Every finding on record at Augusta Health and Rehabilitation

Based on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections with the potential to affect all 37 residents.-Registered Nurse (RN) E did not perform glove change/hand hygiene appropriately during wound care to R10.-Laundry Aide (LA) G transported clean linens throughout the building uncovered.Findings include: Facility Policy titled, Wound Care Policy, last reviewed 08/2025, reads in part: The goal is to promote wound healing, prevent complications, and maintain the highest practicable level of resident health.Dressing changes must include hand hygiene, proper personal protective equipment (PPE). Example 1 On 04/06/26 at 9:45 AM, Surveyor observed Registered Nurse (RN) E perform a dressing change and wound treatment to R10's right forearm. RN E placed a drape on the over-bed table with supplies sitting on top. RN E donned gloves, removed the old bandage, and threw it away. RN E then cleaned the wound, applied skin prep to surrounding area, and placed the new bandage. RN E did not change gloves between dirty and clean procedures and did not perform hand hygiene in between. On 04/06/26 at 10:07 AM, Surveyor interviewed RN E. RN E stated RN E does not usually keep the same gloves on the duration of wound care. RN E stated RN E should have removed RN E's gloves after the dirty part of the procedure, washed RN E's hands, and then donned clean gloves for the clean part of the procedure. On 04/06/26 at 11:38 AM, Surveyor interviewed Director of Nursing (DON) B. DON B was made aware of Surveyor's observation of inappropriate gloving/hand hygiene during wound care. DON B acknowledged RN E should have changed RN E's gloves and performed hand hygiene between dirty and clean tasks. Surveyor reviewed audit form titled, Wound Care Glove Use Competency Sheet, which indicated RN had appropriately completed donning/doffing of gloves and hand hygiene on 11/11/25 signed by DON B. Example 2 The facility policy, titled Clean Linen Handling Policy dated last reviewed, 12/2025, states in part: Clean linens must be transported in: Covered carts. On 04/06/26 at 12:03 PM, Surveyor observed Laundry Aide (LA) G walking through the 300-hall dining room with a cart full of facility linens. The laundry cart was uncovered with linens exposed. On 04/07/2026 at 10:40 AM, Surveyor observed LA G delivering clean linens to the 100 hall. The staff pushed the linen cart which was a tall metal wire shelved cart with open sides and top. The cart contained clean bed sheets, lift slings, washcloths, towels and other bed linens. The cart and linens were not covered. On 04/07/2026 at 10:45 AM, Surveyor interviewed LA G who has worked in laundry for the past 2 years. Surveyor asked how often LA G delivers clean linens to the living units. LA G stated once a day. Surveyor asked if it is always delivered on this cart. LA G stated, They have used this cart for 2 years. When asked about it being covered, LA G stated, It did not come with a cover. Surveyor asked how many linen closets he delivers linen to. LA G stated he takes the linens to all linen closets throughout the facility. When asked what all he delivers on this cart, LA G stated he delivers whites including washcloths, towels, bedding sheets, pads for on beds and lift slings on this uncovered cart. On 04/07/26 at 11:38 AM, Surveyor interviewed DON B. DON B stated it is DON B's expectation the linen cart should be covered while being transferred through the facility/hallway. DON B was made aware of Surveyor's observation. On 04/07/2026 at 4:15 PM, Surveyor interviewed RN H who is the facility's infection control nurse. When told of above observation, RN H stated that the cart for delivering linens should be covered.

Based on observations, interview and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect 4 of 4 residents: (R6, R10, and R25) for proper storage of insulin, (R15) for nebulizer solution storage, and the potential to affect all 28 residents residing on the C-D wing for use of bisacodyl suppositories, tuberculin vaccine, and influenza vaccine.Findings:The facility policy titled, Medication Refrigerator Temperature Monitoring Policy last reviewed on 12/20/25, stated,PolicyAll Medications requiring refrigeration will be stored in a designated medication refrigerator maintained at temperatures between: 36 degrees Fahrenheit - 46 degrees Fahrenheit (2 degrees Celsius - 8 degrees Celsius)Temperature monitoring will be performed daily and documented to ensure compliance with regulatory standards.Temperature Monitoring Procedure1. Daily Temperature Checks Staff will:1. Check refrigerator temperature once per shift2. Record temperature on the Medication Refrigerator Temperature Log.3. Initial and date each entry.2. Acceptable Temperature Range Acceptable range:36 degrees Fahrenheit - 46 degrees Fahrenheit (F) (2 degrees Celsius - 8 degrees Celsius)Temperatures outside of this range are considered out of compliance and notification of the Director of Nursing (DON) B and or maintenance needs to be completed.The Wisconsin Pharmacy Chapter 6 titled, Pharmacy Licenses and Equipment states:(e) Refrigerator means a place in which the temperature is maintained between 36- and 46-degrees Fahrenheit.The Wisconsin Childhood Immunization Guidelines states:1. Vaccines must be stored within these ranges: o Refrigerator: Store between 2.0 C to 8.0 C or 36.0 F to 46.0 F 2. Temperature review and documentation Daily temperature review of each storage unit is required.On 04/07/2026 at 7:55 AM, Registered Nurse (RN) E took Surveyor into the medication room for the C-D wings to get insulin from the refrigerator. Surveyor noted the refrigerator temperature log was incomplete. At the bottom of the log sheet, it read, If temperature falls outside range of 36-46 degrees F for refrigerator or 59-86 degrees F for room temp, immediately notify the DON.On 04/07/2026 at 8:00 AM, Surveyor asked Licensed Practical Nurse (LPN) J to make a copy of this temperature log for the Surveyor. It was noted that the recorded refrigerator temperature for that morning was 50 degrees F.On 04/07/2026 at 8:11 AM, Surveyor asked LPN J, Whose job is it to document the refrigerator temperature every shift? LPN J replied, It is the nurse on this side's job to document this refrigerator.On 04/07/2026 at 8:15 AM, Surveyor asked DON B, Who documents the refrigerator temperatures in the medication storage room? DON B replied, There is a nurse on this side that would document this refrigerator. Surveyor asked DON B, Were you notified this morning that the medication room refrigerator was up to 50 degrees this morning? DON B replied, I was not. Surveyor showed DON B the copy of the refrigerator missing temperatures and temperature out of range and asked to see the log for March on this refrigerator. DON B provided Surveyor with the March log and noted temperature were missing on that log as well.Temperature log dates that were missing:April 2nd, 3rd, 4th, and 6th.March 1st, 5th, 6th, 9th, 12th, 13th, 15th, 16th,19th, 20th, 26th, 28th and 29th.On 04/07/2026 at 8:29 AM, Surveyor made note of all items in the refrigerator.Temperature sensitive biologics in the refrigerator included:Stock Bisacodyl 10mg suppository's (2 boxes)R15's Arformoterol nebulized solution (one box)R25's Humalog (2 boxes) and Glargine (1 box)R6's Lantus (2 boxes) R10's Lantus (one box) and Trulicity (one box)Influenza Vaccine (2 boxes)Tuberculin Aplisol.

Based on observation, interview, and record review, the facility did not provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure the resident can use the assistive devices when consuming meals and snacks for 1 of 1 resident reviewed (R6).-R6 did not receive divided plate, setup, and straws with lids per the care plan.Findings include: Facility Policy titled, Comprehensive Care Plan Policy, no date, reads in part: [[NAME] Health and Rehab] will develop and maintain an individualized comprehensive care plan for each resident to meet their physical, psychosocial, and emotional needs.Purpose: to ensure residents receive coordinated, person-centered care that promotes the highest practicable level of well-being in accordance with federal and Wisconsin long-term care regulations.Implementation of Care Plan: All facility staff are responsible for implementing care plan interventions relevant to their role. Staff must review care plans regularly, follow documented interventions, report changes in resident condition, and document care provided. R6 was admitted to the facility on [DATE]. On 02/11/26, R6's Minimum Data Set (MDS) assessment shows a Brief Interview for Mental Status (BIMS) score of 4/15 indicating severe cognitive impairment. R6's care plan includes in part a problem of R6 is at risk for weight loss, with interventions including provide a divided plate, dycem mat, complete tray set up, and foods and drinks to the left of tray to aid in self-feeding. Provide lids and straws for drinks. On 04/06/26 at 12:20 PM, Surveyor observed R6 was served his tray. R6 did not have a divided plate. Items were not set up to the left side of the tray and R6 was not encouraged to self-feed. Certified Nursing Assistant (CNA) D assisted R6 to eat dependently. On 04/06/26 at 1:58 PM, Surveyor interviewed CNA D. CNA D stated R6 hasn't been feeding R6's self lately and at times will just sit there. CNA D stated as far as CNA knows R6 has always used a regular plate. CNA D stated they have care sheets they carry and the Kardex is in a binder, and these documents have the information they need to take care of each individual resident. CNA D did state R6 had dycem under the drinks and plate. CNA D stated CNA D believes it has been reported to nursing/management that R6 requires more assistance with meals and that R6 requires a lot of cueing. CNA D stated CNA D usually works in the back and would have to ask someone if R6 required a divided plate. On 04/06/26 at 2:03 PM, Surveyor interviewed Registered Nurse (RN) E. RN E stated the CNAs have care cards they get at the beginning of the shift that contains the information they need to take care of the residents. RN E was unaware of the Kardex binder and stated RN E would have to ask someone. On 04/06/20 at 2:07 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the Kardex binders are located by where the CNAs complete their charting as well as near the computers they use at the nurse's station. DON B stated each section is divided by care area and it pulls directly from the care plan. DON B stated any nurse manager can update these as needed and print a new one as changes occur. Surveyor reviewed R6's Kardex which states R6 is a regular diet with thin liquids, R6 requires set up, wears dentures, and receives supplements. There is no mention of the divided plate, the straws with lids, the set-up on the left side of the tray, and the encouraging of self-feeding, present on the Kardex. On 04/07/26 at 8:43 AM, Surveyor observed R6 at breakfast. R6 did not have drinks with lids on and straws, the tray was centered, and no divided plate was present. Dycem was present under plate. Staff gave R6 cues and handed R6 a spoon to encourage self-feeding. On 04/07/26 at 8:47 AM, Surveyor interviewed [NAME] F. [NAME] F stated each resident has a card with needed information for each meal that the kitchen follows. [NAME] F showed Surveyor R6's card which indicated R6 requires a lipped plate for meals. On 04/07/26 at 11:38 AM, Surveyor interviewed DON B. DON B stated the pertinent information in the care plan is also placed onto the Kardex for the CNAs. DON B stated the Kardexes, and care plans are updated as changes are made, and new ones are printed and current. DON B acknowledged R6's care plan contained pertinent information that was not included on the Kardex, and CNAs were not aware of it. DON B also acknowledged the cards with resident information on them in the kitchen were different than the care plan. On 04/08/26 at 7:40 AM, Surveyor interviewed Dietary Manager (DM) C. DM C stated the resident information cards are updated as they appear worn or as changes are made. CNAs may let the kitchen staff know about resident dislikes, therapy may make changes and update the kitchen staff, and/or nursing may also request changes be made. DM C was made aware of the discrepancy between the resident kitchen card and the care plan.

Based on observation, interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of all drugs to meet the needs of each resident. This was observed for 1 of 6 residents (R31) observed during medication administration. Registered Nurse (RN) I did not administer the correct dose of medication to a R31.Findings:Facility policy titled, Medicated Creams, Lotions, Powders Administration last reviewed on 12/20/25 stated, 4. Apply Medication1. Perform hand hygiene and don gloves2. Clean and dry the area if necessary3. Apply thin layer unless ordered otherwise ex: use of dosage cardR31 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated R31 was cognitively intact. R31 had a diagnosis of chronic pain syndrome (pain that lasts for over three months).On 04/07/2026 at 7:15 AM, Surveyor observed RN I administer a topical medicated cream to R31. Surveyor observed RN I place a pea size amount of the medicated cream on the tip of RN I's gloved finger and apply the cream to R31's low back. Then, RN I placed a pea size amount of cream on the tip of RN I's gloved finger and applied to R31's right knee. Surveyor asked RN I, What dose of cream did you give to R31? RN I replied, 4 grams, as RN I pointed to the dose printed on the box the cream came in. Surveyor asked RN I, How do you know how much 4 grams of the cream is? RN I replied, Well, it says here to use the dosing card, but there is no card. RN I then went through other residents' medications in the bottom drawer of the medication cart and found a dosage card for another resident. Surveyor then asked RN I, Based on the pea size amount of cream, how much medication do you feel that you gave [R31]? RN I replied, Probably only like 1 gram on the back and one gram on the right knee.On 04/07/26 at 9:23 AM, Surveyor explained the observation made between RN I and R31 to Director of Nursing (DON) B and asked, What would your expectation be with this medication administration? DON B replied, I would expect the nurse to ask us to find or call the pharmacy themselves for a new dosing card for administration unless the resident only asked for that amount. But then, we would need to call the doctor for a dose change.

Based on interview and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 2 of 4 residents (R29, R4) reviewed for accidents. The facility did not complete a thorough investigation of falls for root cause and implement interventions to prevent further falls. R29 had a fall on 12/19/24 that resulted in a left femur fracture and surgical repair. This example is cited at actual harm. The facility did not complete a thorough investigation of falls to determine staff following plan of care, root cause, monitor for trends, and re-assess interventions to prevent further accidents for R4. This is evidenced by: The facility Fall Evaluation, Intervention, and Reporting policy updated/reviewed 10/10/24 states: All residents will be evaluated for fall risk within 24 hours of admission, with ongoing monitoring as needed, and per CMS guidelines. Residents who sustain a fall will be evaluated at time of event and the following 72 hours. Procedure: A. All residents will be evaluated for fall risk upon admission. B. Care plan to be developed with appropriate approach and interventions for all admits. C. A fall evaluation will be completed quarterly by the MDS coordinator/Nurse, with resident falls and as needed. D. Care plans are reviewed to assure appropriate interventions are in place quarterly, with every fall, and as needed. a. In the event of a resident fall: 5. Update RN/DON or designee to discuss and implement intervention. 6. Complete fall packet and update care plan. 8. Complete detailed progress note to include time of fall, location of fall, root cause of fall, residents range of motion, pain, injury, how you assisted off of floor, RN notification, MD notification, POA notification, and new intervention. 10. Open and complete fall evaluation and pain evaluation. 11. All falls will have an interdisciplinary team (IDT) root cause analysis to assure comprehensive care plan is appropriate and is up-to-date. Example 1 R29 was admitted to the facility on [DATE] with pertinent diagnoses of dementia, polyosteoarthritis, and macular degeneration. R29's most recent Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment, is usually understood by others, and usually understands others. R29 was noted to have lower range of motion impairment on one side, used assistive devices of a walker and wheelchair, and was a dependent assist with walking 10 feet. R29 had 2 or more falls since admission with no injury and no falls with minor or major injury. R29 had a recent surgery repair of fractures of the hip. R29's care plan dated 11/10/24 included the following: PROBLEM: Activity of daily living (ADL) self-care performance deficit related to dementia. GOAL: R29 will maintain current level of function in cares through review date (01/21/25). INTERVENTIONS: Assist of 1 and front wheel walker for stand pivot transfer and ambulation, use cues for each step of turning sequence, and check on resident frequently. PROBLEM: R29 has had an actual fall with minor injury due to unsteady gait. GOAL: R29 will resume usual activities without further incident through review date. INTERVENTIONS: - 02/12/24: Offer toileting approx. q2hr (every 2 hours). - 04/29/24: Keep bed at mid to low height as R29 likes to sit on the edge of it. - 05/11/24: Wear gripper socks to bed at night to prevent slipping when getting up. - 08/18/24: Educate resident to ensure that she can feel the bed on the back of her legs prior to sitting. - 08/29/24: PM (evening)- Non-skid strips added to floor by bed where R29 stands to get out of bed. - 08/29/24: AM (morning)- Signage hung on wall to remind staff to make sure R29 has gripper socks on, as R29 sometimes dresses herself and does not remember to put on gripper socks. - 09/4/24: Use NH (nursing home) gripper socks at all times when in bed as they have better grip than one resident had on. - 09/9/24: Discuss with family potential of moving resident's room closer to staff for more frequent visualization. (Family declines change of room as they feel it would increase confusion and it is further for her to walk to the dining room. - 10/1/24: Staff to ensure that R29's walker is next to her bed when resident is in bed. - 10/2/2024: Hourly Checks initiated. - Fall on 10/13/24: Sleep study to start at midnight tonight (10/14) so staff can schedule NOC (night) toileting. - 10/24/24: Re-educate staff on new toileting schedule. - 12/28/24: Leave bathroom door cracked and light now at nighttime so resident can locate bathroom easily. - Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. - Sleep study initiated to establish toileting program. - Staff to check on R29 hourly and document. Surveyor reviewed R29's falls documentation and noted the following: The facility utilized a falls documentation system that included incident location, incident description, immediate action taken, injuries, pain, level of consciousness, predisposing environmental factors, physiological factors, situation factors, witness statements, and notifications. R29's falls are documented as follows in part . 09/19/24 at 11:12 PM; fall without injury. MD (Medical Doctor)/POA (Power of Attorney) notified. Investigation determined poor lighting as possible cause. Of note: No intervention was put into place and care plan was not updated. 10/02/24 at 7:01 AM; fall with swelling noted on back of head; MD/POA notified and declined evaluation at hospital. No other injuries noted. Care plan updated to include hourly checks. Of note: No investigation completed to determine root cause. Surveyor was unable to verify hourly checks were completed as noted being initiated on care plan on 10/02/24 or thereafter. 10/13/24 at 5:50 AM; fall with complaint of bilateral leg pain. MD/POA notified. No other injuries noted. Sleep study ordered with plan to implement overnight toileting schedule. Of note: No investigation completed to determine root cause of fall. Care plan not updated. No documentation provided of results of sleep study. 10/24/24 at 2:00 AM; fall without injury. MD/POA notified. Care plan stated to educate staff on new toileting schedule, but no schedule noted. Of note: No investigation completed to determine root cause. No new/revised intervention implemented to prevent further falls. Care plan not updated. 10/30/24 at 2:45 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised intervention implemented to prevent further falls. Care plan was not updated. 11/24/24 at 9:49 PM; fall without injury. MD/POA notified. Determined walker and wheelchair were not in reach. Implemented every 2 hour toileting schedule. Of note: Toileting schedule was already in place on 02/12/24. No new/revised interventions implemented to prevent further falls. Care plan was not updated. 12/05/24 at 1:41 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised interventions implemented to prevent further falls. 12/10/24 at 8:31 AM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised interventions implemented to prevent further falls. 12/19/24 at 10:54 PM; fall with major injury. R29 was found on floor in dining room. Sent to ER for evaluation and found left femur fracture. admitted to hospital for surgical repair. MD/POA notified. R29's hospital record for emergency room visit, states in part . On 12/20/24 at 6:04 a.m. History of present illness: Her workup in the emergency room .remarkable for findings of left femoral neck base fracture on one view x-ray . Surgical report dated 12/21/24 states in part . Open Reduction Internal Fixation (ORIF) left hip Of note: R29 had 8 falls prior to the fall on 12/19/24 with no investigation of root cause and/or new/revised interventions to prevent falls. This resulted in R29's fall on 12/19/24 causing a femoral neck fracture. R29 returned to the facility on [DATE]. 12/27/24 at 9:47 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. Care plan updated to leave bathroom door cracked and light now at nighttime so resident can locate bathroom easily. 01/02/25 at 2:00 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised interventions implemented to prevent further falls. 01/15/25 at 5:00 PM; fall without injury. MD/POA notified. Of note: No investigation completed to determine root cause of fall. No new/revised interventions implemented to prevent further falls. On 02/06/25 at 2:21 PM, Surveyor interviewed Director of Nursing (DON) B regarding falls documentation. DON B stated that prior to the start of survey on 02/04/25, the facility did not have a procedure in place for investigating resident falls to determine root cause and implement appropriate interventions. DON B stated she recognized that not having a fall investigation process in place likely contributed to R29's repeated falls. DON B stated that a new plan of correction was being worked on and would be discussed with Quality Assurance Performance Improvement (QAPI) team to ensure falls are investigated to include root cause analysis, interventions, and follow-up for efficacy. 31086 Example 2 R4 was admitted on [DATE] and current diagnoses included, in part, type 2 diabetes mellitus with diabetic nephropathy, epilepsy, age-related osteoporosis, peripheral vascular disease, congestive heart failure, malignant neuroendocrine tumors, malignant neoplasm of liver, chronic kidney disease stage 3b and depression. Review of MDS dated [DATE] an annual assessment documented Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R4 is cognitively intact. R4 has no impairments to upper or lower extremities, R4 requires staff to setup assistance for upper and lower dressing, and personal hygiene. R4 requires maximum staff assistance to apply footwear. The MDS documented R4 having 1 fall with no injury, 1 fall with injury not major and 2 or more with major injury. Review of R4's care plan documented in part: R4 is High, risk for falls r/t Confusion , Gait/balance problems, Incontinence, Vision/hearing problems R4 does not always recall to lock her brakes which has resulted in falls. R4 requires re-educated for using call light for staff assist during transfers. 1/30/25 Lost balance while getting into lounge chair. Date Initiated: 04/08/2024 Revision on: 01/30/2025 Approaches in part: -12/20/23 Educate R4 on locking brakes before transfers. Date Initiated: 07/15/2024 Revision on: 07/16/2024 -12/20/23 Educate R4 on locking w/c brakes prior to transferring to the toilet. Date Initiated: 04/08/2024 Revision on: 07/16/2024 -1/26/24 Staff to check w/c brakes are on when R4 is sitting in recliner Date Initiated: 07/15/2024 Revision on: 07/15/2024 -1/27/24 Gripper socks on resident feet to help prevent her from slipping Date Initiated: 07/15/2024 Revision on: 01/31/2025 -1/30/25 Reeducated on necessity of wearing gripper socks. Date Initiated: 01/31/2025 -1/31/24 Educated on safe transfers, R4 was able to teach back safe transfers Date Initiated: 07/15/2024 Revision on: 07/16/2024 -1/31/24 OT reeducated R4 that her wheelchair brakes are working, R4 provided teach back. Date Initiated: 07/15/2024 Revision on: 07/16/2024 -2/5/24 Offer R4 to rest in recliner at approx. 2100 to prevent her from falling asleep in wheelchair causing her to fall to floor Date Initiated: 07/15/2024 Revision on: 07/15/2024 -3/22/24 PT to eval and treat due to recent falling. Date Initiated: 07/15/2024 Revision on: 07/16/2024 -4/18/24 Staff to check on R4 at start of NOC shift to assist with getting R4 into recliner safely. Date Initiated: 07/15/2024 Revision on: 07/15/2024 -4/6/24 Check brakes for proper functioning when locking. Date Initiated: 07/15/2024 -4/7/24 Brake extensions added to wheelchair brakes. Date Initiated: 07/15/2024 Revision on: 07/16/2024 -6/30/24 Dycem in recliner and wheelchair. Date Initiated: 07/15/2024 -6/4/24 Staff to check on R4 hourly when in recliner to assure w/c is locked and in proper placement next to recliner Date Initiated: 07/15/2024 Revision on: 07/15/2024 -9/10/24 Encourage R4 to leave door open for better visualization when not on isolation precautions. Date Initiated: 02/05/2025 -Be sure R4's call light is within reach and encourage her to use it for assistance as needed. R4 needs prompt response to all requests for assistance. 1/30/25 Call light placed closer to resident for calling for staff assistance. Date Initiated: 07/16/2024 Revision on: 01/30/2025 -Make sure R4 has both socks on prior to transfers and to call for assistance if she notices that she is missing her sock. Date Initiated: 09/25/2024 -Non-Skid strips applied to floor in front of recliner to aid in prevention of fall. Date Initiated: 07/16/2024 Revision on: 07/16/2024 On 01/30/25, a post fall investigation fall risk assessment score of 75 meaning at high risk for falls. Review of R4's fall investigations: On 01/26/24 at 1:15 a.m., R4 fell in room was found sitting on the floor with no injuries. R4 stated transferring from recliner to wheelchair and missed the wheelchair and sat on the floor. R4 was barefoot and her wheelchair brakes were not locked. Care plan was updated for staff to ensure wheelchair brakes are on when resident is sitting in recliner. On 01/27/24 at 10:36 p.m., R4 fell in room from wheelchair with no injuries. R4 took socks off and wheelchair was not locked. The care plan intervention from 1/26/24 was not followed. On 01/31/24 at 12:05 a.m., R4 fell in room and found sitting on the floor in front of her recliner with no injuries. Wheelchair in front of resident and brakes were on. R4 stated she was just trying to transfer from recliner to wheelchair but she stood up and slid out and she sat on the floor. R4 was wearing grippy socks at the time. R4 then demonstrated how she transfers from recliner to wheelchair on her own and did correctly. Care plan was updated on 01/31/24 to include educated on safe transfers. The facility did not determine a root cause of the fall as to why R4 was self transferring. On 03/21/24 at 9:48 p.m., R4 fell in room sitting upright on the floor next to her recliner with no injuries. On 03/22/24, physical therapy to evaluate and treat due to recent falling. The facility did not determine a root cause of the fall, no new interventions were initiated and no documented therapy recommendations. On 04/6/24 at 9:40 p.m., R4 fell in room found between her recliner and her wheelchair with no injuries. Wheelchair right brake was locked and left brake partially locked. Facility determined wheelchair brakes were not fully engaged. Interventions to check brakes for proper functioning when locking. On 04/7/24 at 10:25 p.m., R4 fell in room while transferring from recliner to bathroom. R4 hit the back of her head. R4 had one sock on right foot and no sock on the left and wheelchair was not locked and brakes were not tight enough. Brake extensions added to wheelchair brakes. This fall has the same issue with functioning of wheelchair brakes. On 04/18/24 at 11:05 p.m., R4 fell in room while transferring from recliner to wheelchair with no injuries R4 was wearing gripper socks and wheelchair brakes were locked. Care plan update Staff to check on resident at start of NOC shift to assist with getting resident into recliner safely. The facility did not determine the root cause of the fall. On 06/4/24 at 12:10 a.m., R4 fell in room out of recliner and wheelchair was not locked. R4 had no injuries. Care plan was updated with Staff to check on R4 hourly when in recliner to assure wheelchair is locked and in proper placement next to recliner. Care plan intervention of locking w/c brakes was not followed. On 06/30/24 at 11:25 p.m., R4 fell in room in front of her recliner with no injuries. R4 was not wearing nonslip footwear. R4 was wearing one regular sock on right foot and left foot bare as resident had removed her leg wrap and socks prior to self-transfer. R4 did not use walker for transfer. R4 stated that she did try to grab onto her wheelchair, but the brakes were not on the wheelchair and it moved with her as she slid to the floor. Care plan updated to have dycem non-slip into seat of resident recliner chair and wheelchair to help prevent resident from slipping off of surfaces. The facility did not investigate to determine if staff followed the care plan of hourly checks of wheelchair placement and locked, and proper footwear. On 09/10/24 at 9:15 p.m., R4 fell in room was found lying next to recliner with no injuries. A small bump to the top of R4's head. Intervention was to keep track of hours of sleep. The facility did not identify a root cause of the fall and did not evaluate hours of sleep to determine further interventions. On 09/23/24 at 8:45 p.m., R4 fell in room and was found lying in front of recliner with no injuries. The root cause was R4 not wearing shoes or socks at the time of fall, wheelchair brakes were locked and R4 uses many blankets when sitting in her recliner. Therapy assessed and R4 is independent to transfer. Resident education on importance of making sure that she had both socks on prior to transfers and to call for assistance. On 01/30/25 at 10:00 p.m., R4 fell in room was found sitting in front of recliner with no injuries. Facility's intervention was to re-educate R4 on the importance of wearing her gripper socks for safety when transferring. The facility did not identify a root cause of the fall and did not assess the repeated intervention of wearing socks to be appropriate. Surveyor's review of R4's falls identified the facility did not complete a full investigation of when staff last observed the resident, determine if staff followed plan of care, determine root cause of the fall, review for patterns/trends, and re-assess the plan of care. On 02/05/25 at 2:15 PM, Surveyor interviewed Director of Nursing (DON) B about the fall root cause. The consulting company came in to assist in September and found where to document in risk management. The root cause is noted at the bottom of the incident report. Surveyor reviewed with DON B, R4's incident reports from 09/10/24 documented on 09/16/24 Nursing to follow up on the bump on top of her head. Resident denied pain over the weekend. Nursing is also keeping track of the hours of sleep that she is getting on every shift since resident has been known to fall asleep frequently while in wheelchair. Resident has previously refused sleep studies. Surveyor asked when you collected the data of hours of sleep did you assess the data and what was the response and any changes. DON B said she will get that information. On 02/06/25 at 8:50 AM, Surveyor interviewed Assistant Director of Nursing (ADON) D about fall investigations with root cause and interventions. ADON D indicated the root cause is talked about in morning meetings on every fall and they go over the interventions and will update the care plan. The care plan should be updated when staff put interventions in place and this has been missed. The consulting company is in the facility reviewing and putting things in place and showing where to document in risk management. When a fall occurs, the nurse will put the note into risk management with the intervention. The nurse will call the manager on call or DON B and will discuss what intervention to put into place and then the team will review the fall in the morning. On 02/06/25 at 12: 25 p.m., Surveyor interviewed DON B about the fall investigation, root cause, and intervention of R4. Surveyor reviewed with DON B the fall investigations are not complete and did not determine if staff are following care plan, root cause of falls, assessing interventions. DON B indicated the facility does have a plan going forward for documenting and assessing the falls.

Based on observations and interviews, the facility failed to ensure the facility's garbage was properly stored in the dumpster. The failure had the potential to promote a breeding ground for pests and rodents affecting all 39 residents within the facility. Findings: On 02/04/25 at 8:15 AM, during initial tour of the kitchen, Surveyor asked [NAME] (I) to show surveyor where the dumpsters were located. [NAME] I led Surveyor out the back of the facility where the dumpster was. The dumpster was overflowing with black garbage bags, and black garbage bags were piled against the dumpster all over the ground in front of and around the dumpster. Surveyor asked [NAME] I about this, and [NAME] I indicated the facility is in outbreak. The facility has always used Styrofoam containers during an outbreak. On 02/04/25 at 11:45 AM, Surveyor asked Dietary Director (DD) H about the dumpsters overflowing and garbage on the ground. DD H indicated the garbage gets picked up twice a week on Tuesday and Thursday. The facility is in outbreak right now and we are using Styrofoam containers instead of plates. Surveyor asked, If there was an outbreak that occurred on Friday and the dumpster filled up over the weekend and you noticed this when you came in Monday morning, could you call and have the dumpster emptied right away Monday? DD H replied, I don't know about that I will have to talk to our Nursing Home Administrator (NHA) and get back to you. On 02/04/25 at 11:50 AM, Surveyor asked Director of Nursing (DON) B about the dumpsters being full of garbage on the ground. DON B indicated the garbage gets picked up once a week on either Tuesday or Wednesday. Surveyor asked, If there was an outbreak that occurred on Friday and the dumpster filled up over the weekend and you noticed this when you came in Monday morning, could you call and have the dumpster emptied right away Monday? DON B replied, I don't know about that I will have to talk to our Nursing Home Administrator (NHA) A and get back to you. On 02/04/25 at 3:18 PM, Surveyor went to ask NHA A about the dumpsters and found DD H was also in NHA A's office. NHA A replied, Look, I can get another dumpster. It will cost us an extra $700 to do it. But, look, we are trying to keep our residents safe and so we give them their meals in the Styrofoam to keep them safe. Surveyor informed NHA A that as we review the kitchen we also look for pest control practices and we make sure that the dumpster area is clean. The facility cannot have garbage lying outside of the dumpster and the dumpster so full that you cannot close the lid.

Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter. For 1 of 1 resident (R32) reviewed with a Foley catheter. R32's Foley catheter was changed on a routine monthly basis without clinical indications and not following professional standards of practice. This is evidenced by: The Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for prevention of catheter-associated urinary tract infections 2009, read in part, E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Facility's policy titled, Catheter Care, Urinary with the revised date of 09/24, documented in part, Changing Catheters, 1. Changing indwelling catheter every 30 days, PRN, or as ordered by physician. It is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Noted references of HICPAC, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. R32 was admitted to the facility on [DATE] and current diagnoses included, in part, malignant neoplasm of bladder, atherosclerotic heart disease of coronary artery, anxiety disorder, chronic obstructive pulmonary disease, and restlessness and agitation. 02/04/25 12:05 PM has a catheter with no concerns or infections, has a leg bag. Physician orders documented on 10/22/24: Change 22 french 30 cc balloon catheter per N home protocol every 30-90 days our protocol is (30 days) and prn if becomes occluded one time a day starting on the 22nd and ending on the 22nd every month for permanent Foley placement for bladder cancer change monthly and prn if becomes occluded hospice provide supplies. Original order from hospice dated 03/13/24 documented, Change Foley catheter 22 French with 30 ml balloon change as needed. Record review did not identify physician rationale or clinical indications for the need to change the Foley catheter every 30 days. On 02/06/25 at 11:13 AM, Surveyor interviewed Director of Nursing (DON) B about the rationale or clinical indication for the change of R32's Foley catheter on a monthly basis. DON B indicated the only note to change the catheter was from hospice order to follow facility protocol. DON B understands a needed medical rationale or clinical indications to change the catheter every 30 days and there was not a medical rationale found to change R32's Foley catheter monthly. DON B indicated the Medical Director will be doing her own research before the policy would be changed.

Based on record review and interviews, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by recognizing or assessing a significant weight loss for 1 of 1 resident (R14) reviewed. This is evidenced by: The facility policy titled: Notification of Changes Policy, last updated on 01/10/25, states in part, Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and their resident's physician, to ensure best outcomes of care for the resident. R14 was admitted to facility on 12/03/24 and has a Brief Interview for Mental Status (BIMS) of 11 out of 15, indicating mildly impaired cognitive level. R14's admission assessment Minimum Data Set (MDS) with target date of 12/09/24, Section K: weight 149# (note: this was an incorrect entry into MDS). R14's care plan, dated 12/12/14, stated R14 is at nutritional risk due to diagnoses of hypertensive heart disease chronic kidney disease, congested heart failure, obesity, and chronic obstructive pulmonary disease. With a goal of not have significant weight gain or weight loss through the next review period of 03/10/25 On 02/04/24 at 10:11 AM, Surveyor reviewed R14's weight record which showed on 12/05/24 R14 weighed 250.2# and on 02/04/24 R14 weighed 227.8#, giving a total weight loss of 22.4# in 2 months. On 02/05/25 at 2:47 PM, Surveyor interviewed R14 regarding weight loss. R14 stated being happy about the weight loss and stated appetite is good and is not concerned with weight loss. On 02/06/25 at 10:25 AM, Surveyor interviewed Director of Nursing (DON) B regarding concerns of weight loss of R14 without documentation, assessments or notification to identify the significant weight loss. DON B stated there is no documentation related to identifying weight loss and there has not been any notification to physician or dietician. DON B confirmed the physician or dietician was not notified of weight change.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 care observations for residents (R) (R13, R192, R6). Staff did not complete appropriate hand hygiene while providing care for R13's personal cares. Staff did not complete appropriate hand hygiene while providing care for R192. Staff used a contaminated scissors and used dirty gauze to complete wound care for R6. This is evidenced by: Facility policy titled, Handwashing/Hand Hygiene, with a revised date of 10/23 stated in part: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene 1. Hand hygiene is indicated: f. before moving from work on a soiled body site to a clean body site on the same resident; Example 1 R13 was admitted to the facility on [DATE] with pertinent diagnoses of cerebral vascular accident (stroke), hemiplegia and hemiparesis (impaired movement) affecting left non-dominant side, obesity, and dementia. R13's most recent Minimum Data Set (MDS) annual assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating cognition intact, is dependent assist with toileting hygiene and personal cares, and always incontinent of bowel and bladder. R13's care plan dated 06/27/24 included: ADL self-care performance deficit with interventions of providing incontinence cares in bed with assist of 1-2. On 02/05/25 at 8:24 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide R13 with incontinence care. CNA C gathered supplies at bedside, completed hand hygiene, and donned gloves. CNA C positioned R13 on left side and cleaned peri-area after bowel movement. CNA C then completed the remainder of R13's personal cares, transferred R13 with hoyer lift to recliner, placed blanket and personal items in reach of R13 without removing gloves and completing hand hygiene. On 02/05/25 at 10:30 AM, Surveyor interviewed CNA C regarding observation during cares. Surveyor asked CNA C why she didn't change her gloves after completing peri-cares after a bowel movement. CNA C shrugged and stated she didn't know. Surveyor asked if she should have changed her gloves before moving on to other cares for the resident. CNA C stated yes, she should have. On 02/06/25 at 2:21 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation of cares. Surveyor asked DON B what the expectation would be for hand hygiene during personal cares. DON B stated that staff are expected to remove gloves, wash or disinfect hands, and don new gloves after completing peri-cares before moving on to the next body part. Surveyor informed DON B of observation of CNA C not completing hand hygiene during cares. DON B stated disappointment as staff are frequently educated on infection control. DON B stated recognition of the risk of infection by not completing appropriate hand hygiene and stated re-education with staff would be completed. 47657 Example 2 On 02/06/25 at 8:09 AM, Surveyor observed CNA C conduct morning cares on R192. CNA C placed wash basin in sink, turned on hot water to run, put on a pair of clean gloves (no hand hygiene conducted prior) and assisted R192 to sit on edge of bed. CNA C applied a gait belt around R192's waist, picked up walker, placed in front of R192 and assisted R192 to stand and pivot to wheelchair. CNA C wheeled R192 to bathroom and assisted using gait belt with transfer from wheelchair to toilet. On 02/06/25 at 8:15 AM, Surveyor observed CNA C remove contaminated gloves, and without hand hygiene, put on clean gloves and removed gait belt from around R192's waist, removed pajamas and urine-soaked incontinent products CNA C removed the gait belt from around R192's waist, removed pajama top and urine-soaked incontinent product. CNA C removed gloves and changed to clean gloves. No hand hygiene was completed in between glove change. On 02/06/25 at 8:17 AM, Surveyor observed CNA C add water and clean washcloths to wash basin and handed washcloth to resident to wash own. On 02/06/25 at 8:19 AM, Surveyor observed CNA C continue cares without conducting hand hygiene or changing gloves. CNA C washed R192's back and upper torso, washing under breasts, rinsed and dried with towel, grabbed a bottle of powder, placed on gloves, applied powder under R192's breast, applied deodorant and applied shirt. On 02/06/25 at 8:22 AM, Surveyor observed CNA C continue cares, remove contaminated gloves, and without conducting hand hygiene, place on a clean pair of gloves and wash and dry R192's legs. CNA C applied lotion to R192's legs, removed contaminated gloves, placed on a clean pair without conducting hand hygiene and applied clean incontinent product, socks, shoes and pulled clean pair of pants to R192's knees. On 02/06/25 at 8:26 AM, Surveyor observed CNA C, without removing gloves or conducting hand hygiene, apply gait belt around R192's waist, move wheelchair close to R192, and assist R192 to stand while CNA C held onto gait belt and conducted peri care on R192. On 02/06/25 at 8:28 AM, CNA C stated to Surveyor, R192 is prone to urinary tract infections, while pulling up clean incontinent product and pants. CNA C assisted R192 to turn and sit in wheelchair, removed gait belt, removed contaminated gloves, and used hand sanitizer to assist with grooming R192 for the day. On 02/06/25 at 8:35 AM, Surveyor interviewed CNA C regarding expectation of facility of when to conduct hand hygiene during cares. CNA C stated after removing gloves. Surveyor shared observation of no hand hygiene conducted after glove changes during cares. CNA C confirmed she had not conducted hand washing or used sanitizer. 46694 Example 3 On 02/05/25 at 6:35 AM, Surveyor observed wound care on R6's left lower leg by Licensed Practical Nurse (LPN) F. LPN F performed proper hand hygiene and put on a gown and single use gloves for this procedure. LPN F then removed a pair of bandage scissors from a box of dressings. LPN F then used that scissors to cut and remove the bandage from R6's left lower leg. LPN F then removed the dirty gloves, performed hand hygiene then put on a clean pair of gloves. LPN F took a stack of sterile 4x4 dressings and soaked them with normal saline and wiped R6's posterior left leg. LPN F used the same dirty 4x4's and cleaned the open and draining wound on the back of R6's left lower leg. LPN F then took the dirty bandage scissors used to cut off the dressing and cut the zeroform gauze and aquacel dressing that LPN F placed onto the open wound. LPN F secured the dressing with an abdominal dressing and covered with 4-inch kling wrap and secured this with tape. On 02/05/25 at 6:59 AM, Surveyor informed LPN F that the bandage scissors were not sanitized before or after procedure. LPN F replied, I should have sanitized after I cut off the bandage and before I cut the sterile dressings. Surveyor then replied, Also, I noticed that you wiped the front of the left leg where there was no open area and wiped with the same saline soaked gauze the open area on the back or side of the left calf. LPN F replied, I should have used a clean gauze for the open area.

Based on interview and record review, the facility did not ensure residents received routine dental services for 1 of 1 resident (R25) reviewed. This is evidenced by: State Operations Manual Appendix PP states in part: The facility must assist residents in obtaining routine and 24-hour emergency dental care. The facility must provide or obtain from an outside resource, in accordance with S483.70(f) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan. R25 was admitted to the facility 04/07/23 with pertinent diagnoses of hemiplegia and hemiparesis (immobility/weakness) following cerebral vascular accident (stroke), malignant neoplasm of brain (tumor), dementia, dysphagia, and depression. R25's most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment, is sometimes understood, and sometimes understands. R25 has impaired range of motion on both side of upper and lower extremities and is dependent assist for oral hygiene. Surveyor reviewed R25's medical record and did not locate any dental service notes. On 02/04/25 at 12:46 PM, Surveyor interviewed R25's Activated Power of Attorney (APOA) regarding dental care and services. APOA stated that facility staff have not provided dental care since R25 was admitted . On 02/06/25 at 2:43 PM, Surveyor interviewed Medical Records (MR) E regarding dental services. Surveyor asked if R25 had received any dental services since admission. MR E stated no. Surveyor asked MR E why these services had not been provided. MR E stated she had asked R25's APOA if he would like R25 to see a dentist and R25's APOA declined. Surveyor asked if MR E had documentation of this declination of dental services. MR E stated no.

Based on observation and interview, the facility did not ensure controlled drugs were stored in separately locked, permanently affixed compartments for 1 of 2 med storage units. Observation of a controlled medication stored in the unlocked refrigerator located in the medication room. Findings include: The facility policy, titled Controlled Substances, dated 04/24, states: .3. Controlled substances are stored in the medication room in a locked container, separate from containers for any con-controlled medications. On 02/05/25 at 9:01 AM, Surveyor observed medication storage area near E dining room with Licensed Practical Nurse (LPN) F. Surveyor observed the medication room door was locked; however, the refrigerator was unlocked with an open 30ml bottle of Lorazepam for R11. LPN F stated the refrigerator should have a lock, but not that long ago we got a new refrigerator, and they never replaced the lock. On 02/05/25 at 12:00 PM, Surveyor interviewed Doirector of Nursing (DON) B regarding finding of a bottle of opened Lorazepam in refrigerator which was not locked in med room. DON B stated she was made aware of the findings, and stated they recently got a new refrigerator and had ordered a lock, but it hadn't been installed, and maintenance is working on that at this moment.

Based on observation and interview, the facility did not ensure staff followed procedures for the accurate administration of medication for 1 of 1 resident (R25). Staff administered multiple medications at once via gastrostomy tube. This is evidenced by: Facility policy titled, Gastrostomy Intermittent Tube Feeding/Medication, with no date states in part: Policy: Licensed nursing staff will feed/provide medication through a resident's gastrostomy tube following orders of the physician. Procedure: 12. Pour 1 ounce (30 cc) of room temperature water into the syringe barrel to check for patency. If water flows freely, the gastrostomy tube is patent. 13. Administer medications at this time, as ordered by the physician. - Administer one medication at a time. - After each medication, flush the gastrostomy tube with a small amount of water. On 02/05/25 at 7:14 AM, Surveyor observed Licensed Practical Nurse (LPN) F training LPN G on medication administration. Surveyor observed LPN F instruct LPN G to remove R25's 6 ordered medications from the blister packs, crush them per order, and place all 6 medications into cup together. LPN F told LPN G to add approximately 50 ml of water to the cup with the crushed medications. LPN F then connected the syringe to R25's gastrostomy tube, checked for residual, and flushed the tube with 200 ml of water. LPN F then administered the 6 crushed medications through the gastrostomy tube, followed with an additional 50 ml of water. On 02/05/25 at 7:32 AM, Surveyor interviewed LPN F regarding medication administration. Surveyor asked LPN F if it was standard practice to administer all medications at once through the gastrostomy tube. LPN F stated yes, because it gets flushed with the 200 ml of water it is ok. On 02/06/25 at 2:25 PM, Surveyor interviewed Director of Nursing (DON) B regarding medication administration observation. Surveyor asked DON B what the expectation is for administering medications via gastrostomy tube. DON B stated that each medication should be administered one at a time and the tube flushed between each medication. Surveyor informed DON B of observation of all medications being administered at one time. DON B stated this was not the expected practice as it could potentially cause harm to the resident. DON B stated that follow-up education would be completed with staff on the safe administration of medications via gastrostomy tube.

Based on interviews and record reviews, the facility did not consult with a physician as indicated by ordered parameters with a significant weight change for 2 of 2 residents (R) R4 and R14. This is evidenced by: The facility policy titled, Notification of Changes Policy, last updated on 01/10/25, states: It is the policy of this facility that changes in a resident's condition or treatment, are immediately shared with the resident and or the resident representative, according to their authority, and reported to the attending or delegate. Example 1 R4 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic kidney disease and diabetes mellitus type 2. R4's annual Minimum Data Set (MDS), dated [DATE], Section K, indicated R4's weight of 193# and no indication of a physician-prescribed weight loss or weight gain regimen. R4's orders, dated 12/14/2023, state to obtain weight daily and notify physician if more than 3 lbs in 1 day or 5 lbs in 1 week. R4 has an order dated 12/12/23 for Spironolactone 25mg every morning for edema. On 02/05/25 at 11:58 AM, Surveyor reviewed R4's weight record and noted the following: 01/28/25 = 205.8 pounds 01/29/25= 213.4 pounds (a gain of over 7 pounds) 01/30/25 = 217.4 pounds (a gain of 4 pounds) On 02/05/25 at 12:21 PM, Surveyor interviewed Certified Nursing Assistant (CNA) L regarding expectation of when to obtain R4's weights. CNA L stated R4 is a daily weight. On 02/05/25 at 12:31 PM, Surveyor interviewed Registered Nurse (RN) M regarding process of obtaining weights, following physician orders of notifying weight outside of parameters. RN M stated that a CNA obtains the weights and places in a notebook. The nurse will then transfer the information into the resident record. When this is done, the system shows the last weight recorded for comparison. If a resident has an order for notifying the MD for specific parameters, then a fax will be sent to the MD for further instructions. RN M was not aware of MD notified of weight gain of R4 outside the parameters or any new orders. On 02/05/25 at 3:33 PM, Director of Nursing (DON) B provided Surveyor with 2 fax documents dated 01/12/25 and 02/5/25 to R4's MD with a report of past month weights. The fax face sheet or weight report identified the significant weight loss above parameters as ordered but the facility did not provide any information pointing out the weight gain per MD order. Surveyor interviewed DON B regarding expectation of following MD orders of notifying the MD if more than 3lbs in 1 day or 5 lbs in 1 week. DON B stated the expectation would be to follow the orders and contact the MD. Example 2 R14 was admitted to facility on 12/03/24 and has a Brief Interview for Mental Status (BIMS) of 11 out of 15, indicating mildly impaired cognitive level. R14's admission MDS with target date of 12/09/24, Section K: weight 149# (note: this was an incorrect entry into MDS). R14's care plan, dated 12/12/14, stated R14 is at nutritional risk due to diagnosis of hypertensive heart disease chronic kidney disease, congested heart failure, obesity, and chronic obstructive pulmonary disease. With a goal of not have significant weight gain or weight loss through the next review period of 03/10/25. On 02/04/25 at 10:11 AM, Surveyor reviewed R14's weight record which showed on 12/05/24 R14 weighed 250.2# and on 02/04/24 R14 weighed 227.8#, giving a total weight loss of 22.4# in 2 months. On 02/06/25 at 10:25 AM, Surveyor interviewed DON B regarding concerns of weight loss of R14 without documentation, assessments or notification to identify the significant weight loss. DON B stated there is no documentation related to identifying weight loss and there has not been any notification to physician or dietician. DON B confirmed the physician or dietician was not notified of weight change.

Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessments for 3 of 12 residents (R) reviewed. (R4, R29 and R32). The facility did not accurately code R4, R29 and R32's MDS assessment with correct number of falls that occurred during the referenced time frame. This is evidenced by: Example 1 R4 was admitted on [DATE] and current diagnoses included, in part, type 2 diabetes mellitus with diabetic nephropathy, epilepsy, age-related osteoporosis, peripheral vascular disease, congestive heart failure, malignant neuroendocrine tumors, malignant neoplasm of liver, chronic kidney disease stage 3b and depression. Review of MDS dated [DATE] an annual assessment documented Brief Interview of Mental Status (BIMS) score of 15, indicating R4 is cognitively intact. Section J documented R4 having 1 fall with no injury, 1 fall with injury not major and 2 or more with major injury. The previous MDS was completed on 08/31/24. Review of fall history during the period between 08/31/24 the previous MDS to 11/27/24 MDS. On 09/23/24, R4 had a fall with no injury. On 09/10/24, R4 had a fall with a small bump to the top of head. No further falls were documented during this time frame. MDS Section J1900 requires documentation of the number of falls since admission or prior assessment, whichever is more recent. Between prior MDS on 08/31/24 and 11/27/24 R4 only had 1 fall with no injury and 1 fall with injury not major. The MDS dated [DATE] was incorrectly coded of R4 having 2 or more falls with major injury. Example 2 R32 was admitted to the facility on [DATE] and current diagnoses included, in part, malignant neoplasm of bladder, atherosclerotic heart disease of coronary artery, anxiety disorder, chronic obstructive pulmonary disease, and restlessness and agitation. Review of MDS dated [DATE] a quarterly assessment documented a BIMS of 15 and 1 fall with no injury. The previous MDS was completed on 08/24/24. Review of fall history documented R32 having no falls during the period between 08/24/24 the previous MDS to 11/20/24 MDS. On 02/05/25 at 1:25 PM, Surveyor interviewed Director of Nursing (DON) B about R32's falls between 08/24/24 and 11/20/24. DON B indicated R32 did not have any falls between those dates. On 02/05/25 at 3:40 PM, Surveyor interviewed DON B about R4 and R32's MDS being coded incorrectly. DON B indicated the MDS was coded incorrectly and starting the month of October the facility had a consulting company in the facility to assist with MDS coding and training the new MDS staff. 49353 Example 3 R29 was admitted to the facility on [DATE] with pertinent diagnoses of dementia, polyosteoarthritis, and macular degeneration. R29's most recent Minimum Data Set (MDS) significant change assessment dated [DATE] noted R29 had 2 or more falls since admission with no injury and no falls with minor or major injury. R29 had a recent surgery repair of fractures of the pelvis, hip, leg, knee, or ankle. Surveyor reviewed R29's electronic medical record and noted the following: On 12/19/24, R29 had a fall in the facility resulting in a left femur fracture and sent to the hospital for surgical repair of fracture. R29 readmitted to the facility on [DATE]. On 02/06/25 at 2:12 PM, Surveyor interviewed Director of Nursing (DON) B regarding MDS assessment. Surveyor asked DON B if R29 had a fall in the facility on 12/19/24 that resulted in a left femur fracture and surgical repair. DON B stated yes. Surveyor asked DON B why the MDS did not reflect this fall with major injury. DON B stated she was unable to state reason why MDS was coded incorrectly as the MDS Coordinator is currently on vacation. DON B had no explanation for why R29 was not coded correctly for having a fall with a major injury on the most recent MDS.

Based on observation, staff interview and record review, the facility did not ensure the comprehensive plan of care was implemented by staff for 2 of the 5 residents (R5 and R4) reviewed. R5's care plan was not followed to receive ambulation assistance to meals. R4's care plan was not followed to lie down for 1-2 hours between meals. This is evidenced by: Example 1: R5 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of bladder, hypertension, anemia, and anxiety disorder. R5's minimum data set (MDS) assessment, completed on 06/01/24, confirmed R5 scored 15 during a brief interview for mental status (BIMS), indicating impaired cognition. R5 requires set-up assistance with eating and oral hygiene. R5 requires moderate assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R5's care plan was initiated on 03/13/24, and included the following interventions: AMBULATION care plan: -Three times daily to meals with stand by assist, gait belt, and wheelchair to follow. As he becomes stronger, he may walk back to room as needed. R5's physician orders indicate: -Per Hospice: Please ambulate R5 three times daily to meals with stand by assist, walker, gait belt and wheelchair behind R5 when needed. On 06/25/24 at 9:42 AM, Surveyor interviewed R5 and asked about cares and staff help. R5 indicated that no one provides him with ambulation assistance. R5 stated, I haven't walked in over 10 days, and it is ordered that staff ambulate me to meals. I feel staff are sitting around instead of helping me. R5 indicated that when he asks staff for assistance to walk, staff just disregard him, and he feels the staff wants him to stay stuck and not improve. On 06/25/24 at 11:55 AM, Surveyor observed R5 self-propel with wheelchair into dining room for lunch. On 06/25/24 at 12:39 PM, Surveyor observed R5 self-propel from dining room and wheel down the hall. On 06/25/24 at 12:43 PM, Surveyor observed R5 arrive in R5's room. On 06/25/24 at 12:59 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D and asked CNA D if R5 is supposed to be ambulated to meals to keep R5's strength intact. CNA D indicated that R5 is a standby assist, and CNA D believes that R5 does ambulate to meals. CNA D indicated CNA D would have to look at the CNA care plan located in the bathroom on the door to know what exact care plan states. Surveyor asked if R5 has ambulated to breakfast and lunch today on 06/25/24. CNA D indicated that R5 has not walked today at all. CNA D suggested to R5 that after CNA D was draining the catheter bag that CNA D could ambulate R5 to the front corridor. Surveyor observed R5 smile and state, Finally someone can ambulate me, I have not been ambulated in over 10 days. On 06/25/24 at 1:11 PM, Surveyor interviewed CNA D and asked when R5 is ambulated do the staff document this in the Electronic Health Record (EHR). CNA D indicated that it would be documented in the EHR if ambulation is completed. Surveyor asked CNA D to see the documentation in R5's EHR of ambulation before meals. CNA D indicated that it has not been completed today on 06/25/24 so there is no documentation to be found. On 06/25/24 at 2:24 PM, Surveyor interviewed CNA F and asked when R5 is ambulated do the staff document this in the EHR. CNA F indicated that it would be documented in the EHR if it is completed. Surveyor asked if CNA F could show Surveyor documentation in R5's EHR of ambulation before meals. CNA F indicated there is no documentation on R5's ambulation for the day. On 06/25/24 at 2:35 PM, Surveyor interviewed Director of Nursing (DON) B and asked if R5 is supposed to be ambulated to meals to keep R5's strength intact. DON B indicated that R5 is to be ambulated to meals and ambulate at least three times a day as care planned. DON B indicated that CNA D should have ambulated R5 to breakfast and lunch today on 06/25/24. Example 2: R4 was admitted to the facility on [DATE] with diagnoses of dementia, insomnia, and osteoarthritis of the hip. R4's Comprehensive Care Plan, states in part; .get [R4] up in the morning and in the bathroom to do Activities of Daily Living (ADLs), lie [R4] down between meals for 1-2 hours so [R4] is not sitting all day . On 06/25/24 at 9:32 AM, Surveyor observed R4 sitting in a wheelchair holding a stuffed animal in the commons room/TV room. On 06/25/24 at 10:45 AM, Surveyor observed R4 in a wheelchair in the hallway near room [ROOM NUMBER]. On 06/25/24 at 11:10 AM, Surveyor observed CNA C come up behind resident and talk to resident and then walked away. On 06/25/24 at 11:12 AM, Surveyor observed a staff nurse push resident slowly down the hallway to the TV room. On 06/25/24 at 11:49 AM, CNA C removed R4 from the TV room and pushed R4 back to room. Surveyor asked CNA C, Why is [R4] in the room? CNA C replied, [R4] likes to listen to old country music and cats. CNA C handed resident a stuffed cat. On 06/25/24 at 12:04 PM, CNA D and CNA C transferred R4 the bathroom. At 12:12 PM, CNA D and CNA C transferred R4 from the bathroom to the wheelchair and taken to the dining room On 06/25/24 at 1:18 PM, R4 was being assisted with lunch by CNA C. CNA C then took R4 back to R4's room and was toileted again. At 1:30 PM, R4 was transferred from bathroom to the TV room. On 06/25/24 at 1:40 PM, Surveyor observed R4 sleeping in R4's wheelchair in the TV room. On 06/25/24 at 2:20 PM, Surveyor interviewed CNA C and asked if R4 is to lie down after breakfast. CNA C replied, After breakfast if [R4] is humming and holding the pet cat we leave [R4] up. Surveyor asked, Has [R4] laid down? CNA C replied, [R4] has not laid down at all today. Surveyor asked CNA C, If the resident's care plan states resident is to lay down for 1-2 hours between meals then what should you do if this resident is humming and holding the cat? CNA C replied, Then I would go to my charge nurse and asked her what I should do. Surveyor asked CNA C if the charge nurse was asked. CNA C replied, Yes. Surveyor asked what the charge nurse stated. CNA C replied, Take the resident back to [R4's] room and turn on some music to see if [R4] will get tired enough to lay down or try toileting [R4]. Charge nurse was not available for Surveyor to interview. On 06/25/24 at 2:54 PM, Surveyor interviewed DON B and asked why R4 was not laid down for 1-2 hours in between meals as per the comprehensive care plan. DON B replied, I can't tell you off hand. I know that [R4] is not supposed to lay down before 8 PM. If the resident is not able to lie down in between meals, then the CNA should tell the nurse and the nurse should document the reason why the care plan was not followed for the resident. Surveyor informed DON B there was no documentation today for R4. DON B did not know the reason for not following the care plan.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program to prevent Legionella, or provide hand hygiene to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 38 of 38 residents (R) residing in the facility. Findings: Example 1 Water Management Plan The facility's policy titled, Legionella Surveillance, Detection and Management states, in part .The facility, has a water management program that is overseen by the Water Management Team. 1. The Water Management Team will consist of at least the following personnel: The Infection Preventionist, Facility Administrator, Medical Director, and Maintenance Director. 2. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 3. The water management program is based on the Centers for Disease Control and Prevention and American Society of Heating and Refrigerating and Air-Conditioning Engineers (ASHRAE) recommendations for developing a Legionella water management program. 4. The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur: a. The control limits are consistently not met; b. There is a major maintenance or water service change; c. There are any disease cases associated with the water system, or d. There are changes in laws, regulations, standards, or guidelines. The policy was signed by Nursing Home Administrator (NHA) A on 11/17/23, Maintenance Director on 11/17/23, and Infection Preventionist on 12/17/23. On 12/19/23 at 7:00 a.m., Surveyor reviewed the facility water management policy. The policy did not include descriptions of the building's water system using text and flow diagrams, identify where areas of Legionella could grow and spread, did not specify control measures or where they would be implemented, and did not indicate how to monitor control measures. On 12/19/23 at 7:34 AM, Surveyor interviewed Maintenance Director F. Maintenance Director F reported the facility does not have a water management program only a policy. Maintenance Director F reported weekly checks are performed on vacant rooms but could not provide supporting documentation. Surveyor requested Maintenance Director F provide additional information related to the facility's water management program; no additional information was provided. Hand Hygiene Example 2 On 12/18/23 at 12:23 PM, Surveyor observed staff serve lunch to R2, R4, R11, R14, R20, R24, R34, R35, R187, and R188. No hand hygiene was offered prior to meal being served. On 12/19/23 at 8:16 AM, Surveyor observed staff serve breakfast to R2, R4, R11, R14, R20, R23, R24, R35, R187, and R188. No hand hygiene was offered prior to meal being served. On 12/19/23 at 2:37 PM, Surveyor interviewed Director of Nursing (DON) B. DON B reported staff had been offering hand hygiene to residents prior to meals. DON B was unsure why staff were not offering hand hygiene to residents prior to meals. DON B reported hand hygiene audits were being completed on staff for the previous six weeks. 48793 Example 3 The facility policy titled, Policy and procedure for the prevention and treatment of skin breakdown, states in part, Dressing change: 7. Put on clean gloves. Loosen the tape and remove the soiled dressing. 8. Put the glove over the dressing and discard it into a plastic or biohazard bag. 9. Wash and dry hands thoroughly. 10. Open dry, clean dressings by pulling corners of the exterior wrapping outward, touching only the exterior surface. 11. Place on a clean field. 12. Using a clean technique, open other products. 13. Wash and dry hands thoroughly. 14. Put on clean gloves . Record review identified that R17 was admitted to the facility on [DATE]. R17's diagnoses included, in part, type 2 diabetes mellitus and heart failure. R17's Brief Interview for Mental Status score (BIMS) was 14, indicating cognitive intactness. On 12/19/23 at 11:08 AM, Surveyor observed R17's wound care performed by Registered Nurse (RN) L. RN L entered R17's room and wiped down the side table with alcohol wipes. RN L went into the bathroom, washed hands and applied gloves. RN L removed foot brace and used scissors to cut old dressing off. Kerlix was removed and RN L discarded the dressing into the trash. RN L removed gloves, washed hands and then reapplied gloves. RN L proceeded to use saline cleanser and pads to wash the wound bed. RN L then threw the dirty pads away in the trash. RN L proceeded to apply Sanytl cream with a Q-tip to the wound. RN L grabbed clean dressing from the package with dirty gloves and cut Aquacel dressing touching the whole Aquacel pad to the length RN L measured the wound. RN L applied the dressing with the same contaminated gloves to the wound. RN L replaced the rest of the Aquacel pad with the package. RN L applied an ABD pad on the dressing and then wrapped the foot in Kerlix. RN L then removed gloves, applied tape, took supplies, and walked out the door to the nurse's cart and applied hand sanitizer. On 12/19/23 at 3:45 PM, Surveyor interviewed DON B about proper infection control measures for wound dressing changes. DON B indicated that the expectations for all nurses during wound dressing changes are to follow the facility policy and protocols and change gloves often. DON B indicated that RN L should have changed gloves and washed hands after cleansing the wound before redressing the wound with a clean dressing. 46694 Example 4 On 12/19/23 at 8:21 AM, Surveyor observed the food cart arrive in the dining room. No hand hygiene given or offered to any residents (R33, R30, R5, R8, R22, R12, R6) prior to their food given to them. On 12/19/23 at 11:56 AM, Surveyor observed residents brought into the dining room for lunch. Surveyor did not see any hand hygiene offered to residents (R33, R5, R8, R22, R12, R6, R29) as they were brought into the dining room. Example 5 On 12/19/23 at 6:46 AM, Surveyor observed medication pass with Licensed Practical Nurse (LPN) H. Surveyor observed LPN H enter R24's room and put on single use gloves without performing any hand hygiene. LPN H then explained to R24 that LPN H has medications for R24 and proceeded to administer medications to R24. On 12/19/23 at 6:59 AM, Surveyor observed LPN H remove medications from the medication cart for R35, touching the computer mouse, drawers on the med cart, medication cup and medication cards. Surveyor observed LPN H deliver the medications to R35's bedside without performing hand hygiene prior to administering R35's medications. On 12/19/23 at 7:02 AM, Surveyor observed LPN H remove medications from the medications cart for R2, touching the computer mouse, drawers, medication cards and medication cups. Surveyor observed LPN H deliver the medications to R2's bedside without performing hand hygiene prior to medications administration. LPN left R2's room and used the ABHR at the medication cart. On 12/19/23 at 7:04 AM, Surveyor asked LPN H, What is the process of hand hygiene with glove use and medication administration? LPN H replied, Hands should be cleaned prior to putting on gloves or giving medications. Example 6 On 12/19/23 at 11:47 AM, Surveyor observed Certified Nursing Assistant (CNA) K empty catheter bag in resident's bathroom. CNA K put on gloves without performing hand hygiene per the facility policy and standards of practice. The remainder of the observation with CNA K was according to the standards of practice. On 12/19/23 at 12:00 PM, Surveyor interviewed CNA K regarding hand hygiene observations made. Surveyor asked CNA K, What is the expectation with hand hygiene associated with glove use. CNA K replied, I should have performed hand hygiene before putting on the gloves. On 12/20/23 at 8:06 AM, Surveyor interviewed DON B. Surveyor asked, What is expected of staff regarding hand hygiene with glove use? DON B replied, I would expect hand hygiene prior to entering resident's rooms and prior to glove use.

Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to all 38 residents (R) in the facility. Findings include: Facility policy entitled Dishwashing sanitization protocol, stated in part, . Before each use, staff must verify that the dishwasher is operating at the recommended high temperature for effective sanitization, sanitization color changing stickers must be used to verify that the dishwasher is achieving the required high temperature for proper sanitization, apply the color changing stickers to designated areas within the dishwasher before each cycle . Facility policy entitled Food storage policy, stated in part, .Food storage procedures for refrigerated storage are followed to diminished environmental and cross-contamination, working containers holding dry food that are removed from their original packages must be dated with the manufactured on or expiration date . Example 1 On 12/19/23 at 8:07 AM, Surveyor observed Cook O cough while serving food from the hot steam table. Surveyor did not observe Cook O turn her head or cover her mouth. On 12/19/23 at 8:50 AM, Surveyor observed Cook O cough while serving food from the hot steam table. Surveyor did not observe Cook O turn her head or cover her mouth. On 12/19/23 at 3:55 PM, Surveyor interviewed Dietary Manager (DM) N and asked what the correct process was for cough etiquette while serving meals. DM N indicated that expectations are if anyone is sick, they do not come to work, if they must cough cover mouth with elbow and face away from food and wash hands appropriately. Example 2 On 12/18/23 at 9:30 AM, DM N indicated that through the process of washing dishes in the prepping kitchen and serving kitchen the facility uses a hot water system to sanitize dishes. DM N noted that an internal temperature is checked before each use of dishes to make sure that dishes are being sanitized at the correct temperature per the facility sanitization policy. On 12/19/23 at 8:37 AM, Surveyor observed Dietary Aide (DA) P wash dishes in the serving kitchen without checking the initial temperature for correct sanitization temperatures. On 12/19/23 at 8:45 AM, Surveyor interviewed DA P and DA Q and asked about checking temperatures when washing dishes. DA Q indicated DA Q usually just checks the external temperature. DA P indicated if the external temperature says P2 for example, DA P just gives it a little tap and the machine usually works great afterwards. DA Q and DA P indicated no external temperatures were checked. Example 3 On 12/18/23 at 9:50 AM, during the initial tour of the serving kitchen, Surveyor observed opened cheese wrapped in saran wrap in the fridge labeled opened 12/11/23 but no use-by date was noted. Surveyor observed in the fridge margarine in a tub labeled 12/10/23 with no use-by date noted. Surveyor observed another margarine container located on the counter as the same opened on 12/10/23 but no use-by date was noted. Surveyor observed in the dry storage area cereal found in clear plastic containers with no use-by date noted. One cereal container of honey nut Cheerios with an open date of 12/14/20 with no use-by date noted. On 12/18/23 at 9:55 AM, Surveyor interviewed DM N and asked about the use-by dates for items found without and how staff would know when to use and to discard. DM N stated that the margarine and cheese do not have use-by dates on them currently, but the margarine is good for a while, and we use it up fast. DM N also indicated that the cereal is good for up to a year and we use that up fast as well. On 12/19/23 at 8:42 AM, Surveyor observed margarine on the counter with no use-by date. Surveyor interviewed Cook O and asked when she would not use the margarine. Cook O indicated that she was unsure when it would expire and that she would need to ask DM N. Example 4 On 12/19/23 at 7:54 AM, Surveyor observed a fan on a high setting on the floor blowing air throughout the serving kitchen from the dirty dish room during the serving of breakfast. On 12/19/23 at 8:25 AM, Surveyor interviewed Cook O and asked about the fan. Cook O indicated that we use the fan when it's hot in the kitchen as we get hot working around all the food. The fan blowing from the dirty dish room and across the floor has the potential of contaminates to be blown on to the food that is being served. Example 5 On 12/19/23 at 7:55 AM, Surveyor observed DA Q pass room tray drink setups across the uncovered hot steam food table throughout the entire breakfast serving time frame while the Cook O was serving other residents' food. On 12/19/23 at 8:45 AM, Surveyor interviewed DA Q and asked what the correct process was for handling trays near the hot steam table. DA Q indicated we typically walk around and hand the other DA the trays, so we don't contaminate the uncovered food on hot steam table. On 12/19/23 at 3:55 PM, Surveyor interviewed DM N and asked what the correct process was for handling trays near the hot steam table during serving time. DM N indicated expectation is to walk around and hand the other employee the trays to not contaminate the uncovered food on the hot steam table. 46694 Example 6 Surveyor reviewed facility's policy titled, PROPER FOOD HANDLING POLICY revised August 16, 2012, which states in part, .Gloves are used in handling food to prevent any bare hand contact. If an employee is wearing gloves to perform a task, it can only be of that one task: example, buttering bread. If handling more than 1 item you must use tongs or spoons, because of handling things in between . R29 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 6 (cognitively impaired) with diagnoses that include dementia, depression, and anxiety. On 12/19/23 at 12:30 PM, Surveyor observed Certified Nursing Assistant (CNA) E touch ready to eat foods with contaminated single use gloves by picking up buttered bread after touching R29's fork, tray, cup of liquid, left arm sleeve and R29's left hand and putting the bread into resident's hand and helping R29 put the bread into R29's mouth. On 12/19/23 at 12:59 PM, Surveyor interviewed CNA E asking what is the process for touching ready to eat foods with gloved hands. CNA E replied, I probably shouldn't have. I probably should have used his fork and not my gloved hands. On 12/20/23 at 7:09 AM, Surveyor interviewed Registered Nurse (RN) D asking what is the expectation when you assist a resident with feeding referring to touching ready to eat foods like buttered bread. RN D replied, I would just use a fork. Surveyor asked, Is there any time that you can just pick up the bread? RN D replied, Yes, if I am wearing gloves and not touching anything else. On 12/20/23 at 8:03 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked, What is your process when feeding a resident with contaminated gloves? DON B replied, I would expect that staff person to take off their gloves and wash their hands. I would expect them to use silverware when feeding ready to eat foods like buttered bread to residents.

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs for residents with pressure wounds and non-pressure related skin disturbances. This occurred for 1 of 4 residents (R) reviewed. (R17). Findings include: The facility policy titled, Policy and procedure for the prevention and treatment of skin breakdown, states in part, Prevention of pressure injuries: b- The care plan for the skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. B. Lower extremity ulcers: III. Treatment of pressure injury- Update the care plan for skin integrity listing appropriate risk factors, turning intervals, and interventions as appropriate . Record review identified that R17 was admitted to the facility on [DATE]. R17's diagnoses included, in part, type 2 diabetes mellitus, and heart failure. R17's Brief Interview for Mental Status score (BIMS) was 14, indicating cognitive intactness. The Minimum Data Set (MDS) assessment dated [DATE] indicated R17's functional status needs limited assistance and one-person physical assistance with bed mobility and transfers and at risk for the development of pressure injuries. Record review identified physician orders continued on 12/11/23, 12/13/23, and 12/14/23 included, in part, removing the footboard on the bed, continuing to offloading, and santyl to yellow wound open areas daily with aquacell, gauze, kerlix wrap with podus boot on at night and off in the morning for heel protection. Surveyor interviewed Director of Nursing (DON) B asking about R17's wound care plans. DON B stated R17 did have a history of multiple blisters and open wounds that started back in October and was at risk of developing pressure injuries. DON B stated R17 did have a pressure injury to the left foot. DON B stated there is no skin or wound care plan on R17's medical record, but there should be one. Surveyor reviewed R17's comprehensive care plan and did not identify any problems, goals, or interventions related to skincare, prevention of pressure injuries, or care of an open wound.

Based on record review and interview, the facility did not complete a thorough investigation of an allegation of sexual abuse for 1 of 1 resident (R8). Findings: The facility's policy titled, Mistreatment, Neglect, Exploitation, Abuse and Misappropriation Prevention and Protection reads, in part . Abuse is any of the following acts committed by any person in contact with the resident: .Abuse also sexual abuse (non-consensual sexual contact of any type with a resident .Sexual abuse is defined at S483.5 as 'non-consensual contact of any type with a resident.' In the event in which any of the above is suspected or identified, staff will immediately stop the situation from continuing, will ensure that the resident is protected facility. 1. The immediate supervisor will contact the Department Director, facility administrator . If the incident is considered an alleged resident rights violation, the investigation begins immediately. 3. If the allegation is of physical or sexual abuse-all non-emergent personal cares are to be STOPPED IMMEDIATELY to prevent evidence contamination and to prevent any additional physical or emotional harm personal cares may cause. 2. An interdisciplinary staff meeting will be held to discuss the alleged incident immediately following the date the facility became aware of the alleged incident. 3. The social services department and/or facility supervisory staff are responsible to interview all parties with knowledge of the alleged incident including: a. Residents b. Staff of all relevant shifts or departments c. responsible party d. other persons of knowledge as necessary e. each person will be asked to complete and sign a written statement of knowledge regarding the incident . R8 was admitted to the facility on [DATE]. Diagnoses include chronic pain, anxiety, and depression. R8 receives hospice services for end-of-life care. Minimum Data Set (MDS) assessment was completed on 09/16/23. Staff assessment for mental status was completed and indicated R8 has a memory problem, severely impaired skills for decision making, and inattentiveness. R8's power of attorney has not been activated. R8 requires staff assistance with all Activities of Daily Living (ADLs). R8 is incontinent of bowel and bladder and dependent on staff for assistance. On 12/18/23 at 10:11 AM, Surveyor interviewed Visitor G, who was visiting R8. Visitor G stated on 12/01/23, a CNA reported that Visitor G had touched R8 inappropriately. Visitor G indicated he was not aware of this report until he returned home from his visit and received a phone call from the facility reporting an incident had occurred involving R8, and Visitor G was asked to not enter the facility until 12/04/23, when a meeting would be held. Visitor G stated not being allowed visitation on 12/02/23 and 12/03/23 was violation of his and R8's rights. On 12/18/23, Surveyor reviewed the facility's self-reported incidents and noted there was not a report or a thorough investigation for this incident. On 12/18/23 at 2:46 PM, Surveyor interviewed Social Worker (SW) C. SW C stated she is responsible for reporting and investigating of incidents and grievances. SW C stated she had a soft file of the incident. SW C reported she interviewed staff but did not interview residents. SW C reported the facility met as a team on 12/04/23 and determined the incident was not of malicious intent. Surveyor reviewed SW C's soft file of the incident, which included: Statement from Certified Nursing Assistant (CNA) J. CNA J's statement read . On [12/01/23] around 3:00 PM, I walked into [R8's] room to see her sleeping. She looked completely out of it as I said her name, and she would not answer. [Visitor G] walked up to us both. I asked if she just fell asleep or not. He said she just fell asleep. I stated maybe I would let her sleep some more, and then I would come in and change her. [Visitor G] said he would check and then stick his underneath her pad. [Visitor G's] hand touched [R8's] vagina and then said nope, she is dry. During that time, [R8] woke up, and I asked if we could check to see if she was wet, and she said yes. The only people in her room then were [Visitor G], [R8], and myself. Email from SW C to Nursing Home Administrator (NHA) A, dated 12/01/23 at 5:01 PM, which read . [R8] was hard to rouse when I went into her room. I said I wanted to talk about [Visitor G] and she opened her eyes. I asked: Do you feel safe when [Visitor G] is here? Does [Visitor G] ever hurt you? Does [Visitor G] ever touch you where you don't want to be touched? She did not respond. Her eyes remained barely open . Surveyor reviewed R8's medical record and did not find on 12/01/23 nurse assessment of R8's vaginal area for physical signs of abuse. On 12/04/23, the facility conducted an interdisciplinary staff meeting. Documentation from meeting read as follows: 12/01/23: Investigation: Writer phoned [Visitor G] to inform of situation and to request he remain out of the building while facility investigates. The facility did not complete interviews with other staff, residents and Visitor G to ensure a thorough investigation was completed.

Based on interview and record review, the facility failed to or ensure the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act to law enforcement, or report an allegation of abuse immediately but not later than 2 hours after the allegation is made, to the state agency when a family member to resident abuse allegation was made. This occurred for 1 of 1 incidents (R) R8 reviewed. Findings: The facility's policy titled, Mistreatment, Neglect, Exploitation, Abuse and Misappropriation Prevention and Protection reads, in part . Abuse is any of the following acts committed by any person in contact with the resident: .Abuse also refers to verbal abuse, sexual abuse (non-consensual sexual contact of any type with a resident) .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Sexual abuse is defined at S483.5 as 'non-consensual contact of any type with a resident.' Allegations of Visitor to Resident Sexual Abuse: The nursing home must ensure that a visitor is not subjecting any resident to sexual abuse. In addition, the nursing home staff must immediately act on any allegation or suspicion that a visitor is engaging in improper sexual activity with a resident .Required to report, Unwanted touching of the breasts or perineal area, Sexual activity or fondling where one of the resident's capacity to consent is unknown. F. Initial Reporting-The Administrator, Director of Nursing, Director of Social Services or designee must immediately (if the events that cause the allegation involve abuse or result in serious bodily injury, nursing homes must report the violation to the administrator of the facility and the DQA no later than 2 hours after the allegation is made and as soon as possible but not to exceed 24 hours if the events that cause the suspicion do not result in serious bodily injury or abuse) report all incidents of alleged mistreatment, abuse, exploitation, and neglect of resident(s), misappropriation of resident property, and injuries of unknown source if the allegation meets the federal definitions of misconduct as listed above in the DQA reporting system. G. Final Report-The Director of Social Services will document all actions taken and other corroborating or disproving evidence in a final summary reported on the Misconduct Incident Report Form, and will assume the responsibility for submitting a copy of the Misconduct Incident Report and all other relevant investigative report vial mail or fax to the DQA within 5 working days of the incident, or the date the facility became aware of the incident. R8 was admitted to the facility on [DATE]. Diagnoses include chronic pain, anxiety, and depression. R8 receives hospice services for end-of-life care. Minimum Data Set (MDS) was assessment completed on 09/16/23. Staff assessment for mental status was completed and indicated R8 has a memory problem, severely impaired skills for decision making, and inattentiveness. R8's power of attorney has not been activated. R8 requires staff assistance with all Activities of Daily Living (ADLs). R8 is incontinent of bowel and bladder and dependent on staff for assistance. On 12/18/23 at 10:11 AM, Surveyor observed R8 was seated in a positioning chair, she was alert and Visitor G was present. R8 was not able to answer questions accurately or audibly. Surveyor interviewed Visitor G. Visitor G stated on 12/01/23, a CNA reported that Visitor G had touched R8 inappropriately. Visitor G indicated he was not aware of this report until he returned home from his visit and received a phone call from the facility reporting an incident had occurred involving R8, and Visitor G was asked to not enter the facility until 12/04/23, when a meeting would be held. Visitor G stated on 12/01/23 CNA J came into R8's room and asked Visitor G if R8 needed anything. Visitor G stated maybe R8 needs to be changed. Visitor G reported he checked R8 by touching the edge of her brief. Visitor G stated not being allowed visitation on 12/02/23 and 12/03/23 was violation of his and R8's rights. On 12/18/23, Surveyor reviewed the facility's self-reported incidents and noted there was not a report of this incident. On 12/18/23 at 2:46 PM, Surveyor interviewed Social Worker (SW) C. SW C stated she is responsible for reporting and investigating of incidents and grievances. SW C stated she had a soft file of the incident. SW C reported she interviewed staff regarding the incident but did not interview residents. SW C reported the facility met as a team on 12/04/23 and determined the incident was not of malicious intent, and that is why it was not reported to the State Agency. Surveyor reviewed SW C's soft file of the incident, which included: Statement from Certified Nursing Assistant (CNA) J. CNA J's statement read .On [12/01/23] around 3:00 PM, I walked into [R8's] room to see her sleeping. She looked completely out of it as I said her name, and she would not answer. [Visitor G] walked up to us both. I asked if she just fell asleep or not. He said she just fell asleep. I stated maybe I would let her sleep some more, and then I would come in and change her. [Visitor G] said he would check and then stick his underneath her pad. [Visitor G's] hand touched [R8's] vagina and then said nope, she is dry. During that time, [R8] woke up, and I asked if we could check to see if she was wet, and she said yes. The only people in her room then were [Visitor G], [R8], and myself. Email from SW C to Nursing Home Administrator (NHA) A, dated 12/01/23 at 5:01 PM, which read .[R8] was hard to rouse when I went into her room. I said I wanted to talk about [Visitor G] and she opened her eyes. I asked: Do you feel safe when [Visitor G] is here? Does [Visitor G] ever hurt you? Does [Visitor G] ever touch you where you don't want to be touched? She did not respond. Her eyes remained barely open . On 12/19/23 at 1:42 PM, Surveyor interviewed NHA A. NHA A stated the incident did not include Visitor G touching R8's vagina, otherwise it would have been reported. Surveyor stated CNA J's statement specified Visitor G touched R8's vagina. NHA A stated Visitor G was not able to come over on the weekend. NHA A reported SW C met with R8 right away and R8 did not respond. NHA A stated, We made sure there was no immediate harm. NHA A acknowledged a self report had not been completed, nor police notified of reasonable suspicion of a crime.

Based on interview and record review the facility did not ensure 1 of 6 residents (R47) were comprehensively assessed by a Registered Nurse when a change in condition was occurring. R47 experienced multiple changes in condition over a 2 day time period: ~Sunday 4/29/18, R47 had increased lethargy, became shaky, and was unable to feed himself. There was no evidence of a comprehensive assessment by a Registered Nurse. ~Monday 4/30/18, R47 had labored breathing, diminished lung sounds, and wheezing. There was a lung assessment, however no comprehensive head to toe assessment was completed at that time. ~Monday 4/30/18, R47 also experienced increased lethargy, impaired coordination, jerking movements, and an increase in temperature. There was no evidence a comprehensive assessment of R47's condition was completed. On 5/1/18 R47 was sent via emergent ambulance to the hospital where he was diagnosed with [REDACTED]. R47 was hospitalized for [REDACTED]. Facility failure to comprehensively assess R47's condition in a timely manner created a finding of immediate jeopardy that began on 4/29/18. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on 6/26/18 at 8:58 a.m. The immediate jeopardy was removed on 6/26/18, however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: R47 was admitted to the facility on [DATE] for therapy and rehab following a recent fall. Pertinent [DIAGNOSES REDACTED]. At the time of admission, R47 was alert and oriented x3 and was his own person. Upon admission, R47 had physician orders [REDACTED]. Review of the medical record finds R47 was transferring with SBA (stand by assistance of staff) and a walker. Entries beginning 4/26/18 indicate R47 is now being transferred with an EZ stand. This is a change since admission when he was SBA with a walker. On 4/28/18, staff are documenting R47 is very tired and more sleepy. On 4/29/18 (Sunday) at 12:47 p.m., LPN-E documented R47 has been sleepy before dinner, and he appears to be picking at things while assisting him with his meal. He states he is shakey (sic) and can't feed himself . The documentation indicates FM-H (Family Member) was visiting and concerned. LPN-E documented, .vitals were stable right now but will monitot (sic) him and update MD (Medical Doctor) tomorrow if continues . Surveyor spoke with LPN-E on 6/14/18 at 10:41 a.m., who stated R47 was alert but sleepy, and he couldn't feed himself because he was so shaky. LPN-E was asked about R47 picking at things. She stated she didn't know what that was about as she was only told of it and thought maybe it was medication related. When asked about a head to toe assessment of R47's condition, LPN-E stated, I don't know what you mean by a head to toe assessment. When asked if an RN had completed an assessment, LPN-E stated she passed on what she wrote to RN-F in report. On 4/29/18 at 7:51 p.m., RN-F documented R47 was very sleepy and needed assistance with eating. Surveyor interviewed RN-F on 6/14/18 at 4:05 p.m. RN-F stated R47 was not as alert or responsive, but nothing that needed immediate attention as this was happening over 3 days. RN-F stated, We had a heck of a time getting him to eat (on 4/29/18), he needed to be fed and the CNA sat down with him. He got more sleepy as time went on. When asked about an assessment, RN-F indicated she did not do a head to toe assessment of R47 even when LPN-E had informed her of R47's changes in condition. A comprehensive nursing assessment should include a head to toe assessment, mental status, functional status, neurological status, cardiac and respiratory status. On 4/30/18 at 10:20 a.m. RN-G documented R47 had diminished lung sounds on both sides, wheezing on exhale, and was complaining of feeling very tired. RN-G left a message for the physician regarding this change in condition. On 4/30/18 at 1:49 p.m., LPN-E documented, .Lethargic and has impaired coordination, some jerking movements and needs to be fed . LPN-E also documented a conversation with FM-H and learned R47 was not taking [MEDICATION NAME] at home and was only receiving 1 [MEDICATION NAME] instead of 2. LPN-E documented she spoke with MD-C's nurse and relayed the change in condition and the information provided by FM-H. MD-C's nurse scheduled an appointment for R47 to be seen the following day. MD-C also ordered the [MEDICATION NAME] be discontinued. Although there was a lung assessment, there was no evidence that assessment was shared with MD-C's nurse and there was no evidence of a comprehensive assessment of R47's overall condition on 4/30/18. On 4/30/18 at 4:41, RN-G documented R47 was unable to follow staff directions, and was unable to hold onto the handles of the EZ Stand. R47's head was hanging forward and he was leaning to the left when seated in the wheelchair. RN-G documented, Resident more lethargic than assessment done at 1000 (10:00 a.m.). [MEDICATION NAME] given at 1500 (3:00 p.m.). FM-H requested [MEDICATION NAME] be held. Surveyor interviewed FM-D on 6/14/18 at 9:08 a.m. FM-D stated she was there on 4/30/18, around 1:00 p.m. or 2:00 p.m. FM-D stated R47 was in his wheelchair and so sleepy he was tipping over and his left hand was actually touching the floor, his coloring was bad, and he was drooling. There were 2 CNAs in the room and they got him to bed using the EZ Stand. FM-D stated R47 was hanging by the belt as he couldn't follow directions to hang on to the handles. There is no evidence of a neurological assessment as he is more lethargic and leaning or a comprehensive assessment of R47's overall condition. On 4/30/18 at 11:00 p.m. staff documented R47 had a low grade temperature of 99.0 degrees with a Rare loose nonproductive cough. (R47's usual temperature was around 97.7 degrees.) On 5/1/18 staff documented R47 was very lethargic and taking shallow breaths with a temperature of 99.9 tympanically (ear). R47 was only able to open eyes briefly and and would mumble answers to questions. A telephone order was received for emergent transport to the local hospital. This is the only entry that included a comprehensive assessment of R47 including all vital signs, neurological and lung assessments. R47 was sent via emergent ambulance to the hospital where he was diagnosed with [REDACTED]. [MEDICAL CONDITION] is a deterioration in brain function caused by many things including toxic medications, infections, and organ failure. It presents with lethargy, tremors, jerking movements, muscle weakness, decline in function, and decline in ability to focus or concentrate. [MEDICAL CONDITION] can be temporary or permanent and often results in death when not treated quickly. On 6/13/18 at 3:58 p.m. Surveyor interviewed the ADON. The ADON stated the physical therapist could not awaken R47; he was really, really lethargic and needed a sternal rub to awaken. (A sternal rub is a neurological test in which the clinician's rubs their knuckles over the person's sternum. This test causes pain that will awaken someone that will not respond to a voice.) The failure to comprehensively and timely assess R47 as his condition changed created a finding of immediate jeopardy. The immediate jeopardy was removed on 6/26/18 when the facility: 1. Reviewed all residents and their medical records to determine if RN assessments were completed; and, 2. Reeducated all nursing staff before the start of their next shift on the scope of practice for an LPN and then need for RN assessments.

Based on interview and record review, the facility did not promptly consult with a physician when a 1 of 6 sampled residents (R47) had a significant change in condition. R47 had a significant change in status beginning 04/29/18 through 05/01/18 and there was no comprehensive nursing assessment provided to the physician to determine the best course of action. On 5/1/18 R47 was sent via emergent ambulance to the hospital where he was diagnosed with [REDACTED]. R47 was hospitalized for [REDACTED]. Facility failure to thoroughly update and consult with a physician in a timely manner on a resident's change in condition created a finding of immediate jeopardy that began on 4/29/18. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on 6/26/18 at 8:58 a.m. The immediate jeopardy was removed on 6/26/18, however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: R47 was admitted to the facility on [DATE] for therapy and rehab following a recent fall. Pertinent [DIAGNOSES REDACTED]. At the time of admission, R47 was alert and oriented x3 and was his own person. Upon admission, R47 had physician orders [REDACTED]. Review of the medical record finds R47 was transferring with SBA (stand by assistance of staff) and a walker. Entries beginning on 4/26/18 indicates R47 is now being transferred with an EZ stand. This is a change since admission when he was SBA with a walker. On 4/28/18, staff are documenting R47 is very tired and more sleepy. On 4/29/18 (Sunday) at 12:47 p.m., LPN-E documented R47 has been sleepy before dinner, and he appears to be picking at things while assisting him with his meal. He states he is shakey (sic) and can't feed himself . The documentation indicates FM-H (Family Member) was visiting and concerned. LPN-E documented, .vitals were stable right now but will monitot (sic) him and update MD (Medical Doctor) tomorrow if continues . There is no evidence in the medical record that the physician was consulted on the increased lethargy, shakiness, or R47's picking at things that weren't there. Surveyor spoke with LPN-E on 6/14/18 at 10:41 a.m. who stated R47 was alert but sleepy, and he couldn't feed himself because he was so shaky. LPN-E was asked about R47 picking at things. She stated she didn't know what that was about as she was only told of it and thought maybe it was medication related. LPN-E stated she did not call the physician as she felt he was ok as his vital signs were stable and they would just monitor him and call the doctor the next day if he became more tired and shaky. LPN-E stated I hate to call the on-call (physician) if they (resident) are just tired and have stable vital signs. On 4/29/18 at 7:51 p.m., RN-F documented R47 was very sleepy and needed assistance with eating. Surveyor interviewed RN-F on 6/14/18 at 4:05 p.m. RN-F stated R47 was not as alert or responsive, but nothing that needed immediate attention as this was happening over 3 days. RN-F stated, We had a heck of a time getting him to eat, he needed to be fed and the CNA sat down with him. He got more sleepy as time went on. When asked about consulting with the physician about this change in condition, RN-F stated, He was resting quietly and I didn't see anything that needed a call. On 4/30/18 at 10:20 a.m., RN-G documented R47 had diminished lung sounds on both sides, wheezing on exhale, and was complaining of feeling very tired. RN-G left a message for the physician regarding this change in condition. On 4/30/18 at 1:49 p.m., LPN-E documented, .Lethargic and has impaired coordination, some jerking movements and needs to be fed . LPN-E also documented a conversation with FM-H and learned R47 was not taking [MEDICATION NAME] at home and was only receiving 1 [MEDICATION NAME] instead of 2. LPN-E documented she spoke with MD-C's nurse and relayed the change in condition and the information provided by FM-H. MD-C's nurse scheduled an appointment for R47 to be seen the following day. MD-C also ordered the [MEDICATION NAME] be discontinued. Surveyor interviewed LPN-E on 6/14/18 at 10:41 a.m. about the call to MD-C's office. LPN-E stated she had only spoken to MD-C's nurse and told her about R47's decline and change of condition with the twitching and lethargy. LPN-E stated she relayed the information shared by FM-H and MD-C's nurse reviewed past labs. LPN-E indicated MD-C's nurse scheduled an appointment for R47 to be seen the next day at the clinic. Although there was a lung assessment, there was no evidence MD-C was consulted regarding the labored breathing, or diminished breath sounds. There was also no comprehensive assessment completed and provided to MD-C. Additionally, LPN-E did not personally consult with MD-C. On 4/30/18 at 4:41 p.m., RN-G documented R47 was unable to follow staff directions, and was unable to hold onto the handles of the EZ Stand. R47's head was hanging forward and he was leaning to the left when seated in the wheelchair. RN-G documented, Resident more lethargic than assessment done at 1000 (10:00 a.m.). [MEDICATION NAME] given at 1500 (3:00 p.m.). FM-H requested [MEDICATION NAME] be held. Surveyor interviewed FM-D on 6/14/18 at 9:08 a.m. FM-D stated she was there on 4/30/18, around 1:00 p.m. or 2:00 p.m. FM-D stated R47 was in his wheelchair and so sleepy he was tipping over and his left hand was actually touching the floor, his coloring was bad, and he was drooling. There were 2 CNAs in the room and they got him to bed using the EZ Stand. FM-D stated R47 was hanging by the belt as he couldn't follow directions to hang on to the handles. There was no evidence staff consulted a physician even though a decline in R47's condition was noted between assessments on the same date. On 4/30/18 at 11:00 p.m. staff documented R47 had a low grade temperature of 99.0 degrees with a Rare loose nonproductive cough. (R47's usual temperature was around 97.7 degrees.) There was no evidence the physician was consulted. On 5/1/18 staff documented R47 was very lethargic and taking shallow breaths with a temperature of 99.9 tympanically (ear). R47 was only able to open eyes briefly and and would mumble answers to questions. A telephone order was received for emergent transport to the local hospital. This entry includes a comprehensive assessment of R47 including all vital signs, neurological and lung assessments. R47 was sent via emergent ambulance to the hospital where he was diagnosed with [REDACTED]. [MEDICAL CONDITION] is a deterioration in brain function caused by many things including toxic medications, infections, and organ failure. It presents with lethargy, tremors, jerking movements, muscle weakness, decline in function, and decline in ability to focus or concentrate. [MEDICAL CONDITION] can be temporary or permanent and often results in death when not treated quickly. On 6/13/18 at 3:58 p.m. Surveyor interviewed the ADON. The ADON stated the physical therapist could not awaken R47; he was really, really lethargic and needed a sternal rub to awaken. (A sternal rub is a neurological test in which the clinician's rubs their knuckles over the person's sternum. This test causes pain that will awaken someone that will not respond to a voice). On 6/25/18 at 10:45 a.m. Surveyor interviewed R47's MD-C about notifications/consultations he had with the facility nurses. MD-C reviewed the clinic's records and this information confirmed his recollection that he received only 2 calls about R47 related to his condition that week. MD-C indicated the first call was received at noon on Monday 4/30/18. The call was to question the resident's medication orders of [MEDICATION NAME] and [MEDICATION NAME] and if they should continue or be changed. MD-C stated the facility reported R47, was more lethargic and had twitching and jerking. MD-C stated No one there (at the facility) asked to speak to me; they just went through the nurse about his meds and had arranged to have him seen at the clinic the following morning (5/1/18). MD-C indicated the second call was received on Tuesday, 5/1/18. At that time, staff reported R47 was very lethargic and had a temperature. MD-C stated it was then he had the resident sent out as an emergency. MD-C stated he remembers wondering, at the time of that second call, what had happened as it's unusual for a patient to all of a sudden get so sick, that usually it is a progression. The physician stated there are 3 doctors, including himself, on an on-call schedule and they can be reached 24 hours a day, every day. MD-C told Surveyor he was not told of: ~R47's shakiness, inability to eat, and picking at things that were not there on Sunday 4/29/18 day shift or evening shift. MD-C indicated the observation made of R47 picking at things sounded like a hallucination and this would be significant. ~R47's breathing difficulties and lung sounds on Monday 4/30/18 day shift. MD-C stated he was told of the request to change R47's medications as he had some twitching. MD-C recalled the emphasis of the call was on changing the medications. ~R47's inability to transfer and follow directions on Monday 4/30/18 evening shift. MD-C stated, We expect and train our nurses to report anything that is not the normal pattern of behavior of the patient for us (physicians) to question if the patient has to go to a higher level of care and nobody called. MD-C also stated he did not know anything of the condition of the patient on 4/23/18 when he was admitted to the hospital and had last seen him on 3/12/18. MD-C again stated the importance of the nursing staff keeping the doctors informed and questioned why the nurse did not talk to him before Tuesday. On 06/14/18 at 11:20 a.m. Surveyor asked the DON if staff should have called the physician on Sunday 4/29/18. The DON nodded her head. The DON stated nurses did not call the the physician when they should have. The DON stated whenever there are changes like R47 had on 4/29/18, she needs to be updated. A nurse can't chart 'we will continue to monitor.' We need to call the doctor. The failure to promptly consult with the physician when R47 had a significant change in condition created a finding of immediate jeopardy. The facility removed the jeopardy on 6/26/18 when the facility: 1. Reviewed all residents and their medical records to identify any potential changes in condition; and, 2. Reeducated all nursing staff before the start of their next shift on identifying changes in condition and consulting with physician timely about those changes;

NOT CORRECTED AT REVISIT (Previous Survey Event ID ZPFM11) Based on observation, interview and record review, the facility did not ensure 3 of 4 residents at risk for falls in a sample of 8, and 2 of 3 supplemental residents at risk for falls, were provided appropriate supervision and assistance devices to prevent accidents. ~Resident #18 was at high risk for falls and had a care plan in place included the use of a personal alarm at all times which the resident had a history of [REDACTED]. The resident removed her personal alarm at approximately 8:00 p.m. on 05/21/11 and fell without sustaining serious injury. The resident continued to remove the personal alarm including times other than at bedtime. Facility staff did not appropriately respond to the resident's behavior of removing her personal alarm and did not complete a root cause analysis of the behavior in order to decrease the likelihood of a serious injury if she fell again. Subsequently, on 06/29/11, Resident #18 removed her personal alarm, fell in her room at approximately 4:15 p.m., and sustained a cervical (neck) fracture requiring surgery with placement of a "Halo brace" to her head for several months. Following readmission to the facility, the injury/surgery caused the resident pain and the halo caused a persistent limitation in functional abilities related to personal cares and activities. ~Following readmission, Resident #18 made at least one attempt to self-transfer from the bed and at least one attempt to self-transfer from the wheelchair before additional alarms were initiated. The resident continued with attempts to self-transfer. Facility staff did not initiate additional interventions for two days related to self-transfers out of bed and for four days related to self-transfers out of the wheelchair as well as for ongoing attempts to remove the personal alarm and/or self-transfer. The facility did not appropriately respond to the resident's behavior of removing her personal alarm and did not complete a root cause analysis of the behavior in order to decrease the likelihood of a serious injury if she fell again. Facility staff did not appropriately address the proper placement and functioning of the personal alarm and the motion sensor to ensure staff would be alerted if the resident sat on the edge of the bed and/or attempted to self-transfer. Subsequently, on 08/17/11 during survey, Resident #18 attempted to self-transfer out of bed with alarms not sounding until the surveyor moved close enough to the motion sensor alarm at the foot of the bed to activate the sound which brought staff in to assist the resident. ~Resident #21 was readmitted following a hospitalization on [DATE] and was upgraded to being at very high risk for falls on 05/30/11. The resident fell while ambulating alone with her walker on 06/21/11 and a therapy screen identified the resident could continue independent ambulation (with the walker). She fell again on 07/01/11 when attempting to get up to ambulate and the physician ordered ambulation with assistance at that time. A personal alarm was also added, however, the resident was able to remove it. The resident developed neurological changes on 07/14/11 that led to emergency room visits on 08/11/11 and 08/12/11 with the most recent episode of left upper extremity tremors on 08/14/11. Facility staff did not appropriately respond to the resident's behavior of removing her personal alarm and did not complete a root cause analysis of the behavior in order to decrease the likelihood of a serious injury if she fell again. Subsequently, on 08/18/11 during survey, Resident #21 transferred herself from the bed to the wheelchair, having removed her personal alarm, and propelled herself into the hallway before facility staff could be summoned by the surveyor. The facility's failure to provide appropriate supervision and assistance devices to prevent accidents created a finding of immediate jeopardy which began on 06/10/11. The current Nursing Home Administrator was informed of the immediate jeopardy on 08/23/11. The immediate jeopardy was removed on 08/25/11 when the facility identified and assessed residents at high risk for falls, put an appropriate plan in place, and trained staff regarding the current plan. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following: ~Resident #10 is at high risk for falls, has a history of falls with the most recent resulting in a head injury, and has a care plan in place that includes the use of a personal alarm at night. The resident has severe cognitive impairment and ambulates independently throughout the facility during the day. The resident was recently identified with a decline in cognition and communication deficits, a decrease in activities of daily living (ADLs), and an increase in behaviors during the evening and nighttime hours. Facility staff did not reassess the resident to ensure he was safe for independent transfers and ambulation, revise the current certified nursing assistant (CNA) care plan to give specific direction regarding when the resident required supervision versus when he could be independent, and consistently put appropriate measures in place to decrease the likelihood of serious injury if he falls again. ~Resident #1 is at very high risk for falls, has a recent history of numerous falls, and a care plan in place that has included several different safety devices at various times over the past three months. The resident has moderate cognitive impairment and requires staff assistance for transfers and ambulation. The resident had 10 falls in the past two to three months. Facility staff did not consistently initiate immediate interventions to: - keep the resident from serious injury; - address what would be done to ensure proper placement and functioning of the alarms; - address what would be done regarding the resident's behavior of removing her personal alarm; - update the care plan in a timely manner to ensure staff were aware of current safety devices; - address why specific safety devices were not in place as directed; and - ensure safety devices were applied and turned on as directed by the resident's care plan. ~Resident #9 was at high risk for falls and had a care plan in place that included transfers to be done with a sit to stand lift in the "AM" and a full body/Hoyer lift in the "PM." The manufacturer's directions and the facility policy allowed staff to utilize the sit to stand lift with one staff assist. There was inconsistency in whether staff used one or two assist to transfer the resident using the sit to stand lift. Facility staff did not ensure the resident's nursing care plan, the CNA care plan, and the therapy care plans were all complete and accurate, and all staff were trained in the most current therapy recommendations regarding how many staff were to be used for the transfers. Subsequently, on 07/24/11, Resident #9 was transferred with the sit to stand lift using one staff assist and the resident slipped from the sit to stand lift, landing on the floor. The fall did not result in serious injury but did cause the resident buttocks/coccyx discomfort to the point of obtaining a physician order [REDACTED]. This is evidenced by the following: Standard of Practice related to falls according to the American Medical Director Association (AMDA) guidelines includes the following information: Falling is a significant cause of injury and death in older persons, especially the frail elderly...efforts should focus on minimizing fall risk and the risk of fall-related injuries...A history of falls is a strong predictor of future falls...After an observed or probable fall or after a fall risk has been identified, a more detailed analysis of the resident's falling or fall risk should occur...It is important to define complications of falls...residents who have a history of falls without significant injury may sustain a more serious injury in subsequent falls. Those with significant osteoporosis are more likely to sustain fractures of the hip, wrist, and spine from falls. Residents with reduced amounts of muscle, fat, and subcutaneous tissue to absorb the impact of a fall also are more susceptible to fractures. Current use of anticoagulants is a risk factor for significant injury from falls...Adjust the resident's care plan as necessary...try to minimize the risk of falling and fall-related injuries...it is often possible to reduce the frequency of falls and the severity of injuries associated with falling...Successful fall management uses a systematic approach that may require repeated reassessment and adjustment... 1. Resident #18 is an [AGE] year-old female with a current weight of approximately 126 pounds who was discharged from the facility on 03/05/11, hosptalized on [DATE] following a fall at home, and re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A fall risk assessment completed by the facility, dated 03/21/11, stated Resident #18 scored 57, which was very high risk for falls (greater than 50). Increased pain, a factor that increased the risk for falls, prompted x-rays which on 04/01/11 identified moderate osteoarthritis of the thoracic and lumbar spine. Resident #18's Minimum Data Set (MDS) with a reference date of 04/08/11 identified the resident had no cognitive impairment, but required extensive assistance for transfers and ambulation. Range of motion (ROM) limitations identified bilateral impairment of upper and lower extremities. The MDS identified no fall history since admission. Nurses' notes from 04/12/11 through 04/27/11 identified Resident #18 utilized a personal alarm which she at times removed and self-transferred without staff assist. It was identified the resident required staff assistance for transfers and ambulation. Therapy notes identified the resident was discontinued from PT on 04/26/11 with a restorative plan put in place that included staff assistance with (transfers) and ambulation. A nurse's note on 04/27/11 identified the resident had forgetfulness and confusion. Surveyor interviewed Director of Social Services (DSS) A on the afternoon of 08/18/11. DSS A identified Resident #18's Power of Attorney for Health Care (POA-HC) was activated on 01/12/11 even though ongoing assessments of her cognition identified scores of 13 to 15 out of a possible 15, indicating no cognitive impairment. DDS A stated the facility had not looked into deactivating the POA-HC because the resident was so forgetful. On 05/21/11, nurses' notes identified Resident #18 had removed her personal alarm so it did not sound and she was found on the floor next to her bed at approximately 8:00 p.m. She did not sustain serious injury. Surveyor reviewed the facility's incident report associated with the fall. A new intervention of assisting the resident to bed earlier at night was initiated. Director of Nursing (DON) C provided a typed statement on 08/18/11 stating that following Resident #18's fall on 05/21/11, new approaches included anti-rollbacks to the wheelchair and education to the CNAs to be sure frequently used items were within the resident's reach. Approaches that were continued included the low bed, wheels locked on the bed, and reminders to the resident to use her call light. A nurse's note on 05/29/11 at 2:41 p.m. stated the resident was "found to be removing personal alarm and transferring self today." Another nurse's note on 06/10/11 at 5:38 p.m. stated a CNA reported the resident "continues at times to remove her PA (personal alarm) and transfer independently." The resident stated she wanted to do things for herself. Staff made no changes to the care plan after the resident had removed her personal alarm at least 3 times in 21 days. Staff did not evaluate the continued effectiveness of using a personal alarm and did not evaluate the resident's toileting schedule or determine with which activities the resident wanted more independence. Surveyor interviewed CNA F on 08/18/11 at 11:10 a.m. CNA F stated she believed Resident #18 had a history of [REDACTED]. Surveyor interviewed CNA G on 08/18/11 at 12:05 p.m. CNA G stated Resident #18 had a history of [REDACTED]. CNA G stated the facility currently used "mostly" personal alarms and motion sensor alarms (in bed) with two residents also using an alarming seatbelt in their wheelchairs. CNA G stated she did not believe there was any resident except possibly one who used any kind of a pad alarm (which would be more difficult for most residents to remove). Surveyor interviewed Nursing Home Administrator (NHA) 2 on 08/24/11 at 12:08 p.m. NHA 2 stated the facility "probably" did not have a policy or procedure for falls from 05/19/11 to 06/30/11. Resident #18's MDS with a reference date 06/20/11 identified the resident had no cognitive impairment which indicated the resident had the cognitive ability to remove a personal alarm, but required extensive assistance for transfers and ambulation. ROM limitations identified no limitations which indicated the resident had the physical capability to remove a personal alarm. A fall risk assessment completed by the facility, dated 06/24/11, stated Resident #18 scored 42, which was high risk for falls (21-50). On 06/29/11, a nurse's note written at 4:15 p.m. identified Resident #18 had removed her personal alarm so it did not sound and she was found on the floor next to her bed. The resident reported she hit her head and stated, "May have hurt my neck." The resident was initially able to move her head from side to side and point her chin to her chest all without increased discomfort and the only visible injury was a small abrasion to the middle of her back. Nurses' notes during the night of 06/30/11 identified the resident complained of increased neck pain, 9 of 10 on a scale of 0 to 10. Facility staff called the physician and Resident #18 was transferred to the hospital and admitted with a "C2 (second cervical) fracture of the body of the vertebra with extension to the left lateral mass ('odontoid type III fracture')." The hospital history and physical stated it was an "impacted mildly displaced" fracture and identified it was necessary to put the anticoagulation on hold. A hospital consultation identified the fracture as a "compression form of fracture," and suggested two options for treatment (both performed under general anesthesia) including internal fixation with surgical placement of an odontoid screw and application of an external orthotic device such as a Halo brace for immobilization of the neck for a minimum of three to six months. Resident #18's legal representative chose to proceed with the Halo brace knowing it would be on the resident for a minimum of three months. Other hospital records identified Resident #18 had a history of [REDACTED]. Surveyor interviewed NHA 2 and DON C on 08/18/11 at 8:45 a.m. Both identified Resident #18 was at risk for falls and utilized a personal alarm prior to the fall on 06/29/11 when she sustained a cervical fracture. Note: "Elderly trauma patients present unique challenges and face more significant obstacles to recovery than their younger counterparts. The effect of head injury is disproportionately severe in elderly and for a given severity of head injury, more patients require admissions and neurosurgical care...The mortality rate increased with age: the highest mortality was observed in patients aged above [AGE] years (28.6%)." (" Geriatric Head Injuries - Experience and Expectations " 2008) Nurses' notes identified Resident #18 returned to the facility on [DATE] with a (metal) Halo brace in place (to the head). A fall risk assessment completed by the facility, dated 07/02/11, stated Resident #18 scored 30, which was high risk for falls (21-50) and ongoing notes included reports of pain, functional limitations related to the Halo brace, and further incidents of transfer attempts without staff assist. On 07/02/11, a nurse's note identified Resident #18 admitted to having neck pain. Surveyor reviewed the resident's Medication Administration Record (MAR). In June 2011, prior to the cervical fracture, Resident #18 was administered Ibuprofen 3 times and received no Tylenol, both ordered to be given as needed. From 07/02/11 through 07/11/11, Resident #18 was administered Ibuprofen approximately 15 times and Tylenol approximately 8 times, one or both given at least daily. Nurses' notes on 07/12/11 identified the resident might be having "uncontrolled pain" and asking for pain medication when her pain was already out of control. An order was obtained at that time and Tylenol 650 mg was scheduled to be given every six hours, with the Ibuprofen to be continued as needed. Following Resident #18's readmission to the facility, nurses' notes on 07/02/11 identified she used a straw to drink fluids as she was unable to flex her neck and staff were instructed to stand in front of her so she could see them. Nurses' notes on 07/07/11 identified the resident slept poorly as she was repositioned approximately hourly during the night (unable to lay on sides) by placing a pillow under the hips to take pressure off the hips and back, she had some difficulty feeding herself, the resident expressed she was more comfortable laying down rather than sitting up, and it was noted she had difficulty participating in some activities as the Halo brace limited her visual field directly below her head. An occupational therapy (OT) restorative referral, dated 08/04/11, identified several precautions including that the Halo "interferes" with the resident's independence and with balance safety. On 07/02/11, a temporary care plan related to Resident #18's adjustment, following readmission, included that the resident utilized a personal alarm and required staff assistance when up. On 07/02/11, a nurse's note identified Resident #18 was noted to have her legs out of the bed at which time socks were applied to the resident and the personal alarm was attached to one of the socks. On 07/03/11, a nurse's note identified the resident had removed her personal alarm so it did not sound and staff found her attempting to transfer from the wheelchair onto the bed at which time the personal alarm was attached to one of her shoes and (the box part of the alarm) to the foot of the bed. On 07/05/11, nurses' notes identified a motion sensor was added (when in bed) and on 07/06/11 it was identified an (alarmed) self-release belt was added when in the wheelchair. Staff delayed by several days in implementing new approaches. The corresponding Care Area Assessment Summary (CAAS), dated 07/07/11, identified the team had determined Resident #18 was at risk for falls demonstrated by the resident's inability to walk alone due to her recent fall with a C2 fracture. Risk factors included potential injury and complications included Parkinson's disease, history of CVA, memory problems, cerebrovascular disease, chronic pain/weakness, history of falls, and occasional bladder incontinence. On 07/09/11, a nurse's note identified Resident #18 was on 30-minute checks. Monitoring checks provided by the facility on 08/23/11 identified the resident was on consistent 15-minute checks that began on 07/10/11. On 07/29/11, a nurse's note identified the resident "was turning off her alarm today and self-transferred" (it was not identified where she was transferring from or where she was transferring to, and was not identified if the motion sensor or alarming seatbelt had alarmed to alert staff). On 08/17/11 at 11:40 a.m., Surveyor observed Resident #18 with her Halo brace intact, sitting on the edge of her bed, leaning far over to the right, with the string of the personal alarm stretched taut, but still attached and no alarm sounding. Surveyor stepped to the door of the resident's room to attempt to obtain staff's assistance for the resident. There were no staff in sight and Surveyor returned to the resident's bedside and moved close enough to the motion sensor at the foot of the bed to set off the alarm. In less than one minute, DDS A responded to the alarm and assisted the resident. Staff had not appropriately addressed the proper placement and functioning of the personal alarm and the motion sensor to ensure staff would be alerted if the resident sat on the edge of the bed and attempted to self-transfer. Resident #18 is still at the facility and continues with the Halo brace in place. Surveyor interviewed Resident #18 on 08/17/11 at 4:00 p.m. Resident #18 stated she could not see this writer unless standing directly in front of her. Resident #18 also stated there were some activities she could not participate in due to the Halo brace. 2. Resident #21 is an [AGE] year-old female with a current weight of approximately 144 pounds who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident's POA-HC was activated on 11/30/10. Resident #21's significant change Resident Assessment Instrument (RAI) with a reference date of 05/24/11 identified the resident had a score of 4 out of a possible 15, indicating severe cognitive impairment. The resident required minimal assistance for transfers and ambulation but extensive assistance for personal hygiene and toileting. There were no limitations in ROM. The RAI identified one fall since admission. The corresponding Care Area Assessment Summary, dated 05/20/11, identified the team had determined the resident was at risk for falls demonstrated by the resident's decreasing ability to judge safe situations due to her Alzheimer's dementia, dystonic posturing (related to impaired muscle tone), and hypertonia of the right upper extremity. Risk factors included memory issues and complications included falls with fracture. A nurse's note for Resident #21 on 05/23/11 identified a fall risk care plan was completed with interventions including standby assist at all times due to cognitive impairment, unsteady gait, and the recent hospitalization . A fall risk assessment completed by the facility, dated 05/30/11, stated Resident #21 scored 53, which was very high risk for falls (greater than 50). Nurses' notes for Resident #21 identified physician orders [REDACTED]. Nurses' notes identified the resident fell on [DATE] while attempting to use her walker from which she sustained a bruise to the left buttock, the plan put in place following the fall was to monitor her visually with her walker to note any change in gait or balance, and a PT screen identified no need for an evaluation. Nurses' notes identified the resident fell again on 07/01/11 while trying to get up to ambulate. The incident report stated the resident was "shaking" when she was found. Physician orders [REDACTED]. A nurse's note on 07/04/11 identified a CNA reported the resident was "taking off her PA and taking herself to the BA (bathroom)." Nurses' notes on 07/09/11 identified the resident was confused and had a personal alarm "but she takes it off and will ambulate independently." A nurse's note on 07/13/11 stated, "Has removed personal alarms several times today." Facility staff made no changes to the care plan or to the resident's level of supervision after the resident had removed her personal alarm numerous times in 13 days. Staff did not evaluate the continued effectiveness of using a personal alarm, did not evaluate the resident's toileting schedule, or determine why the resident continued to remove the alarm. A nurse's note on 07/22/11 identified Resident #21 was seen by a neurologist who diagnosed the resident with probable partial complex seizures and mild Parkinson's (several weeks of upper extremity shakiness and stiffness). Nurses' notes on 08/01/11, 08/04/11, 08/06/11 and 08/11/11 identified the resident had episodes of decreased responsiveness and/or upper extremity tremors. Nurses' notes identified the resident was sent to the emergency roiagnom on [DATE] (Levaquin, an antibiotic, ordered for seven days as well as Keppra, an anticonvulsant) and on 08/12/11. A nurse's note on 08/14/11 identified the resident had continuous left upper extremity tremors and several incidents of hanging her right leg over the side of the bed. A nurse's note on 08/17/11 stated, "She has been taking PA off and ambulates to the bathroom." Facility staff did not put a new intervention in place to prevent serious injury if Resident #21 fell again. Due to a wandering attempt, Resident #21 remained on visual checks every 15 minutes per the current nursing care plan and every 30 minutes per the current CNA care plan. On 08/18/11 at 10:50 a.m., Surveyor observed Resident #21 asleep in bed with her personal alarm attached to her clothing. At 11:05 a.m., from the hallway outside the resident's room, Surveyor observed Resident #21 transfer herself from the bed to the wheelchair (no alarm sounded) and propel herself into the hallway. There were no facility staff in the hallway until 11:07 a.m. at which time CNA F arrived and Surveyor pointed out Resident #21 was in her wheelchair in the hallway after self-transferring from her bed. CNA F confirmed the personal alarm was not present on the wheelchair and proceeded to obtain it from the resident's room and place it on the wheelchair. Surveyor interviewed CNA F on 08/18/11 at 11:10 a.m. CNA F stated she was the bath aide and was unsure how often Resident #21 removed her personal alarm, but added that if it continued, a different type of alarm would probably be needed for the resident. Surveyor interviewed CNA G on 08/18/11 at 12:05 p.m. CNA G stated Resident #18 had a history of [REDACTED]. CNA G stated the facility currently used "mostly" personal alarms and motion sensor alarms (in bed) with two residents also using an alarming seatbelt in their wheelchairs. CNA G stated she did not believe there was any resident except possibly one who used any kind of a pad alarm (which would be more difficult for most residents to remove). Surveyor interviewed NHA 2 on 08/18/11 at 11:30 a.m. who identified Resident #21 was at high risk for falls and utilized a personal alarm. NHA 2 stated she had previous experience with an "alarm free" facility and expressed success with this. NHA 2 expressed understanding of the importance to assess each resident related to the appropriate safety devices necessary. Failure to provide appropriate supervision and assistance devices to prevent accidents put residents at risk that further potential accidents with serious injury could occur, creating a finding of immediate jeopardy. The immediate jeopardy was removed on 08/25/11, by which time the facility had: 1. Identified all residents at high risk for falls 2. Assessed all high risk residents for the most appropriate safety devices 3. Initiated a temporary plan on how they will manage residents at high risk for falls 4. Trained all staff on the temporary fall management plan The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following: 3. Resident #10 is an [AGE] year-old male with current [DIAGNOSES REDACTED]. Current medications include Depakote (anti-seizure medication) and aspirin daily. The resident's POA-HC was activated on 08/04/10. A fall risk assessment completed by the facility, dated 05/16/11, stated Resident #10 scored 39, which was high risk for falls (21-50). Resident #10's MDS with a reference date of 05/16/11 identified the resident had moderate impairment of hearing and vision, communication deficits, and severe cognitive impairment. It was identified the resident required minimal staff assistance for transfers, supervision with ambulation, and extensive staff assistance for dressing/personal hygiene/toileting. ROM limitations identified bilateral impairment of the upper extremities bilaterally. The MDS identified the resident had at least two falls since admission. On 05/27/11, a "Therapy Referral Form" for Resident #10, signed by a nurse, was marked for deficits or changes in falls, cognition, and comprehension, with these additional comments, "Resident has decline in cognition, is harder to re-direct, is disruptive to other residents (more in evening) (increase) in incontinence? Falls & stumbled." The response from therapy was that speech therapy should evaluate cognition. It was signed by an occupational therapy (OT) aide, dated 06/09/11, and followed by the screening form identified below. On 05/31/11, 06/09/11 (both dates present), a therapy screening form for Resident #10 included the following: recent falls; poor memory/recall; more confusion; harder to redirect; independent with transfers and ambulation with "distant supervision from staff to prevent falls;" and, increased incontinence with "supervised" toileting/transfers. It stated neither an OT nor PT evaluation was recommended but a ST evaluation might be helpful to assess the resident's cognitive level within his [DIAGNOSES REDACTED]." The form identified the "Screen Members" as the OT aide who signed the above "Therapy Referral Form" on 06/09/11, a rehabilitation aide, and the DON (the previous DON). Staff did not provide any evidence therapy or nursing reassessed the resident to ensure he was safe for independent transfers and ambulation. The fall assessments and nurses' notes identified Resident #10 had more falls. On 06/16/11 at 2:45 a.m., the resident was found kneeling on the floor in the front lobby sustaining no injury. On 06/28/11 at 9:00 p.m., the resident was found lying on his back in the dining room sustaining no injury. Incident reports related to these falls, respectively, identified staff should encourage the resident to go to his room at bedtime, and staff should attempt to serve the resident's bedtime snack in his room. Staff did not reassess the resident to ensure he was safe for independent transfers and ambulation. On 07/21/11, nurses' notes identified that at 6:00 p.m., Resident #10 had walked through the dining room, grabbed a chair, attempted to sit down, and missed the chair falling backwards onto the floor hitting his head. The resident sustained [REDACTED]. Diagnostic tests/x-rays revealed no significant injury and following treatment to the head laceration, the resident returned to the facility. Resident #10's nurses' notes identified that on 07/23/11, "...gait appears unsteady at times" and on 08/01/11, ..."more tired all the time...starting to get more resistive with cares." Staff did not reassess the resident to ensure he was safe for independent transfers and ambulation and put appropriate m

Based on observation, interview and record review, the facility did not ensure 1 of 6 residents at risk for falls was provided appropriate supervision and assistance devices to prevent accidents. Resident #1 had a recent history of falls and had a care plan in place which required a low bed, floor mats and alarms. Resident #1 had 12 falls in March 2011 and, on 05/17/11, the resident was left alone in the beauty shop under the hairdryer when her alarmed seatbelt sounded to alert staff she was attempting to get out of her wheelchair. Facility staff did not initiate timely and appropriate interventions for Resident #1 on 03/11/11 and 03/24/11 to decrease the risk for serious injury with further falls, and left the resident in an unsafe manner on 05/17/11 placing her at risk for injury. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] following hospitalization for behavior issues during which time she suffered a fractured hip which required surgical intervention. Other [DIAGNOSES REDACTED]. Resident #1's Resident Assessment Instrument, dated 03/28/11, identified some cognitive impairment (able to answer 11 of 15 questions correctly) and the need for extensive staff assistance with transfers and ambulation. Resident #1's care plan, last edited 04/20/11, stated Resident #1 was unable to ambulate independently or function safely in the environment related to the recent hip fracture and subsequent pain, dementia, decline in continence and mobility and a history of falls. Current approaches included a low bed, floor mats, alarms and a seatbelt. Resident #1's nurses' notes identified falls out of bed on 02/23/11, 03/02/11 and 03/06/11. On 03/11/11, nurses' notes identified the resident was found lying with her upper half on the floor and her lower half on the floor mat when staff went into the room to answer the roommate's alarm. Resident #1 had been incontinent of stool when she was found. On 05/18/11 to 05/26/11, Surveyor reviewed the facility's incident report related to the fall on 03/11/11. It was stated staff were not alerted because Resident #1 had taken off her (personal) alarm. "She is not always compliant with call for assist." It was stated the resident was reoriented as to how to use her call light. Interventions currently in place were the low bed, floor mats, the personal alarm and 30-minute checks. There were no new interventions initiated, except to remind the resident to use her call light. Nurses' notes identified Resident #1 had a fall out of the wheelchair on 03/15/11 and a fall out of bed on 03/16/11 at which time the alarm was not attached and not sounding. A new clasp with a lock was placed for the personal alarm to prevent the resident from removing it and it was identified a motion sensor was in place for added safety when in bed. Resident #1's nurses' notes identified falls out of the wheelchair on 03/22/11 and 03/23/11. On 03/24/11, nurses' notes identified the resident had fallen out of her wheelchair. On 05/18/11 to 05/26/11, Surveyor reviewed the facility's incident report related to the fall on 03/24/11. It was stated staff had met all the resident's needs such as toileting and assisted ambulation. There were no new interventions initiated except "will keep her from injury." Nurses' notes identified subsequent falls on 03/26/11 (lowered during a transfer), 03/29/11 and 03/31/11. The last two falls were out of the wheelchair with interventions including medication changes and a plan for an alarmed seatbelt (on order). Surveyor reviewed the facility's fall protocol on 05/19/11 to 05/26/11 which was dated December 2010. It directed the nurse on duty to initiate a temporary care plan, complete the investigation including factors of the fall and interviews with all witnesses, add interventions to the care plan and care card (for the certified nursing assistant) and notify the Director of Nursing (DON) of the fall. On 05/18/11 at 1:45 p.m., Surveyor met with the DON and reviewed Resident #1's falls on 03/11/11 and 03/24/11. The DON was unable to provide evidence there were adequate interventions initiated in a timely manner following the falls. On 05/17/11 from 11:45 a.m. to 11:55 a.m., Surveyor observed Resident #1 sitting in her wheelchair in the beauty shop under the hairdryer which was turned on. There was no staff in attendance during that time. At 11:55 a.m., Resident #1's alarm sounded and she was observed attempting to unbuckle her alarmed seatbelt. Housekeepers P, Q and R responded to the alarm and Resident #1 stated her head was getting hot. The housekeepers were able to assist Resident #1 so she did not get burned from the hairdryer nor injured from a fall. Surveyor reviewed the above incident with the DON and Social Worker (SW) A during the daily meeting with the facility on 05/18/11. On 05/19/11, the facility provided a statement written by SW A regarding the above incident. The statement confirmed housekeepers heard Resident #1's alarm sounding and responded to the beauty shop at which time the Resident #1 indicated to Housekeeper R that she was hot and Housekeepers P, Q and R proceeded to assist Resident #1.

Based on observation, interview and record review, the facility did not ensure all residents maintained acceptable parameters of nutritional status, such as body weight, for 1 of 2 residents sampled for nutritional risk. Resident #1 experienced significant weight loss (5%) in approximately one month and continued to lose weight. Facility staff did not address the resident's weight loss at the nutritional risk meeting nor evaluate and aggressively intervene. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] following hospitalization for behavior issues during which time she suffered a [MEDICAL CONDITION] which required surgical intervention. Other [DIAGNOSES REDACTED]. The initial nutritional assessment written by Dietary Director (DD) N and dated 03/03/11, identified Resident #1 went from a regular diet to pureed (difficulty swallowing) to mechanical soft with a variable food intake (50 - 75%), was on no oral dietary supplements except [MEDICATION NAME] which was ordered related to the open area on the coccyx and was added to the high risk list related to potential for weight loss. "Nutritional risk factor is rated high at this time." The initial nutritional assessment written by Registered Dietician (RD) O and dated 03/04/11 identified Resident #1's nutritional risk as high due to her overall status. On 03/11/11, a dietary note written by DD N identified a weight of 131 pounds which was within Resident #1's normal range, and the open area had healed. "Will continue to monitor for possibly adding to the high risk group." On 03/22/11, a dietary note written by DD N identified a variable appetite with a weight loss of 6.4 pounds in 28 days (4.9%) and an intervention added to the care plan to offer a snack one hour following a meal if she did not eat at least 50% of the meal. "Have added her to the hi (high) risk list to be reviewed monthly. There were no further dietary notes and there was no change in the resident's nutritional care plan after 03/22/11. On 05/19/11 to 05/26/11, Surveyor reviewed Resident #1's food intake records for March and April 2011. It was identified the resident's food intake decreased significantly (in March and April consumed 25% or less for approximately 16 meals and 34 meals, respectively). On 05/17/11 to 05/26/11, Surveyor reviewed weight records which identified the following weights in pounds for Resident #1: 02/21/11, p.m. shift, 131 03/05/11, day shift, 129.4 03/14/11, day shift, 124.2 03/21/11, day shift, 124.6 03/30/11, day shift, 123.6 04/12/11, day shift, 122.4 04/19/11, p.m. shift, 122.6 05/02/11, day shift, 119.2 05/12/11, day shift, 121.6 05/17/11, day shift, 117.4 Resident #1 lost 7 pounds (5%) in approximately five weeks (using the weight of 129.4 as the resident's usual weight), 10.2 pounds (8%) in approximately two months and 12 pounds (9%) in approximately two and a half months. Surveyor observed Resident #1 eating lunch on 05/16/11 and breakfast on 05/17/11 during which she ate independently and consumed almost 100% of her solid foods. Surveyor interviewed the Director of Nursing (DON) and DD N on 05/18/11 at 1:45 p.m. DD N confirmed there were no further dietary notes for Resident #1 after 03/22/11 and the resident was inadvertently left off the list for the high risk nutritional meeting which was held monthly (confirmed by the DON), with a new RD in April. Surveyor interviewed DD N on 05/19/11 at approximately 3:30 p.m. DD N stated Resident #1 was reweighed on 05/19/11 with a weight of 121 pounds.