Every finding on record at Baldwin Care Center

Based on observation and interview, the facility failed to maintain an effective pest control program so the facility is free of rodents with the potential to affect all 30 residents.Surveyor observed mouse droppings in the dry storage room located in the kitchen area.This is evidenced by:Surveyor reviewed facility policy titled, Pest Control, dated revised on 09/30/2024, which stated in part: .-Purpose: To reduce the potential of specific pest problems within the facility.Policy: Maintenance staff will monitor all parts of the building for prevention and elimination of any insects and/or rodents in a safe, efficient manner.Procedure: A specific pest control service plan will always be in place at facility. Services provided will include prevention and elimination of any insects and/or rodents in a safe, efficient manner. The Maintenance Department is responsible for maintaining a current contract with a pest control company.On 12/08/2025 at 8:47 AM, Surveyor entered kitchen and began tour. Dietary Manager F was in kitchen to walk Surveyor around. Surveyor walked into dry storage room and observed sticky stuff on the floor and debris with trash around on floor under dry storage shelves. Surveyor asked Dietary Manager F if the dry storage room has pest control throughout the kitchen. Dietary Manager F reported to Surveyor that Dietary Manager F does not think there is any pest control units in the kitchen or in the dry storage room. Dietary Manager F Manager reported to Surveyor that underneath the dry storage shelves it appeared dirty. Surveyor requested Dietary Manager F to retrieve pest control policy. On 12/08/25 at 8:48 AM, Surveyor interviewed Maintenance H and asked if the kitchen and dry storage area had pest control. Maintenance H reported to Surveyor that the kitchen does not have any pest control units. Maintenance H took Surveyor outside to show Surveyor there was a pest control unit outside the door for coverage of pests. Surveyor did not observe a pest control outside the back kitchen door. Surveyor asked Maintenance H where the pest control unit was, and Maintenance H reported the unit must be covered with snow. Surveyor asked how often pest control comes to the facility to check units. Maintenance H reported to Surveyor that pest control comes monthly. On 12/08/25 at 9:08 AM, Surveyor re-entered the dry storage room and observed the floor to have been swept. Surveyor observed a mouse dropping on a cardboard box located on the first shelf close to the floor. Surveyor continued to observe mouse droppings in the corner of the dry storage room next to the door. While Surveyor was in the dry storage room Maintenance H walked in with a pest control unit in hand. Surveyor had asked Maintenance H if Maintenance H could please observe the corner near the door and the cardboard box which looked like mouse droppings and explain what it might be. Maintenance H looked and stated, I cannot see down that low as my glasses are in the office. Maintenance H asked if Surveyor could pick up the mouse droppings and show him closer. Surveyor picked up the mouse droppings and showed Maintenance H in Surveyor's hand. Maintenance H stated, Oh yup that is mouse droppings, and we had an issue a few weeks ago and set live traps. We thought we fixed the issue.

Based on observation, staff interview and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Dietary [NAME] G did not monitor that dishes were being washed with the minimum requirement of 120 degrees Fahrenheit for proper sanitization of dishes. Findings include:Surveyor reviewed facility policy titled, Dish Machine Temperature, dated revised on 04/2024, stated in part: .-9. If the temperature gauge on the machine malfunctions, staff will need to clean the dishes twice, once via 120 temperature water and dawn dish soap and then run the dishes through the dish machine. A recorded document will be provided next to the dishwasher, and the Dietary Manager will oversee making [NAME] it is completed and communicated to all staff until further notice.Surveyor reviewed facility policy titled, Dish Machine Operation, dated revised on 04/2024, stated in part: .-3. Wash temperature should reach between 120-140 degrees F. and rinse temperature should reach between 140-160 degrees F when washing dishes.Surveyor reviewed Dish Machine Temperature log dated for the month of November 2025, November 26th being repaired at 2:00 PM, Unable to temperature check dish machine.Surveyor observed November 27th and 28th log was blank for temperature checks.On 12/09/25 at 9:44 AM, Surveyor observed dishwasher located in the back of kitchen. On the dishwasher the machine had a label that stated, Temperature wash should at minimum 120 degrees F. Rinse cycle should be at minimum 140 degrees F. On 12/09/25 at 9:52 AM, Surveyor observed [NAME] G wash dishes in kitchen area. [NAME] G began loading dishes into the dishwasher. Surveyor observed temperature of dishwasher on wash cycle with temperature of 111 degrees Fahrenheit, and then the rinse cycle was temperature of 119 degrees Fahrenheit. Surveyor never observed temperature gauge exceed 119 degrees Fahrenheit.On 12/09/25 at 10:01 AM, Surveyor interviewed Dietary Manager (DM) F and asked if the dishwasher is a high temp dishwasher or chemical sanitization dishwasher. DM F reported to Surveyor that the dishwasher is a chemical sanitization dishwasher, and the facility switched over in the last year and half. On 12/09/25 at 3:35 PM, Surveyor interviewed DM F and asked if DM F was aware the thermometer on the dishwasher was not functioning properly, and that staff are not checking the temperature during dishwashing cycle. Surveyor reported to DM F the temperature only rose to 111 degrees Fahrenheit on the wash cycle and 119 degrees Fahrenheit on the rinse cycle when observing [NAME] G during washing of the dishes. DM F reported to Surveyor that the dishwasher had an issue with the booster heater malfunctioning causing the thermometer to not work about a week or so ago and they had someone come out to try and fix it. DM F reported the person instructed DM F that the thermometer will need to be recalibrated. DM F then verbally reported the calibration request to Maintenance H to call the [name of] company who provides maintenance for the dishwasher in the kitchen. Surveyor requested documentation that Maintenance H contacted name of company of the need for the recalibration of thermometer. DM F reported that DM F would gather from Maintenance H. On 12/10/25 at 6:45 AM, Surveyor interviewed DM F who stated, [Nursing Home Administrator (NHA) A] tried calling [name of] company for records that the company was called about the recalibration and there was no recollection that the company was notified. DM F reported to Surveyor that Maintenance H must have not notified the company of the needed recalibration of the thermometer. On 12/10/25 at 7:10 AM, Surveyor interviewed NHA A and asked for confirmation that [name of] company was notified of the need for recalibration of the dishwashing machine in the kitchen. NHA A reported that NHA A made a call yesterday and the company was not aware that the dishwasher needed recalibration. NHA A reported to Surveyor that NHA A placed a work ticket in yesterday on 12/09/25 since it was not completed by Maintenance H. NHA A provided Surveyor with an invoice from the original company that came to repair the booster heater on 12/01/25 that stated, Checked water going in at 200 degrees and coming out at 152 degrees, but that the customers gauge said 120 degrees out, so facility was going to get a new thermometer changed out.

Based on record review and interview, the facility did not ensure residents/representatives received notice before transfer or discharge, notice of bed-hold policy, and did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman Notification for 2 of 2 residents (R7 and R39). R7 and/or representative were not provided/received notice of transfer to hospital, notice of bed-hold policy and facility did not notify Ombudsman of transfer.Facility did not notify Ombudsman of R39's discharge. The facility policy titled Notice of Bedhold Policies undated, states in part: If a Resident of [name of facility] is temporarily transferred to a hospital or another health care facility for emergency care .[Facility] will hold the resident's bed until the resident or residents representative waives the right to have the bed held for the resident.The facility policy titled Notice of Transfer/Discharge undated, states in part, This information is provided to a resident and/or resident representative at the time of the resident's transfer to a hospital of more appropriate health care facility or a discharge to home or a therapeutic leave, so as to inform the resident and/or resident representative of the resident's transfer/discharge and the facility's bedhold policies and the resident's rights to appeal the transfer/discharge.The facility policy titled Notification of Ombudsman states purpose: To provide the Ombudsman with the list of residents who have unplanned transfers or discharges from the [name of facility] monthly R7 was transferred to hospital on [DATE] following a fall with head injury and facility did not provide a copy of the bed hold, notice of transfers or inform the State Long Term Care Ombudsman.R39 discharged Against Medical Advice (AMA) on 10/07/25 and facility did not inform the State Long Term Care Ombudsman.On 12/10/25 at 10:18 AM, Surveyor interviewed Social Worker E and requested documentation of notice of transfer, bed hold and notification to Ombudsman for R7 and notification to Ombudsman for R39. Social Worker E stated she was unable to provide documentation due to being unaware of the need to provide notice of transfer, and notification to Ombudsman for R7, nor to provide notification to Ombudsman for R39's discharge.

Based on observation, interview and record review, the facility did not follow best standards of practice when administering medication for 1 resident (R26) of 25 residents reviewed for medication administrationR26's Gabapentin medication was removed from its original packaging from pharmacy, placed into a medication cup, stored in a locked cupboard to be administered 2 hours later to a resident, which has potential for a medication related adverse event to occur.Findings include:Wisconsin State Legislature, 132.65 Section 7(b) states in part: Additional requirements for unit dose systems.the individual medication shall remain in the identifiable unit dose package until directly administered to the resident.R26 was admitted to the facility on [DATE] and has a Brief Interview for Mental Status (BIMS) score of 3/15, meaning severe cognitive impairment. On 12/09/25 at 7:38 AM, during Surveyor observation of medication administration, Registered Nurse (RN) J prepared R26's morning medications to be given before breakfast. One of R26's medications, Gabapentin (an anticonvulsant which is often used for chronic neuropathic pain control), was scheduled to be given at 10:00 AM daily. RN J removed Gabapentin 100mg tablet from its original identifiable unit dose packaging as received from the pharmacy, placed the medication into a medication cup, labeled medication with R26's name, medication, dose, date and time, and RN J's initials. RN J then placed the medication cup in the locked medication storage cupboard outside of R26's room with intent to administer it at 10:00 AM. It is to be noted that every resident has an individual locked medication cupboard outside of their rooms. Prior to this, RN J verified correct medication and dosage against the physician orders on R26's Medication Administration Record (MAR).On 12/09/25 at 7:40 AM, Surveyor asked RN J the reasoning behind preparing medication ahead of time and storing in R26's medication cupboard. R26 stated it was easier to do this because the medication carts with computers are separate from where medications are stored for residents. RN J indicated when medications are to be given later, this allows the RN to administer the medication without having to bring medication cart back to the room. R26 stated she would be the nurse administering the medication at 10:00 AM.On 12/09/25 at 9:00 AM, record review of R26's MAR shows Gabapentin 100mg tablet to be given at 10:00 AM. This was compared against physician order, which stated same medication, dosage, and time for administration.On 12/09/25 at 11:55 AM, record review of R26's MAR showed RN J's initials for administration of Gabapentin 100mg at 10:00 AM.On 12/11/25 at 7:48 AM, Surveyor interviewed RN D and asked what the facility's practice was for administering medications scheduled for times other than morning, noon, or at bedtime. RN D stated medications are sometimes prepared ahead of time by removing them from the original identifiable packaging from pharmacy, placed in medication cups which are labeled with resident's name, drug name and dosage, and time to be given, and then placed into a locked drawer in the portable medication cart. RN D also stated this was done when residents had requests for medications to be given at different times than their regular medications, for example, after a meal.On 12/10/25 at 12:31 PM, Surveyor interviewed Director of Nursing (DON) B on the facility's standard of practice for administering medications. DON B stated all medications should be administered at time scheduled. DON B stated Centers for Medicare/Medicaid Services states it is allowable to prepare medications ahead of time, if they are labeled with resident's name, drug, dose and time to be given, and placed in a locked area. Surveyor asked DON B if in the event the nurse who prepared the medication had to leave the facility unexpectedly, was it expected for another nurse to administer a medication they did not prepare themselves, and when it was not in its original, identifiable packaging. DON B stated the bubble packaging with more of the medication is in the cupboard, and the nurse administering can either compare the appearance of the medication against the packaging of look-alike medication or throw the medication away and start over. They would contact pharmacy later to replace the wasted medication.

Based on observation, record review and interview, the facility did not ensure procedures were in place to ensure medication with expired dates were removed/destroyed from 1 of 2 medication storage rooms.Four bottles of Aspirin were expired in 1 of 2 medication storage rooms.On 12/09/2025 at 1:40 PM, Surveyor observed the medication storage room on one unit with assist of Registered Nurse (RN) D and observed 4 bottles of Aspirin 325 mg that were expired: 2 unopened bottles that expired June 2025; 1 bottle open with approximately 1/2 of remaining tablets that expired June 2025; and 1 unopened bottle expired August of 2025. RN D stated there was a resident who was in the facility during June 2025, who the bottles of Aspirin were used for. This resident was no longer in the facility and no other resident since then required Aspirin 325mg. RN D stated RN D will destroy immediately. On 12/09/2025 at 1:46 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation of 4 bottles of expired medication in storage room. DON B indicated was not aware of expired medications in medication storage.

Based on observation and interview, the facility did not maintain infection prevention to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infection for 2 residents (R32, R17) of 5 residents reviewed for infection prevention in a sample of 12.Facility did not:Perform hand hygiene between feeding multiple residents at same time which could result in possible infection transmission. Perform hand hygiene after touching contaminated surfaces and prior to feeding residents which could result in possible infection transmission by cross contamination.Offer hand hygiene to residents prior to meal being served.Perform hand hygiene during peri-area cares which could result in possible infection transmission.Findings include: Example 1 Facility policy titled Hand Hygiene Policy for dining room/feeding, revised 03/2023, states in part: Nursing Staff of [NAME] Care Center will perform adequate hand hygiene at all appropriate times to reduce the spread of infection to other residents.before, during and after feeding. Step 1. Make sure all residents are offered the opportunity to clean their hands with hand sanitizer. They do have the right to refuse. Step 3. Staff are to sanitize their hands between each resident when feeding more than one resident. R32 was admitted to facility on 05/31/2012, and has a BIMS score of 0, meaning severe cognitive impairment. R32's Minimum Data Set (MDS), dated [DATE], indicated that R32 requires substantial/maximum assist with feeding. R17 was admitted to the facility on [DATE], and has a BIMS score of 3, meaning severe cognitive impairment. R17's MDS, dated [DATE], indicated that R17 requires substantial/maximum assist with feeding. On 12/08/25 at 12:20 PM, Surveyor observed R32 and R17 sitting alongside each other at dining table with Certified Nursing Assistant (CNA) I between them. CNA I alternated spooning food into the mouths of R32 and R17 with bare hands, using feeding utensils. CNA I touched body surfaces of both residents and did not perform hand hygiene in between alternating feedings for both. CNA I was then observed pouring water from a pitcher into a glass at kitchenette counter, touching counter surface, pitcher, water glass, and another resident's wheelchair with bare hands. No hand hygiene was done before CNA I resumed assisting with feeding for R17 and R32, or in between feedings of both residents. On 12/08/25 at 12:25 PM, Surveyor observed CNA I wipe R17's mouth with a napkin using bare hands, set napkin down onto table, not perform hand hygiene, then assist R32 with feeding. CNA I then wiped R32's mouth with a napkin using bare hands and returned to feeding R17. No hand hygiene done in between. On 12/10/25 at 11:58 AM, Surveyor observed CNA I assist R17 to drink from a glass, holding the straw with bare hands and directing it into R17's mouth. CNA I then proceeded to assist R32 with feeding without performing hand hygiene first. On 12/10/25 at 12:15 AM, Surveyor interviewed CNA I on expectations of staff to perform hand hygiene during feeding assistance of multiple residents at one time. CNA I stated if only the feeding utensils were touched while feeding multiple residents, no hand hygiene in between was needed. CNA I stated there are no instances of cross contamination that happens any other time, including after touching surfaces. CNA I was asked what resources are available for staff to perform hand hygiene during feeding, and CNA I pointed to a sink nearby. On 12/09/25 at 7:43 AM, Surveyor observed two residents be rolled up to a table by a staff person for breakfast. Food was immediately served to both residents without staff first offering hand hygiene to them. Both residents were independent with feeding. No hand hygiene product was available at table for residents to assist themselves to. On 12/10/25 at 11:58 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations of staff were during dining times in regard to hand hygiene for residents and staff. DON B stated all residents are to be offered hand hygiene prior to meals being served. Staff is to wash hands or use alcohol-based product themselves before assisting residents with feeding, after touching contaminated surfaces such as wheelchairs and tables and before feeding residents and in between feeding multiple residents at one time. Example 2 Facility policy titled Perineal (Peri) Care Policy for Elderly Residents revised 03/2024, states: Purpose: To ensure safe, hygienic, and dignified perineal care for elderly residents while preventing cross-contamination through proper glove use and hand hygiene. Under the section identified Procedure B(2) states in part, 2. Specific steps during peri care – you must change gloves and perform hand hygiene at the following points: A. After removing soiled incontinence productsB. After cleaning the genital area (front)C. After cleansing the anal area (back) On 12/09/2025 at 7:18 AM, Surveyor observed CNA C conduct morning cares that included incontinence care on R17. CNA C conducted hand hygiene and donned clean gloves. After completing upper body cleansing, CNA C removed urine soiled incontinent product and did not remove gloves and conduct hand hygiene until the following tasks were completed: CNA C obtained a premoistened wipe from a package, cleansed R17's anal area, touched and positioned a clean incontinent product under R17's bottom, picked up a bottle of powder and sprinkled on R17's bottom, reached and obtained a premoistened wipe from package, cleansed R17's front genital area, fastened clean incontinent product. On 12/09/2025 at 7:43 AM, Surveyor interviewed CNA C regarding facility's expectations on when to remove gloves and conduct hand hygiene. CNA C stated, Before and after all cares and when there is BM on gloves. Surveyor asked what the facility's expectation of glove removal and hand hygiene is when going from contaminated area to clean area. CNA C stated expectation would be to change gloves and conduct hand hygiene. Surveyor shared observation of conducting rectal area cleansing then proceeding to frontal peri care and no observation of removing gloves and conducting during incontinence care. CNA C confirmed, I did not, and stated, Should not go from icky part to frontal part. On 12/09/2025 at 2:02 PM, Surveyor interviewed DON B regarding observation of incontinence care conducted by CNA C, wherein cleansing of rectal area prior to vaginal area and no observation of glove change or hand hygiene in-between. DON B stated was made aware of same and expectation would be for staff to conduct frontal peri care prior to posterior care and to remove gloves and conduct hand hygiene in-between clean/dirty areas.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility did not adequately clean light fixtures that were placed above serving areas. The facility did not ensure staff used proper hand hygiene when distributing food. This has the ability to affect all 39 of 39 residents residing in the facility. Findings include: The facility policy entitled, Use of Plastic Gloves, dated 05/05/21 states, 3. REMEMBER GLOVES ARE JUST LIKE HANDS. THEY GET SOILED. ANYTIME YOU TOUCH A CONTAMINATED SURFACE, THE GLOVES MUST BE CHANGED . f. anytime you tough a contaminated surface. g. During food preparations, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. 4. Wash hands after removing gloves. The facility policy entitled, General Food Preparation and Handling, dated 05/05/21 states, Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and free of injurious organisms and substances. Procedure: 1. The kitchen is kept neat and orderly, a. the kitchen and equipment are clean. On 08/06/24 at 12:14 PM, Surveyor observed Utility Aide (UA) I shuffling through meal tickets, with same gloved hands. UA I grabbed a side salad, removed the plastic and grabbed a clean plate. With the same contaminated gloved hands, grabbed a bun. UA I then used a knife to cut sandwich in half and used dirty gloved hands to grab half of sandwich to put on another plate. With the same dirty gloved hands UA I grabbed a bun out of package and put rib sandwich on another plate. UA I then went back to shuffling through meal tickets, removed gloves, washed hands and put on new gloves. UA I grabbed plate, bun, removed cover from steam table, dished up sandwich and grabbed new plate. This continued for the duration of dining affecting all who were eating in the first dining room. During observations, Surveyor noted a layer of dust on top of the light fixtures that reside above the serving area; dust was visible from 15 feet away. The light fixtures are located over open containers of food that were to be served to residents. On 08/06/24 at 12:23 PM, Surveyor observed Dietary Aide (DA) M serving food to residents. During food service, DA M would touch the meal tickets which were paper and then touch ready to eat buns with the same gloved hand without changing gloves and using hand hygiene practices. DA M would also touch all plates and bowls that were used to serve residents in the dining area. Surveyor observed DA M shuffling through meal tickets then, with same gloved hands, grabbing side salad and buns, grabbed a clean plate, and grabbed a different bun. At no time were the gloves changed. This continued for the duration of the service affecting all residents being served from the second dining area. During observations, Surveyor noted a layer of dust on top of the light fixtures that are above the serving area. Dust was visible from 15 feet away and was located over open containers of food that were to be served to residents. On 08/07/24 at 12:50 PM, Surveyor interviewed DA O regarding the dust on the light fixtures that was still there. DA O said that maintenance is in charge of cleaning them. DA O did step back and look at the lights and agreed there was a layer of dust on them indicating it had not been cleaned in a while. On 08/07/24 at 1:54 PM, Surveyor interviewed Dietary Manager (DM) L regarding expectations for hand hygiene and cleanliness in the serving areas. DM L said they would not expect there to be dust build up above an area that food was being served. DM L also said they have been working on a system where staff are not touching the papers while serving food. When asked about the location of the papers prior to getting to the serving areas, DM L stated those papers (individual dietary tickets) had been everywhere from the kitchen, printer area, and serving area and possibly other places.

Based on observation, interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 39 residents in the facility. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 and Norovirus during an outbreak. -Certified Nursing Assistant (CNA) did not perform hand hygiene during water pass that affected all residents. -Observations were made of the facility not implementing Enhanced Barrier Precautions (EBP) for 2 sampled residents on EBP. -CNAs were observed not wiping down Hoyer lifts after leaving an EBP room for R34 and R16. This is evidenced by: Example 1: Surveyor reviewed Infection Control (IC) surveillance logs and found the facility identified the facility had an outbreak of Norovirus January and February 2024. Surveyor could not distinguish when outbreak began and when outbreak ended. Surveillance logs were observed missing information identifying when precautions were implemented, any testing, last well date, when symptoms ended, when precautions ended, and if provider was notified. Surveyor reviewed IC surveillance logs and found the facility identified the facility had an outbreak of COVID-19 in September, October, and November 2023 that affected staff and residents. Surveyor could not distinguish when outbreak began and when outbreak ended. Surveillance logs were observed missing information identifying where infected staff last worked, when precautions were implemented, any testing, last well date, when symptoms ended, when precautions ended, and if provider was notified. Surveyor reviewed IC August 2023- July 2024 data line lists for residents and staff. Surveyor noted that all line lists from August 2023-July 2024 were inconsistent and missing data. Surveyor reviewed and noted line lists were missing the infection site, pathogen, signs and symptoms, residents', or staff's location, last well date, any summary and analysis of the number of residents and staff who developed infections. Line lists had incomplete data. On 08/08/24 at 8:37 AM, Surveyor interviewed Director of Nursing (DON) B and asked about infection surveillance logs dating back to last survey 08/23 and if DON B could provide line lists for residents monthly. DON B indicated that DON B was confused and unsure what line lists Surveyor is asking for. Surveyor explained to DON B that Surveyor was requesting monthly logs of infections residents acquire and what criteria is utilized to diagnosis appropriate antibiotic usage. DON B indicated that DON B uses the NSHN for this data. DON B indicated that DON B would gather documentation for Surveyor soon. On 08/08/24 at 10:01 AM, DON B provided infection control logs for residents monthly from August 2023-July 2024. Surveyor reviewed infection control logs and observed line list to be missing data. Surveyor interviewed DON B and asked that DON B provide any other documentation pertaining to the norovirus outbreak in January 2024, and the COVID-19 outbreak from September 2023 to November 2023 with information regarding isolation start and stop dates, interventions put into place to prevent the spread of the viruses, and any summary on when the facility deemed the outbreaks to begin and end. Surveyor requested information explaining the location where staff worked during the outbreak that became exposed or infected. DON B indicated to Surveyor that DON B does not have that information and DON B didn't realize it needed to be documented. Example 2: The facility policy entitled, Hand hygiene, dated 03/2023, states in part: .#8. It is necessary to wash your hands at the following times: -before and after gloving or changing gloves. -After handling soiled equipment or utensils . On 08/06/24 from 1:34 PM to 2:02 PM, Surveyor observed continuous observation of Utility Aide (UA) I enter rooms 1-29 without changing gloves in between passing water pitchers. UA I applied gloves without performing hand hygiene. UA I took new water pitcher into each room and brought used water pitcher out of every room. Surveyor did not observe UA I take gloves off, wash hands, or sanitize hands between delivering new water pitchers and touching old water pitchers, placing the water pitchers on cart, then entering more rooms. Surveyor observed UA I continue to other side of the building to deliver water pitchers to rest of rooms in the facility with the same gloves on. On 08/06/24 at 2:03 PM, Surveyor interviewed UA I and asked what UA I's process is for hand hygiene between delivering new water pitchers and taking residents' old water pitchers out of rooms. UA I indicated that normally UA I enters residents' rooms with gloves on, takes the paper off the straws, and then takes residents' old pitchers out, places on the water pitcher cart, and then goes to the next resident and so on. Surveyor asked if UA I changes gloves in between delivering water pitchers between residents. UA I indicated that UA I should be. Surveyor asked if UA I changed gloves and performed hand hygiene in between clean and dirty during water pass. UA I indicated no, UA I did not change gloves and used same pair of gloves for every resident in rooms 1-29. 40181 Example 3 According to CDC guidance entitled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), last updated 07/12/22, .EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization . R15 was admitted to the facility on [DATE] with the following diagnoses, in part, multiple rib fractures right side, acute embolism and thrombosis, chronic peripheral venous insufficiency, and lymphedema. R15 had chronic venous stasis wounds on both lower legs. R15 was re-hospitalized on [DATE] for a ruptured appendix and had an abdominal drain tube in place at the time of the survey. On 08/06/24 at 9:32 AM, Surveyor observed an EBP sign on the outside of the door to R15's room. On 08/07/24 at 2:09 PM, Surveyor observed Registered Nurse (RN) K enter R15's room to assess the drainage tube dressing site. RN K used hand sanitizer and obtained a gauze dressing from R15's medication cupboard prior to entering the room. R15 requested assistance to use the bathroom prior to RN K changing drainage tube dressing. RN K washed hands in bathroom and put on clean gloves. RN K assisted R15 to stand and pivot transfer to the toilet and assisted to pull down pants and brief before sitting down on the toilet. RN K assisted R15 to stand, pull up pants and fasten brief and pivot to wheelchair after R15 was finished using the toilet. RN removed gloves, washed hands with soap and water in the bathroom, and put on clean gloves. RN K lifted R15's shirt, pulled down the side of the pants waistband and unfastened the side of the brief to visualize the dressing over the drain tubing on R15's abdomen. RN K observed the dressing was clean, dry, and intact with no signs of drainage, no redness or tenderness noted around edges of dressing. RN K stated the dressing did not need to be changed. RN K re-fastened the brief and adjusted R15's clothing. RN K removed the gloves and used hand sanitizer. RN K did not wear a gown prior to assisting R15 with any of the high-contact cares. Following the observation, Surveyor asked RN K if R15 was on EBP. RN K said R15 was on EBP because of the drain tube and chronic wounds on the lower legs. Surveyor asked if RN K should have put a gown on in addition to the gloves prior to assisting R15 with high-contact cares. RN K said they should have put a gown on prior to providing cares. On 08/08/24 at 8:38 AM, Surveyor interviewed DON B and reviewed the observation of RN K providing cares for R15 without a gown on. Surveyor asked DON B what guidance they follow for EBP. DON B stated they follow Centers for Disease Control (CDC) guidance for EBP. DON B stated RN K should have worn a gown and gloves to assist R15 with toileting. Example 4 R11 was admitted to the facility on [DATE], and has diagnoses that include dementia, hypertension, bladder neck obstruction, and atrial fibrillation. On the outside of R11's door was a sign that read in part, Enhanced Barrier Precauitions providers and staff must also wear gloves and a gown for the following high contact resident care activities device care of use: urinary catheters. On 08/07/24 at 11:19 AM, Surveyor observed CNA C went into R11's room. Surveyor heard what sounded like a graduate being set on the floor so Surveyor entered the room, CNA C had graduate on the floor, no barrier down and no personal protective equipment (PPE) on. CNA C was in the middle of emptying the catheter bag. Surveyor observed CNA C then get a wipe and wiped the port before closing it and putting the catheter bag away. CNA C then took the graduate with urine in it and dumped the urine in the toilet. On 08/07/24 at about 3:30 PM, Surveyor interviewed CNA C and asked how CNA C knows when a resident is on precautions. CNA C indicated usually there is a sign on the door and a bin outside the room. Surveyor asked CNA C about R11 and if CNA C knew R11 was on enhanced barrier precautions (EBP). CNA C indicated they did not know and asked Surveyor where the gowns are then. CNA C then went to another resident's room and asked a visitor where the PPE was kept. On 08/08/24 at 8:37 AM, Surveyor interviewed RN D and asked how they know if a resident is on EBP. RN D indicated there is a sign on the outside of the door and PPE in cart in the bathroom. Surveyor then asked RN D if a CNA is emptying a catheter should they be wearing PPE. RN D indicated yes. On 08/08/24 at 9:02 AM, Surveyor interviewed CNA E and asked how CNA E knows if a resident is on EBP. CNA E indicated there is a sign on the door and PPE in a 3 drawer bin in the bathroom. Surveyor asked CNA E if a resident is on EBP and you were to go empty the resident's catheter should you wear PPE. CNA E indicated yes. On 08/08/24 at 9:11 AM, Surveyor interviewed RN F, who is also the care coordinator, if a CNA goes in a room to empty a catheter bag and the resident is on EBP should the CNA wear PPE. RN F indicated yes. On 08/08/24 at 10:00 AM, Surveyor interviewed DON B and asked what guidelines they follow for EBP. DON B indicated they follow CDC guidelines. Example 5 Facility policy entitled, Cleaning Communal Equipment, states in part, Policy: Use Sanitary equipment on all residents. Purpose: To prevent the spread of infection from resident to resident. Communal Equipment: .Lift equipment .Action: .Disinfects equipment (non-porous) between each resident using Germicidal/Disinfectant Wipes per manufacturer recommendations . On 08/06/24 at 10:08 AM, Surveyor observed CNA C transfer R34 using a mechanical lift with the assistance of another staff member. At 10:14 AM, Surveyor observed CNA C bring the mechanical lift out of R34's room and bring it into R16's room to assist R16 with a transfer using the mechanical lift. CNA C did not wipe the mechanical lift with a Germicidal/Disinfectant wipe between use. At 10:21 AM, Surveyor observed CNA C bring the lift out of R16's room and place it in a closet in the hallway. CNA C did not wipe the lift with a Germicidal/Disinfectant wipe prior to leaving it in the closet. On 08/08/24 at 8:38 AM, Surveyor interviewed DON B and asked what the facility policy is for disinfecting mechanical lifts between resident use. DON B stated the facility policy stated staff should disinfect the mechanical lifts after each use. Surveyor explained the observation of CNA C using a mechanical lift without disinfecting it between residents. DON B stated CNA C did not follow the facility policy and education would be provided. 43352

Based on observations, interview and record review the facility did not consult with the physician for changes in condition for R3. This occurred for 1 of 2 sampled residents (R) R3. R3 was admitted to the facility on [DATE] and has diagnoses that include heart failure, dementia, type 2 diabetes, major depressive disorder, hypertension and congestive heart failure. On 08/07/24 at 10:01 AM, Surveyor observed Licensed Practical Nurse (LPN) G complete a dressing change on R3's right leg. R3's leg was red and shiny in color; the wounds were weeping and open. R3 was complaining about the back of their calf hurting. After the bandages were applied, R3 and family member decided to go to urgent care to rule out a blood clot. R3 had doctor's orders that read, Weigh 2 times per week, Monday and Friday AM monitor weight call MD if goes up. On 7/01/24, R3 weighed 158.4 pounds. On 07/04/24, R3 weighed 168 pounds. On 7/23/24, R3 weighed 157.6 pounds. On 7/26/24, R3 weighed 164.2 pounds. On 08/02/24, R3 weighed 164.2 pounds. On 08/05/24, R3 weighed 166.8 pounds. On 08/07/24 at 12:13 PM, Surveyor interviewed Director of Nursing (DON) B and asked what the policy was for contacting the doctor for weight gain when a resident has congestive heart failure. DON B indicated if there is a 3 pound weight gain in 1 day or 5 pounds in 3 days. Surveyor then asked DON B for proof of doctor notification for R3's weight gain on 07/04/24 and 07/26/24. On 08/07/24 at 12:35 AM, DON B returned to the conference room and could not find any doctor notifications. On 08/08/24 at 3:40 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if there was a system in place when there is a weight loss or gain. NHA A indicated that the system doesn't flag them. On 08/08/24, Surveyor requested discharge notes from 08/07/24 visit to urgent care. On the Medical Exchange Form, under diagnosis R3 was diagnosed as having cellulitis of the right lower extremity and put on an antibiotic.

Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 28 medication opportunities, resulting in an error rate of 7.14%. Staff administered 2 insulin injections without knowing if the insulin was expired. This affected 1 of 11 residents (R31) observed for medication administration. Findings include: Facility entitled, Insulin Administration, stated in part, .Steps in the Procedure .3. Remove insulin from storage point. 4. Check date medication was first opened. 5. Check expiration date . According to the American Diabetes Association, insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 and 86 degrees F for up to 28 days and continue to work. After 28 days the insulin should be discarded. On [DATE] at 7:26 AM, Surveyor observed Licensed Practical Nurse (LPN) J administer two insulin injections to R31. LPN J took two insulin pens out of R31's medication cupboard, Insulin Glargine and Insulin Novolog. LPN J verified the pens with the orders on R31's medication administration record. LPN J prepared both insulin pens per proper procedure and showed the pens to Surveyor. Surveyor noted neither pen was dated with date opened or discard date. Surveyor asked LPN J what the facility policy was for dating insulin pens when first opened. LPN J stated they were supposed to label the pens with the date opened, so they know when to discard the pens. LPN J then looked at the date dispensed on the medication labels and wrote a date opened on each insulin pen. LPN J then administered both insulin injections to R31. LPN J did not verify when the pens were opened or if they were beyond the discard date prior to administering the injections. On [DATE] at 12:13 PM, Surveyor interviewed Director of Nursing (DON) B and asked the facility policy for labeling insulin pens when opening for the first time. DON B stated the nurses should label all insulin pens with date opened when they take out a new pen, so they know when the pen should be discarded. DON B stated LPN J should have discarded the pens if the opened and discard dates were unknown.

Based on observation, interview, and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R4) received care consistent with professional standards of practice to prevent and promote healing of existing PIs. R4 did not have comprehensive weekly assessments of R4's pressure injuries. Physician was not notified when PI had increased size or changes in drainage. R4's pressure relief for ankle was not observed. R4 was not repositioned as instructed on the PI care plan. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 07, March 2024, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side-lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free from the bed, use heel offloading devices for high-risk pressure injuries. Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2019, Pressure Injury Prevention Points, accessed 19, August 2024, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Assess the physical characteristics of the wound bed and the surrounding skin and soft tissue at each pressure injury assessment. The facility policy entitled, Skin Conditioning Monitoring, dated 06/15/23, states in part: .1. Head to toe skin assessment upon admission and weekly. 2. Risk assessment Braden scale upon admission, weekly x4, and ten quarterly, annually, and with significant change of condition. 3. Comprehensive skin risk data collection upon admission, quarterly, annually, and with significant change. 7. Notify MD and obtain orders to treat skin breakdown and notify family/responsible party. Initiate new orders. 8. Document in nurse notes giving description of characteristics of area. Weekly assessment, measurement, and status of area to be documented weekly in nurses' notes until resolved. Document condition with treatment and or observation of area on treatment record. 9. Initiate appropriate measures to aid in prevention of skin breakdown (skin care for dry skin, turning/repositioning schedule while in bed and chair). Update plan of care as appropriate. 11. MD will be updated if area opens or deteriorated. Changes in medical interventions as needed will be obtained . R4 was admitted to the facility on [DATE] with diagnoses including, in part, two stage II PIs, one stage III PI, paraplegic, neurogenic bladder, anemia, coronary artery disease, heart failure, anxiety, and depression. R4's Minimum Data Set (MDS) assessment, dated 04/09/24, identified on admission that R4 had a Brief Interview for Mental Status (BIMS) score of 13. This indicated R4 had moderate cognitive impairment. The MDS assessment also identified R4 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R4 was determined to be at risk for PIs and currently had two stage II PIs and one stage III PI. Surveyor reviewed R4's care plan: Initiated on 04/12/24: -Assess skin condition as appropriate. Treat as ordered. -Hospice doing wound care. Facility staff doing prn wound care. -Keep skin clean and dry, develop monitoring turning schedule, observe skin during cares. -Encourage/assist to assure position changes every two hours minimum. -Elevate heels off the surface of the mattress to reduce pressure on heels. Initiated on 05/16/24: -Air mattress on bed. Initiated on 06/05/24: -Apply barrier cream to peri rectal area. Surveyor reviewed Activities of Daily Living (ADL) sheet: -Turn about every 2 hours when in bed. -Bed mobility with 1-2 assist. -Transfer Hoyer with 2 assists. Surveyor reviewed admission assessment: -On 03/28/24, 3 pressure injuries to coccyx, right knee, and right ankle. Facility did not complete a complete PI assessment for R4 upon admission, to include physical characteristics of the wound bed and surrounding skin/soft tissue such as categorizing the stage of the PIs, size/surface area, tissue type, color, peri wound condition, wound edges, sinus tracts: i.e., undermining, exudate, or odor of the PIs. Surveyor reviewed Braden Scale for predicting pressure sore risk assessment: -On 03/29/24, resident scored 13 indicating that R4 was at moderate risk for pressure injuries. No other Braden scale assessments were completed. Surveyor reviewed comprehensive skin risk data collection sheet dated 03/29/24 which indicated, Resident is on hospice and is paraplegic and has 3 pressure injuries to coccyx, right knee, and right ankle. Surveyor did not observe any other skin risk data collection sheets since 3/29/24. Surveyor reviewed progress notes: -On 05/03/24 - Resident has open areas on coccyx, right knee, and right ankle. Receives application of dressings. -On 05/23/24 - Dressing changed to right outer ankle, foul smelling drainage present, area cleansed and patted dry. Silver alginate applied per instructions. Foam dressing applied with skin prep. The MD was not notified of the foul-smelling drainage. -On 06/26/24 - Left lower buttock necrotic eschar black and brown wound bed, unstageable 2 cm x 2.5 cm x .5 cm. -On 06/27/24 - Left gluteal fold 2.5 cm x 2.5 cm x .5 cm. Surrounding skin discolored and scarred. Wound bed is 100% necrotic adherent brown, black tissue present. -On 07/24/24 - Left lower buttock becoming deeper and larger, 3 cm x 3.7 cm x 1.3 cm. Unstageable eschar necrotic brown and black slough. The MD was not notified of the deeper and larger condition of the PI. -On 07/24/24 - Stage 3 PI right lateral malleolus. Slough 100%, pale yellow, pallor noted, light serous non-odorous 1.9 cm x 1.5 cm x .3 cm. -On 07/24/24 - Stage 2 PI left mid buttock (left gluteal fold) .7 cm x .7 cm x .1 cm. -On 07/25/24 - Stage 3 PI right lateral malleolus. 1.9 cm x 1.5 cm x .3 cm. -On 07/31/24 - Dressings changed to buttock areas and right outer ankle stage 3, use of pressure reduction/relieving devices in place, teaching resident how to reposition self, benefits of doing this. Resident continues to have open area to left gluteal crease with 70% necrotic tissue with 30% red/moist tissue at wound edges. -left lower Buttock: Necrotic tissue 4 cm x 3.8 cm x 1.4 cm (this is larger since last assessed 7/24/24) -Right lateral malleolus: Stage 3 slough pale yellow, pallor noted, no change, 1.5 cm x 1.3 cm x .4 cm. -Left mid buttock (left of gluteal fold/coccyx): Stage 2 granulation reddened area 1.2 cm x1 cm x .1 cm. -On 08/07/24, Left buttock unable to stage and coccyx unable to stage. Right outer ankle stage 3 worsening, current treatments calcium alginates, foam dressing, teaching resident how to self-reposition self, use of pressure relieving reduction devices, -Left lower Buttock: Necrotic tissue 4 cm x 4.5 cm x 1.5 cm. Stage 3 (larger than 7/31/24 assessment, MD not notified, no changes in treatment) -Right lateral malleolus: Stage 3 slough pale yellow, pallor noted, no change, 1.3 cm x 1.5 cm x 1.5 cm. -Left mid buttock (left of gluteal fold/coccyx): 4 cm x 3 cm x 0. 0.5 cm area of undermining present at 12 o'clock. (MD not notified of undermining of the PI) Surveyor notes that weekly comprehensive PI assessments were not being completed 3/28/24 - 7/24/24. Observations: On 08/07/24 at 7:20 AM, Surveyor observed R4 lying in bed sleeping supine with buttocks directly on bed. Surveyor observed R4's feet lying directly on the mattress with no elevation of heels. R4's feet were positioned outwards with R4's lateral malleolus ankle area touching the surface of the bed applying pressure directly to the ankles bilaterally. Surveyor did not observe Podus boots in place or any other device to prevent pressure from occurring to R4's ankles. On 08/07/24 at 9:15 AM, Surveyor observed R4 lying in bed at 30-degree angle with buttocks directly on bed. Surveyor observed R4's feet lying directly on the mattress with no elevation of heels. R4's feet were positioned outwards with R4's lateral malleolus ankle area touching the surface of the bed applying pressure directly to the ankles bilaterally. Surveyor did not observe Podus boots in place or any other device to prevent pressure from occurring to R4's ankles. The following occurred on 08/08/24 during a continuous observation from 6:38 AM-8:47 AM, for 2 hours and 9 minutes: Surveyor observed R4 lying in bed supine resting with feet lying directly on the mattress with no elevation of heels. R4's feet were positioned outwards with R4's lateral malleolus ankle area touching the surface of the bed applying pressure directly to the ankles bilaterally. Surveyor did not observe Podus boots in place or any other device to prevent pressure from occurring to R4's ankles. On 08/07/24 at 1:56 PM, Surveyor interviewed LPN G and asked what interventions were put into place to prevent the PI or minimize the PI from getting worse. LPN G indicated that LPN G was unsure what interventions were put into place and would need to check. LPN G indicated that R4 has an air mattress in place and R4 is supposed to reposition every 2 hours as well. Surveyor indicated to LPN G that through observations R4's feet have been directly positioned on bed without heels being floated or ankles being propped with any devices to prevent pressure to the ankles. Surveyor indicated to LPN G that Surveyor observed that R4 is paraplegic and can't readjust or hold feet upright. R4's feet fall to the sides bilaterally and then direct pressure is being placed on the lateral sides of the ankles. Surveyor asked LPN G if staff utilize Podus boots or foam wedges or any devices to keep R4's ankles from falling to the side and causing continuous pressure. LPN G indicated to Surveyor that Podus boots are a good idea and that currently right now R4 does not have any devices to aid in relieving pressure to R4's right ankle besides repositioning every 2 hours if R4 does not refuse. LPN G shared that R4 has long standing PIs from when at home on hospice services. LPN G went on to say that R4 has nutritional deficiencies per resident's choice to eat foods of choice and for pleasure on hospice services. R4 does not get adequate protein for healing, due to R4's choices. R4 spends a lot of the day in his wheelchair, as this is his choice. If R4 is approached to reposition, R4 gets angry. LPN G stated staff offer and encourage reposition, but honor R4's choice as he continues to receive comfort focused cares on hospice for end stage congestive heart failure. On 08/08/24 at 10:03 AM, Surveyor interviewed Director of Nursing (DON) B and asked when R4 was admitted what skin breakdown did R4 have. DON B indicated that R4 had air mattress in place, turning and repositioning every 2 hours, cushion applied to wheelchair, and encourage R4 to reposition often. Surveyor asked DON B when the air mattress was implemented. DON B indicated that R4 is on hospice and since hospice won't order an air mattress unless someone has skin breakdown the air mattress was not ordered until 05/16/24 but that it doesn't make sense because R4 was admitted with severe skin breakdown. DON B indicated that implementing air mattress in a timely fashion was missed when providing cares for R4. Surveyor asked DON B what interventions were put into place to prevent the PI from occurring or to minimize the PI from getting worse once facility observed R4's right ankle PI. DON B indicated that R4 had air mattress in place, turning and repositioning every 2 hours, foam applied to wheelchair foot pedals because sometimes R4 wants to sit in wheelchair more than R4 should, and encourage R4 to reposition often. DON B indicated that at first hospice was completing wound care Monday, Wednesday, and Friday. Hospice was doing the weekly assessments from 3/28 - 7/24/24. This is the reason for lack of assessments in the medical record. Currently the facility provides wound care Monday, Wednesday, and Friday. DON B indicated the facility staff are doing weekly PI assessments since 7/24/24. DON B indicated that staff should be completing weekly skin assessments and if any concerns or changes the physician should be notified immediately. Surveyor indicated to DON B through observations R4's feet have been directly positioned on bed without heels being floated or ankles being protected from pressure with any devices. Surveyor asked DON B if staff utilize Podus boots or foam wedges or any devices to keep R4's ankles from falling to the side and causing continuous pressure. DON B indicated that Podus boots are not being used for R4's feet bilaterally. DON B indicated currently there are not any other interventions than stated before. Surveyor asked DON B how often Braden scales are completed on residents. DON B indicated that Bradens are completed on admission, weekly, and then quarterly. Surveyor asked DON B if R4 had any Braden scales completed for R4's skin. DON B indicated R4 received a Braden skin assessment on admission. Surveyor requested the Braden Skin Assessment for R4.

Based on observation, interview and record review, the facility did not prepare, distribute and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. Kitchen staff did not check the temperature of a reheated piece of left-over chicken after cooking in the microwave and served to R10. Dietary Aide touched bun with dirty gloves when serving meals in the Whispering Pines kitchenette. This affected all 17 residents (R) served meals from that area. (R10, R21, R6, R8, R4, R13, R33, R28, R34, R18, R23, R14, R2, R29, R16, R12, R5) The facility did not ensure the foods were served at safe temperatures in accordance with professional standards for food safety. Staff did not check the temperatures of the food prior to serving meals in the Woodland Heights kitchenette. This affected all 16 residents (R) served meals from that area. (R20, R238, R26, R19, R22, R1, R31, R17, R3, R27, R32, R9, R35, R7, R25, R24) Findings include: Food code requires potentially hazardous food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees Fahrenheit (F) for at least 15 seconds before serving. Facility policy entitled Food Temperatures, last revised 05/05/21, stated in part, .All food that is served to residents will be checked each meal and recorded on the daily menu in the provided space, before and after meal service . Facility policy entitled Use of Plastic Gloves, last revised 05/05/21, stated in part, .Hands are to be washed and gloves applied when handling food directly with hands, anytime you touch a contaminated surface, the gloves must be changed; after coughing, sneezing, touching hair or face . Example 1 On 08/16/23 at 11:52 AM, Surveyor observed Cook M prep leftover chicken in main kitchen and reheated the chicken in the microwave. Cook M pulled chicken out of the microwave but did not check the temperature of the chicken before placing a cover on chicken and into warming cart to take to Whispering Pines kitchenette. On 08/16/23 at 12:00 PM, Surveyor observed in Whispering Pines kitchenette Dietary Aide (DA) L sanitized hands and apply gloves. DA L checked the temperature of chicken with results of 149 degrees F and served the chicken to R10. Surveyor interviewed DA L who indicated food temperatures get checked before and after serving residents food. On 08/16/23 at 12:35 PM, Surveyor interviewed Cook M and asked what the process and expectation is for checking the temperature of foods. Cook M stated it is facility policy that all food temperatures get checked when it is done cooking in the kitchen and recorded on the menu above the grill for each day of the week then logged in book once completed. Cook M stated once the food is in the kitchenettes the servers are to check food temperatures before and after serving the food. Cook M stated the chicken that was given to R10 was leftover chicken from a previous meal and reheated in the microwave. Cook M indicated that Cook M did not check the temperature of the chicken before sending it out to the kitchenette. Example 2 On 08/16/23 at 12:10 PM, Surveyor observed DA L touch her nose that was dripping with sweat with her gloved hand and wiping it off. DA L then grabbed a bun with the same gloved hand and served hot ham sandwich to several residents in the dining room. Surveyor observed DA L continue to serve all resident trays for the Whispering Pines unit with those same contaminated gloves. On 08/17/23 at 10:30 AM, Surveyor interviewed Dietary Manager (DM) J and asked what expectations are for hand hygiene in the kitchenettes when serving food. DM J stated all staff are supposed to wash hands thoroughly and use gloves appropriately when serving food. Staff should not touch ready to eat foods or serve food with contaminated gloves. Surveyor asked DM J what the process was for checking food temperatures. DM J stated food temperatures are checked when it is done cooking in the kitchen then again before and after in the kitchenettes on the units. DM J stated the correct process for when the chicken was reheated in the microwave should have been to check the temperature immediately after taking out of microwave and that was not done. 40181 Example 3 On 08/16/23 at 12:01 PM, Surveyor observed DA E receive the hot foods from the kitchen and place them in the steam table in the Woodland Heights kitchenette. DA E stated they did not check the temperature of the foods prior to serving meals in the kitchenette because the food temperatures were checked in the main kitchen prior to sending them out. At 12:15 PM, Surveyor observed DA E begin serving lunch to residents on the Woodland Heights unit. On 08/17/23 at 10:30 AM, DM J informed Surveyor the facility policy required staff to check the food temperatures in the kitchenettes prior to serving meals to residents.

Based on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less. During medication administration task, surveyors observed 3 errors out of 36 medication opportunities, resulting in an error rate of 8.33%. This affected residents (R20 and R4) 2 of 5 residents in the medication administration sample. Observations revealed Registered Nurse (RN) F placed Pulmicort inhalation solution and Ipratropium-Albuterol inhalation solution (2 separate medications) into the nebulizer cup for R20 and documented the administration time at 8:08 AM. R20 did not start administration of the two nebulizer solutions until 11:10 AM. The AM medication pass time range was between 7:00 AM until 10:30 AM, resulting in the two medications being administered late. RN K administered insulin medication without checking the expiration date for R4. Findings include: Example 1 On 08/16/23 at 8:08 AM, Surveyor observed RN F insert Pulmicort inhalation solution and Ipratropium-Albuterol inhalation solution in the nebulizer cup that was in R20's room. R20 was not in the room. On 08/16/23 at 11:10 AM, Surveyor observed RN F in R20's room to see if R20 had completed the nebulizer medication solution that was placed there this morning around 8 AM. R20 said no, she has been busy today. RN F asked that R20 do the nebulizer treatment now. R20 started the nebulizer treatment at this time. On 08/16/23 at 2:08 PM, Surveyor asked the Director of Nursing (DON) B what the AM time range was for giving medications. DON B said 7-10:30 AM. The medication was not given within the ordered timeframe. R20's record review indicated physician order for Pulmicort 0.5mg/2ml suspension inhalation twice a day at AM and hour of sleep (HS), and Ipratropium-Albuterol 0.5mg/3ml - 2.5mg/3ml solution inhalation three times a day at AM, 1400, and HS. 48793 Example 2 On 08/16/23 at 8:15 AM, Surveyor observed RN K administer insulin Lantus pen 25 units subcutaneous in abdomen. Surveyor observed there was not an open date with initials on pen. Surveyor interviewed RN K and asked what process was if there is not an opened date on pen and RN K indicated she was unsure and would find out. RN K prepped insulin pen, applied needle, and then proceeded into R4's room. Surveyor observed RN K alcohol wipe the abdomen and administered Lantus insulin pen 25 units subcutaneous. On 08/17/23 at 8:00 AM, Surveyor interviewed DON B and asked what the expectation of administrating and labeling of insulin pens in use. DON B stated all insulin pens are labeled and initialed when opened so others know when the expiration date would be for the pen. DON B indicated common practice is after 28 days of it being opened it expires. If there is no label then it should be disposed of and new one administered. DON B verified RN K did not follow the correct standard of practice for verifying and administering insulin pens.

Based on interview and record review, the facility did not ensure prescribing provider evaluated the resident and documented a clinical rationale for extending PRN (as needed) anti-psychotic medication beyond 14 days for 1 of 5 residents (R) reviewed for unnecessary medications. (R13) R13 had an order for PRN olanzapine (anti-psychotic medication) for greater than 6 months with no end date and no documentation of evaluation by prescribing provider with a rationale for continuing the anti-psychotic medication beyond 14 days. Findings include: R13 was admitted to the facility on [DATE] with diagnoses including in part, Parkinson's disease, unspecified dementia, repeated falls, long term use of anticoagulants, and right clavicle fracture. R13's Minimum Data Set (MDS) assessment, dated 06/09/23, identified R13 had a Brief Interview for Mental Status Score of 08. This indicated R13 had moderate cognitive impairment. The MDS assessment also identified R13 had no hallucinations or delusions, no physical or verbal behaviors, and no rejection of cares or wandering behaviors during the assessment period. Review of R13's medical record identified the following order, dated 02/09/23, olanzapine 2.5 mg [milligrams] daily PRN for hallucinations/anxiety/agitation. There was no end date for this PRN anti-psychotic order. Surveyor was unable to find any documentation in R13's clinical record of evaluation by prescribing provider every 14 days to renew the PRN anti-psychotic medication. Surveyor was unable to find any documentation of a clinical rationale for extending the PRN anti-psychotic medication greater than 14 days. On 08/17/23 at 10:49 AM, Surveyor interviewed Director of Nursing (DON) B about R13's order for PRN olanzapine with no end date. Surveyor requested documentation to show evaluation by a provider with clinical rationale to renew the PRN anti-psychotic medication beyond 14 days. DON B stated R13 was receiving hospice care and the hospice provider was responsible for that order. DON B stated they would look for that information and would also reach out to hospice to see if they could provide that documentation. On 08/17/23 at 12:03 PM, DON B returned with copies of all behavior documentation for R13 since February 2023. Initial behavior documentation mentioned an episode of disturbing hallucinations about dead bodies prior to the orders for scheduled and PRN olanzapine. The remainder of the behavior documentation showed only one episode of disturbing hallucinations since that time. A note dated 06/18/22, stated R13 was upset about a hallucination that R13 had surgery and a knife that cut her throat. The note stated R13 was reassured and redirected and calmed down. Most of the documentation stated, No behavior issues or No paranoid behaviors or hallucinations observed. Surveyor identified several notes identifying R13 saw people or things that were not there. The documentation noted R13 was not upset by these hallucinations and was easily redirected and reassured. At 12:03 PM, DON B also provided the hospice interdisciplinary team review notes as physician evaluation and rationale for continuing the PRN anti-psychotic medication. Surveyor reviewed that documentation with DON B and identified there was no mention of the physician's evaluation of R13's behaviors or hallucinations and no documentation of a rationale for continuing the PRN anti-psychotic medication.

Based on observation, interview and record review, the facility did not provide pharmaceutical services, including dispensing and administering of all drugs, to meet the needs for 2 of 12 residents (R20 and R26). Registered Nurse (RN) F dispensed R20's nebulizer medication solutions into the nebulizer cup without R20 in the room and then documented in the Medical Administration Record (MAR) that the medication was administered at that time. R20 did not self-administer the nebulizer medication until three hours later. Lung sound assessments were not completed daily as per facility policy. Certified Nursing Assistant (CNA) G applied prescribed Nystatin cream to R26. This was evidenced by: The facility policy, entitled Administering Nebulizer Medications, dated 6/1/23, states: .After medication administration is completed .Document administration of medication. If resident is chronically on nebulizer treatments, then lung sounds need to be listened to at least once daily . The facility policy, entitled Medication Administration Policy, dated 5/11/23, states: .All medications are administered by licensed staff to the correct resident in correct dose via the prescribed route at the times ordered by the physician . Example 1 R20 was admitted to the facility on [DATE] and had diagnoses that included in part chronic respiratory failure with hypercapnia and hypoxia, other disorders of the lungs, obstructive sleep apnea, chronic diastolic congestive heart failure, disorders of the diaphragm, atrial fibrillation, chronic obstructive pulmonary disorder (COPD), and acute and subacute respiratory conditions due to chemicals, gases, fumes, and vapors. R20's Minimum Data Set (MDS) assessment, dated 08/03/23, indicated that the Brief Interview for Mental Status (BIMS) was 15 indicating R20 was cognitively intact. R20's Care Plan, dated 05/18/23, stated: .Problem: altered respiratory status. Interventions include: monitor oxygen saturations, administer nebulizer treatment per doctor order, monitor for side effects of respiratory medications, assess respiratory status, assess breath sounds, monitor pulses, assess skin temperature, assess for pain, Ok to self-administer nebulizer treatment after nurse sets up . R20's self-administration of medication assessment completed on 05/02/23 with re-evaluation on 08/03/23 stated: .R20 wishes to self admin nebulizer after nurse sets up. R20 was assessed by nurse to be able to administer safely. Nurse to set up nebulizer and wash nebulizer after use. On 08/03/23 nurse comments stated R20 continues to be safe to self admin nebulizer. Nurse to continue set up . R20's respiratory assessments were completed daily but did not include breath sounds daily. R20's MAR indicated on 08/16/23 RN F documented Pulmicort and Ipratropium-Albuterol nebulizer medication given at 8:08 AM. Surveyor observed R20 self-administer this dose at 11:10 AM. R20's provider orders included Pulmicort 0.5mg/2ml suspension inhalation twice a day AM and hour of sleep (HS), Ipratropium-Albuterol 0.5mg/3ml - 2.5mg/3ml solution inhalation three times a day AM, 1400, and HS. R20's vital signs including pulse and oxygen saturations were monitored at least daily with no abnormal readings noted. On 08/15/23 at 9:51 AM, Surveyor interviewed R20 concerning the nebulizer. R20 said the nurse will fill the nebulizer medicine into the nebulizer cup while R20 was at breakfast and then R20 will take the nebulizer once back in her room. R20 said I think there was nebulizer medication in there now. On 08/16/23 at 8:01 AM, Surveyor observed R20 walk to the dining room and sat down at the table for breakfast. On 08/16/23 at 8:08 AM, Surveyor observed RN F insert the nebulizer medicine in the nebulizer cup that was in R20's room. R20 was not in the room. Surveyor asked RN F how does R20 know there was medicine in the nebulizer since the resident was not in her room at this time. RN F said R20 knows to take the nebulizer when she gets back in the room. This routine has worked out great for administering the nebulizer. RN F said she will check back before lunch to make sure R20 had taken the nebulizer. Surveyor asked RN F if R20 had a self-administration of medicine assessment complete to be able to do this. RN F said yes R20 had the assessment done and it was in her chart. On 08/16/23 at 8:36 AM, Surveyor observed R20 return to her room and sat in the recliner that was next to the nebulizer machine. R20 did not start the nebulizer. On 08/16/23 at 8:52 AM, Surveyor observed R20 did not use the nebulizer yet. On 08/16/23 at 9:25 AM, Surveyor observed R20 was not in her room. R20's nebulizer cup contains liquid to the top. R20 did not use the nebulizer yet. On 08/16/23 at 9:35 AM, Surveyor observed R20 was back in her room sitting at her desk. R20 did not use the nebulizer yet. On 08/16/23 at 11:10 AM, Surveyor observed RN F was in R20's room to see if R20 had completed the nebulizer medication solution that was placed there this morning around 8 AM. R20 said no, she has been busy today. RN F asked that R20 do the nebulizer treatment now. R20 started the nebulizer treatment. On 08/16/23 at 11:12 AM, Surveyor asked RN F what time she documented R20's nebulizer that was currently going. RN said she marked it in the MAR when she set it up this morning around 8 am. RN F said that she was just in the room to make sure R20 had completed the nebulizer from this morning. Since R20 did not complete the nebulizer yet, RN F told R20 to do the nebulizer now. RN F said she was going to set up for the next dose of Albuterol/ Ipratropium and showed Surveyor that she currently had in her hand the next dose of Albuterol/Ipratropium. RN F said she will set up the next dose of Albuterol/Ipratropium after lunch since R20 was currently doing the first dose. Surveyor asked if there needs to be a certain amount of time in between administration of the doses. RN said no, that was not how this order was written, it can be given any time as long as it was given three times a day. On 08/16/23 at 2:08 PM, Surveyor interviewed the Director of Nursing (DON) B and asked what the process for administering nebulizers to a resident who had an order and assessment completed for self-administration of the nebulizer. DON B said the nurse would set up the nebulizer with the medicine solution and hand it to the resident to complete the treatment. Respiratory assessment, listening to the lungs, was prompted to be completed when documenting the nebulizer was given. Surveyor asked DON B if it was ok for the nurse to set up the nebulizer medicine in the nebulizer cup when the resident was not in the room for the resident to take when they get back into the room. DON B said no, that was not okay. Surveyor asked DON B what time the MAR showed the nebulizer for R20 was marked as administered this morning. DON B looked at the MAR and said it was marked as given, no time. DON B said she will call the electronic medical record contact to find out what time the medication was marked as given. Surveyor asked if a nurse should mark the time a medication was administered when it was placed in the nebulizer machine and not the actual time the medication was administered. DON B said no, medications need to be documented the time it was administered. Surveyor asked DON B what the AM time range was for giving meds. DON B said 7-10:30 AM. On 08/17/23 at 9:00 AM, DON B provided the MAR which indicated the Pulmicort and Albuterol/Ipratropium was administered on 08/16/23 at 8:08 AM. Example 2 R26 was admitted to the facility on [DATE] and had diagnoses that included in part dementia with other behavioral disturbance and rash. R26's provider orders included Nystatin topical cream, apply to affected peri area twice a day for 7 days for rash. Start date 08/07/23. On 08/16/23 at 9:00 AM, Surveyor observed Certified Nursing Assistant (CNA) G and CNA H perform morning cares for R26. No other staff was in the room. CNA H told Surveyor they were applying Nystatin cream to R26 because she had a rash. CNA H than gave the tube of Nystatin cream to CNA G who applied the cream to the resident. Nystatin cream was a prescribed medication for R26. CNA G and CNA H were not medication techs and should not administer medication to residents. On 08/16/23 at 9:29 AM, Surveyor spoke with RN F to ask who applies Nystatin cream to R26. RN F said the nurses usually do, but RN F said she had at times asked the CNAs to apply the cream. On 08/16/23 at 2:10 PM, Surveyor spoke with DON B to ask if it was okay for a CNA to apply Nystatin cream to a resident. DON B said no, Nystatin is a prescription and needs to be applied by a nurse.

Based on observation, interview and record review, the facility did not ensure a resident received treatment based on current standards of practice for jejunostomy (J) tube for 1 of 1 residents (R) with a J-tube. (R15) Staff did not check for proper placement of R15's J-tube when providing treatment and administering medications and nutrition via J-tube. This is evidenced by: Facility policy entitled Gastric Tube Feeding, last revised 05/11/23, stated in part, .Check for residual and placement by attaching sixty ml piston syringe to gastric tube and gently pull back, if meet resistance as aspirate content, stop procedure, if no resistant, not amount of residual, then return gastric contents back into stomach. Appearance of gastric content implies that the tube is patent and in the stomach. If gastric content does not appear, then the tube may be against the lining of the stomach or may be obstructed therefore report complications promptly to the supervisor and the attending physician . R15 was admitted on [DATE]. R15's Minimum Data Set (MDS), dated [DATE], stated in part, diagnoses of quadriplegia unspecified, anoxic brain damage, cerebral palsy, and gastrostomy. On 08/16/23 at 9:50 AM, Surveyor observed Registered Nurse (RN) K crush medications on medication cart, enter R15's room and headed to bathroom. RN K washed hands in bathroom and mixed medications with water and set on bedside table. RN K uncovered R15 and took the J-tube, detaching the cap on J-tube then attached syringe and tried to draw back stating she was checking for placement. RN K was struggling with pulling back syringe, so RN K stopped and unhooked syringe. RN K drew all medications into syringe from graduate and pushed through J-tube without verifying proper tube placement. RN K flushed 30cc in between administration of medications. RN K disconnected syringe and took items to bathroom to rinse out. RN K exited R15's room. On 08/16/23 at 3:00 PM, Surveyor observed RN K enter R15's room and go into bathroom and washed hands. RN K gathered feeding tube supplies and set it up on side table. RN K uncovered R15's blanket, detached the cap on J-tube and connected syringe to J-tube. RN K proceeded with flushing J-tube with 50ml of water without assessing proper placement. RN K administered two Replete (nutritional formula) bottles via J-tube with operation of Kangaroo pump running at 110ml/hr. RN K unconnected syringe and covered R15 back up. RN K went to bathroom and washed tube feeding supplies and hands. RN K exited R15's room. On 08/17/23 at 8:00 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the facility process is for tube feeding. DON B stated that the facility expectation for tube feeding is all nurses pull back with syringe to check gastric contents for proper placement first, and then push back in and start the flush, then continue with either feeding replacement or administering of medications. DON B verified RN K did not follow the correct standard of practice for verifying tube placement prior to administering medication or formula through the tube.

Based on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living (ADL) for 1 of 12 residents (R15) reviewed. During two observations of cares provided to R15, the nurse providing cares did not speak to R15 or explain what cares they were going to provide. This is evidenced by: R15 was admitted on [DATE]. R15's Minimum Data Set (MDS), dated [DATE], stated in part, diagnoses of quadriplegia unspecified, anoxic brain damage, cerebral palsy, and gastrostomy. Surveyor reviewed R15's nursing care plan which, stated in part, .for functional level [R15] is total assist/cares and unable to communicate needs. Interventions included in part, . all staff speak directly to [R15] and explain what you are doing by utilizing the blink method (1 blink for yes and 2 blinks for no) when asking questions, speak in normal volume, use objects, drawings, gestures, writing, facial expressions, use orange binder in room for communication aide, and communication board hanging on bookshelf . On 08/16/23 at 9:50 AM, Surveyor observed Registered Nurse (RN) K crush medications at the medication cart, then RN K entered R15's room without announcing herself and headed to bathroom. RN K washed hands in bathroom and mixed medications with water and set on bedside table. Without speaking to R15, RN K uncovered R15's blanket and took the J-tube and administered medications. RN K, without announcing to R15, also administered morphine liquid with a syringe under R15's tongue. During the whole process, RN K did not communicate with R15 and did not announce herself. There was no conversation observed. On 08/16/23 3:00 PM, Surveyor observed RN K enter R15's room, announced herself by name and went straight in bathroom and washed hands. RN K gathered feeding tube supplies and set it on side table next to bed. Without speaking to R15, RN K uncovered R15's blanket, detached the cap on J-tube and connected syringe to J-tube. RN K next administered two Replete bottles via J-tube. RN K pulled blankets back to cover R15. RN K went to bathroom and washed tube feeding supplies and hands. RN K exited R15's room. During the whole process of administration RN K did not communicate with R15 and no conversation was observed. On 08/17/23 8:00 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations were of a normal routine when staff is delivering care to non-communicating residents. DON B stated it was expected that all residents were treated equally. DON B stated procedures were to be explained to the individuals and correctly performed. DON B stated that it was expected that all non-communicative/non-verbal residents were still treated as everyone else because they still may be able to understand what's going on around them.

Based on observation and interview, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and did not ensure medication was labeled to determine the expiration date for 1 of 1 resident (R) (R4). R4 had one insulin Lantus pen not labeled with an open date or expiration date of medication. Findings include: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Surveyor reviewed policy Insulin Administration, last revised on 06/15/23, stated in part, .remove insulin from residents' cupboard outside his/her room, check the expiration date before administering . On 08/16/23 at 8:15 AM, Surveyor observed Registered Nurse (RN) K take insulin Lantus pen and stated she was giving 25 units to R4. Surveyor observed there was no opened date with initials on insulin pen. Surveyor interviewed RN K and asked what the process was if there is not an opened date on insulin pen and how would you know when it expires. RN K stated she was unsure and would find out. RN K prepped insulin Lantus pen, applied needle, and then proceeded into R4's room. RN K alcohol wiped the abdomen and administered Lantus insulin pen 25 units subcutaneous. On 08/17/23 at 8:00 AM, Surveyor interviewed DON B and asked what the expectation is of administration of insulin and what is the process for labeling the insulin pens in use. DON B stated all insulin pens are labeled and initialed when opened so others know when the expiration date would be for the pen. DON B indicated common practice is after 28 days of it being opened it expires. If there is no label then it should be disposed of and new one administered. DON B verified RN K did not follow the correct standard of practice for verifying expiration date and administering insulin pens.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 36 residents in the building. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system to include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Identify where control measures should be applied. - Include a process to confirm the WMP was being implemented and was effective. - Document and communicate all the activities. Registered Nurse (RN) K spilled resident's (R4) medications on the medicine cart and picked them up with her bare hands to place them back in the medicine cup. RN K then administered these medications to R4. RN K did not use gloves when administering tube feeding to a resident. This was evidenced by: Example 1 The facility policy, entitled Water Management Program (WMP), dated 06/15/23, states: .Attached is the facility floor plan to show the flow of water systems within the facility .Housekeeping staff will flush the water weekly in every room from the shower head, sink, toilets, and other water fixtures for a minimum of five minutes and two toilet flushes. Documentation of flushing will be kept and reported to the Quality Assurance Committee . On 08/17/23 at 11:03 AM, Surveyor interviewed Maintenance Director (MD) I concerning the facility's WMP. MD I provided a flow diagram that only showed where the water enters and exits, the water lines, and where the hot water heaters were located. The diagram does not identify all locations where Legionella could grow and spread, nor where or what control measures should be applied in the water system. Surveyor asked MD I what measures were in place to prevent the growth of Legionella in the facility. MD I stated on a weekly basis the cleaning staff complete two toilet flushes for each toilet and all showers and sinks were flushed for five minutes. MD I stated there was currently no documentation on this measure. Surveyor asked MD I how the facility monitors the measures they have in place and ways to intervene when control limits (temperature range of 105-115 degrees F and chlorination levels) were not met. MD I stated if the control limits were not met, the disaster plan will kick in and we will use emergency bottle water and the fire department provides non drinking water. We will fix the problem and retest. 48793 Example 2 On 08/16/23 at 7:20 AM, Surveyor observed RN K administer medications to R4. Pills fell out of medication cup onto medication cart and one medication on the floor. Surveyor observed RN K push medications back into cup with bare hands. RN K administered pills to R4. No hand hygiene was performed until after RN K administered medications to R4. Example 3 Facility policy entitled Gastric Tube Feeding, last revised 05/11/23, stated in part, .Place the equipment on a clean bedside stand or overbed table, wash hands and dry thoroughly, wear gloves and drape resident's chest with a towel On 08/16/23 at 9:50 AM, Surveyor observed RN K crush medications, enter R15's room and headed to bathroom. RN K washed hands in bathroom and mixed medications with water and set on bedside table rearranging the table and R15's bed. RN K did not apply gloves and proceeded with drawing all medications from graduate into syringe and pushed through jejunostomy (J) tube. RN K then flushed 30cc in between administration of medications. RN K disconnected syringe and took items to bathroom to rinse out. RN K did not wear gloves or practice standard precautions while working with R15's J-tube. On 08/16/23 at 3:00 PM, Surveyor observed RN K enter R15's room. RN K went to bathroom and washed hands. RN K gathered feeding tube supplies and set it up on side table. RN K uncovered R15's blanket, detached the cap on J-tube and connected syringe to J-tube. RN K did not apply gloves. RN K proceeded with flushing J-tube with 50ml of water. RN K next administered 2 Replete (nutritional formula) bottles via j-tube. RN K unconnected syringe then covered R15 and exited R15's room. RN K did not wear gloves or practice standard precautions while working with R15's J-tube. On 08/17/23 at 8:00 AM, Surveyor interviewed DON B and asked what expectations are when administering medications and medications are dropped on medication cart and/or on the floor. DON B stated the expectation would be to throw the pill away that was on the floor and get a new one. DON B stated the expectation for picking up the other medications on cart would be to apply gloves and not touch pills with bare hands. Surveyor interviewed DON B and asked what the facility process for infection control standards when administering medications or treatments for tube feeding. DON B stated that the facility expectation for tube feeding is nurses wear gloves during process to follow standard precautions. DON B verified RN K did not follow the correct standard of practice for infection control precautions prior to administering medication or formula through the J-tube.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe environment to help prevent the development and transmission of communicable diseases, infections, and COVID 19. This has the potential to affect all 29 residents. Facility staff were not wearing eye protection in resident encounter areas when transmission levels are high. This is evidenced by: According to Centers for Disease Control and Prevention (CDC) guidance for Responding to COVID-19 in Long-Term Care Facilities (LTCFs), health care personnel (HCP) working in facilities located in counties with substantial or high transmission: .eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. On 08/09/22 at 1:15 PM, Surveyor observed Activity Director (AD) C in dining area with residents with a facemask on and goggles on her head On 08/09/22 at 1:49 PM, Surveyor observed 7 residents in dining room for BINGO. AD C was in the dining room with the residents with goggles on her head and a face mask on. On 08/09/22 at about 11:40 AM, Surveyor observed 2 Dietary Staff (DS) F and DS G in the kitchenette getting ready to serve lunch. Residents were in the dining area. Both staff were wearing only a surgical mask and served lunch with only a surgical mask on. On 08/09/22 at about 11:45 AM, Surveyor observed Cook E bring out the lunch meal to the kitchenette wearing only a surgical mask. On 08/09/22 at about 11:40 AM, Surveyor interviewed dietary manager (DM) D and asked if dietary staff wore goggles while serving food from the kitchenette. She indicated they do not because they are not feeding the residents or with them for 15 minutes or longer. Surveyor asked if there was a policy on that or a source of where that came from if she could provide it to Surveyor. DM D brought Surveyor a policy entitled, Facility Policy Manual, revised on 03/10/22. Under PPE it reads in part whenever someone is in direct patient contact, they will wear a surgical mask and eye protection. On 08/09/22 at about 9:31 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked what PPE staff were to be wearing. NHA A indicated because County positivity rate is high staff should be wearing a mask and goggles. On 08/10/22 at 9:00 AM, Surveyor interviewed DON B and asked what PPE staff are required to wear. DON B indicated a surgical mask and goggles if they are within 6 feet of a resident for longer than 15 minutes and that is the direction they received from their Medical Director who also wrote their Facility Policy. Example 2: On 08/09/22 at 7:20 AM, Surveyor observed LPN I during medication pass not wearing eye protection when COVID-19 community transmission levels are high. LPN I was observed by Surveyor throughout the day performing nursing duties to several residents without appropriate eye protection. On 08/09/22 at 7:38 AM, Surveyor observed RN J during medication pass not wearing eye protection when COVID-19 community transmission levels are high. RN J was observed by Surveyor throughout the day performing nursing duties to residents without appropriate eye protection.

Based on observation and interview, the facility failed to have a system in place to ensure the residents are safe from the environmental hazard of hot water temperatures and remain free from accidents. This has to potential to affect 6 (#12,#15, #16, #18, #19, #20) residents who ambulate with dementia, and can wash their hands independently. This also has the potential to affect six residents who have diabetes with potential altered skin sensitivity due to neuropathy, that can wash their hands independently (#17, #21, #22, #23, #24, #25). The failure to monitor and adjust water temperatures in order to prevent potential for burns created a finding of Immediate Jeopardy situation that began on 03/08/16. The Nursing Home Administrator (NHA), Director of Nursing (DON), and administrative intern were notified of the Immediate Jeopardy at 4:00 p.m. on 03/08/16. Immediate Jeopardy was removed and corrected on 03/08/16; however, the deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by the facility's failure to provide supervision and assistive devices to prevent incidents and accidents for 3 of 12 sampled residents (#11, #6, #1). 2. Resident #11 sustained a second degree burn when a Certified Nursing Assistant (CNA) did not follow the care plan. Resident #11 coffee was not served in an insulated cup with a lid and she was not provided with a protective apron. 3. Resident #6 was at high risk for falls and the facility staff did not provide fall precautions according to care plan. 4. Resident #1 was noted to have two falls. The facility did not do a thorough investigation to determine root cause and analysis of falls and did not provide appropriate interventions to prevent future falls from occurring. Facility nursing staff did not assess resident after falls were determined. 5. Resident #1 had a choking incident and the facility did not provide a dietary assessment, and did not implement appropriate interventions to prevent future choking incidents from reoccurring. This is evidenced by: 1. Scalding/third-degree burns can occur in three minutes at 124 degrees F. This drops to one minute at 127oF, 15 seconds at 133oF, and 5 seconds at 140oF. However, many elderly may experience scalding at even faster rates because they can have decreased skin thickness, peripheral neuropathy, decreased skin sensitivity, and greater recoil or reflex time. On the initial kitchen tour on 03/07/16, Surveyor reported to the survey team that the water was very hot in the kitchen, and it was hard to wash her hands without discomfort. On 03/08/16 at 7:38 a.m., Surveyor observed personal cares for Resident #4. As Certified Nursing Assistant (CNA) D was washing her hands in the bathroom sink, Surveyor could see steam coming from the water. CNA D stated, This water is so hot. We will have to tell maintenance again. On 03/08/16 at 9:35 a.m., Surveyor went back to Resident #4's room to check the water temperature. At the same time Maintenance Worker (MW) F was going into the room and started working on the handle. Surveyor asked MW F to check the water temperature. MW F got his thermometer and checked the water temperature and had a reading of 135.8 degrees. Surveyor asked if MW F knew what the problem was. MW F stated, I have to fix the handle; the handle must have fallen off. Surveyor observed MW F fixing the handle. MW F then put the faucet back together and ran the water and again tested the water temperature. The reading was 135 degrees, when MW F said, I am not checking it any further. It is still rising. Surveyor asked what temperature the water should be. MW F stated, 112 degress is where I would like it. Surveyor then left the room and went to the survey team to get assistance checking the other rooms for water temperatures. Surveyor checked the following rooms: Room # 1 at 9:38 a.m. - 135.8 degrees (as above) Room #17 at 9:45 a.m. - 126 degrees Room #10 at 9:50 a.m. - 138.4 degrees Room #6 at 9:53 a.m. - 124 degrees Room #3 at 9:55 a.m. - 124 degrees Surveyor checked the following rooms: Room #39 at 9:48 a.m. - 130 degrees Room #37 at 9:49 a.m. - 124 degrees The sink by the computer alcove room - temp 138 degrees, surveyor unable to hold hand under the water because of the extreme hot temperature. The red area on Surveyor 's hand lasted for more than one hour. Room #36 at 9:55 a.m. - 134 degrees (Resident #26). Resident #26 was asked if the hot water is always so hot. Resident #26 stated to Surveyor , It is always hot. I can not spend much time washing my hands. Room #30 at 10:03 a.m., 130 degrees, visible steaming from the water. Surveyor checked water temperatures in the following rooms: Room #43 = 124 degrees Room #26 = 135 degrees (Resident #12) Room #25 = 138 degrees (Resident #15) The survey team checked temperatures in 12 bathrooms and found that water temperatures were above the recommended limit of 115oF in all 12 bathrooms. Temperatures were 124 - 126 degrees in five bathrooms (Room #43, #37, #3, #6, #17), (A third degree burn can occur in 3 minutes); in two bathrooms the temperature was between 127oF to 132 degrees (#39, #30), (A third degree burn can occur in 1 minute); in five bathrooms the temperature was 133 degrees or above (Room #1, #36, #26),with the maximum being 138oF in two bathrooms (Room #25, #10). (A third degree burn could occur in 15 seconds in these rooms). Surveyor and Surveyor interviewed MW F at 10:15 a.m., who acknowledged the facility does not keep any logs of water temperatures. MW F stated that all temperatures are adjusted at the faucet in each room, and they do get complaints of hot water temperatures and fix as they are reported. Not all concerns are documented. When asked if a plumber has been called in to assist with the problem, MW F indicated there is no reason to call a plumber because they know why the temperatures are hot. MW F went on to say, It is the way the system is designed. If the handle comes loose the plastic mechanism moves, so you have to move it one tooth over to adjust the temperature up or down. This happens one to two times a month. On 03/08/16 at 10:28 a.m., the Director of Maintenance (DOM) H was interviewed by Surveyor . DOM H stated, We do not really like this system, but that is the way it was designed. We are not impressed with it. The handles come off affecting the water temperature, then we are called to fix it. On 03/08/16 at 11:15 a.m., Surveyor and Surveyor interviewed DOM H again about the system in place that regulates the water temperatures. DOM H was asked how the water temperature was controlled. DOM H stated, The temperature is controlled at each sink. Under each handle is a limiter. This limiter has to be adjusted at each individual faucet to control the temperature. If a CNA knocks the handle off it will affect the temperatures. Surveyor asked if they have a policy or procedure in place to monitor the limiters and water temperatures. DOM H stated, No, we check rooms if we have time, not on any regular schedule. If we get a maintenance slip about the faucet handle falling off we go and check it then. Surveyor asked if there is any documentation that the water temperature was fixed, and what the temperature was after the faucet had been fixed by maintenance. DOM H said, No we do not document the water temperature before or after we fix it. Surveyor asked if at this time all rooms had been checked for safe water temperatures. DOM H stated, No, not that I know of. We are working on it. On 03/08/16 at 12:15 p.m., Surveyor interviewed Registered Nurse (RN) E about the water temperatures. RN E stated, Some rooms are hotter than others. It is not too hot for me, but I like hot water. It is too hot for the residents. On 03/08/16 at 1:25 p.m., Surveyor interviewed CNA D about the hot water concerns noted with cares this morning. CNA D stated, I have noticed hot water problems before in other rooms. The water is just too hot. We pass it on in report and then maintenance is suppose to fix it. Failure to ensure that water temperatures were not too hot so as to prevent scalding/hot water burns created a finding of immediate jeopardy. The Immediate Jeopardy was removed on 03/08/16 after the facility checked and adjusted all resident sinks. The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by the following: 2. Resident #11's [DIAGNOSES REDACTED]. On 08/02/15, an assessment for burns was completed for Resident #11. The total score was eight. A score of 6-10 points required the use of an apron and cup. The facility self-report submitted to Division of Quality Assurance (DQA) Office of Caregiver Quality on 10/12/15 contained the following information: Resident #11's ADL sheet (Aspects of Daily Living) identified she was confused at all times, her vision was poor, she required assistance of one with eating and she was to use covered cups with hot liquids. Resident #11's Interdisciplinary Plan of Care (IPOC) problem Alteration in Nutrition contained the approaches, 10/15/14 Assist resident with meal set-up and eating. Provide covered cup and protective apron when providing hot beverages related to a burn score of 7. Resident #11's special dietary needs included cups with lids and apron for hot beverages. On 10/07/15 at 6:24 p.m., an entry was made in Resident #11's nurses' notes: Incident: Abdominal burn. Time of Incident/Accident: 10/07/2015 at 2:45 p.m. Describe what happened: Resident was found with coffee spilt on her abdomen by CNA (first name). Describe what happened: Resident was given a covered cup of coffee by (CNA P's first name). Injuries? If yes, please describe: 15 cm (centimeter) x10 cm reddened area on residents left side of abdomen and going down left side. Peeled/open area observed on left abdomen measuring 11 cm x 3 cm. Witness to accident/incident: None. Treatment given: Residents wet clothing was removed and a cool moist compress was immediately applied to reddened area/open areas on left abdomen and side. Resident sent to BAMC (Baldwin Area Medical Center) ER (emergency room ) to be evaluated. New intervention: Resident to wear clothing protector with supervision when drinking hot coffee. The Incident/Accident Assessment and Report contained the same information as the nurses' notes on 10/07/15 at 6:24 p.m. The Occurrence Report completed on 10/07/15 identified Resident #11 spilled hot coffee on lower left abdomen resulting in a burn. The caregiver at the time was CNA P. Resident #11 was sent to ER and returned with orders for silvadene and dressing changes. Analysis of cause: resident given hot liquids - apron/clothing protector not in place. Intervention to minimize reoccurrence: apron/clothing protector on when given hot liquids/staff education. Resident #11's Nursing PM Shift Interactions stated: 3 pm: at 3:45 pm, her light was going off. She was alert and in a good mood trying to crawl out of her recliner. She was burned on her stomach from a coffee spill so I made sure she was safe and went and grabbed the nurse. Resident #1's [DIAGNOSES REDACTED]. Burn by hot liquid. On 10/07/15, CNA P completed a witness statement. I answered the resident's call light. When I entered the room she was in her recliner. I asked her How may I help you. She replied she wanted a cup of coffee. I put the coffee in a sippy cup. Another light went on so I put the coffee on the residents bedside table. I told her I'd be back as soon as possible. I had to toilet another resident so I was gone approximately 10 minutes. (CNA's first name) answered room 12 before I returned. (CNA's first name) discovered the coffee spilt in the resident's lap. The NHA's statement on the Misconduct Incident Report identified the NHA and DON spoke with CNA P and indicated that he should not work with the affected resident. On 03/10/16 at 12:50 p.m., Surveyor interviewed the NHA and DON who stated CNA P had not followed Resident #11's care plan. Resident #11 was to use an insulated coffee cup with a lid for all hot liquids. CNA P had placed the hot coffee in a sippy cup (non-insulated with a spout). CNA P did not utilize the protective apron when he provided Resident #11 with the hot coffee. The protective apron is cloth with a material on the back that prevents liquids from soaking through onto the resident's clothing. 3. On 03/07/16 at 1:41 a.m., Surveyor reviewed the medical record for Resident #6 and noted the following: - MDS, dated [DATE], states Resident #6 is at high risk for falls and requires extensive assistance from facility staff for all transfer needs. - CNA care plan, received 03/07/16, states Resident #6 is a hoyer lift with the assist of two staff members, is to have a low bed, tab alarm on at all times and is to have a gray fall mat (landing strips) while in the bed. On 03/08/16 at 7:21 a.m., Surveyor observed both CNA J and CNA K provide personal cares for Resident #6. Resident #6 was lying in bed, which was low to the floor. There was a gray fall mat along side of the bed and a tab alarm was hooked to Resident #6's shirt. Surveyor observed CNA K raise the bed into a high position, remove the tab alarm clip and lay it on the mattress next to Resident #6's head. CNA K then picked up the gray fall mat and placed it along side the wall next to the bed. CNA J was in the bathroom preparing a basin of water and preparing wash materials for personal cares. CNA K then left the main room and entered the bathroom with CNA J. Surveyor observed Resident #6 in a high bed, with no tab alarm, no fall safety mat and unattended for a total of 1 minute and 15 seconds. After this noted time, both CNA K and CNA J came out of the bathroom and proceeded to provide personal cares for Resident #6. On 03/09/16 at 9:32 a.m., Surveyor discussed above noted safety concerns with the DON. The DON agreed that both CNA K and CNA J should not have left Resident #6 alone without a tab alarm, in a high bed and no floor mat. 4. On 03/07/16 at 2:15 p.m., Surveyor reviewed the medical record for Resident #1 and noted the following: - MDS, dated [DATE], states Resident #1 is at high risk for falls and requires assistance with ambulation. MDS states Resident #1 has had falls with no injuries prior to last MDS being completed, which was on 05/29/15. - Comprehensive nursing care plan, received 03/07/16, states Resident #1 is at risk for falls and injury due to history of falls, use of psychotropics, impaired sense of balance and delayed bone healing with cervical fusion. Care plan states staff are to encourage Resident #1 to ask for assistance and does self transfer and fall at times, explain risks of falls, has a weak left side as a result of a CVA, is to have half side rails x1, observe for unsafe conditions and situations, make sure resident is safe and report incident to nurse immediately. - CNA care plan, received 03/07/16, states Resident #1 is independent in his wheelchair and requires the assistance of one person at times when unsteady. Safety device includes the use of double half side rails. Care plan does not indicate Resident #1 is a fall risk or has had falls in the past. On 03/08/16 at 8:23 a.m., Surveyor reviewed nursing notes for Resident #1 from 12/01/15 - 03/07/16 and noted the following nursing entries: - 12/02/15: NOTE: Resident's driver reports that resident was exiting Pizza Hut .while getting into the car he fell . Driver assisted him up and into the car. Driver stated he didn't hit head. Resident denies pain or discomfort related to incident. No noted injury. Will monitor. - 12/20/15: BEHAVIOR: Call received from (hospital) ER. Resident had called to ER complaining of pain from his fall and wanted an MRI done .Ambulance left at 1315 (1:15 p.m.). On 03/09/16 at 9:32 a.m., Surveyor interviewed the DON in regard to the above noted nursing notes for Resident #1. The DON stated no investigation into either fall was completed and the nursing staff did not assess him appropriately and no interventions were implemented to prevent future falls from occurring. The DON stated she was not made aware of either incident by nursing staff and felt nursing staff should have notified her immediately. 5. On 03/07/16 at 2:15 p.m., Surveyor reviewed the medical record for Resident #1 and noted the following: - Comprehensive nursing care plans, received 03/07/16, did not indicate Resident #1 was at risk for choking and did not provide interventions to prevent choking incidents from occurring. - CNA care plan, received 03/07/16, did not indicate Resident #1 was at risk for choking and did not provide interventions to prevent choking incidents from occurring. - Resident #1 has a physician ordered general diet. On 03/08/16 at 8:23 a.m., Surveyor reviewed nurses notes for Resident #1 from 12/01/15 - 03/07/16 and noted the following nursing entry on 02/04/16: NOTE: 911 called at 1850 (6:50 p.m.), resident had small emesis after 911 called, ambulance arrived at 1855 (6:55 p.m.) and medical exchange form and paperwork given to EMS. Resident left via ambulance at 1910 (7:10 p.m.). Hospital called at 2045 (8:45 p.m.) that resident was returning to (facility). Resident returned to facility at 2100 (9:00 p.m.). No new orders. (Physician) comments on medical exchange form: uncomplicated episode of aspiration/choking no residual sequela; return to nursing home and resume cares. On 03/08/16 at approximately 8:40 a.m., Surveyor requested a copy of the facility's investigation into the above noted choking incident. No investigation was provided. On 03/08/16, Surveyor reviewed the ER report, dated 02/04/16, and noted the following: THROAT PROBLEM: This is a new problem. The current episode started today (pt. choked on some milk at (facility)). The problem has been resolved. Neither side of throat is experiencing more pain than the other. There has been no fever. The pain is at a severity of 0/10. Associated symptoms comments: none pt (patient) asymptomatic now. He has tried nothing for the symptoms. Pt was eating a subway sandwich at the time EMS arrived and doing well .He does not feel there is anything wrong at this time and is comfortable returning to nursing home .IMPRESSION AND PLAN: Resume previous dietary precautions per Speech Therapy. There were no dietary precautions or speech therapy notes found regarding this incident. On 03/08/16, Surveyor requested a copy of speech therapy notes for the above noted incident from the DON. The DON later told Surveyor that Resident #1 had not been seen by Speech Therapy for the above noted incident and no Speech Therapy notes were available. On 03/10/16 at 7:35 a.m., Surveyor interviewed Dietary Manager (DM) A in regard to the above noted choking incident. DM A stated she had heard about the choking incident the day after it happened (02/05/16). DM A stated she was told by facility staff that Resident #1 had choked on a subway sandwich. DM A stated Resident #1 often likes to order his food from an outside restaurant and will eat it here in the facility. DM A stated she did not assess Resident #1 and did not downgrade his diet. DM A stated it would be up to the physician if an assessment should be done and no orders were written for her to assess. DM A stated that it is normal, if any resident in the facility who chokes, that a physician's orders [REDACTED].#1 for the above incident. DM A stated she was not sure why or how Resident #1 had choked because she had already left for the day when it happened on 02/04/15. On 03/09/16 at 9:32 a.m., Surveyor interviewed the DON in regard to the above noted choking incident and discussed concerns that no investigation had been completed to determine root cause and analysis of choking incident, no interventions had been implemented to prevent future choking incidents from occurring, no notification to Speech Therapy had been initiated and no dietary assessment had been completed. No further information was provided.

Based on observations, interviews and record reviews, the facility did not ensure 4 of 13 sampled residents (#12, #11, #10 and #3) were provided with appropriate supervision and/or assistive devices to prevent accidents. The facility did not ensure safety to prevent injury from environmental hazards. Resident #12 experienced a decline in functional mobility and a falls care plan was initiated on 11/30/12. Resident #12 experienced a fall on 12/1/12. Following the fall, the facility did not investigate and analyze the potential causes of the fall and did not initiate new interventions to prevent further falls. Resident #12 fell again 5 days later on 12/6/2012 which resulted in a fractured right femur. Resident #11 exited the building on two occasions. Resident wanderguard was placed on the metal portion of his wheelchair, which is against manufacturers guidelines. Resident #10 and Resident #3 were assessed by the facility to be safe with smoking materials locked in a locked box in their room. The residents were non-compliant with this and the facility policy is that all smoking material shall be locked at the nurses' station. The entry door to the whirlpool room on the south hall had deep scratches rough and splintered that could cause potential injury to a resident. This is evidenced by: 1. Resident #12 was most recently admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #12 was independent in transfers, ambulation in room and toileting, as indicated on her 10/18/2012 Minimum Data Set (MDS) and care plan. On 10/24/12 a doctor's order was obtained for PT/OT to eval and treat related to right leg pain and a decrease in mobility. Resident #12 MDS dated [DATE] indicated a BIMS (Brief Interview for Mental Status) score of 11 out of 15, indicating moderately impaired cognitive skills. The MDS reflected Resident #12's memory recall was poor. As of 11/9/12 Resident #12 remained independent in ambulation in her room. On 11/21/12, Resident #12 was started on Lasix, a diuretic. Nurses' notes were reviewed by surveyor on 1/29/13. The nurse's note on 11/26/12 indicated Resident #12 was grabbing at items in the air and seeing things on the floor not there. On 11/30/12 Resident #12 experienced additional hallucinations. A doctor was not updated regarding this change in mental status. On 11/30/12 a temporary care plan was initiated with a problem of "At risk for falls due to: general weakness, decreased functional mobility to transfer self or ambulate, visual or hearing impairment, incontinence." Approaches initiated were: place call light in reach, remind resident to ask for assistance with transfers and ambulation as appropriate, pressure alarm to wheelchair and bed, remove hazards in room, hallways, alert resident to changes in environment, encourage to consume 75-100% of meal and observe for changes in cognition. The nurses' notes stated "at 11:30 p.m. on 12/1/12 Resident #12 was found on the floor in her room." The fall investigation states she was sitting in her recliner prior to the fall and was attempting to get out of her chair. The fall was unwitnessed. Resident #12's chair alarm did sound. Resident #12 did have a low temp (92.5 degrees) following the fall. The resident's daughter indicated it is normal for her to run low temps. The doctor was updated. The fall investigation did not include consideration of the addition of Laxis on 11/21/12, a potential increased need for toileting or the recent change in mental status (hallucinations) as possible causes for the fall. The fall report identifies the "new intervention" as "re-educate on the use of her call light." No injuries were noted with this fall. The facility assessed Resident #12 as having memory and cognitive impairments and was also experiencing hallucinations. It is questionable if re-education on-call light use would be an appropriate intervention for Resident #12. No new interventions were added to Resident #12's care plan to prevent a similar fall from occurring. Nurses' notes on 12/7/12 indicate Resident #12 experienced a second fall. She was found at 10:40 p.m. siting on the floor next to the closet. She had been sitting in her recliner prior to the fall and the alarm did sound. Resident #12 stated she was trying to ambulate herself to the toilet. The resident's leg was bent and painful, she also stated she did hit her head when asked. Resident #12 was transported to Baldwin Area Medical Center and then transferred to United Hospital. Resident #12 suffered a fractured right femur which was surgically repaired. The hospital report dated 12/12/12 states "fracture was surgically repaired, but unfortunately she did not recover well from the surgery. She was diagnosed as having [DIAGNOSES REDACTED] on EEG." Resident #12 was transferred back to Baldwin Care Center with comfort cares and enrolled in Hospice. Surveyor interviewed the Director of Nursing (DON) on 1/30/2013. The DON stated the fall investigation is what is in the nurses' notes. There is not additional investigation or notes. The DON stated Resident #12 did usually stay up later and at times did use her call light appropriately. Surveyor asked DON if reminding her to use her call light was a new intervention. The DON stated "that had been in place, it is standard operating procedure." The DON did indicate there had been no falls prior to 12/1/12. 2. Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. Nursing Notes beginning on 8/24/12 note Resident #11 is "anxious at supper, had to leave and meet people on bus," he was easily redirected. On 9/18/2012 the nurse's notes state the resident was outside in front of the building at 4:40 p.m., one of the physical therapists had found him when she was leaving and brought him back in. The alarm did not sound when resident exited. In the nurses' notes it states "No alarm sounded. Resident left the building with his walker. His wheelchair contains wanderguard." Surveyor interviewed NHA on 1/31/13 at 4:15 p.m. NHA confirmed Resident #11 went out with his walker. At this time the wanderguard was placed on his walker. -On 9/30/12 nurses' notes state Resident #11 expressed the need to go and look for his truck. -On 10/4/12 nurse's note states "does not wander." -On 10/8/12 Resident #11 wanted to look for a ride home. According to nursing notes he insisted a guy was waiting for him and he was looking for his keys. Resident #11 MDS dated [DATE] reflects a BIMS score of 2/11 indicating severe impairment. The MDS identifies no behaviors and no wandering. Resident requires limited assistance for ambulation with walker. Resident #11's care plan dated 10/24/12 identifies the resident as a wanderer related to dementia. Approaches at this time included wanderguard bracelet on walker, check nightly. On 11/10/12 the nurse's note state, Resident #11 left the facility and was found in the parking lot near the road "attempting to wheel self up a slight incline back toward building." The facility investigation identified it was likely the resident left after 1:10 p.m. and was found and brought back in by a visiting family member at 1:30 p.m. The resident did have a wanderguard on his wheelchair, however, the alarm did not sound. The wanderguard and door alarms had been checked and were thought to have been functioning properly. Surveyor interviewed DON who stated following this incident it was discovered the manufacturers guidelines are to not have the bracelet within "so many inches of metal." At this time all residents with a wanderguard were checked and bracelets were reapplied. A review of the manufacturers guidelines state "Warning...Do not place the signaling device on or next to metal, such as wheelchair frames..." 3. Resident #10 was admitted on [DATE]. He was alert and oriented and independent with all cares. Resident was admitted with a TBI (Traumatic Brain Injury), depression and anxiety with his POA (Power of Attorney) activated. His mini mental score on 7/23/12 was 29/30. Social Services notes on 7/10/12 indicate Resident #10 expressed a desire to start smoking again. He was reminded the facility is "tobacco free." Surveyor review Social Services notes on 1/29/13. An entry dated on 7/11/12 stated "Resident #10 again brings up topic of smoking with social worker." Social worker reminded him of previous conversation and facility policy - smoke free. The facility and Resident #10's mother were aware he had purchased cigarettes and currently has them at the facility. Resident #10's mother removed them from his room. -Social services notes on 7/13/12 state Resident #10 informed facility staff he had no intentions of quitting smoking. He was found smoking by the side door. He did give the cigarettes and lighter to staff. -Social services note dated 7/19/12 state cigarettes were removed from Resident #10's room. -Social Services note from 8/2/12 note Resident #10 was smoking on grounds. He did give the cigarettes to the administrator. A smoking assessment completed on 8/10/12 indicated Resident #10 is a safe smoker, "smokes in appropriate off-facility area." The assessment states he keeps smoking paraphernalia in a locked drawer in his room. Facility policy dated 01/20/10 outlines at "#4. All cigarettes and matches will be kept locked in the medication room." 4. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/29/12 a smoking safety assessment was completed for Resident #3. The safety assessment showed, "Resident #3's smoking paraphernalia would be kept in a locked box." The resident's care plan for smoking outlined Resident #3's cigarettes are stored in her refrigerator in her room. The CNA (certified nursing assistant) care plan read: SPECIAL NEEDS: Does go outside to smoke. Facility policy dated 01/20/10 outlines at #4. "All cigarettes and matches will be kept locked in the medication room." On 01/29/13 at 8:00 a.m. Surveyor observed Resident #3 outside of the facility near the employee entrance sitting at a table smoking a cigarette. Surveyor stepped outside and talked to Resident #3 regarding where her cigarettes and lighter are kept. Resident #3 responded, "I keep my cigarettes in the refrigerator in my room and I keep my lighter in here." Resident removed a small plastic container from her coat pocket and showed Surveyor inside of the container was 2 cigarettes and a lighter. Resident #3 stated, "I keep this in my coat pocket in my room." On 01/30/13 at 9:25 a.m. Surveyor and RN (Registered Nurse) X went into Resident #3's room to verify where cigarettes are kept. RN X opened the refrigerator in Resident #3's room and showed Surveyor a plastic see through bag that contained numerous cigarettes and returned the bag to the refrigerator shelf. While RN X looked in Resident #3's drawers in her night stand and her dresser she stated, "She (Resident #3) used to have a locked box in her room she would keep her cigarettes in but I don't see it anymore." On 01/30/13 at 9:35 a.m. Surveyor met with RN AA and reviewed the discrepancies regarding Resident #3's care plan, CNA care plan and smoking assessment with RN AA. RN AA verified the facility policy clearly reads "all cigarettes and matches will be kept locked in the medication room." RN AA was also able to verify Resident #3 keeps her cigarettes in her refrigerator in her room while keeping her lighter in her coat pocket in her room. RN AA verbalized the discrepancies between the documents reviewed. On 01/28/13 at 11:25 a.m. during the initial tour, Surveyor observed the whirlpool tub room located on the south hall. The door through which residents would enter and exit had several deep scratches rough and splintered at the edge and sides of the door, approximately 8-10 inches from the floor. These rough edges had the potential to cause resident injury if their leg or foot would come in contact with those areas of the door while entering or exiting the whirlpool room. Surveyor was touring with Registered Nurse (RN) AA. Surveyor pointed out the scratches and rough edges of the door and expressed concern of potential resident injury. RN AA agreed and said it could cause skin tears.

Based on staff interview and record review the Facility did not ensure that each Resident is offered the pneumococcal immunization unless the immunization is medically contraindicated or the Resident has already been immunized for 6 of 11 Residents reviewed for their immunization status . Resident #4 was admitted to the facility on [DATE]. Resident #4's immunization record is blank and there is no documentation in the medical record that Resident #4 was offered the pneumococcal immunization. On 12/15/10 Resident #4 was readmitted to the Facility with a [DIAGNOSES REDACTED].#4's pneumococcal immunization status. Resident #4's legal representative was then contacted and Resident #4 was to receive the immunization on 11/9/11. Facility staff were unaware of Resident #15, #9, #10, #12, & #7's pneumococcal immunization status. Findings include: On 11/8/11 at 11:27 a.m., Surveyor # interviewed RN-C, who stated either she or the nurse admitting the resident asks the resident's pneumococcal vaccination status on admission. If the resident or family does not know the status, the floor nurses do not do further research to ascertain the status; they should let RN-C know follow-up is needed, but sometimes they forget to inform her that she needs to follow up on the immunization status. RN-C stated when she is aware she needs to further research a resident's immunization status, she calls the clinic, and looks the resident up in the WIR (Wisconsin Immunization Registry). RN-C stated she does not always document information she receives regarding the resident's immunization status. Surveyor # asked who oversees the pneumococcal vaccine program to ensure residents status is obtained so the vaccine can be offered when appropriate. RN-C stated no one really oversees who had it (the pneumococcal vaccine) or who they need to follow up on. 1.) Surveyor # reviewed Resident #4's medical record on 11/7/11 through 11/9/11. Resident #4 is an [AGE] year old male originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #4 was sent to the hospital on [DATE] and returned to the facility on [DATE]. Resident #4's health care power of attorney was activated on 3/14/11. Resident #4's admission MDS (minimum data set) with an assessment reference date of 2/5/10 documents for the question is the pneumococcal vaccination up to date "no" is answered. If the pneumococcal vaccine not received state reason. "Not offered" is answered. The standing orders document "Pneumovak IM (intramuscular) upon admission if no record of previous vaccination." The hospital history and physical/discharge summary for date of admission 12/14/2010 and date of discharge 12/15/2010 documents for final diagnosis "pneumonia." Under diagnostic findings documents "A chest x-ray shows questionable mild infrahilar infiltrate on the right, no significant consolidation. The left lung is clear." Under impression documents "An [AGE] year old male with pneumonia and baseline mental status changes and dementia." Under the plan documents "We will discharge him back to the Baldwin Care Center today, to continue with oral antibiotics for the pneumonia." "We will also include albuteral neb (nebulizer) q (every) 4 hours p.r.n. (as needed) and [MEDICATION NAME] neb 0.5 inhaled q 12 hours for 1 month for pneumonia." The Resident Immunization Record is blank for the "pneu. (pneumococcal) vaccine date" and Surveyor # was unable to locate documentation that Resident #4 had received the vaccine prior to admission or was offered the pneumococcal immunization. On 11/8/11 at 1:13 p.m. Surveyor # informed RN (Registered Nurse)-C that during Resident #4's record review Surveyor # noted that Resident #4 had been hospitalized for [REDACTED].#4's immunization record is blank for the pneumococcal immunization and Surveyor # could not locate any documentation that Resident #4 had received the vaccine or had been offered the pneumococcal immunization. Surveyor # asked if RN-C knew the immunization status for Resident #4. RN-C informed Surveyor # that she would have to find out and get back to Surveyor # . On 11/8/11 at 3:10 p.m. during the daily exit conference Surveyor # informed the Administrator and RN/Interim DON-E that Surveyor # is unable to determine Resident #4's pneumococcal immunization status. On 11/9/11 at 7:43 a.m. Surveyor # asked RN-C if she had any information regarding Resident #4's pneumococcal immunization status. RN-C informed Surveyor # that she contacted Baldwin Medical Center and they did not have any information so she called Resident #4's son and left a message. RN-C informed Surveyor # that Resident #4's son did not call back yet. On 11/9/11 at 1:49 p.m. Surveyor # asked RN/Interim DON (Director of Nursing)-D if RN-C was in the Facility. RN/Interim DON-E informed Surveyor # that RN-C has left for the day. Surveyor # asked RN/Interim DON-E if she had any information regarding Resident #4's pneumococcal immunization status. RN/Interim DON-E informed Surveyor # that RN-C told her that they are still waiting for Resident #4's son to call back. On 11/10/11 at 7:51 a.m. Surveyor # asked RN/Interim DON-E if there was any information regarding Resident #4's pneumococcal immunization status. RN/Interim DON-E informed Surveyor # that Resident #4's son called back last evening informed them that his father had not received the immunization previously and gave permission for Resident #4 to receive the pneumococcal vaccine. RN/Interim DON-E informed Surveyor # that Resident #4 received the pneumococcal vaccine last night. 2.) Surveyor # reviewed Resident #15's medical record on 11/9/11. Resident #15 is an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an assessment reference date of 10/4/11 documents for the question is the pneumococcal vaccination up to date "no" is answered. If the pneumococcal vaccine not received state reason. "Not offered" is answered. The Resident Immunization Record is blank for the "pneu. (pneumococcal) vaccine date" and Surveyor # was unable to locate documentation that Resident #15 had received the vaccine prior to admission or was offered the pneumococcal immunization. The standing orders document "Pneumovak IM (intramuscular) upon admission if no record of previous vaccination." On 11/9/11 at 10:45 a.m. Surveyor # informed RN (Registered Nurse)-C that Surveyor # had reviewed Resident #15's medical record and noted the immunization record is blank for the pneumococcal immunization and Surveyor # could not locate in Resident #15's medical record that Resident #15 had received the immunization prior to admission or that Resident #15 was offered the pneumococcal immunization. RN-C informed Surveyor # that she would look into this and get back to Surveyor # . On 11/9/11 at 11:05 a.m. RN-C informed Surveyor # that she had gotten busy and didn't check to see if Resident #15 had already received the vaccine or needed to be offered the pneumococcal vaccine. On 11/9/11 at 11:33 a.m. RN-C informed Surveyor # that she had contacted St. Joseph and they are sending her the information that Resident #15 received the pneumococcal vaccine in September 2009. Facility staff were unaware of Resident #15's pneumococcal immunization status until questioned by Surveyor # . 3.) Surveyor # reviewed Resident #9's medical record on 11/9/11 & 11/10/11. Resident #9 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an assessment reference date of 11/2/11 documents for the question is the pneumococcal vaccination up to date "no" is answered. If the pneumococcal vaccine not received state reason. "Not offered" is answered. The Resident Immunization Record is blank for the "pneu. (pneumococcal) vaccine date" and Surveyor # was unable to locate documentation that Resident #9 was offered the pneumococcal immunization. The standing orders document "Pneumovak IM (intramuscular) upon admission if no record of previous vaccination." On 11/9/11 at 11:33 a.m. Surveyor # interviewed RN (Registered Nurse)-C regarding Resident #9's pneumococcal immunization status. Surveyor # informed RN-C that during Resident #9's record review Surveyor # was unable to locate if Resident #9 had the pneumococcal immunization prior to admission or did Facility staff offer the immunization. RN-C informed Surveyor # that she would look into this and get back to Surveyor # . On 11/9/11 at 1:49 p.m. RN/Interim DON (Director of Nursing)-D informed Surveyor # that RN-C placed a call to Glenwood City clinic to see if Resident #9 had received the vaccine yet. Surveyor # inquired if RN-D knew what Resident #9's immunization status was. RN-D replied that they were waiting for a return call. On 11/9/11 at 3:04 p.m. RN/Interim DON-D informed Surveyor # that the Glenwood City clinic called back and informed them that Resident #9 received the pneumococcal vaccine on 11/1/02. Facility staff were unaware of Resident #9's pneumococcal immunization status until questioned by Surveyor # . On 11/9/11 at 3:35 p.m. during the daily exit conference the Administrator and Interim DON-D & Interim DON-E were informed of the above. On 11/10/11 at 8:09 a.m. Surveyor # asked RN-C if a Resident receives the pneumococcal immunization before age 65 do they administer a booster. RN-C informed Surveyor # that it is there policy if a Resident receives the vaccine before age 65 then they would administer another vaccine five years after. RN-C informed Surveyor # that noted that Resident #9 received the immunization before 65 and would be going over the information. 4.) Surveyor # reviewed Resident #10's medical record on 11/9/11. Resident #10 is a [AGE] year old female originally admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Resident #10's healthcare power of attorney was activated on 6/17/11. The Resident Immunization Record is blank for the "pneu. (pneumococcal) vaccine date" and Surveyor # was unable to locate documentation that Resident #10 was offered the pneumococcal immunization. On 11/9/11 Surveyor # interviewed RN (Registered Nurse)/Interim DON (Director of Nursing)-D regarding Resident #10's pneumococcal immunization status. Surveyor # informed RN/Interim DON-D that during Resident #10's record review Surveyor # was unable to locate if Resident #10 had the pneumococcal immunization prior to admission or did Facility staff offer the immunization. RN/Interim DON-D informed Surveyor # that she would look into this and get back to Surveyor # . On 11/9/11 at 3:05 p.m. RN/Interim DON-D informed Surveyor # that Baldwin clinic faxed over the pneumococcal information for Resident #10 today. Surveyor # was provided with a copy of the immunization record from Baldwin clinic which indicates that Resident #10 received the [MEDICATION NAME] 23 (pneumococcal V23) on 11/7/1996 and 1/1/2001. Facility staff were unaware of Resident #10's pneumococcal immunization status until questioned by Surveyor # . On 11/9/11 at 3:35 p.m. during the daily exit conference the Administrator and Interim DON-D & Interim DON-E were informed of the above. 5). Resident #12 is [AGE] year old female who was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. On 11/9//11 at 9:00a.m. Surveyor # reviewed the medical record of Resident #12. During this review it was noted on the Baldwin Care Center Resident Immunization record the pneumococcal vaccine was blank. Also the Minimum (MDS) data set [DATE] states the pneumococcal was not offered. Surveyor # spoke to Registered Nurse-C regarding any documentation that Resident received or didn't receive the pneumococcal vaccine. RN-C along with Surveyor # reviewed the medical record and could not find any documentation regarding the pneumococcal vaccine being offered. A review of the Care Area assessment dated [DATE] states Resident #12 was admitted to the facility on an Antibiotic [MEDICATION NAME] for chest congestion and cough [MEDICAL CONDITION]. On 11/9/11 at the daily exit meeting the above information was shared with the facility. The facility did not know if Resident #12 was offered the pneumococcal vaccine or not. On 11/10/11 at 8:00a.m. the facility provided Surveyor # a flow sheet from the Preventive Services/Chronic Care Management that was faxed to the facility on [DATE] at 7:11p.m. which notes Resident #12 did receive the [MEDICATION NAME] on 9/26/07. 6.) Resident #7 was admitted to the facility on [DATE] with metastatic [DIAGNOSES REDACTED] (smooth muscle [MEDICAL CONDITION]). On 11/7/11- 11/9/11, Surveyor # reviewed Resident #7's medical record. Resident #7's Resident Immunization Record, which was blank. Surveyor # observed Resident #7's MAR (Medication Administration Record) indicates Resident #7 did receive the influenza vaccine on 10/6/11, but no documentation was locate indicating if she received the pneumococcal vaccine. On 11/8/11 at 9:30 a.m., Surveyor # interviewed LPN (Licensed Practical Nurse)-K regarding infection control. LPN-K stated she monitors the influenza vaccine program, but referred Surveyor # to MDS (Minimum Data Set) RN (Registered Nurse)-C for questions regarding the pneumococcal vaccine program. On 11/8/11 at 11:27 a.m., Surveyor # interviewed RN-C, who stated either she or the nurse admitting the resident asks the resident's pneumococcal vaccination status on admission. If the resident or family does not know the status, the floor nurses do not do further research to ascertain the status, they should let RN-C know follow-up is needed, but sometimes they forget to inform her that she needs to follow up on the immunization status. RN-C stated when she is aware she needs to further research a resident's immunization status, she calls the clinic, and looks the resident up in the WIR (Wisconsin Immunization Registry). RN-C stated she does not always document information she receives regarding the resident's immunization status. Surveyor # asked who oversees the pneumococcal vaccine program to ensure residents status is obtained so the vaccine can be offered when appropriate. RN-C stated no one really oversees who had it (the pneumococcal vaccine) or who they need to follow up on. On 11/9/11 at 8:28 a.m., RN-C informed Surveyor # that she called Baldwin Clinic and their records document Resident #7 received the pneumococcal vaccine on 11/14/1998. RN-C confirmed that prior to 11/9/11, facility staff were not aware of Resident #7's pneumococcal immunization status, six months after her admission.

Based on observation, interview, record review and a review of the facility investigation, the facility did not ensure 2 of 4 residents at risk for falls, from a sample of 4, was provided appropriate supervision and assistance devices to prevent accidents. Resident #1 had a history of [REDACTED]. The resident had a nursing care plan in place which required a silent alarm to be used in the bed and in the recliner and a seat pressure alarm to be used in the wheelchair. The resident had a Certified Nursing Assistant (CNA) care plan in place which required a silent alarm to be used in the bed and in the recliner, a pressure pad alarm to be used in the wheelchair and a TABS (personal) alarm to be used when in bed and when in the "chair." The resident's nurses' notes identified the use of a TABS alarm at all times. The resident had falls on [DATE] out of the wheelchair (no new interventions), [DATE] out of the recliner (no new interventions until [DATE] when therapy was initiated) and on [DATE] out of bed (a low bed with a landing strip was initiated) sustaining a possible re-injury of the right hip/pelvic bone. On [DATE], Resident #1 was assisted into the wheelchair by facility staff and the TABS alarm was not attached to the resident. The resident was found face down on the floor in his room with his buttocks in the air and his feet tangled in the wheelchair pedals and had complaints of left hip discomfort, bilateral knee pain and right arm pain. The resident was transported to the hospital where x-rays identified a left hip/pelvic fracture with moderate displacement. ~Facility staff did not ensure both the nursing care plan and the CNA care plans identified the use of the TABS alarm, did not ensure the term "chair" was clearly identified to specify its use in the wheelchair and/or in the recliner, did not immediately initiate new interventions following falls on [DATE] and [DATE], did not put new interventions in place with evidence of increased anxiety on [DATE] (leading to a fall with possible injury on [DATE]) and on [DATE] did not attach the TABS alarm to the resident in the wheelchair as was required per the nurses' notes and the CNA care plan (although the wording was not entirely clear). Resident #2 had a history of [REDACTED]. The resident had falls out of the wheelchair on [DATE] and on [DATE]. The resident had a current nursing care plan in place which required that the resident's feet not be reclined when in the recliner. The current CNA care plan did not include this intervention. On [DATE], Resident #2 was observed during survey to be sitting in his recliner with his feet elevated. ~Facility staff did not immediately initiate new interventions following falls on [DATE] and [DATE] and did not ensure the current CNA care plan identified the intervention not to elevate the resident's feet when in the recliner. This is evidenced by the following: 1. Resident #1 had resided at the facility for several years. [DIAGNOSES REDACTED].). Medications included Trazadone 75 milligrams (mg) at bedtime for insomnia with an additional dose that could be given if awake for 1 or more hours after the initial dose and Vicodin, 1 tablet, every 6 hours prn (as needed) for pain. Resident #1's quarterly assessment, dated [DATE], identified Resident #1 had confusion and anxiety with 2 falls in the previous 6 months and alarms included a silent alarm in the bed and recliner and a pressure pad alarm in the wheelchair. A TABS/personal alarm, attached to the resident with a string and a clip, was not identified at that time. A Fall Risk Assessment completed by the facility, dated [DATE], stated Resident #1 scored 20, which was high risk for falls. Resident #1's nursing care plan at that time stated the resident had a history of [REDACTED]. Alarms included a silent alarm in the bed and recliner and a pressure pad alarm in the wheelchair. A TABS alarm was not identified on the care plan. On [DATE], a nurse's note identified Resident #1 utilized a silent alarm in the bed and in the recliner, a pressure pad in the wheelchair and a TABS alarm at all times. The nursing care plan was not updated to require a TABS alarm at all times. A nurse's note on [DATE] on the night shift identified Resident #1 should be monitored to prevent him from getting up by himself to go to the bathroom as he did make attempts to get up unassisted. A nurse's note on the day shift identified Resident #1 attempted to transfer into the recliner unassisted and when staff responded to the alarm, the resident was lowered to his knees. A nurse's note on [DATE] identified only the pressure alarm in the wheelchair was alarming on [DATE] as the resident had unclipped his TABS alarm. Nurses' notes on [DATE] identified Resident #1 had poor short-term memory and poor balance with alarms continued for safety. The care plan was not updated following the fall of [DATE]. On [DATE], nurses' notes identified Resident #1 appeared anxious and was observed self-transferring several times back and forth between the wheelchair and the recliner. On [DATE], nurses' notes identified at 7:25 a.m., staff responded the sound of the TABS alarm and found the resident sitting on the floor after he had attempted to self-transfer from the recliner to the wheelchair. The nursing care plan was not updated immediately following the fall of [DATE]. On [DATE], a physical therapy (PT) evaluation was initiated for Resident #1 related to strength, balance and activity tolerance limiting the resident's transfers and gait. Resident #1's Medication Administration Record (MAR) from [DATE] through [DATE], identified the following pain medication was administered: ,[DATE], Tylenol 650 mg for general discomfort; ,[DATE], 1 tablet Vicodin for knee pain; ,[DATE], 23, 27, Tylenol 650 mg for restlessness; and, ,[DATE] and ,[DATE], Tylenol 650 mg for general discomfort. There was no documentation the pain medication was given for specific complaints of back, pelvic or hip pain. On [DATE], nurses' notes identified Resident #1 attempted to stand without staff assistance almost continuously without direct one to one attention. On [DATE], nurses' notes identified at 5:30 a.m., staff responded to the sound of the bed alarm and the TABS alarm and found Resident #1 ambulating with his walker before staff could reach him and the resident fell , landing on his left side. It was identified the resident complained of left hip pain with transfers and was transported out by ambulance for evaluation. Surveyor reviewed, from [DATE] to [DATE], Resident #1's emergency room records related to the [DATE] visit there following the fall. CT exams of the cervical and lumbar spine were negative for acute fractures but showed degenerative changes. An x-ray of the pelvis included the following statements. "AP supine view of the pelvis is compared with prior examination of [DATE]. A fracture of the right inferior pubic ramus was present at the time of the prior study. On the current study fracture lines are visible indicating the fracture has not healed or there has been a recurrent injury in this location...There is no acute fracture or dislocation of either hip. The final results identified the appearance of the "right" inferior pubic ramus raised concern for a non healed fracture or a recurrent injury at a prior fracture site. Resident #1 was returned to the facility on [DATE] with orders for Ibuprofen 600 mg 3 times a day and Tylenol 1000 mg at bedtime, both for 10 days. The nursing care plan was updated to initiate a low bed with a landing strip (next to the bed). Resident #1's MAR, following the fall on [DATE], identified a significant increase in the use of the prn Vicodin: 1 on [DATE]; 3 on [DATE]; 2 on [DATE]; 2 on [DATE]; 1 on [DATE]; and, 2 on [DATE]. On [DATE], an order was obtained for Resident #1 that Vicodin, 1 tablet, could be given every 4 hours prn and for an Aqua K (heating pad) for 30 minutes 4 times a day prn for back pain. On [DATE], an order was obtained for Xanax 0.25 mg every 4 hours prn for anxiety. On [DATE], the resident was sent to the clinic and an order was obtained for Motrin 800 mg 3 times a day prn for pain. Over the 8 day period from [DATE] to [DATE], prn Xanax was administered on 7 days, with Vicodin administered on 3 days, both medications sometimes administered twice daily. The MAR and the nurses' notes identified the Vicodin was given for back and/or hip pain, but did not identify which hip was painful. On [DATE], the nursing care plan was updated to initiate that Resident #1's feet should not be elevated when in the recliner. On [DATE], the Medical Exchange Form, sent from the facility to the physician, identified Resident #1 complained of both right and left hip pain. Surveyor reviewed, from [DATE] to [DATE], the physician evaluation of Resident #1's clinic visit on [DATE]. It was stated by the physician that he reviewed the emergency room notes from [DATE] and, "...it is clear that he is probably having pain from his recent fall, which is likely to have caused his pelvic fracture. Along with his [DIAGNOSES REDACTED]." It was identified the physician chose not to repeat x-rays at that time. Over the 5 day period from [DATE] to [DATE], prn Xanax was administered on all 5 days, with Vicodin administered on 3 days, both medications sometimes administered twice daily. The MAR and the nurses' notes identified the Vicodin was given for back and/or hip pain, but did not identify which hip was painful. On [DATE], a nurse's note identified Resident #1 required a TABS alarm at all times as well as the pressure alarm in the wheelchair. The resident's nursing care plan identified a silent alarm to be used in the bed and in the recliner and a seat pressure alarm to be used in the wheelchair. The resident's CNA care plan identified a silent alarm to be used in the bed and in the recliner, a pressure pad alarm to be used in the wheelchair and a TABS (personal) alarm to be used when in bed and when in the "chair." The nursing care plan did not identify the use of the TABS alarm. The CNA care plan did not ensure the term "chair" was clearly identified to specify its use in the wheelchair and/or in the recliner. On [DATE], nurses' notes identified at 10:55 a.m., staff responded to the sound of the wheelchair pressure alarm and found Resident #1 face down on the floor in his room with his buttocks in the air and his feet tangled in the wheelchair pedals. It was identified the TABS alarm did not sound as it was not applied when staff assisted him into the wheelchair. It was also identified the resident had hit his head and complained of left hip discomfort, bilateral knee pain and right arm pain. Resident #1 was transported out by ambulance for evaluation. Surveyor reviewed, from [DATE] to [DATE], the facility investigation regarding Resident #1's fall on [DATE]. The investigation included two CNA care plans, one that was in place in the resident's room at the time the resident was placed into the wheelchair and another that was placed in the resident's room by Licensed Practical Nurse (LPN) A just minutes before the fall occurred on [DATE]. The initial CNA care plan identified a pressure pad alarm in the wheelchair and a TABS/personal alarm when in bed and "chair." The new CNA care plan placed by LPN A identified a pressure pad alarm in the wheelchair and a TABS alarm at all times. The facility's investigation regarding Resident #1's fall on [DATE] included a statement from LPN A which identified at 10:55 a.m. she had just left Resident #1's room after placing a new CNA care plan in the room when a CNA called out that Resident #1 was on the floor. Surveyor interviewed LPN A on [DATE] at 1:10 p.m. LPN A stated she was temporarily assigned to update CNA care plans and that during the week of [DATE] she revised all the CNA care plans and put the new ones in the residents' rooms. LPN A stated on [DATE] she went into Resident #1's room to place his updated CNA care plan, said hello to him as he sat in the wheelchair, did not observe what devices he had in place and just minutes later heard a CNA calling out that Resident #1 had fallen. LPN A identified Resident #1's CNA care plan that required a TABS alarm in the "chair," meant any chair, including the recliner and the wheelchair. LPN A stated the TABS alarm is used for residents because it generally sounds first (before the pressure pad alarm) when the resident leans forward. LPN A stated Resident #1 deteriorated over his last month at the facility and could no longer propel his wheelchair independently. The facility's investigation regarding Resident #1's fall on [DATE] included statements from CNA B and CNA C (LPN, but working as CNA on [DATE]). CNA B's statement included the following. At 10:35 a.m. Resident #1 was in bed and calling out that he had to go to the bathroom. CNA B and CNA C changed the resident's incontinence pad but did not take him to the bathroom. They assisted him into the wheelchair. CNA B buttoned the resident's shirt and CNA C combed the resident's hair. The footrests were put on the wheelchair. They forgot to attach the TABS alarm and left the room at approximately 10:40 a.m. CNA C's statement included the following. CNA C and her partner went into Resident #1's room at approximately 10:35 a.m. and assisted him from his bed into the wheelchair but did not take him to the bathroom per the resident's request. CNA B took care of the resident's upper part and CNA C took care of his feet, placing them on the footrests of the wheelchair. They left the room at approximately 10:45 a.m. The TABS alarm was not addressed. Surveyor interviewed CNA/LPN C on [DATE] at 1:20 p.m. CNA/LPN C identified Resident #1 utilized a pressure alarm in the wheelchair and added that a TABS alarm would not necessarily prevent him from falling. CNA/LPN C stated she had a concern that Resident #1's care plan was vague on [DATE] and did not ensure the term "chair" was clearly identified to specify its use in the wheelchair and/or in the recliner, especially for staff who would be unfamiliar with the resident. CNA/LPN C stated it was not unusual at that time that CNA care plans were not up to date, but added that recently the CNA care plans were being updated more timely. CNA/LPN C stated she was aware that Resident #1 was to have a TABS alarm in the wheelchair on [DATE] and aware that the CNA care plans were to be followed. The facility's investigation regarding Resident #1's fall on [DATE] included statements by the Director of Nursing (DON) that Resident #1 was to have a TABS alarm attached when up in the wheelchair per the CNA care plan. During an interview with Surveyor on [DATE] at 3:35 p.m., the Nursing Home Administrator (NHA) identified Resident #1 was at risk for falls and utilized both a pressure pad alarm and a TABS alarm when in the wheelchair. Surveyor reviewed, from [DATE] to [DATE], Resident #1's hospital records related to the [DATE] fall. CT exams of the head and cervical spine were negative for acute findings. CT of the lumbar spine, dated [DATE], included the following statements. "There is partial visualization of an acute appearing left inferior sacral ala fracture with chronic appearing insufficiency fracture vertically proximal to this. Left iliac crest also appears fractured just inferior to the sacroiliac joint with a centimeter and a half anterior displacement. CT of the pelvis is recommended." The history and physical, dated [DATE], stated the resident complained of left hip pain and low back pain with marked ecchymosis (bruising) on the inner aspect of the left thigh. CT of the pelvis, dated [DATE], included the following statements. "There is a fracture deformity of the left iliac wing...This region appeared fractured on the prior CT from [DATE]. This may represent a fracture with re-injury recently, given the callus formation. There is an associated fracture of the left supra-acetabular region...This is likely subacute in nature as there is callus formation present. There is a comminuted (fragmented) fracture of the left inferior pubic ramus...and a probably avulsion (tearing away) injury about the right ischial tuberosity...There is an additional fracture deformity of the left sacral ala...which is not completely visualized. There is a soft tissue hematoma about the left iliacus muscle about the fracture..." The final results identified there was a comminuted fracture about the left inferior pubic ramus and that the left iliac wing fracture might represent a re-injury. A consultation report written by Physician D, dated [DATE], confirmed a left "pelvic fracture involving the innominate (hip bone) with moderate displacement." Resident #1 was admitted to the hospital with [REDACTED]. The resident subsequently expired at the hospital on [DATE] after not responding to intravenous antibiotics for the pneumonia. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission nurses' notes identified the resident's cognitive status as oriented to self and family and confused at times, behavior as agitated and transfers requiring 3 staff. Ativan was ordered to be given as needed. Resident #2's Certified Nursing Assistant (CNA) care plan, dated [DATE], identified safety/support devices as a TABS alarm at all times, a silent alarm in the bed, a low bed and a floor mat alarm. A landing strip and anti-tips (for the wheelchair) were both added in longhand (undated). Resident #2's nurses' notes over the next 2 weeks identified the resident was restless, agitated, resistive, observed to self-transfer without staff assistance and noted to have increased knee rigidity (Baclofen ordered). On [DATE], nurses' notes identified at 4:15 p.m., staff responded to the sound of the TABS alarm and found Resident #2 lying on his left side next to the wheelchair in his room. It was identified the resident had a small contusion (bruise) to the left side of the face near the cheekbone, below the left eye. Surveyor interviewed the Director of Nursing (DON) on [DATE] at 3:00 p.m. The DON stated a therapy referral was made following the fall on [DATE] and a high back wheelchair was recommended. Surveyor reviewed, from [DATE] to [DATE], the physical therapy (PT) and occupational therapy (OT) records, the nurses' notes, the nursing and the CNA care plans, as well as other parts of Resident #2's record. There was no documentation as to when the high backed wheelchair was initiated. On [DATE], [DATE] and [DATE], nurses' notes identified Resident #2 was restless/agitated and made attempts to get out of his wheelchair unassisted which required the administration of Ativan and one to one staff supervision. On [DATE], a comprehensive nursing care plan was initiated for Resident #2. The problem related to falls and potential for trauma identified an impaired sense of balance, fall (or near fall) in the past 6 months and declines in both cognitive and functional status. Interventions included a TABS alarm at all times, a low bed with a landing strip next to the bed, an alarmed floor mat, a silent bed alarm and anti-tips for the wheelchair. Rollbacks were added for the wheelchair, but not dated. On [DATE], nurses' notes identified at 5:15 p.m., staff walked by the resident's door and noted Resident #2 laying on his back with his head on the floor. He had previously been sitting in his wheelchair in his room. It was identified the resident had removed the TABS alarm thus it did not sound. The nursing care plan was not updated until [DATE] for the use of a pressure pad alarm in the wheelchair and in the recliner, with a landing strip also when in the recliner. The care plan also was updated at that time to keep the resident's feet down when in the recliner and for a foot buddy on the wheelchair for transport only and then to take it off. The CNA care plan was updated with all of the above except for keeping the resident's feet down when in the recliner. On [DATE], the nursing care plan was updated to discontinue the silent bed alarm. On [DATE], Surveyor observed Resident #2 at 12:40 p.m., 2:15 p.m. and 3:25 p.m. resting in his recliner which was reclined back and his feet elevated with a floor mat under the reclined footrest. Surveyor interviewed CNA E on [DATE] at 3:25 p.m. CNA E identified she was familiar with Resident #2. CNA E stated she was not aware of any restrictions that Resident #2 could not sit in his recliner with his feet up. On [DATE], the nursing care plan still included the statement to keep the resident's feet down when in the recliner, but the current CNA care plan in the resident's room on [DATE] did not include this intervention. On [DATE], Surveyor observed Resident #2 at 9:35 a.m. sitting in his recliner with his feet down and resting on the floor. Surveyor interviewed CNA F at that time who identified she was familiar with Resident #2 and stated as far as she knew, it had been on the resident's CNA care plan for approximately 2 weeks that he should not sit in the recliner with his feet up. Surveyor and CNA F reviewed the current CNA care plan in Resident #2's room at that time and noted that, "Keep feet down when in recliner" had been added in longhand (not dated) to the typed care plan that was dated [DATE]. Surveyor interviewed the Nursing Home Administrator (NHA) and the DON on [DATE] at 2:20 p.m. and discussed the surveyor's observations on [DATE] of Resident #2 in the recliner with his feet up. The DON confirmed the intervention of having the resident's feet down in the recliner was an intervention added when the falls committee met on [DATE] in response to the resident's 2 recent falls out of the wheelchair. Surveyor interviewed the DON on [DATE] at 3:00 p.m. The DON stated the pressure alarm was initiated in the wheelchair and the recliner following Resident #2's fall of [DATE] (but not initiated for 6 days until [DATE]) and a therapy screen was requested the week of [DATE] to [DATE] regarding the use of the recliner. The DON confirmed that the therapy screen/evaluation was not done until [DATE] and that therapy recommended the recliner chair should not be utilized as a recliner (the resident's feet should be kept on the floor and not reclined up).