but was unaware of the status at this point and she had not written a progress note on the status. E. Additional informationOn 4/24/23 at 2:56 p.m. the NHA provided more documentation from the social service department. The social service note dated 4/20/23 at 4:20 p.m. The SSD contacted the dental provider to inquire about billing. The note indicated that Resident #53 felt her problems with speech were related to her lower dentures not fitting right. The social service note from 4/21/23 at 1:38 p.m. revealed a call was received from the dental provider indicating the prior approval for lower dentures was denied and the next step was to try the resident's secondary insurance. The SSD requested to speak with the dental manager to discuss the PETI process. The social service note dated 4/24/23 at 2:07 p.m. The SSD received a call from the dental provider who indicated dentures were denied by Medicaid due to frequency. Medicaid only paid for dentures every seven years and it had only been four years for Resident #53. The process had been started for authorization from Residents #53's secondary insurance. The facility would purchase dentures if denied by secondary insurance.

Based on observations, record reviews, and staff interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of foodborne illness in one of one kitchen. Specifically, the facility failed to ensure food holding temperatures were at appropriate levels to prevent the growth of foodborne pathogens. Findings include:I. Professional referenceAccording to The Colorado Department of Public Health and Environment (CDPHE)The Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 4/26/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, "Food shall have an initial temperature of 41 degrees Fahrenheit (F) or less when removed from cold holding temperature control or 135 F or greater when removed from hot holding temperature control."II. Facility policyThe food and nutrition services policy, revised November 2022, was provided by the corporate dietary consultant (CDC) on 4/20/23 at 3:35 p.m. It read, in pertinent part, "Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices."'Danger zone' means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F, allowing the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed."The longer food remains in the danger zone the greater the risk for growth of harmful pathogens."Mechanically altered hot foods prepared for a modified consistency diet remain above 135 Fahrenheit during preparation or they are reheated to 165 Fahrenheit for at least 15 seconds if holding for hot service."III. ObservationsOn 4/20/23 beginning from 11:00 a.m. to 12:25 p.m. lunch meal services were observed from the tray line. Nutritional specialist (NS) #1 took the initial holding temperatures of the hot foods on the steam table and the cold foods in the service area; then took food temperatures again at the end of the meal service. The food holding temperatures did not hold to safe levels throughout the meal service (see the professional reference and facility policy above). Observations of the food temperatures at 12:25 p.m. at the end of service revealed:-Cornbread prepared with milk and an internal temperature of 103 F; -Mashed potatoes had a temperature of 130 F;-Gravy had a temperature of 104 F; and,-Puree ham had a temperature of 131 F. The puree ham, gravy band mashed potatoes were in eight-ounce containers on the steam table which had a sixteen-ounce steam table hole. The food items mentioned above did not hold the appropriate temperature throughout the lunch tray observation. IV. InterviewNS #1 was interviewed on 4/20/23 at approximately 12:35 p.m. The NS said the food should be held on the steam table at 140 F for hot foods, and cold foods below 41 F. She said some of the food items did not reach the appropriate temperatures therefore she had to send it back to the main kitchen to be reheated. The nutritional specialist lead (NSL) was interviewed on 4/20/23 at approximately 12:51 p.m. The NSL said the cook should ensure food items reach and maintain the appropriate temperatures. She said the steam table should have the right size of containers to ensure the food maintains the appropriate temperatures. The corporate dietary consultant (CDC) was interviewed on 4/20/23 at 1:15 p.m. The CDC said the steam table should hold the hot foods at 140 F and above throughout the whole meal service. She said it was important to ensure food is served under the proper temperature to prevent the spread of foodborne illness and contamination of food. The CDC said she would ensure that the kitchen staff was re-educated on the importance of food reaching the recommended temperatures and ensure the appropriate pans were used for the steam table.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to perform wound care in a hygienic manner. Findings include:I. Professional referenceAccording to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 4/27/23 from: https://www.cdc.gov/handhygiene/providers/guideline.html (2020), it read in pertinent part, "healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in a healthcare settings)."II. Observations and staff interviewsThe physician documented the following wound care order Anasept antimicrobial external gel 0.057% (specialized wound gel). Apply to the left heel wound topically everyday shift for wound healing. Cleanse with wound cleanser( saline solution to clean wounds), pat dry, apply anasept cover with non-adherent dressing and wrap with kerlex (rolled gauze). Ordered 4/14/23On 4/19/23 at 1:45 p.m. licensed practical nurse (LPN) #3 was observed providing wound care to Resident #28. The supplies brought into the resident's room were a pair of yellow handled scissors removed from caddy on the medication cart with no name to identify who they belonged to, a tube of anasept gel, one non stick telfa pad, gauze, kerlex, wound cleanser and tongue depressor. LPN #3 set up clean working environment on bedside table by draping barrier pad on table and a secondary barrier pad under Resident #28's left heel. LPN #3 performed hand hygiene with soap and water then applied gloves. LPN #3 removed the old dressing by cutting through kerlex with yellow handled scissors. The date on dressing removed was 4/18/23. The old dressing had dried blood on kerlex when it was removed and the telfa pad was stuck to resident wound. LPN #3 applied wound cleanser to moisten old dressing for easier removal. The telfa pad was observed to have dried blood on it post removal. LPN #3 then collected clean gauze, sprayed several gauze pads with wound cleanser and wiped the heel wound two times with the same piece of gauze. LPN #3 patted the wound dry with a new piece of gauze used twice over the area. LPN #3 then removed gloves and applied new gloves without performing hand hygiene between the glove changes. LPN# 3 then applied anasept gel to a tongue depressor and applied gel to the wound bed. LPN #3 then removed her gloves, collected the new telfa pad with bare hands and applied to the wound, collected kerlex and wrapped gauze around resident's heel, ankle and foot to keep dressing in place. LPN #3 secured the dressing with tape, dated and initialed it. LPN #3 then washed her hands with soap and water. LPN #3 exited Resident #28's room and returned to the nurses medication cart to collect sanitizing wipes. LPN #3 returned to Resident #28's room with sanitizing wipes and sanitized the scissors, anasept gel tube, wound cleanser, and the resident's bedside table. The sanitized supplies were not allowed to air dry before LPN #3 collected them with her bare hands and held them up against her body. LPN #3 lowered the resident's beds and advised the resident that the certified nurse aide (CNA) would return to assist her to get out of bed. LPN #3 returned to the medication cart, placed yellow handled scissors in the top drawer of the medication cart, then placed wipes in the bottom drawer of the cart. The anasept gel was placed in a zip lock bag in a compartment in the medication cart separated from medications. LPN #3 was interviewed on 4/19/23 at 2:00 p.m. LPN #3 said some treatment supplies were kept in the medication cart as the treatment cart was full. She revealed she placed the tube of anasept gel and yellow handled scissors belonging to Resident #28 into another resident's bag on the medication care. LPN #3 then removed gel and placed into Residents #28's bag without performing sanitization of the tube. LPN #3 removed yellow handled scissors and placed them into the top drawer of the medication cart without sanitizing them. LPN #3 acknowledged that she used the yellow handled scissors for all resident treatments on her hallway. LPN #3 acknowledged she removed her gloves during wound care because she did not want the tape to stick to her gloves but understood there was a risk of infection because of this. The director of nursing (DON) was interviewed on 4/20/23 at 11:10 a.m. The DON said hand hygiene should be performed at pertinent parts of wound care upon entering the room a nurse should perform hand hygiene, then apply gloves, remove old dressing, clean wound, change gloves, provide wound care, then remove gloves and perform hand hygiene at end of care. Hands should be washed with soap and water if visibly soiled at any time. Each resident should have their own scissors for wound care, they should not be shared among residents due to infection control practices. Scissors should be cleaned with a disinfectant wipe regardless if they were only used on one resident.